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Adapting our Practice to New Needs (Part 1) - Text Transcript

- (Shelly) As well, so it's a pleasure to welcome back Dr. Camille Kolu, and I will turn the webinar over to you.

- (Camille) Thank you so much.

Thank you so much, Shelly.

I sure appreciate it.

Same as you did, I'll make sure that you all can hear me.

And Shelly's nodding.

I think we're good to go.

Okay.

I think first, just a little note if you were in that presentation several years ago now you will recognize a little bit of this information maybe a lot of it, and I think it couldn't be better you know, to hear this kind of thing multiple times there's always a new reflection that I have when listening to something that's really, really speaking to me.

And so I hope that you'll have the same kind of response.

Certainly if you think of questions today we are going to do part two in a couple of weeks and I love to integrate what you're thinking about as we move on.

And so please feel free to add something in the chat and that may not be something you do until we get done here today.

So keep them coming if you think of any good questions for followups, well we're focusing on multidisciplinary practices, but a lot of what I'm gonna share with you today is just kind of the nitty gritty at first about how we view trauma and how I view it within behavior analysis, which is my field, but also how I embrace all the different professions that I have to work with and I'm privileged to work with.

And I'll share a few of those with you in a moment here our partners of course are APSEA and I just put my different ones up here so you can find them on the web if you need to, but I'm really, really excited to be back with your special education authority.

And I'm sorry I can't be there in person, that's always very exciting.

Any success stories I share today are always products of intense collaborations.

I mentioned that a moment ago and this is the case to the extent that I always ask my behavior analytic partners, how many of these they partner with, and I would share with you as I typically do, behavior analyst are usually really low.

They will usually say three or four of these, most of the special educators on the other hand and the different related field will say, Oh gosh, you know almost everything on this list, if it were to be relevant.

And so that's really something I wanna commend you all for doing, the more the better and certainly the more collaborative participation I have on my teams, the better it works and the least, the less time that it takes to solve a complicated problem.

So all of these people are, are huge but especially in education I'm gonna share a few different ones that were really key and a couple of the case studies that were review today and the next time as well we'll go more into depth on those.

So I wanted to share the abstract as well.

It's here and hopefully you've received the slides and you can go back to this if you need to.

I think something interesting here is the last sentence that I wanna equip you with tools.

And by that, I mean physical things that you can take home.

And so if you see something mark the tool today or a little form or a checklist in almost every case with maybe one exception, that's a big assessment.

You should receive these afterwards.

And, that's important because as you see here on the bottom of the side, sometimes we're not sure that there was trauma and we can't always document it but we can still do something about it based on how the child or the student is doing in our services.

And so even when we suspect there was a history there but we can't document it for sure there is going to be something we can do about it in terms of working from a really informed standpoint about what we need to take into account.

So, I don't know who coined this term TIBA but I use it for a lot of reasons.

And I use it in my practice with a lot of my clients even those who you may not respect will need it.

And the reason is after I'm working with autism it's highly likely that that child is going to be impacted by the things that come with autism, you know challenging behaviors, a higher risk of being bullied a risk of not being understood with in terms of their communication attempts.

This translates to some times especially where I live in, in North America.

Those children are more likely to enter foster care just because of having autism because of having challenging behaviors and things that sometimes parents can't handle on their own.

Sometimes around here to get funding you've got to sign a waiver and give up your child to the state for a little while.

And the child goes into some kind of foster care that takes care of the behaviors for a while.

Well, once you're in foster care there's a greater likelihood of experiencing some kind of abuse there.

And this happens to the extent that after I look at the prison statistics, I was utterly shocked.

You may not be, but up to about 80% at any given time.

So this may fluctuate a lot 70, 80, 60 but definitely a huge majority of people who will spend time in prison have also experienced the foster care system and have also experienced some abuse and neglect though, I think if you look at the people that behavior analysts like me try to serve, then our population is necessarily going to be touched by trauma.

And that's true for us.

It's true for you too, if you're working in partnership with behavioral services or you're addressing behavioral challenges in some other way, in your role as a school psychologist or as an educator or one of the many, many partners that we all have.

So learning from my perspective.

I know that you have an ethics code too if you are purely an educator those statistics are American, but they are I was really surprised that everybody has sort of a high statistic and it varied a lot.

I mean, even in America it went to 60% some years, 65, some years it was 82.

I'd be very curious as well as to know if it was that high in Canada, I'm not sure but I wanted to share this important piece that anybody that you work with who is a behavior analyst or yourself if you are a BCBA, we have an obligation especially under this ethics code to ensure that when we're using aversive procedures they must be accompanied by an increased level of training supervision and oversight.

And we've got to evaluate whether those procedures are effective or not, but I want you to think for a second.

This is only, whether this is only talking about procedures we know about that are aversive.

And so, as I look at all of my clients in the past 15 or so years working in the field, I think, you know for how many of those clients was I doing something aversive that I didn't realize because of something they went through in the past, which ended up conditioning approach from new people as aversive or some kind of reinforcement system that I'm trying to use as aversive or as, as coercive.

And so that's going to be where we're coming from.

Now the new ethics code does not mention aversive procedures in the same way, the new one comes out in 2022 and it mentions punishment based procedures but that's definitely related to coercion and adversive practices.

So same story, same thing still applies here.

Now I work as, Shelley mentioned across the lifespan.

So with all kinds of clients all kinds of developmental differences sometimes there's no diagnosis at all but somebody is simply maybe a young mother.

She's 15, she's going through trauma.

She has been through it and she wants to stop that cycle of abuse in her family now, or a young little girl on the bottom right here was going through feeding therapy.

And we discovered something about that therapy that was aversive.

Certainly the top, right, little man represents somebody that I'm working with in foster care and geriatric practices on the upper left here.

But we're gonna kind of focus on the bottom left quadrant to meet a young lady in a few minutes, as Shelly did mention I usually throw this slide in there just to show you what the two branches of my practice do, what I'm talking to you about today is kind of coming on over from the right side, the continuing education perspective.

But all the client work that I do with families is this kind of on the left that's what we do at cuspemergence.

Certainly if you don't get your chat and if you have a question later please use that email on the bottom for me, that's fine.

It's kolubcbad@gmail.com So I'd be happy to hear from you anytime there.

Now let's share the learning objectives which we'll get back to today especially we will be going over the first and second ones which are talking a little bit about procedures that might be contraindicated for some of our students who have special backgrounds related to trauma.

And second, I'll be sharing different examples of how I used some of the tools I've developed in my practice trying to avoid those contraindicated procedures trying to do more in terms of assessing risk.

And then later on I think maybe the second half will be more geared to really looking at this features of these cases and how we're incorporating the multidisciplinary support that we find so important after trauma.

So my first question for you all is does your student history of going through something aversive impact how you work with them?

Does it impact it already?

Because my thought is that almost everybody that I work with you're aware in some way that you really need to be careful when somebody comes in with a known history of aversive, either aversive conditioning practices let's say they were in a terrible car accident and they went through some medical remediation and now they've got white coat they're afraid of people in authority, they're a student who really shrinks when people come in the room to sort of mess with them you might recognize physical prompting procedures really freak them out.

That's, it's very aversive now because of all of the touching and unwanted things that had to just happen to them while they were going through that therapy or maybe you worked with somebody who went through ABA and after a few experiences, they really find approach from different caregivers a little aversive.

So people of conditioning experiences do affect what we do.

We're not always sure exactly what to do, but I'm guessing that you have a, you have a way of knowing when somebody seems a little bit reluctant to engage with you as an educator or as a team member.

And we're sort of in the mode of trying to figure that out for a little while, how do we learn?

What do we do to approach them differently?

Are we gonna jump right in with instruction delivery?

Is praise going to work with this individual?

or are we gonna need to be a little bit more low key and neutral?

So I'm guessing that you have some thoughts about this already in your own practice.

Now a lot of times the things that we consider especially in behavior analysis to be best practiced really aren't when we take that history that I just mentioned into account.

And so I'm gonna talk about the history for a minute.

I'm gonna show you different, different kinds of clients.

So we'll have six of them on this screen.

You can imagine one client who's been through food insecurity, maybe they're coming from an educational or an immigration.

I should say, Kent in Denver, where all of a sudden now they're going to be integrated into a public school system but there was some severe food related neglect not by any purposeful means, but just by what they went through when they were coming up from South America, and now they're hungry they're coming into the public school.

And maybe the very first thing that behavior analysis might say, we should do, maybe we're gonna not need to do that at first.

Another one is, picture you have a client coming and who's brand new and they have gone through previous sexual abuse, okay?

Maybe there's a different client who is got medical complications now from everything they went with a very young child and in your classrooms, sometimes they are without warning.

They're soiling their area and they're smearing their feces.

And they're doing things that seem a little inexplicable but you recognized something is related to the previous background, something they've been through another one here is maybe there was previous neglect or adverse circumstances, and maybe this' just related to things happening to them like their parents had died or they've gone through really serious poverty related issues where somebody might have been through reactive attachment disorder type things physical abuse, sexual abuse.

And I wanna really highlight the last phrase inconsistent caregiving in childhood whatever that looked like for them maybe different foster homes and families in succession.

And then perhaps there's a person here in your school who has been through a lot of neglect, they've been involved with law enforcement and they've been suspended and they are using a lot of challenging behavior.

So you have kind of six different pictures of the kinds of folks that I might be working with in terms of what they went through.

These are historical features of their posts, right?

So if these are the, are the cases for your students I'm going to share just one or two.

We're gonna put a box on each one of these to share a couple of procedures that otherwise might be best practiced but things I'm gonna be especially cautious with.

So in that first example, with food related neglect the first thing I'm going to do is nuts edible reinforcement.

I'm not gonna pair myself with food delivery.

I'm not gonna do a kind of preference assessment and find out does she like gummy bears or this gum drops instead I'm not going to do that, I might get there eventually if it's something that's appropriate, it may not never be but that's surprising to a lot of behavior analysts who think, well these are best practices and we would just use this typically.

Now some of the ones on this list make more sense, right?

Like doing one-on-one without any oversight simply not a good idea, don't schedule one-on-one with somebody brand new to your services who's just been through sexual abuse.

It's the kind of touch that we do that might be scary.

It's the risk that they are going to have trouble relating back to us and his caregivers.

And there might be allegations made, there might be communication issues there, there might be trauma therapy that needs to take place before.

So the first thing we often do in ABA practice is schedule some time for one-on-one, I'm not gonna do that at first with somebody who just has a recent history of sexual abuse with a person in power, on the medical complication side I'm going to be really careful with different kinds of toileting procedures.

And again, these aren't all things that you use necessarily but I'm just sharing examples, right?

Some of them are related more to the school setting like using attention related extinction using time out in terms of attention reinforcement.

Some of these things on the left quadrant are things I want to avoid using it first with somebody who's been through that history.

I also might really watch out for using contingent praise statements at first and trying to establish compliance related behaviors with someone who has just been through maybe a seven or eight year history of the kinds of things that give rise to reactive attachment issues.

So if somebody has been through that and has been through lots of caregivers, lots of change in caregivers I don't wanna try to go for compliance right away.

I don't wanna teach the foster parents how to establish it.

I don't want to use contingent praise for their behavior.

These are things I wanna avoid at first, most important I think to you is, is a group of people all related by that thread of special education is this idea that list the most punishment is often built into our behavior plans as the best practice.

Really, it's almost never a good idea in terms of behavior support any way to deliver just a little punishment and then more and more and more.

And the reason is it might seem like you're doing a least restrictive procedure here because you're not gonna give much punishment unless it's warranted you're, you're amping it up.

But what it actually does is if somebody has just been through neglect and maybe has gone through some law enforcement coming in, well if you give a little punishment like suspending a child and then maybe bringing in a a security officer and then the principal and getting stronger and stronger in terms of who is coming in the room, because this behavior happened, then the child or the student can actually start craving that thing.

And so it can end up backfiring on us as educators and end up conditioning as reinforcing something that we wanted to be punishing we wanted the meaning, if something is punishing, then by definition it's going to stop the behavior or decrease it.

But if the child is actually engaging in more and more behavior just to produce these increasing levels of punishing attention then we're actually having the opposite effect.

And so all of these are explored a little bit more on a blog post that I wrote a few months ago now.

But just to give you an idea there are lots of these procedures.

And again, some of these seem best practice but they wouldn't be they would be contraindicated at first.

That's not to say, you're not gonna get there eventually with some of these things I never get to list the most punishment, it's never something I use So there is something in the literature as well, if you're interested in ethics is you can go and look up what happened at Sunland Miami.

And if you're a behavior analyst you can see Bailey and Burch's text, especially I think their second edition really goes into this story.

And, and the story you'll learn that they were this is not something ethical that they were doing.

This is back when it was called behavior modification not a really fine grain analysis of behavior but there was deprivation, bribery, manipulation, coercion all things you can associate with bad behavior analysis, that's all there.

As a result, people needed to take special care after serving somebody who's come out of that kind of condition with things like reliance on tangible consequences for good behavior, and even doing a preference assessment where you're just saying which of these would you like?

would you prefer?

Oh, okay.

And then you're putting that aside and going to something else.

Well that situation can seem very coercive to a person who's just been through some neglect or has had things stolen for them.

And so some of my inner city kids down in Denver respond really poorly to preference assessments something I and my team thought was completely benign until we kind of looked at their history and we saw why this was happening.

So, interesting points there on contra-indicated procedures and just overall, that's why I started getting very very interested originally in what a behavior analysis would look like if it was really trauma-informed.

Now a lot of people that I work with were asking, but is that true?

Do you really need to do anything different?

Can't you just do behavior analysis as usual?

Are there really any differences at all?

And you know, it's not only on the functional side and there, the answer is obviously to me there's a lot of differences in how I implement an FBA and how I take risk management into account differently but on the topographical side too meaning in terms of what the kids are right in my classroom, there's a difference.

So for example there's a difference in their typical behaviors there's a difference in terms of their skills, their characteristics are different.

Some of the sensory differences have been pretty powerful and in particular, the otis on my team have really helped me to appreciate that one of the key differences after a trauma is my students often have a different pain threshold now, whether it's higher or lower.

I spent time with someone who works to the lawns band.

I also know that this is part of, or related to the fact that a long time later when there's 30 and 40 and 50 these are the thing clients I'll have that if we don't get this solved, they will be experiencing challenges with chronic pain disorders and they'll be experiencing challenges reporting their pain, challenges getting help for things that are happening in the body.

They may be experiencing a lot of somatic conditions things that don't seem explicable but that are all traceable back to what they went through early in life.

There's also a high risk of a lot of these I, the behaviors like sexualized behaviors, parentified behaviors things that a social worker has taught me about.

And that I've seen a lot with my, my students and teams splitting behaviors, different things like this.

So not only are there differences in those aspects but in the, in my students' response to treatment there's a difference there too.

And so different response to what I'm doing in terms of praising behavior I have mentioned that a couple of times or simply a difference in how they respond to social mediated stimuli, sometimes a big class-wide, token system that's going to call out appropriate and inappropriate behavior and let everybody know who's doing what, is really counter indicated for someone who's been through a challenging life circumstances in their paths with respect to trauma.

There's a lot more here there's differences in the parenting skills in the skills that I'm going to need as a team member to support that family, I often have do a bit better job of really clarifying my role and being careful not to take on too much.

A lot of times the family or child has gone through so much that they just will latch on to anybody who can seem to help and then we'll be getting inappropriate questions not inappropriate from them meaning whatever the client asks is fine for them to ask.

They're not the ones being unethical.

It's me that has to monitor my ethical response to an extent that I don't overstep my boundaries either boundaries of competence or my role or my scope.

And so we'll talk a bit later about how I think especially in the second piece where we focus on the multidisciplinary component, it's about important clarification who we are and what we can do and how we need everybody else is still important.

There's also a difference in risks and this would be one of the most important pieces to me.

And this is for several reasons it, it includes going and testifying on the stand after serving a family, who's been through abuse and neglect and trauma also supporting a team who's new to supporting trauma.

We need to be able to make sure that they are equipped to handle the risk and you can't handle what you can't see coming and so just knowing that people going through trauma confers a greater risk for their lifetime in terms of the medical challenges they'll go through.

But here I've, I've mentioned other ones there's risks of sexualized behaviors, risks of additional physical or sexual trauma if I would mention, if you're interested in things like acceptance and commitment training, if you've heard of that or acceptance and commitment therapy they have amazing data on some of this that none of ties back to if somebody is at risk of you might not think of somebody who's gone through sexual trauma as being more at risk of going through more, but we are So after we go through something, it's it's almost like we're, we're disempowered and we're, we might use, we might encounter that again and we're more likely to encounter it again and they have some data on why that might be and things we can do instead, they kind of hold that past or help people change that trajectory.

But there are also risks because of the missing skills somebody has.

So I have, I already mentioned, I think think about the connection between autism and going through trauma.

If you already have a deficit with respect to communicating and using certain verbal skills and you're being exposed to something challenging, then you might have a risk of not reporting that or a lack of self-advocacy skills.

Sometimes the very skills we need are being punished by important caregivers in our lives or they're being extinguished because nobody can meet the needs that we are trying to express.

And so we turn to using really unsafe behaviors instead, that make complete sense and that I would think of as really resilient things to do that might need to be changed later but are very important at first.

As well, dangerous behaviors might've been modeled and even valued and it's important to know they might've been useful before somebody was removed from an unsafe condition.

So your trauma, your client, my client, and yours we're all still people with preferences, interests, feelings, desires, choice, somebody who uses behavior in the context of our current and past environments.

And that word context in the context of our past that's an important idea in behavior analysis because on the one hand, you may have heard a lot.

I'm speaking to non behavioral people for a second about the function and the function is always important you know, is always this behavior paying off in the moment?

is it producing something the client needs?

or is it helping the client articulate something?

All of that is very important and I, my hands are here in the moment, right?

But in terms of the people who went through something really important in the past too, those things still matter.

So we could call them functions, but they're more removed.

They're not the immediate functions.

They're the, the function that was important in the past we might call it a distal function or an historic function or even a molar function of their behavior.

So I also mentioned our client is still at risk of being exposed again to abuse or trauma by well-meaning people.

And that means we have to be extra careful to do protective things, to do risk mitigation and risk documentation a little differently.

Then there's still people who matter where all people who matter, some of their needs might be outside of behavior analysis' purview.

I think I might mention a couple of examples later on, especially next time but just about the cuff, I can say sometimes it's been more important to help the family connect with a social worker to get her a ride to work, then it is to solve her child's little issue with throwing things.

And that's not to downplay any kind of behavioral challenges that we need to help follow.

But sometimes there is a real human need that has to be taken care of first.

Our students may have skill gaps because of their history or medical impact of trauma.

So some of my clients were in and out of different school systems over the course of many years and really lost a lot of valuable educational time.

A lot of my clients who come in without having strong math skill or reading skills are that way because of all the time missed, especially because of going to the hospital and being re-stabilized in terms of their medication, or they had lived somewhere where there wasn't really good access to education.

Now I mentioned already that our clients may use behaviors that have problematic functions, the views were once useful and maybe their only hope.

And so it's really important to take this into account as we're meeting them and with with compassion in mind, at the very beginning they have experienced possibly behavior analysis and highlighted this piece here that was part of harmful treatment.

Now don't worry,(laughing) if you're scared about it just acknowledging that, go ahead and call it out go ahead and acknowledge it.

At any time if I'm on a team who says that to me in kind of a hush touched way, you know, I think that this this behavior analyst was actually part of the problem.

And my first response is never to say, Oh my God, well that doesn't happen anymore.

Especially not on my watch.

Just think about behavioral analysis there's always something positive and good, that's not the case, we must be realistic and it's better to build a bridge to acknowledge that piece and move on.

Then it is to actually try to counter that history which is very real to many of our people.

We may have had members of our own teams who abused us or who didn't stop the abuse when it was happening.

And unfortunately, in a lot of situations I have seen that happen before.

I'm going to mention a friend Aniyah, he was a 14 year old trans girl and I'm doing this because she's a case study that we'll return to a little bit today.

I can tell you that first of all the reason they called me in was her, she had an ABA school we were trying to get her back to, but you'll see some of the pattern of her getting stuck in a very consistent pattern that I've seen a lot.

So this is sort of a, a situation that's happened before but I'm going to use her story to help illustrate a point and to show a tool, her school wanted consultation to really understand why nothing was working before they brought her back into the treatment.

And with all contextual information, I believe that the more, you know, the more it makes sense.

And so we know she's been living in the hospital on the wait list for residential treatment, one thing we know, we also knew that she was kicked out of multiple schools for really terrifying behaviors.

The schools were afraid of moving on with her.

She had had lots of run-ins with the law at her young age, she'd been in juvenile detention.

She had had a lot of behaviors modeled for her there and in the biological family homes she had been exposed to some other things.

She had started gang activity and robberies and participating in prostitution herself and drinking starting when she was very young so eight or nine years old.

And unfortunately her once adoptive parents had given her back to the system and there was some gang related abuse before that that I mentioned.

So she had a lot that was going against her.

And if you think about it, the story you're seeing on the screen is what we often hear about a client.

And it feels very heavy and we're sitting in our classroom trying to get ready for the next year thinking, Oh my gosh, how am I gonna how am I gonna support this person?

You know I have evolved the next tool that I'm gonna show you in a lot of ways over the years, but at its core we are developing something called the Client at a Glance.

This is a version that uses the iPad.

And the point of the client at a glance is to communicate good stuff about somebody not just everything you just saw on the screen.

Now, her picture helps with that, that kind of lightens it, doesn't it?

I think her flashy background here that she chose because she said it looked like the nails.

She loves to do nails.

And it looked like one of the jobs she had just done on someone's nails.

And she chooses as a client things to put here in the top left piece.

And so picture then instead of first seeing somebody's binder you just see a little slide about them that they participated on imagine if the first thing you know about a Aniyah is not not what I just shared but the fact that she loves doing nails, the fact that she loves listening to music, the fact that she is good at yoga and getting better loves teaching it.

And she likes painting and collages.

Those are her favorite things.

Okay.

Now we also start to learn how her daily residential staff help.

These are some of the things they're doing right now helping her read and follow directions for nail designs and teaching others a new yoga pose once a week.

Now that's really behavior analytic in a way.

So think about what I shared with you about clients who come in with this massive educational deficit okay.

Every time at first, before we started all this every time we would give her the easiest assignment to read, she was way below grade level.

I mean, some of the second grade stuff was still really confusing to her.

And she was really ticked off about anything we would put reading in front of her and she just shut down or assaulted people.

However, when we developed some programs in which all she had to do is read some little instructions accompanied by some visuals about how to do a nail and new nail technique or a new pose and the description of it.

And then she was invested in teaching that to a staff member.

She really likes that.

And so what we are doing here is trying to take some clients' centered pieces of her program make them really obvious to staff and putting that right there the first thing they see about it and this is something staff can follow along with every day.

They also were supposed to remind her to tell them where she was going when she opened the door because that was a big piece.

Is, it used to be little meant, but now it's a safety issue that we're kind of getting control of her And now here's some things she needs.

She needs weekly preventative visits with police.

And also with the people in this school remember how I mentioned that list of most punishment that was so unhelpful.

Well, when we stopped that in her special education program and instead started having staff walk her down the hall at first, and then she could just go anytime.

The visit with her principal, instead of only having that principal come in after she had an unsafe behavior episode which is how it was set up in her behavior planet first all of a sudden that preventive skill on our part made such a difference for her.

And so these are, again, the things she needs what it's starting to look like to you is maybe a little mini behavior plan just some one page version of her behavior plan and this can be adapted for any client.

So there's some notes here on team reminders.

There's some cautions there on things she struggles with.

And then we use these little icons to show where the the little, the little light in bold is a trigger for her.

So it says there are triggers here.

I think it got a little misplaced but educational activities and reading are a trigger.

Okay.

And then there's one at the bottom down there too.

So we're trying to work in kind of a techie way to use something she likes something to communicate quickly with staff but also share her trauma related background here without making a big deal of it but building it in when it's needed.

I'm going to show you a little bit more about her treatment now.

So remember that I mentioned the cycle that she was kind of stuck in.

So she would go to juvenile detention or some version of that in there back in the hospital for some unsafe behavior.

And then she would get discharged and try a little stint in the community in residential treatment.

that invariably it would fail.

She was engaged in some behavioral management practices with her team, but they wouldn't work.

She would go right back into the system.

And here she went just rolling around this little last cycle.

Well, I was determined to do it a little bit differently.

And so we talked about how let's do a risk versus benefit analysis of everything we could be doing.

So let's look at all the options we have here, this document in a better way all the risks that each option entails.

And as we did that we also looked at the functions of her behavior in a more broad way.

And so yes, as you can see here on the bullet there were immediate functions of attention and escape.

Yes.

So she use behaviors to get out of school.

Yes.

A lot of the behaviors were attention producing for her marks.

There was also a major contribution of historical trauma when we really looked for it.

There had been lots of rapes in her previous hospital, like setting guides.

There had been sexual assaults in her biological family home.

There had been car accidents.

There were some traumatic brain injury type of contributions to things that were going on behaviorally And so some of the learning challenges by the way, were contributed to by some of these traumatic brain injury type deficit.

So when we really looked at that, what did that mean?

There was medical functions of some of her behaviors.

There were historical contributions from the trauma she'd been through and there was some chronic unmanaged pain from some of her previous assaults and once or twice she had been beaten after reporting that pain.

See it when it come up later.

Well, one of the things we had to do was to really retrain her physical management staff to not set off a lot of triggers right away when they were just trying to solve a problem but it would put her into kind of this cycle of acting out in residential treatment and going back into juvenile detention.

And so that was a really important piece that I'll address later.

She did start to improve after we did certain things like when we incorporated those historical functions, she started to make some progress.

When we looked at the physical characteristics of what she described as her past attacks and who is doing some of the physical interventions we needed to address that we use staffing huddles, we use a TIP-like procedure.

And, I don't know if you all have heard of this, but it's well based in our behavior and analytic literature it's kind of, it's being used now instead or in combination with the idea of the social story.

And so you probably have incorporated the social story well take, ride on to what a story is trying to do.

TIP means Teaching Interaction Procedure and so it's, we might use a story with the Aniyah but at the same time, we're teaching, give me a rationale for it and then instructions and then examples.

And non-examples within that.

And so the teachers are the ones giving the stories and they read a story and they come up with examples and non-examples themselves.

And then they act out what are we gonna do when this happens?

And so an example would be with a non contingent reinforcement example that I shared with you earlier, which just means preventive interactions with her in, in her case for police officers.

But also her principal in the school is the principal read the story about why Aniyah needed this difference.

And they saw examples of how to respond and non-examples things not to do.

And then we role played with, with her, the principal and then she was easily able to say, okay, well I can do this.

I'm gonna be preventive with Aniyah I am gonna meet with her every Tuesday now.

And when she comes to my office I'm gonna know how to respond.

So when we incorporated all of that and I'm thinking of this is system support and a real multidisciplinary approach here she did start to make progress.

Now, if I had Aniyah in the completely different situation of just being back at her ABA school I don't think it was safe to treat her behavior yet until I addressed everything I just shared with you.

And so I started to come up with this model.

You might hear me describe the safety model either today or at a different one of our subsequent meetings, but the point is I want to know with any client, should I be doing this?

Should I be jumping in to behavior and analytics supports or have we not established everything that's going to take to keep her safe.

And so for me, these are the things it's going to take.

The team is gonna need better supervision.

And so that entails better case supervision and support.

We're gonna use high levels of funding agents that are gonna know about this case.

We're gonna tap into law enforcement support community helpers.

In her case it required me going to hospital management to get approval for some things and educate them about the risks, if we didn't.

Another piece of it is the A in the SAFETY stands for we're gonna need to do assessment of risks and do it better and do it in more and do it often and communicate about it.

And so this includes not only analyzing risks versus benefits of any option that we're looking at including should we start services or should we even take this client but also documenting risks, learning about them sharing them with the team making decisions.

And again anything that you see here is it's going to correspond with something in our ethics code.

If you're a behavior analyst, especially the new ethics code which incorporates this new kind of decision-making model around page four and five, I believe on how to really look at risk in a kind of a different way.

Also the F in the model is for how important it is to expand your FBA.

We need to include functions of history and medical contributions of trauma or anything we look at when we're talking about behavior after trauma.

And like if you noted, it's not an, it's not it's not something that behavior analysts were that familiar with doing, although in the science of behavior if you don't look at the application, but you look at the science way back to the fifties and sixties I was always looking at what had happened in the past and how that influence behavior long in the future.

And so it's there in the historical roots of our fields but we haven't really been looking at it in terms of a concerted effort to document these things in our FBA.

And that's what we're trying to add.

Now, there's also a lot of looking at the environments making sure the team is ready to implement the plan and mentioned a lot of preventive skills.

And I'll, I'll always be harping on those.

There's a lot of preventative things you can do before somebody comes into a classroom.

And that usually involves for me, teaching all the adults in the room, how to know how to stop praising behavior or stop giving instructions and know when it's time to just do neutral interactions with somebody on kind of a time-based schedule until they feel like it's safe for you to be there.

And when you can start adding in instructions.

And so those are research-based techniques but they're really important, especially after trauma.

Triage is also really important.

And for me, this just means collaboration and preventative problem solving before something goes wrong.

We can talk a little bit about that one next week.

So we're doing this in an effort to make sure that we don't hurt, you know, our our goal is always to do no harm and then beyond that to help, well, unfortunately a lot of this stuff is hidden.

We don't always know why somebody is acting the way that they are acting, but if you look about it in our culture, we're all trying to understand this in a way that we weren't.

I think a few years ago I really was surprised when Shelley and the other members of her team with APSEA contacted me a few years ago because it was sort of novel then it was newer.

People were starting to discuss trauma, behavior analysis hadn't really started that very much at all education with getting a good start.

Certainly it's everywhere though.

And these are a few of the reasons I believe that this is happening is we've had a few landmark studies in the past few years, really in 10 to 20 years.

And we'll talk about a couple of those in a minute.

There have been some wide spread efforts to incorporate this in educational practices in terms of social justice and what we look at as a culture and certainly we had COVID last year just start to effect a sheer majority of everybody, right?

The huge, huge numbers of people now reporting mental health issues that weren't before.

Within a couple of months after lockdown started happening in places, we were seeing things like a hundred percent increases in self-injury with children and this, these have only snowballed.

They have not gotten better yet.

So there are now there are better media and publication tie-ins too to start to connect for the public, how going through trauma results in these a long lasting completely life-changing medical differences.

So differences in how people respond to stress over their lifetime and impact something like giving a person who's gone through some trauma in their history, a huge increase in their rates of things from immunology problems to a lot of heart disease stress-related problems with blood pressure, a lot of diabetes differences.

And this particular tie-in to medical problems is when that I'm mentioning because Dr. Nadine Burke Harris has done so much work on this.

I don't know if you've heard of her but she has a wonderful Ted talk on what the body does in response to childhood trauma.

And she really started looking at this especially when she had a pediatric practice and sort of an urban area heavily impacted by trauma.

And some of her children literally stopped growing after going through some sexual assaults, literally stopped growing.

So for four years, that's little boy that she writes about in her book, The Deepest Well wasn't making any progress on his growth charts and she could find nothing wrong except for this one tie-in to what had happened in the past.

That turns out to be highly significant for a lot of people.

But before some of her work we only really had known about this from the ACEs' studies.

And as you probably know that was a majority of middle class white men.

And so to have this opportunity that she writes about to look at it with children who are growing and experiencing these things and to see what it's doing in real time has been hugely impactful.

I think this is significant to behavior analysis too.

And I think ABAI agrees she's our presidential scholar this year, and will be giving a talk in May.

I hope that you can attend that, it's totally virtual.

So I'm probably gonna be there even though I'll be out but she's gonna talk about some of the links between going through trauma and then not only what it does but what we can do about it, which is highly significant.

There are some great, easy, some expensable things that we've educators and behavior analyst and all of the therapists, all of the side professions we can all work together to really make a difference.

So tune into that talk.

Now I wanted to just go back to that idea about contraindicated procedures and remind you of really what that means.

And some of this was relevant for Aniyah.

We need to avoid certain things and make sure that we were cognizant of other features of her case.

So number one, contraindicated procedure just might be something that maybe your team suggest you should do, but you know something is wrong because you're not individualizing it enough.

So a contraindicated procedure may be one that works for everyone else, but it's not being individualized to this client based on their history.

And for that reason you need to hold off on that for a minute.

It may also be something that may be a risk versus benefit analysis is just would be risky so, if you do an analysis of it's really like a tea chart here's the pros and the cons and his short-term and long-term potential impacts of the things I'm considering in all my behavior analytic options here.

And I discover, you know what, It suggests that there's a big risk of this.

Let's, let's not do this right now.

Even if it's something you normally would do it could also mean you're failing to take into account something that is historically important for them.

It could be a procedure that could worsen behavior given somebody's history.

It could be something that might condition yourself as aversive if you accidentally do it.

And so an example might be I'm coming in with a case where, and I'm not a diagnostician but some of my clients are diagnosed with reactive attachment disorder, for example.

So if that person has that diagnosis they've just been through lots and lots and lots of coercive experiences with other adults.

I don't wanna just work on compliance right away with me and try to condition myself as somebody to just obey and praise their behavior.

I don't wanna do that.

It could condition me as aversive from the very beginning, things that rely on consequences, excuse me, consequences.

When the delivery or withholding a consequence right now might only increase punishment for a client and things that are not helpful at first may still be able to be faded in later with careful planning and when the data indicates it could be helpful.

So again, a contraindicated procedure is not one that you won't ever use but one that you need to be initially very careful with I'd like to return to the multidisciplinary team for Aniyah just for a second to highlight what she found super helpful.

I probably mentioned her occupational therapist.

I'm not, I'm not sure if I did specifically for her but I mentioned to you how important that person has been on my team, especially with some of the sensory differences with my clients.

Well, she was also the safe person on a Aniyah's team and there always needs to be one in your functional behavior assessment.

You should start documenting the role of that person and how important that might be.

Dr. Nadine Burke Harris' work also indicates that having a good relationship is one of the six protective things that will help people rebuild their lives after trauma.

The school psychologist was also invaluable to us.

Obviously he assisted the team to understand the triggers for Aniyah and some of their relationships to trauma the behavior analyst on her case with helping teachers document, when a behavior happened out of the blue, what does that really mean?

So we ended up, I'm going to show you later on a tool called the I-PASS and this is something we work together with.

So the I-PASS helped operationalize what the hidden triggers kind of were in the different sensory environments.

And then we could work better on functional communication because we were more aware of, well there is something going on in her visual field or the thing that she experienced ...

It was anything in terms of her sensory environment we would put it on the I-PASS.

And just to give you a preview that stands for the Inventory of Potential Aversive Stimuli and Setting events They kind of takes behaviors in terms of out of the blue and puts them in the context of something that was really happening.

If we're looking very close.

The principal was also super helpful and as I mentioned, they followed a preventive plan to visit Aniyah when things were going well and not just reactively following her behavior plan the social worker was invaluable too, yes.

So Marsha, are we gonna see it as a tool later on on this screen, but I-PASS was the inventory of potential aversive stimuli and setting event.

The social worker helped us gather information on her past you know what, I'm gonna write that down an inventory of potential aversive stimuli and setting event.

Okay.

And we'll share a copy.

So looking at an Aniyah's past was super important and something that was kind of scary but after we documented some of those tie-ins we could make a very much more trauma informed FBA or behavior assessments.

And at the things I miss we're doing all that.

I remember the little iPad version I showed you of the client at a glance form and had her picture on it.

Well, the residential counselors at the time were doing all those daily staff duties that I highlighted that were so important while she was waiting for a different foster home.

They can't gain for her.

And so these team members were super helpful.

I couldn't have done it without them, in terms of it being it was a successful strategy reused but it was not going to work if one of us were not on board.

And so we'll have different examples next time about this.

Now, while you've mentioned ACEs before and mentioned Nadine Burke Harris's work with them.

But for a moment we gonna pause and kind of go back and look at where those ideas came from and just kind of talk about this and how it leads to what we're doing in behavior analysis now, and how to integrate this.

So I'm sure you recognize that term adverse childhood experiences.

Well, it was interesting to me to read how it's a dose dependent phenomenon meaning the more you were affected by the more difficult the outcomes were for you.

So Dr. Felitti and Anda looked at this and really Dr. Felitti was the guy who saw people in his practices in his obesity clinics who were gaining back the hundreds and hundreds of pounds they lost.

And when he interviewed them, it was related to trauma and it surprised him at first, but this is the case.

And he started interviewing all his patients for it and learning that some of the problems that it seemed like inexplicable medical issues were actually related to childhood traumas but we don't wanna just look at childhood events because aversive conditioning is impactful too.

And so we're bringing in adverse conditioning and I'm gonna share with you, it's well known in behavior analysis, obviously in the past, they used it but we try not to use it now.

And I think there is a problem that in a, in our field we often think, well we're not using aversive conditioning.

That would be terrible.

We don't wanna use that.

The problem is we're doing it without meaning to because we don't understand what somebody went through.

And so that's my point here on the second bullet there.

So we're accidentally subjecting them to a aversive control without knowing it.

I'm gonna share with you some examples of how children are kind of affected by what they went through in the past even if they're super young.

So just for a second, bear with me if you're a behavior analyst you might find it interesting to think about this slide as kind of an analog to attachment.

So going through disruptions in the everyday rhythms of their caregiving experiences or going through disrupted attachment can produce these different behaviors after a while that are not really a function of what's happening right now.

So for example, when I'm doing reunification work with families and they had been abused and neglected and then then removed well, when the judge ordered that we reunite them all of a sudden some behaviors come bad.

and imagine if you are in a classroom it is very difficult to know why behaviors are happening out of the blue.

They really might be happening out of the blue.

They are not triggered by anything in the environment.

Maybe the child just had a visit last night with previously abusive caregiver.

So there is a specific part of the brain I'll zoom through this slide, but you have it in case you need it, a particular part of the brain, it looks like this piece, this little hippocampus on the bottom left, which is named for the seahorse but that part of the brain tells the difference between is something safe now, or is it unsafe?

This ends up being really important because if kids can't tell the difference between is this situation safe or not because it resembled something in the past or it was conditioned as aversive in the past.

Or maybe even if you wanna think about act that idea of acceptance and commitment therapy.

There's an explanation there too.

I don't have to get into it, but overall after trauma we can't tell the difference anymore between whether something is safe or not.

And so that means kids are being triggered without us meaning to.

This is Jonah's story.

It's been loud all day in the hallway, and he's sitting in math, all of a sudden the political science classroom down the hall erupts again, they're shouting and laughing.

They're doing debate lessons and they're watching election coverage.

People are cheering.

And most of the kids in Jonah's math class have kind of taken this day in stride but his teacher notices he has crawled under his desk and he's just freezing down there and he's urinated on the floor.

And she's a little confused, you know in terms of behavior analysis and what she's been trained to do, she's thinking I don't wanna just get him out of math for this.

I don't know if he's trying to escape the situation is this related to something and she didn't really know what to do.

As I've noted here for the first time this teacher had started to think that really seemed to happen right when the kids got loud in the hallway.

I wonder if it could have anything to do with that.

Well, imagine what happened with his behavior analysts went home she did a home visit, and here's what she saw.

He's playing on the floor.

There happens to be sports on there were a couple of people over to watch the game.

The same thing happens Okay.

He's everybody starts screaming and shouting when there were touchdowns.

And all of a sudden he jumps, he startles, he urinates, he freezes.

Okay.

So in the brain what's going on there's a condition stimulus.

Something happens.

Well, there's a part of the brain that's deciding.

Was that good?

Or was that bad?

Meaning, has this been paired before with something aversive or something good?

Well, if it's good then you can start approaching again.

If it, if it was just a sound that had just been paired with everyday noises, all the kids go back to work but for Jonah, something else is happening.

And I say avoidance here, but it could also be learned helplessness type behaviors like freezing.

So I have shared with you just a little bit about who's doing what in the brain.

That's not super important to know.

My main point is that you can't do both at the same time.

One pathway is to approach things, one pathway is to freeze and get shut down.

You can't do both at the same time, I'll say that again.

And so that's news to some educators that I've supported and it feels relieving to know that is he can't just get unstuck really quickly.

There might be a period of time where you can't come over and speak with him and that make a difference for him.

And so when his plan and we'll do his case study next time on his plan, it looked a little different.

There had to be some time to give him to let him just come back to us.

And as we got better at predicting when those things would happen we got better at giving him some support.

Though, I mentioned the I-PASS earlier.

This is just a visual of it's first page.

It's simply a front and back little thing.

And we're just gonna kind of mark off what's going on for any person during a challenging episode.

So we're gonna try to record what was happening in the environment and give an example of that.

Now I mentioned earlier that some of my students don't respond very well to praise.

And so for about five or six years I've been using this second little tool which helps me try to communicate with my students what I can do when I need to approach them.

And I need to make a correction for their behavior or talk to them or praise something.

What they want me to do?

And really this is as simple as it could be.

I'm just asking them for their opinion.

And I'm getting a little bit of that on paper.

If they're nonverbal, I might use some cards with smiley faces and things and give them examples and work on it.

If I have a teacher who taught them last year this is really helpful to give to all the parents and say, what was helpful or what was really harmful.

Can you give me an idea?

And then I can integrate that in my classroom.

So again, all of these documents will be shared with you all afterwards.

So my point in about knowing what kids went through if I can know what a student was experiencing is that I can make predictions and know about risks.

So, I know I'm kind of bluffing over this slide that I wanna share it with you.

You have it when you're, when you're done with this presentation, you'll have all these slides.

My point, is that anything in red here?

These are things I can know, just because I know this part on the left, there was an older sexual abuse survivor.

She had left a foster care experience, she had intellectual delays and she was assaulting different teens and she was making false accusations.

So I knew about that.

Well, that told me all of these things I can do on the right.

To mitigate risks.

And so it helps me be super predictive and to know about what somebody went through.

I don't mean I can predict what they'll need exactly what I can at least reduce the risk of harming other people.

I can be more likely to select a treatment that might be effective for her.

I can support caregivers and teachers and knowing what to expect in the classroom a little bit better.

Sometimes I'm even able to prevent some overmedication.

So something we didn't talk about is how that ADHD looks very similar in presentation to having gone through trauma, if I knew the child went through trauma.

Maybe my first med is not gonna be go to ADHD medication.

If I have that conversation with a physician maybe they'll also say, Oh, okay.

So that medication actually looks like he would need it but he might not respond well to it.

It might actually make behavior worse and I can be kinder during a tough episode, I think it's easier to be kind.

Actually, when we reveal a medical contribution of trauma I feel like people understand this better.

I'll give you a really simple illustration here with a little girl named Sophie.

So she was going through feeding therapy.

Don't you know, if you've heard of non-removal of spoon therapy that's where you stick a spoon in the child's mouth.

And if the child spits the food out, you just leave it there until they swallow the food.

And you're trying to use extinction.

Well, that's not appropriate for everybody.

For her she was going through this kind of therapy and her mom was in on it.

Her occupational therapist was running in.

I mean, it was all set up and and well sanctioned by her medical community but she kept vomiting and turning her head.

And so I'm highlighting there we know there's some unconditioned things happening, some conditioned responses happening and what we're really hoping for at not me, but people running this are hoping that there's gonna be extinction.

She's gonna stop vomiting.

She's gonna just eat the food.

She's gonna learn how.

Well, that was before we got her diagnosis.

She had Celiac disease.

This is an example I give a lot because number one it was so shocking, but imagine the meaning of that.

Imagine, knowing that we had been presenting an a conditioned aversive stimulus to her, pairing it with food and pairing it with mom, pairing it with therapy what's supposed to be helpful.

So the point is, is that nothing changed in terms of her body?

What changed was the diagnosis?

What changed was her information?

nothing about her changed.

So that meant that we were the ones providing the inappropriate treatment all this time.

Okay.

And it meant her specific learning history was the reason that this was not gonna work eventually.

And the reason we shouldn't have been doing it reason it was risky though, we didn't know that.

And so, again, going back to that idea and ethics, my my question is what should we be doing if we're actually applying behavior analysis to clients without knowing what might be aversive?

That's on us.

And every member of the team has a responsibility to look into that and make sure that we're not doing that.

So just to review some of what we discussed today we talked about applications of behavior analysis after trauma and how those can be super helpful.

I mean Aniyah's life was just completely changed.

We shut down that cycle.

She's been a really good program now has a foster family who wants to adopt her.

Everything is back on track, but I believe it's because we did a lot of risk analysis of everything we did.

And we incorporated those historical contributions.

I showed you a couple of tools today and we'll do a lot more of the tools next time.

And we'll put those in the context of really multi-disciplinary case studies especially just share with you what we did for Jonah and how we could solve some of his issues that had been going on ever since his abuse to neglect.

If you haven't read the Bruce Perry book the boy who was raised as a dog I think it provides a lovely perspective on healing and trauma, just like it says here, he talks about what can happen after trauma and some of his wonderful experiences with respect to integrating supportive techniques after somebody has been through that, he talks about behavioral symptoms too.

He says, we need to understand how persistent these kinds of things are.

And so from my perspective that's really what is, is we're trying to use behavior analysis to treating, not trauma itself that's for Bruce Perry and you if you're a mental health therapist, but for me I'm gonna treat the behavior side of it.

And I'm gonna include documentation of all these histories and their significance and the risks and do that in this context of rich team collaboration.

And so for me, that's my answer to what kids need in terms of behavior because sometimes they do still need behavior support and at the same time some real strong mental help support it at the same time.

We're gonna stop here today and my contact info is right there on the screen for you.

I'm hoping that if you have an added questions over here that you will do so now or feel free to ask Shelly or ask myself or anything that you're hoping to address next time as well

Serving Children & Youth Who are Deaf, Hard of Hearing/Blind or Visually Impaired