Text Transcript: Adithyan (Dithu) Rajaraman, PH.D., BCBA

Good morning.

My name is Lisa Doucette and I am the superintendent of APSEA.

I'd like to take an opportunity to welcome you all to the autism and education Symposium.

I would also like to thank the team thank the team members who worked hard to arrange the Symposium as you all know, there's always lots of behind the scene work that happens to organize the events such as this the interprovincial autism and education working group continues to work together to support professional learning via the aie symposiums as well as webinars keeping Educators up to date with current research related to best practices in the area of autism and other related areas information papers the take flight series to name a few.

I want to thank the aie working group for all you do to support this important work.

The aie partnership is an example of the high level of professional learning and supports possible for educators and partners in the Atlantic provinces when we work together and it is important for us to recognize those team members and the important work they do to support the folks who support Learners in the Atlantic provinces.

So I wanted to take an opportunity to introduce the wealth introduce the working group community.

So from New Brunswick, we have Katherine bro and Monique Monet lab primer.

From Newfoundland and Labrador we have Lori penny.

From Nova Scotia.

We have Kim Reno-Briscoe and from Prince Edward Island.

We have Raeanne Adams.

And at from APSEA we have Shelley McLean and Kyle Hatt and I understand that they will do some further introductions about their roles in the work they do in the provinces as we move through Symposium.

I just wanted to take a an opportunity on behalf of that seat to thank you all once again for the work that you do and I'm sure we're all looking forward to the next two days of professional learning.

So I will now turn the virtual floor over to Katherine bro.

Who's going to introduce our first keynote speaker.

Thank you.

Before I introduce our presenter, I want to mention to those seeking bcba CEUs that you should have received a ceu form along with the zoom link.

If you did not receive the form and need one, please email Kyle Hatt and he'll send that form out to you this morning.

There will be Verification codes provided verbally and in the chat two times during the presentations and you must enter both codes on the form to receive CEUs at the end of the Symposium simply return the ceu form to Kyle Hatt and your ceu certificates will be emailed within a couple of weeks.

If you are a member of another profession other than bcba or bcaba and you wish to obtain education credit for the Symposium presentations, you will have the opportunity to request certificates in the Survey Monkey survey, you'll receive at the end of the symposium.

The certificate should contain the information you need for continuing education purposes, but if not, feel free to email Kyle Hatt and he'll ensure that you get the information you need.

And now it's my pleasure to introduce our first presenter Dr. Ditu Rajamaran.

Ditu says he has blessed to have had the opportunity to interact with and learn from Children and adolescents with and without disabilities for 14 years.

He Can he completed his Doctorate in applied Behavior Analysis at Western New England University under the advisement of Dr. Greg Hanley?

In 2019.

He joined the faculty at the University of Maryland Baltimore County where he mentored undergraduate and graduate students in Psychology with an emphasis on Behavior Analysis.

This emphasis on Behavior.

Excuse me, this fall Dr. Raja Raman joined the faculty in the department of pediatrics at Vanderbilt University Medical Center.

Where he serves as the Director of behavior analysis research within the treatment and research institute for autism spectrum disorders.

He has published research in the Journal of Applied Behavior, Analysis Behavior, Analysis and practice and autism.

Research and practice interests include the assessment treatment and prevention of dangerous Behavior with an emphasis on investigating trauma-informed approaches to behavioral.

Excuse me, trauma-informed approaches.

The aim of his research is to is intimately connected to the goal of being able to provide safe dignifying yet highly effective Behavior analytic services to the underrepresented individuals in underserved communities, and now I give you our presenter Thank you so much for that introduction and good morning everyone.

It is a seven am here in Nashville, Tennessee where I'm coming from.

I understand.

It's 9:00 am in the Atlantic province's and so I hope we all have our coffee.

As I share my screen here.

Could somebody maybe just one of the one of the panel members just met mentioned in the chat or say out loud if you could see my screen, okay?

Yep, we're good to go.

excellent Thanks so much.

Thanks for inviting me to be here with you for the autism and education virtual Symposium for the next three hours.

I'm not had the pleasure of visiting the Atlantic province's yet.

I grew up in Detroit, Michigan.

So most of my trips to Canada were visits to Toronto and of course taking every single cousin who ever visited from India to Niagara Falls.

Anyway, boy, it would have been wonderful to meet you all in person and eat catch up flavored potato chips with you, but I'm nevertheless so grateful that Shelley McLean and the Symposium organizers and extended an invite to me for this wonderful event.

Hello and happy belated Canadian Thanksgiving or as many of you probably call it.

Thanksgiving I'm thrilled to be here with you to discuss how we can promote safety and compassion in the assessment and treatment of dangerous Behavior.

If you serve individuals Autistic or otherwise who engage in dangerous and challenging behavior in any setting in the home in the school and Clinics in hospitals or in residential facilities or anywhere else?

I hope that some of what I described today will be relevant and perhaps helpful to you and your practice.

The model that I'm going to be describing today, sometimes referred to as the enhanced Choice model was developed and evaluated by a community of researchers and practitioners and I am genuinely blessed and honored to be here on behalf of these tremendous colleagues mentors students and Friends.

And before we go any further, I should address the potential elephant in the room or cats in the room who are my two sons chip and Louis whenever I have something serious to do like I don't know give a presentation to you all they always seem keenly aware of my diverted attention and go out of their way to get in my way.

If I lock them out, they will make me pay for it.

So you may see some boys join me in the office today and I apologize in advance if you're distracted by their cuteness or by a close-up of one of their butts.

I'm excited to share some stories and data with you today because they have changed who I am as a practitioner and a researcher and a human being who has relationships with autistic individuals.

And through everything I've learned from my colleagues and of course from my clients and their families.

I actually hope to convey to you just one main point.

Which is that it is possible to meaningfully address dangerous Behavior while keeping children and caregivers safe.

While showing concern for their emotions sensitivities and preferences.

And without relying on physical management tactics during our interventions.

So if you leave my talk today, and you only learn one thing.

I hope that it is this message.

When I say meaningfully address, I mean that we can understand the challenging context that reliably trigger dangerous behavior and we can teach multiple important skills that individuals can use in those contexts so that the dangerous behavior is no longer needed.

In other words, although challenging Behavior can be challenging to address we can do so successfully with empathy and compassion infused into our process.

I plan to describe a process I use when giving the opportunity to address dangerous Behavior.

I'll share applications of this process across Clinic school and home settings.

If you notice some redundancy and repetition what I describe across these three service settings, please know that my intention is not to bore you.

Rather, I hope to leave you with a clear picture of methods and expected outcomes.

And I hope that the data and stories that I shared today will help me arrive that and explain the generality of the take-home point you see here.

As mentioned if you have any questions, please feel free to use the Q&A function or even the chat function in the in the zoom.

I can't currently see any of them come in just because of my because I'm sharing my screen and I have presenter view on also, this is Louie.

Can you say hi?

He's not gonna say hi.

But anyway, if you have questions, I'd like to take a break I think maybe every hour or so, but they'll probably be some natural breaking points at which point we can all stretch text check tiktok for five or seven minutes and then we'll come back address some questions before moving on to the next content.

Before diving into the content allow me to introduce myself as I'm meeting many of you for the first time.

My name is adityan Raja Raman, but I go by the I'm an assistant professor in Pediatrics a Vanderbilt University Medical Center where I'm currently serving as the Director of behavior analysis research at the treatment and research institute for autism spectrum disorders or Triad.

If you're not distracted by this tale, then you're clearly not paying attention.

Hater by training and ever since my first job out of college.

I've served Children and adolescents with and without intellectual Developmental and emotional challenges who are in certain therapeutic or educational placements because of their dangerous behavior that they routinely exhibit Vanderbilt University is located in beautiful Nashville, Tennessee, which is considered to be in the south of the United States for those of you who don't know.

And based on this map.

The Atlantic provinces are kind of in the southern part of Canada.

So you might say that Nashville is like the Atlantic provinces of the USA.

Although as much as I love living in Nashville, the southern part of the USA is a very racist.

So as a brown skin dark skin person who looks like me.

I have to say that I'm feeling much more comfortable in this Zoom safe space than I do in several parts of Tennessee.

So thank you for being so welcoming today.

I joined the Triad organization at Vanderbilt University Medical Center because they provide Behavior analytics services to public schools in every District in every County in Tennessee from Urban to incredibly rural from under-resourced to even more under-resourced and they tend to be the first call when children are exhibiting dangerous behavior in these schools.

Behavior analysts that Triad are often tasked with helping children who spend an exorbitant amount of their day out of the classroom due to their dangerous behavior in seclusions and physical restraint procedures.

So I joined this group because the opportunity to help these children and their Educators and families and because the group's values align very closely with mine.

Some of these values include the following themes which I hope that you pick up on during today's talk.

I think that people are awesome in the dangerous behavior is not I speak not only to my fellow behavior analyst in the room and Educators that are here, but directly to autistic people members of the neurodivergent community and neurodivergent allies.

I'm going to speak today about children with brain and behavioral differences and some of the stories.

I tell may make it seem as though I'm only focusing on their negative characteristics in service of illustrating how our treatment model helped them.

I wish to State unequivocally that I do not think ABA is meant to be used to change who people are.

I wish I don't think that it's meant to get them to stop engaging in behaviors that are merely an expression of themselves.

Rather, I believe that the great promise of ABA of Applied behavior analysis is that it can Empower individuals with skills and repertoires that allow them to advocate for themselves while keeping them in their loved ones safer.

People Are Awesome dangerous behaviors are worth eliminating so that everyone can see that.

Life can be traumatizing but applied Behavior.

Analysis need not be.

I believe that every individual who joins the field of ABA or special education does so intent on helping their fellow humans navigate the challenges that life throws at us.

I find it unfortunate that some who we serve have have experienced or perceived ABA as one of those challenges rather than a university positive universally positive experience on route to an improved quality of life.

I hope that some of what I shared today provides a sliver of evidence or hope that we can greatly reduce those negative experiences and perceptions of Aba.

And finally if I sound critical of ABA in any way, please know that I believe that it is a great freaking time to be a behavior analyst.

In the past few years.

I have witnessed a dramatic tonal shift in the way that we which we talk about and teach about ABA evidenced by this very conference that is invited speakers to talk about the role of assent choice and compassion in Behavioral Services and in educational settings.

Across every domain of Service delivery and research there's a shift in tone that's reflected of reflective of past mistakes and one that looks forward with a greater sense of responsibility to Those whom we serve.

One of the reasons that I'm both cognizant of present tensions pertaining to Aba and hopeful about the future comes from some survey data that my team recently collected pertaining to the topic of the use of physical management and Behavioral Services.

Let's start there.

When I talk about physical management just so that we're all understanding the same terms that we're using.

I use it as an umbrella term that includes both physical restraint as well as physical guidance procedures where physical restraint refers to physical holding or securing of an individual for a brief or extended time period and physical guidance refers to manipulating some part of the client's body.

This may or may not be a foreign concept to you.

But in all likelihood it's a topic many of you are entirely to familiar with.

In fact, although I can't see the chat just to get a little bit of active responding going.

I would love it if you could.

Well in a moment, I'll give a prompt for you to maybe drop some information in the chat.

So so please be prepared.

physical management is often employed during the course of Behavioral Services this many of you know, for reasons that I hope to clarify today when I was beginning to discuss the precarious relationship between Behavior analytic procedures and physical management and some contemporary criticisms of ABA as a whole Some of my undergraduate students at my former job at the University of Maryland Baltimore County who were uninitiated to the ways of ABA passed and present started asking great questions about how commonly such procedures were employed in ABA practice.

Anyway, I was talking about how I was talking about how I was speaking with undergraduate students who were like, what do you mean they're using physical Management in ABA?

They didn't fully understand it.

So with their help, we eventually conducted an online survey asking some of these questions and assessing the nature and feasibility a physical management procedures used in applied Behavior analytic practice.

We conducted this survey because we had no idea the extent to and the conditions under which people were actually implementing physical Management in their practice.

Perhaps more importantly.

We didn't know where Behavior analysts stood regarding their opinions on the use of physical Management in their practice and ABA practice at Large.

To our knowledge social acceptability of the general use of physical management has actually never been systematically evaluated.

We have a handbook in our field devoted to crisis Management in service of individuals who engage in dangerous Behavior.

Dr.

Wayne Fisher and colleagues published a chapter in that handbook wherein they delineated three primary reasons why Behavior analysts might Implement physical management procedures such as restraint or physical guidance.

The first is as part of a comprehensive Behavior treatment program.

Some examples might include physical guidance and an escape Extinction procedure something.

I'll talk a little bit more about later.

the second is in the form of timeout from reinforcement as in escorting a client to a seclusionary timeout room or something of the sort.

Now the third is in an emergency procedure for ensuring the immediate safety of clients staff and caregivers.

An important distinction I want to make here is that although physical management is often used in emergency situations?

It is also sometimes programmed into behavior intervention plans.

So we surveyed Masters and doctoral level board certified Behavior analysts.

Our survey contained 52 questions and took about 25 minutes to complete.

The link to the survey was sent out to over 21,000 bcbas.

716 responses were returned all of whom gave informed consent.

and I'd like to just give a quick shout out to one of my stellar former undergraduate research assistants Olivia schweigerath Who played an integral role in constructing the survey in an online platform and graphing the data that I'm about to show you?

Now I'd love nothing more than to go through each of the 52 questions.

We asked.

And to read to you the 716 responses that we received each one.

But I worry that if I do that.

We might still be sitting here when the next pandemic rules around.

Because it too soon to joke about that.

Rather allow me to share some key findings and articulate some key takeaways.

First I'll let you peruse the demographic information of those who were generous enough to complete our survey.

As you can maybe see respondents were primarily bcbas who identified as white cisgender women, which is perhaps unsurprising considering recent demographic data released by The bacb are credentialing body for Behavior analysts.

I think this speaks to the tremendous amount of work we have to do in our field to create a more diverse Workforce to better represent the individuals that we serve.

Anyway, those who responded to our survey were relatively evenly distributed across the age ranges of clients that they served and across settings in which they practiced Aba.

With a plurality of respondents having a caseload of 10 or fewer clients at the time that they completed the survey.

We asked folks if any of their current clients have ever experienced physical management.

Has been we surveyed reported that at least one of their clients had experienced physical management either as an emergency procedure or as a procedure that's programmed into their behavior plan.

That is a lot.

That is concerning.

However, we also learned that only a small percentage of clients on any one person's caseload had experienced physical management.

So although most bcbas have at least one client that experiences physical management.

It doesn't appear to reflect the majority of clients on their caseload.

Now one reason that clients may not may have not experienced physical management, maybe due to their size or the severity of their behavior.

If you look at the bar graph on the top right of your screen, you can see that almost a hundred of the 760 respondents reported that 25% or more of their clients on their current.

Caseload are too large.

Or engage in behavior.

That is too dangerous.

For physical management to even be considered an option.

When we specifically asked if physical management was incorporated into Behavior plans for individuals.

About half of participants indicated that they have Incorporated physical management into a behavior program.

A programmed procedure and this means that there are pre-specified conditions under which physical management would be implemented.

So maybe now is a great time if you could just throw in the chat, if you have I don't I'm not necessarily aware of how this works legally in Canada.

But if you could drop a line in the chat, have you implemented physical management with your clients?

If so, how much?

Or how regularly only to the extent that you're comfortable.

While you're doing that I'll take a closer.

Look at people's varying experiences to show you how they correlate with their opinions about physical management.

This pie chart depicts the answer to the question.

How often is physical management implemented with the client on your case load who experiences it most frequently?

It's perhaps encouraging that a majority about 55% of respondents in dark gray and olive green.

Reported that their most restrained client experiences physical management only once a per month or even less frequently.

On the other hand its concerning to me that about 30% of respondents reported using physical management with a client several times a week or more frequently.

With 10% of folks saying that they have a client who is physically managed every day or multiple times a day.

Now I ask that you look at this other pie chart depicting bcba satisfaction with the frequency with which they Implement physical management procedures.

Again, a majority of peer satisfied which I suppose is a good thing.

But about 20% report feeling unsure or straight up dissatisfied with how often their implementing physical management.

Notice the aesthetic similarity between these two pie charts that similar colored slices appear to make up similar proportions of the pie.

Seemingly a similar amount of folks who Implement physical management quite rarely appear to be satisfied with their frequency.

and vice versa folks who routinely use physical management appear dissatisfied with their frequency.

Now my hunch is that these are the same people that the folks who report satisfaction with physical management are those who don't use it that often and vice versa?

But my main point here is I suspect that there's contingent of behavior analysts who are in practice who use it frequently and aren't happy about it.

Perhaps the most significant finding we obtain from the survey pertains to bcbas opinions on the broader use of physical management and behavior in ABA practice or Behavioral Services at Large.

And subsequently their opinions on whether or not they feel that there are procedures and the literature.

In best practices that provide alternatives to the use of physical management and everyday practice.

specifically a majority 58% of folks articulated that they would like to see less physical Management in Aba that same majority 59% to be more precise.

Felt that the literature does not at present at least in 2021 when we administered the survey.

Have Solutions or alternatives to the physical management of which they wish to see less.

This represents members of the discipline and their opinions of their own practices.

To say nothing of individuals who are the recipients of these Services their families and the broader community of disabled and autistic individuals and their allies.

Regarding bcba experiences.

We see that many practitioners have been involved in physical Management in some capacity.

Quite an alarming few have Incorporated it into Behavior plans and there appears to be very ability with the frequency with which and the context in which physical management has been implemented.

However, there are outliers Within These data that I believe should not be ignored.

And regarding bcba opinions.

The overwhelming sentiment seems to be that less physical management would be better.

But that there may not be adequate resources at present to just make it go away.

What do you think about physical management?

This poor guy.

He had a he was sick a few months ago, and we had to like kind of restrain him to give him antibiotics and it didn't feel great.

I think about that a lot when I think about the clients with whom we work and the the well, I'll share more about that in a minute.

I shared this information with you to convey that if you are or have been serving clients for whom physical management occurs, routinely and you feel like it's a lot.

Please know that you're not alone.

Please know that a large majority of professionals who serve autistic individuals Implement these procedures despite having varied opinions about their efficacy and their achiness.

I also share this information because I think it serves as a useful backdrop to discuss the need for alternative procedures.

I promise that I will share some alternative procedures soon.

Earlier, I mentioned that the assessment and treatment model that I'm going to describe today change who I am as a practitioner and a researcher.

And to help describe that existential transformation of mine.

I'd like to tell you a little bit about my history in the field of Applied Behavior Analysis to share a bit about how my past has influenced my present.

I received my early training and behavior analysis at the New England Center for Children in central, Massachusetts.

It is a day in residential school about 20 miles outside of Boston with a reputation for providing state-of-the-art care for some of the most severely intellectually in developmentally impaired children in New England.

The children I serve at this school engaged in very dangerous Behavior.

In the states as I'm sure it's probably similar in Canada residential programs are reserved for children and adolescents whose behavior is quite literally too dangerous for them to live at home.

Now I consider myself truly fortunate to have received early training and experience at the New England Center.

This is a picture of their Satellite Campus located in Abu Dhabi in the United Arab Emirates where I had the privilege of working for a year.

Unfortunate because I was introduced to some of my favorite people in the world.

to behavior analysis into that feeling of satisfaction and camaraderie that you get when you work together with a team to demonstrably improve the lives of the individuals you serve Perhaps I'm most fortunate that in applying behavior analysis with some children with really serious intractable Behavior challenges.

I learned about the ways in which our environments influence our Behavior.

And the powerful assumption that if some type of behavior is occurring with regularity it is being reinforced.

That means that behavior that occurs regularly is producing some sort of important consequence and Improvement in the individuals environment.

And we call those important consequences reinforcers.

furthermore if some type of behavior is being reinforced.

Then that means that there are environmental contexts and moments that make those reinforcers more valuable to an individual.

And that their environmental cues that signal the opportunity to produce those reinforcers by engaging in these particular types of behavior.

And whether we're talking about ordinary Behavior, like checking your Instagram on your phone or extraordinary Behavior, like banging your head into windows and attacking your parents.

That same assumption is proven useful in our understanding of why extraordinary and dangerous behaviors occur with such regularity.

and importantly if we can identify the variables that are unique to an individual circumstances and learning history.

We can indeed influence behavior in a positive way.

I know many of you are familiar with this as it is the behavior analytic approach to understanding and improving socially important Behavior.

Like I said, I was exposed to this Approach at the New England Center for Children.

And in addition to learning a bit about the utility of the behavior analytic approach.

I also learned a set of efficacious Behavior reduction techniques.

Predicated on the assumption that we can change the course of behavior if we know enough about what's reinforcing it.

finally an importantly I learned a set of physical management procedures for when problem Behavior became too dangerous in spite of the various Behavior reduction techniques.

We had in place.

And seclusion or Restraint of the escalated individual was necessary to ensure their safety and the safety of others.

Now it's important to me that I shared these three takeaways on the same slide because although the first two constitute how I was taught to think about our understanding of addressing problem Behavior.

And although the physical Management training that we received was meant to apply in emergency situations only.

We often found that the emergency situations arose during our well-meaning attempts to implement our Behavior analytic Behavior reduction protocols.

I'll tell you what, I mean by that.

Many interventions for Dangerous Behavior involved differential reinforcement with Extinction.

It is a very common procedure that simply involves providing reinforcement for some form of appropriate behavior while not providing reinforcement for challenging Behavior also known as putting challenging behavior on extinction.

Now this Arrangement usually yields an increase in the likelihood of that appropriate behavior and a concomitant reduction in the likelihood of challenging Behavior.

at the New England Center where I worked We put a lot of challenging behavior on extinction.

And this was for good reason.

This was evidence-based practice.

Because what we know about implementing Extinction in the treatment of problem Behavior.

Is that it is highly efficacious.

And sometimes even necessary in order to achieve desirable reductions and challenging Behavior.

By necessary.

I mean that there are several studies some of which are sampled here.

Showing that only providing reinforcement for alternative Behavior was not enough to significantly impact the likelihood of problem Behavior.

Extinction of problem Behavior was a necessary complement to the differential reinforcement arrangement.

What we also know about programming Extinction for challenging Behavior.

Is that it can lead to Extinction bursting and other forms of dangerous Behavior?

And furthermore when we use Extinction to treat Behavior that's sensitive to escape as a reinforcer that is when kids engage in dangerous Behavior to get out of certain expectations demands or activities.

this process often requires physical management physical management of children who are engaging in already dangerous Behavior can lead to further escalation of that behavior and unsafe situations.

And we've seen these collateral effects of Extinction play out at least a dozen times over in the literature.

But this is also something that I experienced with great regularity and in the name of differential reinforcement while I was working at the New England Center.

escalation calls for additional staff equipment application physical restraint you get the picture?

Nobody was a fan of it, but everybody including myself understood physical management to be sometimes necessary in order to achieve the main effects of a behavior analysis.

Once I left neck, I began my PhD training at an outpatient clinic in Springfield, Massachusetts.

Under the advisement of Dr.

Greg Hanley We're based on the same assumptions about why problem Behavior occurs.

I learned a different process to go about assessing and treating it.

I learned how to conduct what we call practical functional assessment or PFA.

and skill-based treatment or SBT process the process initially described by Handley and colleagues in 2014 involves first understanding the reinforcers contributing to the maintenance of a client's problem Behavior and the context in which problem behaviors likely to occur.

and then teaching those clients how to communicate cope and cooperate with others when experiencing those challenging situations.

So before discussing the enhanced Choice model what I mean to discuss today, I'd like to spend a few minutes providing an overview of how this process is typically carried out.

I'll Focus here on some of the more important lessons that relate to minimizing risk and promoting safety in the treatment of dangerous challenging Behavior.

The first commitment to this process that promotes safety.

Is that we don't attempt to analyze dangerous Behavior without first asking about it.

We ask folks familiar with the challenging Behavior to tell us everything they can about all potential topographies of challenging behavior and all possible triggering events and reinforcing events.

So that we can design a contingency that can be safely tested in a functional analysis.

One of the most important bits of information that we obtain from caregivers during this interview.

Pertains to non-dangerous challenging behaviors that seem to proceed or reliably co-occur with more dangerous forms.

More on that in just a bit.

A second commitment is that we don't attempt to treat challenging behavior until we can safely turn the behavior on and off in a functional analysis.

Now I use a particular type of analysis called an interview informed synthesized contingency analysis or isca.

In which we combine all of the events that caregivers tell us.

About to see precisely how they influence the challenging Behavior.

This is different from what you may have read about in terms of a standard or traditional functional analysis where we pick apart the independent variables that might be influencing problem behavior.

And we test them in isolation rather than doing that.

We combine all these variables into a single contingency and I'll describe what that looks like with a quick example.

During an interview.

Sorry.

This is an example with a young fellow a four year old boy named Brandon who was one of the first clients with whom I implemented this process.

during an interview Brandon's parents painted a picture of how episodes of challenging Behavior typically went down at home.

See when Brandon was asked to engage in solitary or daily living tasks.

When his parents' attention was diverted for even a minute when he couldn't have the toys or gadgets that he wanted in that moment.

And when his family members would not comply with his unique and frequent requests.

He often engaged in self-injurious Behavior aggression meltdowns as well as some less dangerous, but still challenging Behavior like like whining screaming stomping.

And he would do that basically until those behaviors resulted in Escape From those solitary or daily living tasks undivided attention from a parent uninterrupted access to toys and Mom's iPhone and immediate compliance with any of his requests.

Brandon's parents told us that these events occurred simultaneously a lot of the time and they're busy household.

They had three kids at home.

So we combined all these events and saw that this synthesized contingency was indeed functionally related to Brandon's problem behavior in that.

We only observed problem behavior in that test condition in which that contingency was present.

And we did not observe any of that challenging behavior when the contingency was absent.

Or when Brandon had free access to all of those suspected reinforcers.

Conducting an analysis when I like I said I use the iska as my functional analysis of preference.

Is important because it gives us scientific evidence of what is evoking and reinforcing challenging Behavior.

But equally important is that it teaches us how we can provide Brandon with everything he needs and thereby stop challenging behavior before things get violent and unsafe.

Here's an image of that same functional analysis graph.

But the three panels below it represent Brandon's challenging Behavior within each of the three test sessions of the analysis.

These panels are sort of like a time-lapse with seconds along the x-axis so that each horizontal panel represents a 300 second or five minute test session.

The Thin Line that you see it toward the bottom where the yellow arrows are pointing represent programmed reinforcement meaning that during those periods of time Brandon had all the toys attention and acquiescence that he could hope for with no demands presented The absence of the Thin Line in that same horizontal plane represents the programmed establishing operation and what I mean by that is that that's when those are periods of time when his parents would take away his toys or preferred activities divert their attention and instruct him to engage with some solitary tasks or to go clean up or something like that.

If you see black diamonds that represents a single instance of challenging behavior that occurred during the establishing operation when we predicted that it would occur.

and in this case a hundred percent of those observed responses were non-dangerous precursors, like whining or stomping white diamonds would represent challenging behavior that occurred during reinforcement.

But you can see that that never occurred in Brandon's functional analysis.

in other words We found that our synthesized establishing operation or EO was potent enough to turn on some type of problem Behavior quickly.

And perhaps more importantly we found that our synthesized reinforcers giving Brandon all the things that we suspect that he loved or needed in that moment was powerful enough to turn that behavior off immediately.

That latter component being able to turn Behavior off by providing reinforcers.

Is a little counterintuitive but it's especially important in this assessment process.

To increase and maintain safety throughout the treatment process.

So after we've identified that safe but evocative context in the isca that context were behaviors likely to occur, but that we can kind of shut it off by providing reinforcement.

A third commitment is to teach clients multiple skills that can help them navigate these everyday challenges and get their needs met.

Thereby rendering challenging Behavior unnecessary.

The first skill we teach is simply communication.

Whether or not children have a strong language repertoire whether or not we teach local communication sign language communication using a picture exchange system or simply pointing to an icon.

We always start by teaching novel communicative response and we teach that by recreating the context that I just described in the test condition of the iska where we routine periodically interrupt their way of kind of doing things.

And with a little bit of prompting and a little bit of differential reinforcement, we teach that client to request those the same reinforcers that were maintaining their challenging behavior in the iska.

So whereas in the Esco we would say we're all done with these toys.

I need you to go clean up and they might say I don't want to and we'd say oh, that's okay.

We don't have to clean up right now, but we can keep playing.

In this treatment phase or we teach communication we would say all right stuff.

Your your stuff's all done.

I need to go clean up.

You could just say more time, please or you could say can I have my way please and when they admit that response we say oh, of course.

Yeah.

We don't need to clean up right now.

It can keep playing.

Once the client I'll mention right now that I'm gonna give kind of several examples of this.

So hopefully that paints a clearer picture if you're if you're if you're sitting and you're going I'm not fully understanding what these procedures look like.

I hope to illustrate it with some more case examples.

Anyway, once the client demonstrates that they can communicate for their reinforcers in lieu of engaging in that challenging Behavior.

We carefully begin to deny some of those requests.

They'll say can I have more time please and we'll say no not right now.

And we teach them an explicit coping response or tolerance response to that immediate disappointment.

And once our clients can handle the disappointment of not immediately getting their way.

We begin to shape cooperation or what we sometimes call contextually appropriate behavior during periods of non-reinforcement.

This process that I'm describing right here is called skill-based treatment.

I'll briefly illustrate what that looks like with Brandon's treatment data.

And I'm going to share a couple of graphs that look like this.

So allow me to kind of Orient you to all the proper components.

Along the x-axis.

We have kind of sessions each session represents five of those exchanges five trials were where the adult says.

Alright, we're all done.

And then we prompt some type of behavior.

When we see that Target Behavior.

We say never mind.

You can go back to read what to reinforcement and we play with them for for a period of time.

Along the y-axis from top down.

We have problem Behavior or challenging Behavior, which for brand was a large class of behaviors aggression self injury, but also whining stomping crying protesting.

And then also those social skills that we taught in treatment such as functional communication responses.

tolerance or coping responses And contextually appropriate behaviors.

Like I said, Brandon's data aren't super important to the meat and potatoes of today's talk and I'll provide a more careful walk through later on but here I want to emphasize that we did not move on from one treatment phase until the next until we repeatedly observed the targeted social skills at the exclusion of challenging Behavior.

we did so as to not push Brandon beyond what he was capable of and we let his behavior his performance guide us as to when he was ready for the next challenge.

I also want to point out that our treatment process with Brandon culminated in much the same way as has been described and published studies of this process.

With challenging Behavior completely eliminated during those challenging situations and consistent emission of talk all targeted social skills.

Building off client success and making performance-based decisions.

Like these helps us avoid large bursts of challenging Behavior as it helps avoid expecting too much of clients when they're not ready.

and everything I'm saying is hopefully a shining endorsement of a super safe process until you take a closer.

Look at Brandon's challenging Behavior throughout the process.

Do you notice the bumps along the road to treatment?

It looks like the Rocky Mountains or something.

I like to call it the Rocky Mountains.

Not not only because the process was a bit Rocky but because Brandon used to show up in the clinic with like these muscle shirts and he was like the most jacked four year old I've ever seen.

but anyway He's Jim goals for me.

He's fitness goals for me.

despite all of the PFA and SBT elements that I just described that are meant to ensure safety in the process.

We still saw several bursts of challenging Behavior.

some of the time and this escalation was a direct result of Brandon's challenging Behavior contacting Escape Extinction.

That is when he was non-cooperative or engaging and challenging Behavior a little bit when we were imposing some of those demands and instructions our procedures dictated that we would follow through with those instructions that we would not let him get out of the demand.

We would say no, I do need you to clean up clean up like this.

That's how you do it.

And then we would actually physically guide him to clean up the toys.

and this bumps in the road to treatment that we saw.

More often than not were were explosions that occurred while we were forcing Brandon through those expectations.

You know Escape Extinction that Messi procedure that I just mentioned that sometimes necessary in order to achieve important reductions and challenging Behavior.

Yeah, it's been a critical part of the skill-based treatment that I just described ever since the first publication in 2014.

And in fact, although there have now been over 50 single subject demonstrations in the literature of socially validated awesome outcomes with respect to dangerous Behavior.

It's worth noting that all of the examples of successful outcomes that you see up here on this slide have involved that programmed Extinction of challenging Behavior.

Now skill-based treatment would synthesize reinforcement is obviously a multi-faceted multi component treatment package.

If you are familiar with functional analysis and functional communication training and you're sitting there today going what is he talking about functional communication is typically I take the iPad.

I remove the iPad.

I say iPad, please and I give the iPad back.

You might be hearing what I'm describing and saying this sounds like a like a zoo of a tree that there's just lots of lots of different moving pieces going around.

There are likely also.

plenty of Behavioral processes at work What I'll say, is that while we know very little about the relative contribution of each behavioral mechanism.

We don't know currently whether it's positive reinforcement or the extinction process.

That's kind of driving the bus of this Behavior change.

It seems reasonable to infer that Extinction.

Played an important role in the outcomes that we've seen in these dozen or more studies with respect to challenging Behavior.

Please recall what we also know to be true about Extinction.

Extinction often leads to bursting and other forms of dangerous challenging Behavior And it often requires physical management implement.

If you're familiar with follow through Aba.

Or if you've ever seen any feeding interventions that are that are based in ABA that involves something called non-removal of the spoon where you hold the spoon up and you do not remove it until the child consumes the food.

That's highly aversive to them.

Then you may know what I'm talking about.

And you may also know that it is not a pretty process.

That it often leads to escalation of dangerous Behavior.

And that it is just not an ideal way to interact with those who we serve.

I share all this information because it underscores the importance of safety in the treatment of dangerous Behavior.

When we assess and treat a child's Behavior.

We have to acknowledge that we are building a relationship with that child.

I don't believe that the procedures that I just described are great ways to build a positive relationship.

I believe that positive and productive relationships require safety and trust between the child and their caregiver or their educator.

Now it's worth mentioning that the potential for actually, you know what I see that it's eight o'clock right now.

So we've been at this for about an hour.

This might be a great place for us to take maybe a five minute break.

So I will set a timer for five minutes if that's cool and we can come back.

Wait.

I have 802 on my laptop.

Why don't we come back at 8:08?

And did too Shelly.

I just want to pop in with a bcba verification code for folks who might be collecting CEUs.

This is a good time.

So the code which is also going in the chat as we speak is eight eight seven zero six.

Thank you so much, and we will take a short break and be back shortly.

All right, I have 808 so If it's alright, I think we'll continue.

I scrolled through the chat and I didn't see any questions.

Can anyone confirm that?

It sounds like sure did too.

It's Shelly there there wasn't I guess a question so much as a an inquiry, I guess about your perspective on writing restraint procedures into a Behavior Support plan kind of that emergency procedure as a last resort.

So just wondering what your thoughts are on that.

Uh, certainly I have a bit about it at the end where I'll go into it more detail, but I'll but it's worth mentioning that I completely acknowledge the need for emergency restraint procedures.

I think that I what I was hoping to distinguish is there that there are some folks who through what we understand about ABA we tend to put these plans in place as like part of the behavior intervention not even necessarily as an emergency, but it's like if client it's their head twice.

We're gonna go in and restrain and sometimes That is to kind of mitigate.

Further escalation and so sometimes it is still considered a safety measure.

But sometimes it's kind of also therapeutic like let's let's restrain so that as a punishment procedure or let's do Escape Extinction as an Extinction procedure.

So that distinction to me is important and I think if I'm understanding the question, I completely support the need for or understand the need for emergency procedures.

I I'll go as far as to say as much as I don't like it as much as I've reflected on my practice in the amount of times that I've used restraint something I'll share more about later.

I don't think that it's something that we should legislate to to make illegal in all schools because I do understand and appreciate that.

There will be some situations where where it might be needed.

If a student is attacking another student if a student is sexually assaulting another student or staff member.

These are some very serious emergency situations.

What I hope that I can articulate after I describe some of the procedures that I promise.

I'm about to get through very soon.

Is that we can I think we can set up situations where we greatly reduce the need for those restraint receivers.

I think that we can incorporate additional procedures into our everyday practice.

That can sort of mitigate that risk.

So thank you so much for asking that question.

If I may I'll continue with the talk if that sounds good.

Yes, absolutely.

Thank you.

Awesome.

Great.

Thank you so much.

Um, so, you know, we were just talking about how some of these procedures are a bit ugly and messy and often get worse before they get better, but I think that it's worth mentioning that escalation.

The potential for escalation may not even be feasible with certain clients or in certain settings.

Some of you I did see in the chat that many of you indicated that you have implemented physical management, but some of you may know about clients whose Behavior gets so dangerous where that that implementing these as procedures would be unwise it would result in immediate restraints.

But I'm also talking about settings in which physical restraint is not an option either by law.

In certain School settings or as a practical matter in the home setting where it's just one caregiver in their child.

So in other words despite the documented effectiveness of those skill-based treatment procedures that I just described.

They may still not be feasible under conditions in which the mere possibility of escalation is untenable.

This was certainly the case for Jeffrey.

A nine year old boy who came to our Clinic a few months after Brandon.

And whose practical functional assessment experience really led us to develop the enhanced Choice model that I'm about to describe.

Where do I even start with Jeffrey?

he was the coolest kid Jeffrey was a nine year old boy with ADHD in generalized anxiety disorder.

And he knew what he liked.

And he knew what he didn't like.

And he wasn't afraid to articulate it.

Jeffrey was one of those people that you kind of immediately wanted to impress.

But you also started never did or at least I never felt like I did.

He was a big gamer.

He showed up to our Clinic with a Nintendo DS as well as an iPad and literally played them both simultaneously.

He was a Minecraft and Yu-Gi-Oh and Mario expert.

He liked all sorts of games, but let me be more specific.

Jeffrey like winning games He did not like losing games.

Jeffrey's parents told us that he basically always had to have it his way across the day in school and home.

He didn't like to be told what to do in any context.

But especially when it came to homework and to game night.

His parents were Gamers, too.

board gamers they raised Jeffrey on Family Game Night, but hadn't been able to do that for a couple of years because of the meltdowns that would occur if he didn't get to play by his rules or if he, you know heaven forbid didn't win.

As you can see here.

Jeffrey also engaged in some sophisticated aggression.

sometimes involving choking and sometimes involving nearby objects.

In addition to having a history of aggression and meltdowns.

Jeffrey had also taken to running away from home or school whenever he was pushed too far.

His parents came to us.

After his third police escort from the school due to dangerous elopement running away from school.

And they reported that Jeffrey became highly agitated whenever School Personnel or the police attempted to manage him physically.

Jeffrey was on the verge of being expelled from his school.

And had also been hospitalized following uncontrollable meltdowns in his home.

This is a typically developing kid a language-wise.

He has a sophisticated language repertoire.

He did have a diagnosis of ADHD and generalized anxiety disorder, but there were just several moments throughout his day where he couldn't handle the situation and it resulted in such major escalation that he was that the police were called on him and he was hospitalized.

So when Jeffrey came to our Clinic we did but we were trained to do.

We invited Jeffrey into a room populated with all of the suspected reinforcers and establishing operations that his parents kind of reported.

We set up a context wherein our establishing operation.

Involved either interrupting his unique way of playing.

By either telling him to go work on writing homework or to play but to play by adult directed rules.

When we began interrupting his unique way of playing.

We saw challenging Behavior immediately.

And eventual attempted elopement from the room.

Now our traditional Clinic procedures did not allow for escape from the room.

even during reinforcement periods So as to not confound our functional analysis and so as to keep things contained within our Clinic rooms.

See that things quite literally escalated.

Specially after we blocked Jeffrey's exit from the room.

Imagine This Jeffrey a kind of a thick strong nine-year-old boy engages in one instance of problem Behavior.

He swiped his homework off the table which we reinforced by relenting.

We said no, you don't have to do homework.

Why don't we go back to playing but he was he was wise to what was happening and he kind of grown fed up with the room.

And he made a beeline for the door.

I was the analyst for this analysis and I recall that my physical Management training from the New England Center kicked in as soon as I observed Jeffrey attempting to leave the clinic group.

Just so during Jeffrey's reinforcement interval when he was supposed to be enjoying reinforcing engagement with an adult.

We were essentially wrestling as he was fighting me to get out.

I like to talk about how our clients should be happy relaxed and engaged during reinforcement.

In those earlier isca graphs that I showed you a Brandon's data during that brief analysis whenever we turned Behavior off by giving Brandon his reinforcers.

He returned to that happy relaxed and engaged State almost immediately.

Jeffrey was unhappy not relaxed and disengaged and it was clearly related to the fact that we were quite literally not allowing him to escape the room as per our traditional Clinic procedures.

And other major reason that we kept those doors closed that I forgot to mention is because this clinic in fact, I think it occurred in this room that you see right here.

It was right smack in the middle of a university classroom building with classes right across the hall.

Jeffrey was yelling some not suitable for work stuff at me while he was attempting to run out.

And we were not in that clinic certified to perform any physical restraint procedures.

It was clear after one day of analysis that our traditional model of skill-based treatment involving Escape Extinction with physical guidance.

Wasn't going to cut it.

It was clear.

That Jeffrey did not trust me.

I feel confident in saying this because Jeffrey indicated as much during our analysis.

One of the last things he yelled on the floor after unsuccessfully attempting to wrestle his way out of the room.

Was Dad.

Why do you keep bringing me to these people who hate me?

I never want to come back to this effing place again.

We knew that Jeffrey had been seen by other helping professionals.

We thought we were different because we understood the behavioral approach to challenging Behavior.

We discovered that from Jeffrey's perspective.

We were not.

We were at a Crossroads and we could either discharge the family and not help them because we were not equipped to physically manage Jeffrey per our traditional procedures.

Or we could alter the way that we did things.

So our experience with Jeffrey and our unsuccessful attempts to conduct a safe analysis.

Helped us arrive that this question.

Is it possible?

to achieve the effects of skill-based treatment without any of the negative collateral effects more specifically can we achieve the positive documented effects of skill-based treatment?

without ever evoking dangerous Behavior And without ever touching clients.

We attempted to answer these questions through what we call the enhanced Choice model.

my goodness It only took an hour and 20 minutes to get to the enhanced Choice model that I've been promising to describe.

I hope you're caffeinated.

anyway Rather than close the door.

We opened three of them.

in the enhanced Choice model children such as Jeffrey were offered options to enter a practice context in which those skill-based treatment procedures were implemented but with some modifications that I'll describe in a minute.

They could enter a hangout context in which the evocative conditions of the treatment were never present and they had kind of free access to some positive reinforcers some preferred activities.

Or they could leave the therapeutic environment all together and return to their regularly scheduled activities.

at the start of each visit children were immediately offered these choices.

And these choices were concurrently and continuously available for the duration of the treatment process.

I'm going to talk about how we applied this model to treat dangerous Behavior across three independent contexts.

And Outpatient Clinic like like where Jeffrey experienced this a City public school.

and a home setting and I'm going to share with you the outcomes of our initial study as well as some follow-up studies on this enhanced Choice model.

Then because I'm describing how we made multiple simultaneous modifications to typical skill-based treatment procedures.

I'll share some thoughts about what I think we can and cannot yet conclude about the enhanced Choice model.

I'll share what I think is ready for prime time and what what could benefit from more research?

And I'll try to connect those thoughts to a discussion about the immediate implications of the model.

to your practice speaking of practice clients who experience the enhanced Choice model always have the option to engage with treatment and practice their skills.

and speaking of seamless Segways the practice context consisted of typical skill-based treatment procedures Those that were originally reported in Hanley at all.

Wherein as a review We progressively teach and reinforce communication coping and cooperation with adult instruction while not reinforcing problem behavior in any way.

Now we did make four notable modifications in this practice context.

to attempt to minimize escalation of problem Behavior first we used a slight variation of the extinction procedures described that I described earlier.

In that traditional model Escape Extinction involves what we call three-step prompting.

Tell him show him help him.

Tell him as you give the demand I need you to put your toys away.

Show him his put your toys away like this you do it it's it's kind of a progressively more intrusive prompt.

And then the third one is help him where I physically pick up someone's hand and say that's putting your toys away you do it.

That's the traditional model in the enhanced Choice model that physical guidance step was just never programmed.

instructions during the El we're still represented but only vocally positive reinforcers such as tangibles attention and compliance with certain requests.

Those things were still withheld.

And the expectation was just kind of left in place vocally every five or 10 seconds.

Second in the spirit of establishing trust and Rapport and maintaining a positive therapeutic relationship.

The child was told pretty explicitly what they would be working on for the day.

The child was made aware of the most challenging establishing operation that they would experience.

Should they choose to practice?

And the response or response is required of them in order to return to reinforcement.

Here's an example.

If we were starting a new treatment phase where we're now going to introduce that coping response.

We're now can introduce some disappointment.

We might start the day off by being like Jeffrey you killed it yesterday every single time.

I interrupted your way of playing you didn't run out of the room.

You didn't flip the table.

You just said, excuse me.

May I have more time please and I was happy to honor that and give you your time.

Today if you choose to come into the practice space.

Some of the time I'm not going to give you your way immediately.

I'm gonna say no buddy.

You cannot have your way we need to get to work.

But don't worry.

All you need to do is say something like no problem, or I'm cool with that.

And as long as you engage in that coping response, I will immediately reinforce it.

I will honor it by letting you get back to doing things your way.

We might have also said something like hey, you know yesterday you chose to hang out for most of the day or yesterday.

You kind of left early.

And some of that you know, you were having a tough time saying hey, I'm cool with that when I was telling you no and I acknowledge that that's really hard.

So if you're cool with it, we're gonna practice it again today know that it's just practice.

Know that you always have the option to go hang out at any point.

And know that you can talk to me or you can leave at any point as well.

I want to make it clear that that level of transparency outside of this session.

Telling them explicitly what they'll what they can predict to experience in the session.

Did not change the unpredictability of the sessions of the schedules of reinforcement in session.

This is something that I forgot to mention earlier.

As we introduce new skills into the skill-based treatment.

So for example, let's say that Jeffrey had learned to communicate had learned to tolerate cope with being told no and we start to introduce some cooperation targets some contextually appropriate behaviors.

We still reinforce all of those earlier skills on what we call an intermittent and unpredictable schedule.

What that means is that even if I've now been working with Jeffrey so that he's now practicing writing for three minutes at a time or he's you know, writing his name down something.

Every once in a while if I interrupt him and I say listen, but we're all done playing I needed to get ready for work.

He might say, excuse me did too.

May I have my way please and every once in a while, I would say heck.

Yeah, of course you can have your way.

So so there is an unpredictability to the session while you're in there and we do that for various reasons, but primarily we do it because it really helps.

Ensure cooperation it helps kids remain engaged with the process.

It helps kind of keep hope alive that not every time I'm being interrupted.

Am I going to be asked to write an essay?

But we still give them a ton of transparency on the front end so that they can know to expect the unexpected to predict the unpredictable.

third while contextually appropriate chains of behavior were being shaped during delays to reinforcement.

Choices were offered to the child some of the time.

In the traditional model where I describe Brandon's process.

Whenever we would interrupt them we take their stuff away and we'd start engaging in adult directed expectations.

The adult was always in control of every specific expectation.

but in the enhanced Choice model We'd give children choices every once in a while.

the studies that are cited here have time and again proven that offering choices is a pretty low cost way to increase cooperation and decrease challenging Behavior.

So even though Jeffrey's hardest homework was writing.

The stuff that he struggled with most was writing essays.

He was like fourth grade.

every once in a while we'd say Sorry, buddy.

We do need to get to work, but you're being super flexible.

If you want we can work on writing or math homework.

Or we'd say we can work on writing we have to work on writing.

But if you want this time, you can choose to write it or you can dictate it and I'll write it for you.

This isn't necessarily how real life works.

So as we move through treatment, we did fade how often we were doing that.

But we used it as a vehicle to facilitate cooperation.

and to increase child agency and autonomy in the process that fourth and final component that's a bit different from the traditional procedure.

Is that that choice to hang out or to leave?

Was always available.

in the clinic where we worked and when I was in at life skills Clinic we had another room that was called The Hangout space.

We were fortunate to be able to use two rooms promise.

I'll talk it later on about what to do when you don't have that space.

Children could elect to hang out instead of practice by requesting it.

Or by simply going there.

Keep in mind that one of Jeffrey's most concerning problematic responses was elopement running away from adults.

And we scored that in our sessions if he exited the threshold of the practice room.

So in this case if he were to just go to hang out by running away from me.

It would by definition be considered challenging Behavior.

But we allowed it anyway.

And you'll see in a minute that that never occurred.

in the hangout space instructions were never presented So in the practice space we might be in the middle of an instruction.

I need you to work on this writing paragraph right now if they then were to go into that hang on because we would immediately say, you know what never mind we don't need to do that right now.

They could also bring toys.

They can ask any available member of the team to come join them.

And they could converse with them.

so in other words all of the categorical reinforcers that were present in the practice context were available for free in some form in the hangout context.

And this context was always available to the participant.

We call that none contingent reinforcement.

Finally if participants indicated that they wanted to leave the clinic and go home.

This was honored at any point during the visit.

No questions asked.

thus although differential reinforcement in the practice context did include some type of Extinction program for all challenging Behavior.

The enhanced Choice model was designed such that participants who experienced it always had more than one way to escape bed evocative condition.

Our aim here was to minimize the need the necessity to use challenging behavior in order to get out of those evocative situations.

And by doing so physical intervention was never programmed and it was never needed.

And our initial study of this process.

We implemented it with three pair of participants of varying ages and diagnostic profiles.

I already introduced Jeffrey.

But Ali and Jackson also communicated vocally.

at a developmentally appropriate level Although they were four to Jeffrey's nine.

Although they were younger than Jeffrey and admittedly less dangerous from the perspective of imminent harm.

They both did have histories of directing their challenging Behavior towards siblings and other young children.

The severity of which appeared to be worsening with time according to parent reports.

They were both also described as having hair trigger reactions to not getting their way.

Maybe you've met children like this where it's very high energy.

You need things to be going perfectly in the second something to interrupted.

There's an eruption.

But the main point here for all three of these children.

Is that they were highly reactive?

And diverse to being physically managed.

Okay, here are the functional analysis data for Jeffrey Ali and Jackson.

There's a lot of text up here, but I'll summarize for all three children.

The interviews with parents suggested that challenging Behavior.

Is similar what is sensitive to a similar synthesized contingency that I described with Brian with Brandon?

Escape from something aversive.

Access to positive reinforcers like particular toys particular activities particular attention interaction particular types of attention and something that we call request compliance.

All of these kids who have relatively strong language skills made a lot of unique and idiosyncratic requests.

And the moment that one of those requests wasn't immediately honored they would engage in challenging Behavior.

But more often than not resulted in that thing being honored one way or the other.

The functional analysis data that you see on the left side of the screen confirmed that indeed these contingencies were relevant to their problem Behavior.

I want to mention that aside from Jeffrey's kind of isca sessions.

In which we blocked his exit and then he began you got more violent and he wrestled with me.

All of these analyzes involved challenging behavior, that was fairly benign.

As analysts were quick to reinforce non-dangerous topographies.

That were reported to co-occur with the more dangerous forms.

I put these I put all the text up here so you could see how individualized this process can be.

some folks in in my field in the field of behavior analysis who are critical of this process often talk about how We're just throwing the kitchen sink at challenging behavior.

And therefore it's not personalized and individualized.

But that is not the case.

In fact conducting interviews with caregivers and with people who are intimately familiar with challenging Behavior.

Enables us to make highly personalized assessment and treatment contexts for these children.

But worth noting that escape from something.

Was included for all three children.

I've been talking about Jeffrey.

So I'll use his data to illustrate how the process was embedded into the enhanced Choice model.

Here are his treatment data.

similar to Brandon's graph from earlier sessions are depicted along the x-axis.

This is the progression of events.

Problem Behavior challenging behavior from whining from protesting which were the non dangerous typographies and the white triangles.

Those are at the top and then the challenging dangerous typographies aggression shoving rest choking property destruction.

Those are depicted in black circles.

And then in the subsequent panels, we have the targeted social skills the skills that we ultimately taught to replace the challenging Behavior.

I'll just highlight for one quick second.

Please.

Do note that the challenging behaviors depicted across two categories.

We depicted the dangerous as well as the non-dangerous.

And you can see that Jeffrey engaged in absolutely.

No dangerous Behavior throughout this treatment process.

And that all challenging Behavior was a limited by the end.

Jeffrey learned the target communication and coping skills very quickly.

He was the man.

And from a scientific perspective, it's worth noting that these emerged and were only observed when they were included in the synthesized contingency.

The gray shading in these graphs represents where that contingency was applied.

That is we when we took that situation.

We said we're all done doing homework.

I need you to I'm sorry.

We're all done playing.

I need you to go at work on writing homework.

We would teach the skill of communicating say my way, please sure you can have these things back say, excuse me that through May I have my way, please that's a little more polite.

Sure, you can have these things back.

May I have my way please and then we'd say no you cannot and we taught Jeffrey to say I'm cool with that and we say sure you can have these things back.

and please note that those skills only emerged when we taught them and when we predicted that they would this gives us a little bit more confidence that that contingency is is indeed really important to Jeffrey.

That having those reinforcers is Meaningful to him and that avoiding those establishing operations.

Is Meaningful to him is important to him.

The panel on the second from the bottom depicts the percentage of opportunities in which he engaged in contextually appropriate behavior.

Or cab that was expected of him during those periods of non-reinforcement.

You can see that the percentage of calves of Jeffrey's cabin engagement remain high nearly a hundred percent.

Even though time that was spent in the establishing operation increased.

What that means is that as we increased periods of instruction in both amount and difficulty.

He still continued to cooperate quite a bit.

Those numbers that you see with the yellow arrows correspond with escalating adult expectations.

by the end of this process Jeffrey was not engaging in any challenging Behavior.

He was consistently communicating.

coping and Reading Writing and engaging and adult directed play.

all of the things that were highly evocative of challenging behavior in Baseline and based on Parental report.

And this terminal outcome.

Is similar to what we typically observe when we conduct kind of the traditional skill-based treatment procedures.

This graph looks a lot like Brandon's graph.

But this isn't the whole story of the enhanced Choice model.

The whole story can be seen better here by zooming into this bottom panel.

Panel depicts Choice data for every visit to the clinic for Jeffrey.

Visits are along the x-axis not sessions but visits.

Each time they came to the clinic and there's corresponding dates beneath them.

And the choices that Jeffrey made within a visit are displayed sequentially from bottom up.

along the y-axis So it's kind of a different sort of time-lapse.

This is a time lapse of each visit.

Categorizing where Jeffrey allocated his time between practice hang out and and leaving.

In case you can't see that the legend gray shading represents time that he chose to practice or kind of typical Clinic processes black shading suggests that he chose to go hang out in that space with free reinforcement.

And white shading indicates when he asked to be done for the day and to leave before the scheduled visit was up.

You'll see that Jeffrey seldom chose to hang out despite its continuous availability for free reinforcement.

He chose to practice for the duration of each visit on most days.

And I think it's important to note that he chose practice exclusively for the duration of his last eight consecutive visits to the clinic.

When he was experiencing the most challenging schedules, that's when we were pushing him the hardest.

Now there were four days in which Jeffrey chose to leave the clinic early.

Let's take a closer.

Look at what happened on those days.

in the context of this larger figure the visit bars on the bottom panel line up with the final session conducted that day.

I removed the communication and Toleration data so that I could enlarge it.

And so that you can see the link.

between Jeffrey's challenging Behavior his level of cooperation as we introduced longer and more challenging periods of instruction throughout cab chaining.

Our cab expectations our instructions and how they progressed.

And the choices that Jeffrey made in relation to those expectations.

Chaining caps progressively increasing the amount of cooperation that we expect from children.

Is all about first things first.

Especially when Jeffrey has the continuous availability to go hang out or leave.

We needed to start incredibly gently.

Asking very little of Jeffrey to take his hand off of his iPad to maybe look up from his Nintendo DS.

To put his iPad on the table.

Maybe well, we made sure that he was cooperative with and willing to engage in those expectations before asking him to transition from that format the fun mat to the work table.

You'll notice that we took a step back after progressing to level five level five and the data may give you a clue as to why.

So what's happening in level five?

Let me just read it real quick.

Forget.

It's oh, yeah, it's when we asked him to write a story about a preferred topic.

Level 4 was write a small paragraph level 5 was right a whole story.

You see despite trying to be proactive.

We took two largely there in asking him to go from that small paragraph.

to the large story I hope that you'll notice that Jeffrey did not resort to having any challenging Behavior or dangerous behavior in those situations.

And instead as evidenced by the white on the bottom panel.

He politely asked to leave.

This in fact during one of those.

Visits.

I remember this like it was yesterday Jeffrey complained of a stomach ache.

He was like I was like, alright, buddy.

We got to write about Halloween your favorite holiday, and he was like to two I really do want to write it, but I think I got food poisoning or something.

I don't know if I could do it today.

Is it cool if I go home for the day and maybe I don't know.

Maybe I can work on it.

Later.

To which we of course said, yeah, but yeah, you can do that.

And Jeffrey took two steps outside of the clinic room saw his dad and goes so Dad.

Are we still gonna stop at Wendy's on the way home?

Was he telling the truth?

I don't know.

Did we honor his requests to be all done?

You better believe we did.

Recall that.

This is the same child who cursed my name and swore that he would never come back to this Clinic.

and by this phase and treatment he was sheepishly and apologetically but appropriately with the drawing Ascent to participate in treatment.

With the promise of coming back to try again on another day.

We saw that by offering these choices to hang out and leave.

Jeffrey chose them in lieu of engaging and dangerous Behavior.

Not often, but when he wasn't ready to cooperate.

We adjusted our expectations to achieve the desirable performance out of Jeffrey.

And then we moved on to more challenging context again.

So in some in 20 visits across nine weeks Jeffrey experienced an efficacious skill-based treatment within an enhanced Choice model.

That involved almost no challenging Behavior.

I promised I will walk you through these graphs, but I'll just mention that Ali and Jackson's experience in the enhanced Choice model yielded very similar outcomes.

and two more demonstrations that we can use a personalized synthesized contingency identified in a practical functional assessment.

To teach a complex repertoire of social skills.

That effectively replace challenging Behavior across multiply multiple evocative contexts.

And that we can do this well offering the ongoing option to participate in that treatment or not.

Ali elected to hang out three times during the process And Jackson, he used that space a little bit more frequently.

But both were engaging in desirable Behavior by the end of treatment.

and importantly for me dangerous Behavior never occurred during Ally's treatment and occurred only on three isolated incidents in Jackson Street.

The enhanced Choice model led to a near 100% reduction in challenging Behavior produced a hundred percent cooperation with adult instructions that were shown to to cause problem behavior in the Baseline.

And that were reported as relevant to caregiver goals.

And choice model was proven efficacious.

And the results of the outpatient study were promising.

So we wanted to evaluate the model in a school setting with a focus on extending procedures back into the classroom once successful.

In this next part of the study I was so fortunate to work with some exceptional people from Vanderbilt down in Nashville.

This was while I was in graduate school.

I had linked up with them and we started a research collaboration and fast forward to this year.

Now I work there so that was kind of that's kind of a fun little side effect but nevertheless these folks down at Vanderbilt were contracted by a City public school to help address the behavior of the school's more challenging students.

We're starting to get the flow of this now so I can maybe go through a little bit more quickly.

But in that in that public school, we worked with two clients Peter and Hank.

Peter wasn't eight year old student with an Autism diagnosis and Hank was diagnosed with ADHD as well as he was categorized as emotional disturbance which in the states is a special education classification for folks who engage in serious challenging Behavior.

That's not otherwise explainable by a cognitive deficit or an intellectual developmental disability.

Peter had to return to this specialized school from a general ed school because of head directed self-injurious Behavior.

and Hank had basically not done any work that year.

And also had a history of stabbing teachers with classroom items like pencils and scissors.

It's worth mentioning that Peter was a was a white young man and Hank was a black young man.

You'll notice that Hank did not have an Autism diagnosis.

We're not diagnoseditions, but my colleagues were pretty sure that he would have received an Autism diagnosis.

This is another kind of major systemic issue in the United States education system and diagnostic system where white children are more likely to receive an Autism diagnosis and be filtered to Aba services and high quality services.

Whereas minority children black and brown children are often relegated to the under-resourced school setting and are not given that autism diagnosis that ensures that yeah that guarantees that they receive a particular type of care.

Also worth mentioning is that because my colleagues from Vanderbilt were considered non-district Personnel in this public school.

They were legally prohibited from physically managing these students.

That said prior to their participation in this process.

Both Peter and Hank spent significant portions of their days outside of the classroom in and out of seclusion and restraint procedures due to very dangerous challenging Behavior occurring in the school setting.

Once again, the functional analyzes revealed behavioral sensitivity to the same synthesized contingency escape from something to tangibles attention and request compliance.

Maybe it's as unique to being in the school setting.

But much like, you know, my current undergraduate students homework is the worst and playing games with a friend is the best.

And these skills that you see in the red box are those that we focused on strengthening during the cooperation phase for these young men?

Procedures in the school were very similar to those in the clinic.

the differences only in the environmental setup of the school versus the clinic This was a we call it a pullout model.

So visits began when the analyst that the Vanderbilt analyst popped into the students classroom and asked if they wanted to participate in treatment.

Unlike the clinic which had separate rooms for practice and hang out.

The Vanderbilt folks could only use one larger room.

So they implemented the extremely high tech solution.

of a piece of tape to divide the classroom into practice and hangout space.

If Peter or Hank chose to leave rather than go home, they would just return back to the classroom and just follow whatever the activities were going on in the classroom.

But otherwise procedures were identical to that which by which I have described earlier today.

I just want to cut to the chase.

I'm so proud of these two young men.

the treatment worked in the pullout context for Peter and Hank both were engaging in desirable social skills at the exclusion of challenging Behavior by the end of treatment.

Please take a look at the black.

Data path on the top line to see that Hank literally never occurred engaged in dangerous behavior during this process and Peter engaged in a very very sparingly.

Hank also, never chose to hang out.

It was all he was just engaged with practice.

I've been thinking about this a lot lately because we've been working with more black children in schools in public schools, and they're often really treated.

Poorly or less than or second class citizens and here was a situation where Hank received undivided attention from an adult.

Even though that attention was sometimes challenging.

Hey, I needed to get to work Hank was willing to engage with this process despite having a complete free access to hang out.

Peter did choose to hang out a few times.

But it was really brief moments when he when he was having a moment of being upset and it was for four minutes total.

So moving on following the successful treatment and this pull out practice context.

We had an opportunity to extend the procedures back into their classroom to reintegrate them meaningfully into their classroom.

You see these pull out sessions that you see here all the data.

That's up on the screen right now.

Was conducted by graduate interns in the Vanderbilt special education program.

Who had no prior experience with this process, but who were being supervised by bcbas down at Vanderbilt?

Who also had no prior experience with this process?

But together following these successful treatment processes.

They set out to train the lead classroom teacher and some para professionals.

Who also had no prior experience with this process, but who observed some of these sessions?

Oh one more commitment that I think ensures safety that I didn't mention a while ago.

Is that we don't attempt to shape Cooperative behaviors in other contexts until we've achieved success in the initial context.

What I mean by that is that Peter and Hank learned a variety of academic skills in that one situation that pull out room with one analyst across five trials sessions.

And they were darn good at those skills by the end of the treatment as you saw in the graphs.

But we did not move on to extending those effects until we saw success in the initial context.

However, the team wished to extend treatment so that it was implemented by a classroom teacher and by paraprofessionals in the relevant classroom and across entire class periods.

Instead of just kind of like 15 or 20 minute bursts.

We like to take each of these steps one at a time ensuring success with the prior step before moving on to the next one.

here's what that kind of treatment extension process looks like We start by training a relevant person by bringing the teachers into the pull-out space and coaching them through the procedures.

We this is an updated kind of rubric that I didn't make one of my colleagues at Vanderbilt recently shared it with me and allowed me to use it today.

But we use a sort of training rubric similar to this.

To outline procedural dues and don'ts essentially describing what I've been describing to you today.

We try to create accessible handout to give to these teachers and educators.

And we individualize these forms to each child.

And we engage in a process that we call behavioral skills training.

That process always starts with instruction.

imagine that we're talking about Hank's teacher on the last day of treatment sessions with The Graduate intern Hank's teacher was given this rubric.

Then on the next day she came to the practice room without Hank.

And the analysts who worked with Hank reviewed the rubric with her instruction.

I took about 30 to 40 minutes the analysts provided rationale and solicited questions from Hank's teacher.

The analyst then role played the part of Hank.

I'm gonna be the child and I want you to practice putting some of these trials in place interrupting me.

taking my stuff away ask directing me to go to work and I want you to only reinforce the desirable behavior, and I want you to keep the expectations in place if I engage in challenging Behavior or non-cooperation.

That kind of role-play continued until the teacher put five trials in place.

And Report reinforce different chains of appropriate behavior on that sort of intermittent unpredictable schedule.

Without emitting any Integrity errors or Fidelity errors?

Or we brought Hank back in the analyst did roleplay a session where they engaged in a little bit of challenging Behavior.

I forgot to mention the first time through there like I'm gonna do this as though I'm engaging in perfect desirable Behavior.

That's where Hank is at right now.

But when we introduce a new person he might start to some of those challenging behaviors might relapse you might say Anyway that this then was done again until there are no errors and importantly until the teacher said hey, I think I feel comfortable trying this out with Hank.

Or you can I'll avoid going down a rabbit hole.

Treatment Integrity is important, but I put just as much weight.

In in adults reporting that they feel confident and competent with procedures.

The classroom teachers were ready to implement the treatment in the pull-out context with their students.

And here you see the data from that process.

At the end of each treatment graph, you can see the final two data points from the sessions where Hank and Peter's classroom teachers implemented the sessions in the pullout context.

It's right under that phase label RP meaning relevant person.

The important thing here is for you to see that performance on all measures communication Toleration cooperation.

And of course challenging Behavior.

was the exact same as what was observed with that graduate intern with the expert you might say once we saw that success in the pullout context with the classroom teacher and the paraprofessional And once the teacher reported that they felt ready to try this in their own classroom.

We moved the treatment from the pullout space to the classroom.

And we asked the teacher to still do those five trials sessions.

And here you see the final two data points from that phase.

identical client performance once that was observed we then said let's stretch it across an RTP or a relevant time period Teachers would say yeah, I have like these 45 minute math blocks and I'd love to try to do this thing where it's not so much about me waiting one minute, but it's more like when it naturally occurs, I just interrupt Hank say hey buddy.

I need to put those toys away.

We're all we're doing instruction now.

Sometimes I reinforce his request to have his way.

Sometimes I tell him no and I reinforced his coping response.

And then other times I just invite him to come sit with the rest of the class and do math or do read it.

We achieved these outcomes.

We successfully reintegrated Peter and Hank into their classroom.

Across 30 to 45 minute chunks of time.

A particular note.

I like to show kind of Peter's data.

If you look to the bottom right of your screen, you'll see that Peter's proportion of time in the gray shading or in instruction.

Was much greater than it's time spent doing things his way and reinforcement.

Yet no challenging Behavior was observed.

Last thing I'll mention about this is that during this entire process including the treatment extension?

Peter and Hank have the option to go hang out in the classroom.

They kind of just created a safe space in the corner and they said at any point you want to back out of what we're doing.

You can go sit there and that in that corner and you can take your some of your toys with you.

But they never by the end of the treatment extension both Hank and Peter were engaged with classroom activities for the duration of those.

sessions We asked their classroom teachers some questions regarding the social validity of the procedures and outcomes.

Both following the pull-out model as well as the extension back into the classroom.

And their teachers both found the effects of the treatment on problem behavior and cooperation.

to be very satisfying highly satisfying you might say and importantly they rated their own confidence and implementing these procedures very highly following behavioral skills training.

Now I'm eager to share how we extended this process and outcomes to a Telehealth model in the home, but I know that we all need a break.

Thanks for sticking with me so far.

I have nine.

Oh six.

Is it cool if we take another five minute break and we come back at 9/11.

Sounds perfect.

Thank you.

Thank you so much everyone.

I'm having a good time.

I hope you are too.

Oh.

Hi did to it Shelly just before you start up again.

There were a few questions in that last section that I wondered if this would be a good time to check in with you.

I love that.

I think I creeped a little bit on the chat and I saw one of the questions but I'll let you moderate sure.

So one of the questions and this was a bit of a theme but for younger children or Learners who have less Advanced verbal skills, or for whom comprehension is a challenge are there modifications to the process in particular the transparency of the day's activities.

Yeah, and it's the this next study that I'm going to share was with a learner with weaker with a weaker language repertoire.

So I'm it's almost as though I planted that person in the audience.

Thank you.

Julie and Shelly for discussing it.

But I'll share a little bit about some of the modifications that we made for a learner with with a much less developed language repertoire.

Awesome.

Another question was have you ever had a student who's always choosing to hang out or leave?

And if so, what do you do?

Uh, so I'm proud to report that well, I yeah, let's just chat about it right now when my team was first discussing these procedures.

Dr.

Greg Hanley somehow somewhere just felt in good faith that children will choose to participate.

and I was probably the chief skeptic where I was like, there's no way children are gonna choose to hang out a hundred percent of the time.

Why would they ever come into a room where we're taking their stuff away and asking them to do things if they can have it for free?

Is that have faith trust the process and in that first study those five cases that I just described all of those clients chose to practice 96% of the time.

Despite having the ongoing option of free reinforcement.

in replications that I've done not necessarily for research, but clinically we see that students pick.

Choose to practice about at least 90% of the time especially when we're careful about introducing new expectations where we don't push children too much.

so what I'll do at the end of today's talk is kind of summarize what I think are the strategies that are contributing to the choice to participate in practice.

that said there are there is Gonna Come a client who's gonna choose Hangout.

a couple of main observations that I'll make now before before proceeding is that Part of the spirit of offering that other space.

Is because children like Jeffrey like Ali Jackson and Hank.

Who have interacted with Behavioral Services before often don't?

trust adults I feel as though we've gamed them too much we said hey, you can have this reinforcer.

If you come take your meds and then we make make sure they eat the meds and we say sorry you didn't get the reinforcer you these are some of my experiences working in a residential setting and I'm not blaming anybody but myself.

But I do believe that.

There's a trust there's a trust Rift.

So I say that to underscore the importance of the following recommendation.

The recommendation of children are choosing to hang out reliably instead of practice.

Is that your first step?

Should not be to make hangout worse.

Your first step should not be well, it's been a week and they're choosing to hang out.

Let's take the iPad out of hangout and then we'll only restrict it for when they're choosing to practice.

I think that that's a bad strategy because I think that it erodes rather than facilitates Trust.

and Whenever I try to typically see that kids shut down even further.

They go.

You know, what if that's how you're gonna play this then I'm never gonna participate in your Content in your practice context.

Of course, I'm talking about the type of Learners that I've described already those sophisticated folks where there's like Words opposition is a big part of the combativeness.

So the strategies that I do recommend.

first and foremost are to take a look at the practice context maybe get some video footage try to share it with team members and try to get a sense of what might be.

So evocative or or Difficult about that situation right now.

And the solution is not to remove it for forever, but it's to break it down.

So the example that I shared with Jeffrey was meant to illustrate that when he chose to hang out.

We didn't say or when he chose to leave a few days in a row.

We didn't say.

Okay.

Well now you can't leave or now.

You can't take your iPad into the hangout space instead.

We looked at what was happening in the practice context.

We realized that we were asking too much of him.

We task analyze that as we broke down the steps of the behaviors that we were expecting of him.

And then we we lowered the expectation.

To me.

It's a that General strategy is really helpful of approaching things in very small incremental steps.

I want you to think about when you interrupt a child's play and you ask them to go to the table to get ready for work.

Think about the sheer number of actual behavioral responses that occur between putting your toys down and getting ready for work.

There's hundreds.

If not thousands of independent component teeny tiny responses.

And so when we when we start our expectation with go sit at the table and we notice challenging Behavior.

That's an opportunity for us to break that down.

Is there a smaller behavior that I can ask and importantly that I can reinforce to teach children that even their slightest amount of cooperation?

Is is Meaningful is important to me and I want to honor it and reward it.

With some reinforcement, so that's a general strategy and then the second strategy that I'll share is to be transparent with children.

Of course this applies for children with stronger language skills, but when we mess up, it's I like to cop to messing up.

I like to tell people I'm sorry that we've been pushing you too far.

I understand that the practice context is really challenging right now and I want to do what I can to fix it.

So maybe we can engage in a conversation.

What are the things that you don't like?

A great example of that actually happened with Jeffrey.

He chose to leave two consecutive days in a row.

I was worried that he wasn't going to come back.

So when he came the next day I said, we don't need to go to the practice room just yet.

I first wanted to share that.

I'm sorry if we pushed you too far.

Do you think you could talk a little bit about what has been bothering you about the treatment room?

And he said something really beautiful.

He said, you know, I understand that.

I'm here to work on writing because I hate writing.

But I just wish we didn't have to always work on writing in the room.

And of course, that's what I was practicing with him because that's why he was in the clinic.

That was his most evocative EO.

So Jeffrey really taught us that we should not only vary the types of instructions that we should be teaching.

But that we should sometimes offer choices.

And when we gave Jeffrey that choice of every once in a while like you can either do writing or math.

He was more on board to not only come into the practice room.

But to do writing the few times that we asked him to do it.

So those are the general strategies that I'd recommend when folks when kids are routinely choosing to hang out.

Some thanks so much.

There but maybe we'll save those to the end and let you go through the next piece of the process.

That sounds so great.

Thanks so much.

Thank you for these wonderful questions.

Please do keep them coming.

I think I have about 20.

Five-ish minutes of content left and then hopefully they'll be room for questions.

I'll talk now about this final study and I'll share how we adapt and extended this model to Telehealth during the pandemic.

Some of what I say here may be a repetition from earlier today.

But my hope is that you if you feel like it's getting repetitive that you can start to see through that and see why I think it's important that we ensure safety and Trust during these processes.

safe and trusting environment These are my parents.

Everything I am today is because of them.

From my extreme privilege of being able to pursue a PhD during my 20s instead of getting a for real job.

to my severe obstructive sleep apnea acid reflux and persistent hypertension I owe everything to my parents.

But my South Indian Tamil speaking parents is that they've always provided unconditional love and support to me.

They've always had my back.

See what I did there have my back.

And specially they've had my back with respect to my professional trajectory.

On the right you can see them even humoring Me by reading articles from the Journal of Applied behavior analysis on a long flight.

Although even they will admit they didn't understand a word both of my parents immigrated to the US from a city called chenang located in the state of Tamil Nadu in India.

And in fact, we visited Chennai around the time that I was graduating college.

And because I'd expressed intentions of teaching autistic individuals post College.

My mom took immediate action made some calls to her cousins friends cousins friend.

And arranged for us to visit a school for autistic children and teenagers in Chennai.

Thinking she might be able to hook me up with a job out of college.

It definitely wasn't the right choice for me to move to India at the time, but that visit was incredibly formative for me.

When my mom saw students who were my age who looked like me.

Some of whom displayed so much frustration and struggled to communicate even their most basic wants and needs.

She compelled me to do my part to help my Indian brothers and sisters in the same way that I've been privileged to help American children over the past decade.

now fast forward to the pandemic in 2021 when I was working as a new assistant professor at the University of Maryland, Baltimore County.

And I was terrified and nervous about becoming an independent researcher and Unsure how to go about conducting research with children during a lockdown.

A few months into that lockdown another wonderful South Indian mother who also spoke Tamil just like my parents.

sujata contacted me out of the blue from Chennai.

Because her teenage son was having a really difficult time during the lockdown.

While they were cooped up in their high-rise flat he was engaging in behavior that was getting more dangerous and more pervasive with each passing day.

And Mom or sujata was unsure how she could help him and keep things safe at home.

Sojata's son Sachin was 13 years old autistic, and he communicated using mostly gestures or one to two word phrases and he only used phrases of words that he was very comfortable with.

I'll refer to sujata as Mom.

And I will refer to Sachin as the young man or her son to help with the translation of this talk.

Mom pursued and obtained a bcaba after receiving her son's diagnosis.

She's ride or die I tell you.

And she reached out to me because she was Loosely familiar with these PFA and SBT procedures.

And she must have known that I was twiddling my thumbs in my bedroom while quarantining.

She wanted support and implementing an assessment and treatment process with her son because her son was growing increasingly agitated at home and he was actually capable of seriously harming himself and others.

And Mom did not have any support locally.

When we first met she noted that her son would likely not be able to return to his school.

Once the lockdown was over if the dangerous behaviors persisted.

Especially because many of these expectations, I'm sorry many of these episodes of behavior surrounded expectations that were common at school.

But she further felt.

That she was losing her relationship with her son and was worried that she couldn't support him any further without any help.

So mom's call presented us with an opportunity to help her and her son while conducting research that might help others.

Could tell a health consultation help this teenage boy and his mom have a more positive relationship free from dangerous Behavior exhibited at home and in an underserved area.

The short answer to that question according to previous research is yes.

although quite recent several empirical studies and literature reviews have taught us that we can greatly reduce challenging behavior in homes across the globe.

Using functional analysis and functional communication training procedures and adding adaptations to cultural adaptations.

In a manner that's acceptable to caregivers.

The studies cited here represents some terrific and exciting work to help bring efficacious procedures to underserved areas around the globe.

But sorry to be a heel again.

Although we have ultimately successful demonstrations of efficacy via Telehealth in the literature.

We have less evidence of those processes.

Being delivered in a manner that is truly safe for the client and caregiver throughout.

In other words much like most of the published literature reporting the process of fct.

And much like what I kind of talked about earlier with Brandon's problem Behavior data.

the bumpy one these these studies often show an ultimate reduction in challenging Behavior.

But almost always shows some level of that challenging behavior during treatment.

Don't take my word for it, please go check out the data reported in these studies.

In fact some researchers.

Have even argued that observing dangerous behavior during a session is important maybe even necessary in order to treat it.

I'll say that again more emphatically.

The field of behavior analysis has a rich history of assuming that in order to treat dangerous Behavior.

We must repeatedly observe it and evoke it.

No pain, no gain.

I know I discussed this earlier.

So I apologize for being redundant.

But I believe that this point is important and bears repeating.

A lot of our best ABA practices have historically required that we evoke challenging Behavior.

Or at least repeatedly present challenging evocative situations.

In order to address it.

A lot of these procedures like fct and stuff that I described were initially implemented and researched in settings that endeavored to follow through with expectations.

No matter what and respond with physical management tactics if Behavior got too dangerous.

And across the vast majority of our literature clients have not typically had the option to opt out of their treatment.

I want you to think about that in a Telehealth context.

Where the resources to help our 10,000 miles away.

I'll admit that this Prospect was slightly terrifying to me.

Because I know that exposure to those challenging situations is critical to overcoming them.

Kids do need to practice skills and authentically challenging situations.

But if I were to provide remote consultation to this mother from my bedroom in Baltimore And I was asking her to implement procedures that may evoke her son's dangerous behavior in order to teach him that that behavior will not be reinforced.

and in the name of Aba The mom said no.

Thank you, and I was with her.

I hope that you'll agree that safe Telehealth consultation is a matter relevant to incorporating Ascent choice and compassion into Behavioral Services for autistic children.

Because Telehealth will probably be here for the Long Haul.

Some of you probably engage your practice via Telehealth.

It has the promise to help us expand services to far-reaching areas.

But the large majority of folks served by Behavior analysts and special educators are also at greater risk for having experienced trauma in their life.

Something I'll talk about in a few minutes and refining procedures to maximize safety and minimize potential retraumatization seems Timely.

I won't go through this again.

But here's a slide that kind of summarizes the procedures that I've talked about today.

And the procedures that we reported in the study about the enhanced Choice model.

But I will point out.

That these procedures are intimately linked.

To these four icons you see on the right.

establishing trust and safety emphasizing skill building promoting choice and shared governance or shared treatment planning and acknowledging the potential of trauma and its potential impact.

These represent the core commitments of what has come to be known as trauma-informed care.

trauma-informed approaches to Aba are geared toward minimizing re-traumatization.

And facilitating meaningful participation in one's care or therapy.

And this can be achieved by first acknowledging the possibility.

That one has experienced trauma.

Designing a therapeutic experience that ensures safety and Trust.

Giving them control over the process as much to the extent possible.

And emphasizing skills that Empower clients to be able to better navigate their own challenges.

The procedures that I are described here that I've summarized today.

When they were applied across clinic and school settings as you saw earlier today.

We were able to successfully teach social skills and eliminate dangerous Behavior.

But I want to share these graphs in particular on the same slide which depicted their dangerous and non dangerous Behavior.

To highlight again that we did this without evoking any dangerous challenging Behavior throughout the process.

as a point of comparison Here's what problem Behavior data typically looks like during skill-based treatments such as the one that I described with Brandon at the start of today's talk.

When the enhanced Choice model is not in place.

Notice the bursts of challenging behavior on everyone's journey toward an ultimately successful outcome.

I'll show you that comparison again.

This is how much dangerous behavior is expected to occur when enhanced Choice procedures are implemented?

versus when they are not the enhanced Choice model helps ensure safety during assessment and treatment and I think it's in large part because giving individuals the choice to participate in the therapy empowers them to have a little more control over when and how they experience their biggest challenges.

Now we have reason to believe that the enhanced Choice procedures can promote safety with children with strong language skills, but such and the young man I was tasked with helping did not have a strong of language skills and was actually a few years older than the children reported in the initial study.

So he was a teenager.

Furthermore he wasn't in school.

So he didn't have a trained professional serving him to provide this kind of assessment and treatment.

therefore our ultimate question was whether or not procedures similar to the enhanced Choice model could be extended to serve an autistic adolescent teenager such an with less developed language skills via Telehealth consultation.

With a parent as a primary implementer.

Just a quick overview of our setup.

We scheduled three one hour meetings per week.

And I'd provide live coaching to to sachin's Mom during the treatment assessment and treatment sessions.

We met separately about twice a month to discuss progress problem solve so I can answer any questions and so that we could just kind of gossip about the latest Bollywood drama.

We conducted these sessions in their flat relying on the living room space as well as their balcony.

Here's a kind of what that layout looked like.

The living room served as the treatment context with space for reinforcement as well as adult-led expectations.

And the balcony served as his hangout context because we didn't have a separate room.

So as as I've mentioned several times already, he always had the opportunity to give and withdraw ongoing Ascent throughout the treatment process.

His functional analysis and functional assessment process yielded another similar story.

It's it's almost like children like to do the things that they like to do and they don't like to do the things that they don't like to do.

But Mom was able to take all of his preferred items and activities phone some lentils for him to play with some blocks and a mini trampoline and she brought them into that reinforcement space.

And the establishing operation was that you would periodically ask him to put that stuff away and either come do homework or put that stuff away and come engage in physical activity specifically yoga and stretches that he found highly aversive.

The data shown here very quickly show that he engaged in mostly non-dangerous Behavior relative to dangerous Behavior.

But furthermore if you see the white data points representing free access to reinforcement.

You'll see that he did not engage in any challenging behavior when he had his reinforcers and he engaged in a predictable amount of challenging behavior when those reinforcers were removed when those expectations were put in place.

If you blinked you might have missed it, but the young man sahil engaged in one quick.

Slap to the Head.

Mom said let's do some physical activity.

He started jumping up and whining he had one quick slap to the head and that was the most dangerous behavior that we saw during the analysis.

It occurred when Mom asked him to engage in physical activity.

And she made it clear to me that if she were to persist with those adult directed expectations, he would engage in more dangerous forms of problem behavior and would ultimately attempt to beat her up.

She also confirmed with me that episodes usually started with some of that jumping and whining before escalating to those extended meltdowns.

So rather than wait to see all the dangerous Behavior.

We reinforced those early indicator behaviors or precursor behaviors.

Taking note from over a dozen studies.

That have confirmed that you can analyze dangerous behavior in a scientific sense by reinforcing its Associated less dangerous responses.

This is a hill that I'm willing to die on.

It's what I believe is one of the most important single most important finding from the functional analysis literature in the past 20 years is that in order for us to understand behavior and scientific sense.

We need not see the most dangerous form.

We can make an inference based on seeing earlier forms, thereby.

Promoting what I think is compassion in the assessment process.

It's compassionate because it teaches such an that.

He need not escalate in order for us to understand his behavior.

It's compassionate compassionate to Mom because it says we trust your expertise.

We know that you know your child best.

And we don't need to see it because we we don't believe you we've seen enough and we're willing to work with you.

Here's what it looked like when my man chose to take a beat and hang out on the balcony which happened about eight times during treatment for an average of about two minutes time away from participating in therapy.

If he wanted mom to come sit with him.

She would.

I got to tell you such and was a king and sometimes he'd like to spread out like the royalty he is.

And I think it's also important that I reiterate.

That in typical applications of the enhanced Choice model that children usually have those stronger language skills, and we get a sense that they understand the difference between the contingencies and the hangout Space versus the practice space.

As you can see such and didn't have a strong language skills.

Because expressive and language repertoire was not reliable enough for us to be sure that he understood.

But Mom continued to remind him of the option regularly.

And she was also great and using her body language to back off to indicate that the balcony was his safe space.

So as soon as he crossed that threshold she would just say, okay.

Yeah, you can just you can have take a beat there if you want kind of thing.

Here are his treatment data depicting his behavior during the practice sessions in the living room.

You've seen this graph a few times before I'll try to be brief.

The sessions are along the x-axis.

The target responses are depicted along the Y axes.

each data point represents one session which consists of five learning trials Is challenging Behavior at the top?

We got that Baseline in our isca that when Mom would would traditionally typically ask him to stop doing what he's doing and do homework or do physical activity.

He would engage in some form of challenging Behavior.

But when mom taught him to simple communication response of tapping his chest, he learned it pretty quickly and it rendered that dangerous behavior and non-dangerous problem Behavior completely unnecessary.

She then taught him to vocally ask for my way.

Followed by the slightly more polite my way, please.

After he was communicating beautifully she began to deny his requests teaching him to say something like okay to help him cope with the disappointment.

Once he acquired those communication and coping targets.

She started to carefully introduce her expectations during periods of non-reinforcement.

Starting with simple instructions.

I'm showing the same thing.

I showed with Jeffrey but just graphed a little bit differently.

She started with simple instructions to put his toys down walk over to the workspace gather some materials.

Then she progressed to actual academic work such as math and reading homework.

Which we systematically increased in amount and difficulty from one or two math problems to like 45 discrete math problems or reading problems.

And then finally interspersing some of that exercise and yoga which you may remember was quickly evocative of challenging Behavior.

You will also see that these expectations were met with nearly 100% cooperation throughout the treatment.

In a final video, I'll show you a clip toward the end of the treatment when such and well was followed his mom's lead to do a studio namaskaram or what white people call a sun salutation, which is the type of yoga or what white people call yoga.

One last thing.

I wish to point out with that video.

Is that as soon as she said we're all done.

You may notice that such an immediately grabbed the mat and then took it back.

Suggesting that it still wasn't his preferred activity.

It's not like all of a sudden yoga became supremely reinforcing.

He was still pretty motivated to put it away and get back to his.

stuff that he liked but I think it shows that this process helps us teach kids to cooperate and be willing to engage with adults in a manner that's still respects their individuality and their independence.

I'm really proud and happy for this beautiful young man and his mother for choosing to participate in this process for all the important gains they made and I'm also personally excited that we were able to achieve these gains without seeing a single instance of challenging Behavior throughout the process that was implemented via Telehealth consultation.

I'll quickly share that Mom expressed appreciation for how safe she felt during all of our Telehealth sessions.

She found the process to be helpful in terms of meeting the goals.

She had for such an an importantly added that she did not feel that the process contributed to any trauma or even negative emotional behavior for either her or such an finally Although as a parent it may sometimes be tough to let your child go hang out on the balcony instead of listening to you.

She reported that she felt very comfortable allowing him to do.

So at any point and also felt that having the option was very important to such an success.

I've just got a few more slides now and I actually might skip through some of them so that we have time for questions.

But taking together these studies suggest that it's possible to meaningfully address dangerous Behavior while keeping children and caregivers safe.

while showing concern for their emotions and preferences and without relying on physical management tactics.

now, I think I got a sense from some of you in the chat that That that this may or may not apply to your practice that there may be situations that are very very different from what I've described.

And I think it's important that I emphasize that when I say that these outcomes are possible.

I mean that there is a world in which our most dangerous clients can be free from the trappings of challenge severe challenging Behavior.

In a manner that does not evoke more behavior during that process.

My assertion is not meant to discount or look down upon.

What is probably the reality in many settings providing Behavioral Services for children with dangerous Behavior?

It's very challenging to address challenging Behavior.

And I just described a highly systematic relatively resource intensive process in which we had a lot of control over the environment and therefore Behavior.

I'm sensitive to how this differs from the everyday treatment of dangerous behavior in practice.

If I'm making a point here that seems a little provocative to you.

Please know that it is only to say that while there may still be a place while emergency procedures are likely to continue to need to be there for when safety is just imminent matter.

I believe that if we Embrace some of the elements of these enhanced Choice model procedures in your practice today or tomorrow.

That we can greatly eliminate the extent to which we incorporate these tactics into our behavioral plans.

And we can also greatly reduce the frequency with which these emergencies occur.

Thereby greatly reducing the necessity for restraint.

Some of the tactics that I believe promoted safety in the process are here on this screen.

We didn't rely on physical guidance to drive Behavior change.

We established Rapport by clearly outlining expectations and providing regular feedback.

And we embedded Choice making opportunities.

Into the treatment whenever we could including an importantly the choice to opt out.

It's my belief that these three tactics.

Are possible in everyday practice?

outside of a focused and intensive behavioral intervention If you're a practitioner responsible for Designing behavior intervention plans.

You can choose to program Choice making opportunities.

You can choose to routinely make expectations clear.

And you can choose to commit to a hands-off model.

These tactics seem not only likely to minimize that escalation but to promote the acquisition of adaptive and Cooperative Behavior as well.

Now, I understand that that last one just choosing to avoid physical management.

Is easier said than done?

Especially in the moment when behavior is escalating in severity and risk.

So I'd like to offer an additional tactic for you to consider in your everyday practice that may help minimize escalation.

Are you ready?

Just reinforce the heck out of problem Behavior.

And do so with all possible reinforcers for that behavior.

It's counterintuitive but very important.

The condition in which all suspected reinforcers for challenging behavior is present.

Is a condition in which that challenging Behavior doesn't stand a chance?

Here are two of the iscus from today's presentation.

Please notice that not a single instance of challenging Behavior was observed during any control condition for any isca that I talked about today.

Please also notice that in Brandon's within session data.

That probably that challenging Behavior never occurred even during the test conditions during any interval in which he had reinforcement.

Reinforcing challenging Behavior promotes safety in the moment because when children have their needs met they no longer need to engage in further dangerous Behavior.

I ask that you notice one more thing about this point.

Please notice the generality of this phenomenon.

These are two large data sets taken from two studies published by my colleague, Dr. Josh Jessel.

When synthesized reinforcement contingencies our personalized from interviews with caregivers and important people in a child's life.

And those reinforces are given freely to individuals who exhibit problem Behavior.

The almost unanimous outcome is that problem Behavior does not occur.

Reinforcing it with all possible reinforcers turns it off immediately.

Of course.

This isn't the long-term solution.

Because this by definition by the definition of reinforcement, this is likely to increase the future probability of problem Behavior.

but in the moment this tactic may help you live to teach another trial without needing to restrain someone.

It may help your clients understand that they can trust and approach you.

And when coupled with a more intensive focused intervention, like the one I described I think it can lead to socially meaningful resolution and elimination.

of that challenging Behavior I have some slides to kind of re-emphasize those points about trauma-informed care.

But for the sake of having time for questions, I'll skip it and I'll just say that the model that I described today.

I believe that it is entirely consistent with the commitments of trauma-informed care.

That is that there's literature out there providing guidance on how to support Learners who may have experienced trauma or who may be at risk for trauma.

And these are the commitments that that literature tends to espouse that we need to ensure safety.

We need to promote choices and give Learners give individuals control that we need to be trustworthy with them and that we can do Empower them by teaching them skills.

And I'll sort of conclude by saying that behavior analysis should be trauma-informed and that if you heard anything from this presentation today, I think that it that behavior analysis can be trauma-informed.

And that it is possible to meaningfully address dangerous Behavior.

while keeping children and caregivers safe while showing concern for their emotions and sensitivities and while not relying on any physical management tactics Let's stop there.

Thank you so much for your time.

I cannot believe you're still here.

I'm amazed.

This is like a freaking Lord of the Rings movie.

We're sitting for so thank you so much and we have a few minutes left for questions.

Thank you so much.

And there are so many great questions.

I'm not sure we'll get to them all but we'll see what we can do.

So one of the questions was if the the exit option is not an exit to ever get regular space that would be safe.

So if the exit option that the student is looking for is to wander the halls or the playground and it may not necessarily be a safe option.

How do you address that?

I see what you're you're saying kind of during during the practice context.

Yeah.

So exactly that's a great question.

I honestly I think it's helpful for to not think of that necessarily as the exit option and to think of that maybe instead as part of the reinforcement context.

So we typically implement this process with Learners that are sort of in crisis and who are taking up a lot of resources in the first place.

And when we try to understand what are all the reinforcers for their for their challenging Behavior?

Oftentimes it is just the freedom to sort of move about places.

And I worked with so many clients where we're like, oh, they cannot go into that particular room because it's gonna become unsafe.

And when we engage in this interview process with adults and with caregivers, we're often able to unpack what is unsafe about it.

Well the thing that's unsafe about it is that if they go into that room, they're gonna want Skittles and I can't give them Skittles.

I just can't Okay, so that's different than saying that the room is evoking dangerous Behavior.

It's telling me that the denial of the Skittles in the room is evoking dangerous Behavior.

So what we'd recommend in that case is well, let's bring those skills into this room.

In fact Skittles is maybe a bad example.

I don't love to incorporate food into these treatment processes, but typically when children are wandering around We like to look at it, especially in our initial assessment phase as that they are hunting for reinforcers.

And we like to follow their lead during that brief assessment phase to understand what those reinforcers are and to try to bring them into our treatment space to the extent that possible so that we can incorporate it into the practice context as well as the hangout context.

now giving them choices to move about does not mean that they're free to do anything.

So I think I should also make it clear that there we've opened three doors not a million doors.

One of those doors is to come into the practice.

The other one is a specific space that we've delineated for them to go hang out freely.

And then the third option is to go back to their regularly scheduled activities where you'd follow your typical Behavior plan.

If you're at a point where your typical Behavior plan means that they're running around and that they're causing a lot of they're having a lot of challenging Behavior.

I would still recommend that you try to you try to re-examine that relationship and you reexamine the daily plan to provide more reinforcement to provide more allowance rather than not and then carefully in a controlled manner introduced denials of those things introduce kind of those evocative situations.

I'm not sure if that directly answer the question, but It's what I got right now.

That was very helpful.

Thank you so much.

One of the participants was wondering about what the transition from the hangout time or space back to practice activities.

Looks like another great question.

Thank you.

You think that we would have covered all the procedural details in three hours, but turns out not.

If children again to reiterate what I said earlier when there was a question a big purpose or Spirit of having on is to teach kids that it's no that it's no problem that we are not bothered when they are with drawing a scent instead.

We're getting analytic and we're thinking about why are they withdrawing a scent?

So if children choose to go hang out, we typically say sure thing.

That sounds great and we let them hang out oftentimes.

We'll interact with them.

And every five minutes or so, we'll just say hey, we've been hanging out for a little while.

Did you want to maybe try another practice session or do you want to continue to hang out?

And it's all about being a cool character.

You know, I don't typically wear my suspenders at work.

But if I did I'd be like you want to maybe do some more practice or should we just hang out here and if they say I want to hang out we honor it and if they say I want to go back to practice we honor that if the whole day goes by and they just have said hang out we say thank you so much for being safe.

For we always want to celebrate something good that they did.

Thank you for electing to hang out instead of pushing me or something like that.

And then we might reflect.

Why are they?

Why are they trying to leave the the practice session?

Can I make it a little easier for them tomorrow?

Can I can I make it more likely that they'll be successful in that practice context tomorrow.

Awesome.

I'm gonna try to squeeze in a couple more.

It's kind of like Sophie's Choice.

Which which one do I choose of all the great questions?

Have you ever used Choice?

Yeah.

There you go.

I think I'll hang out.

Do you ever use visuals to support the students in making choices?

Absolutely.

Well, I don't I I can't admit to there being a great deal of research on that.

But the general strategy is make performance-based decisions.

If you're noticing that children are having difficulty making these discriminations among one context and the other take some time to help teach it to them.

That is we might create a spend a day just being like this is a hangout day.

I'm gonna put a big hangout sign on the wall.

I'm gonna remove and by visuals.

I I don't think it's just about putting up a red card or yellow card will remove all of the aversive stimuli from the room.

I've done that before we take out the work table from the room to say that this is the hangout space.

So those visuals can can indeed be helpful, especially when we have Learners who don't who where we can't use the language to kind of mediate that discrimination so visuals can be helpful.

And I feel as though the way that you kind of get a sense that your learners understanding.

This distinction is when they behave as intended, you know, when they're using the hangout in those moments where it seems like they're getting a little agitated.

But if they're having challenging Behavior instead of using to hang out my thought is how can I make hangout a more attractive option for them?

How can I make it more discriminable for them?

And I guess piggybacking on that.

If you have a student who's for the whole day, they're kind of access the same space.

Would you schedule that practice time?

And the rest of the time they just have access to the space Oh, there's a fantastic question.

The answer is absolutely.

Yes.

Now there's more nuances to this.

And if you're if any of you are interested in engaging with these procedures, but you're like I still want to learn more.

And if you're on Facebook.

I would strongly encourage you to join the Facebook group.

PFA and SBT Community I can even maybe type in the chat.

Oh, where'd it go PFA and SBT Community.

I think the second half of that is called like my way to hre or something like that.

It is a phenomenal group of people who have very strong values that are aligned with mine align with what I described today and they they have made so many documents and helpful resources on how to do this.

To bring that back to this question.

I don't think that it's necessarily always the best idea especially if you're learning how to do these processes to just roll them out across the day.

You should have control context when you have a lot more control about those reinforcers where you can take one hour of the day to bring skittles into a room and then otherwise keep it in the closet so that you can really manage the contingency with great control.

for the rest of the day Children can be sort of in business as usual.

But again if if children are kind of in crisis already, I would recommend what we kind of call a universal protocol, which is closely aligned with the final point that I made that we just tried to Let kids experience more of a reinforcing context.

We remove any non-essential demand until we can carefully introduce them to the child in the treatment context.

And we follow their lead to the extent possible.

We make choices available to them at the extent possible.

But I don't know but but yes, but then aside from that as many scheduled doses of the treatment as you can put in there the better but I would certainly think about trying to find a specific time where you know, you have one or two people or or one person can dedicate their hour to it where they're not at risk for being called away to go support some other staff or something like that.

Awesome.

Thank you so much and I see that Chelsea has put the link in the chat.

So thanks Chelsea.

Thank you.

Chelsea.

Looks like we have some group members in here and I put the CEO code for.

Bcdas in the chat.

So it's nine two four three three, and if you missed it in the chat, you can scroll back up there and find it the two I just want to say thank you so much for your time this morning and I'm seeing folks saying this was much better than Lord of the Rings.

I would have to agree.

I read I read that to a class once when I was teaching English literature way back in the day.

And yes, this was far more engaging I have to say so thank you.

I'm gonna come up with a you shall not pass graphic for the I mean, there you go.

You certainly given us lots to think about and I think for some of us, you know a way to rethink maybe some of what we've typically done in our professional practice.

So thank you so much particularly thinking about your messaging around ascent and choice and establishing trust and safety.

There's certainly areas that have been, you know, focus of much discussion among this group as well across the Atlantic provinces.

So we really appreciate you sharing your work and your perspective on that and I have a feeling we may be working together again and engaging you again as we go forward, We sincerely appreciate your time.

Thank you so much.

Thanks to all of you again.

I can't I can't believe that you're still here with me Shelley if if it's helpful at all if there's a way to get the transcript of the chat or the Q&A and if there are any lingering questions, I'm happy to look through them and maybe type up some responses for you to distribute or something like that and I can also share my slides.

I know that people ask for that.

Yes.

Thank you so much and I will mention that I did too has very graciously agreed to let us record the presentation today.

So will everything with the recording and the handouts and all of those things will be available on the website in the coming weeks.

Once we have a chance to do some editing and so on.

So thank you so much everyone.

Look forward to seeing many of you back here at one o'clock Atlantic time 1:30 Newfoundland and there is a new link for the presentation this afternoon with Dr. Peterson.

So we will see folks then and again thanks to you so much.

We appreciate it.

You're so welcome.

Is it possible Shelley?

I don't know if I can email everyone.

Oh, I'll just drop.

Email in the chat real quick in case anybody does want to follow up or ask any questions awesome.

But otherwise, yes.

Thank you all so much.

Enjoy the conference.

I can't believe this lineup.

I'm stoked.

All right.

So are we thank you for being part of it.

Take care.

Take care.

Have a great day.

Everyone.

Bye.