- So I just want to take a minute to introduce our presenter and I was very, very privileged to have the opportunity to listen to a presentation, actually, to participate, it wasn't listening.
It was participating in a full day presentation that Saundra Bishop did last spring for the Association for Behavior Analysis International Conference which was such a valuable learning opportunity.
So Saundra Bishop is the Founder, CEO and Clinical Director of Basics ABA Therapy, based out of Washington DC.
She's also President-Elect of the DC Association for Behavior Analysis.
Saundra has over 18 years of experience working in the field of applied behavior analysis and with people with autism or autistic people and she's been a board-certified behavior analyst for 11 years now.
She's especially passionate about trauma informed behavior management and models that focus on self-advocacy rather than compliance.
And she's a certified clinical trauma professional.
So I'm thrilled to be able to introduce to you Saundra Bishop and I will turn the presentation over to her.
- Thank you, thank you, thank you.
I'm super excited to be here.
I may have shifty eyes for just a few minutes.
My eight year-old dislocated her leg yesterday, like not just her knee, like her full bone came out and she's fine, but she's at school today and they texted me like two hours that she was in pain and I missed it.
So my partner is talking to the school and I'm just like, looking to see what's happening with my baby.
So I'm just looking at my phone to see the texts that have them say that she jumped up after five minutes and it's fine.
So nonetheless, I'm here to talk about Trauma Informed ABA.
This is applicable to trauma informed behavior management, behavior plans, all of that stuff.
So it's gonna be really, really applicable across various populations, which is I'm sure why a lot of you all are here.
So I had a great introduction to me before here.
So just a couple of things that I'll add is, that I also was a foster parent for seven years and I've adopted three kids from foster care, which sort of gave me an interesting perspective, which we'll talk about in a minute.
The other thing that's very interesting, for those of you who are in ABA, is that there was a recent report that came out a year ago, that at the time, two thirds of BCBAs had been certified in the last three years, which means that the field is full of really new clinicians.
And so being the BCBA for 11 years, it's almost 12 years, is a very odd place because I'm not exactly senior, right?
Those are the BCBAs that got certified before there was an exam 20, 30 years ago, but I'm not brand new.
And so there's this weird group of us in the middle, right?
We're not doing this old school ABA and we're not, you know, brand new clinicians and it really gives me the opportunity, I think, to really affect change, 'cause I was trained by the old generation and I've learned a lot as you know, we've really had the opportunity to listen to autistic advocates who had ABA conducted by this group.
And you all, right, 'cause most of the ABA practitioners and other providers who are at these workshops are most likely part of this new group, really have the opportunity to affect change in the services that we're providing to kids and adults.
So our objectives here is that we're gonna be able to recognize what a trauma event is.
We are gonna be able to define how trauma events can function as setting events, which we'll learn, there are things that cause or make a behavior more likely to occur and then we're gonna be able to implement trauma informed antecedent interventions, addressing the trauma event setting events.
So what that means is we're gonna be able to know how to implement an intervention that targets that triggering trauma event.
So just a few notes for those of you in the ABA field right?
We're gonna assume the trauma events are real, right?
We'll talk about the science later.
Also for those of you who are used to talking to the ABA folks, we're gonna use some casual language here, for ease, for accuracy and for effect, right?
I can operationally define things, right?
Like we do in IEPs, things like that, that says that, you know, being anxious is standing with the heart racing and pacing back and forth, right?
But that's gonna be really annoying and it's gonna take forever, so I'm gonna use words, like anxious, safe, re-traumatize, and I'm gonna use words like kind and mean, right?
I reckon you'd use those in IEP, right?
We're not gonna write those in a behavior plan but I think it's really important that when we're talking about trauma-informed interventions, we think about those words, are we being kind in our interventions, is our intervention just mean, right?
And so you're gonna hear me use those words, but just know that like we really can translate those words and if you like, really need me to do that, send me an email and I'll write you an operationally defined definition and I'll roll my eyes at you, but I can totally do it for you if that's what you want.
I'm also gonna use identity-first language, right?
Which means I'm gonna say autistic people and I'm not gonna say people with autism generally.
I'll switch around just a little bit because autistic people are a monolith, but generally speaking, autistic adults, autistic advocates, the people who are talking to us about the ADA they experienced, say that they want to use identity-first language.
Also, I wanna say that everybody in this training and I'm gonna talk about how to write trauma informed behavior plans.
You need to be sure you're working within your competencies.
So I'm gonna give all sorts of tips, all of these great things, but you need to be sure you're writing these plans with proper supervision and in conjunction with anybody's therapist or psychiatrist or any other mental health provider that should be giving input based on trauma histories.
Also, we're gonna be discussing difficult topics, including COVID-19, we're gonna be talking about abuse and neglect, I'm not gonna be using trigger warnings or content notices because this is a training on trauma, but take breaks if you need to and take care of yourself.
I love communication during my trainings.
Talk to me, send me messages, like I love it, it's great.
We are gonna be doing examples.
You are gonna be wasting your time if you don't type things in the text box or think about it or engage while we're doing examples, this training will be super boring and it's not gonna make any sense if you're not following along with me and doing the things.
This is not a training that you can check your emails and do other things during.
If that's your plan right now, just log off, because you're not gonna get anything out of this training.
If you put questions in the comments, Shelly says she's gonna try to shout them out to me.
I may or may not answer them right now.
If I can't get to them, I'm gonna ask you to ask them again at the end 'cause I'm not gonna remember them.
And we're gonna go through an example at the very end.
So you're gonna leave with a trauma-informed intervention for you to take out to the world with you.
And I want y'all to be my best friends.
I wanna build networks and relationships with people.
I don't know how to use LinkedIn, but I made my account and I wanna have LinkedIn friends except for I'm scared of it, but I do know how to email.
So if you wanna email me and be my clinical best friend and do trauma informed work with me, send me an email.
Okay, so why am I doing this?
So I became a foster parent in 2011, right?
I had a baby, little, tiny baby, she was two years old and I had been an ABA already for like seven years and she was born and I thought, oh my goodness, I have been leaving these babies, these autistic kids that I'm working with to cry on the ground and doing all of these things and I'm being so mean to them.
Maybe ABA is terrible, right?
And then I had the honor of getting an award from a prominent autism agency.
Right, and I say autism agency, because they're not an organization supported by autistic adults.
And the honor wasn't that I got the grant, the honor is that it was protested by the Autistic Self Advocacy Network.
And people sit outside and I thought, why are these people protesting?
And I listened to them and I said, what is happening, why don't you like ABA?
And they said things and mostly it was about these things that weren't kind about what we do, right?
These plain ignoring, these you know, these follow-throughs without replacement caters and I thought, that is terrible.
That's old ABA, we don't do that anymore.
Right, which is ridiculous, of course people do that.
We absolutely do that, I have a whole other webinar on it.
It's great, you should attend it.
But I started to change what I did and I started to make my ABA kinder.
And I started to make sure that kids had an out.
And I started to make sure that I looked at social validity.
And so then in 2011, I became a foster parent and I started taking the trauma informed classes in order to work with the kids who'd experienced trauma.
And in trauma informed models, right?
Which a lot of you are probably familiar with, you're taught and this is a very basic understanding, if a kid is throwing a shoe at you, you need to hug them, right, you need to love on them, because they're trying to reject you, right?
You love on them, they throw their shoe at you, you love, you love, you love, you don't reject them.
But in the ABA, if a kid throws a shoe at you, you ignore that.
And obviously these two things are different and when you do it in ABA, it usually works.
When you do it in trauma, it usually works.
But when you do it wrong, it's catastrophic.
And so I needed to figure out a way to bridge these two models because sometimes the kids in the trauma-informed situations never stop throwing the shoes and also, we can't expect foster parents to just have shoes thrown out them forever, even while they're trying to build those relationships.
And so I started really thinking about it and really trying to build these models.
And so that's where I came up with this model of looking at trauma as a setting event.
And so that's really what we're gonna focus on now.
And so what we're gonna look at is, the very basics of behavior, right?
Most of you have probably seen this, right?
You've got your data collections, you've got your Antecedents, Behaviors, Consequences and Functions, right?
And so your antecedent, right?
That's what happens right before a behavior.
Your behavior is what you see.
Your consequences, what happens after, and the function is why the kid is doing it, right?
So my antecedent is I see my coffee, right?
My behavior is I drink my coffee.
My consequence is it tastes delicious.
My function is access to my coffee, right?
So as long as my coffee tastes delicious, as long as it makes me feel well-rested, I'm gonna continue to drink my coffee.
Now, if my consequence ends up being that it tastes gross because my milk went rotten, right, and every time I drink my coffee, it's nasty, I'm gonna stop drinking my coffee, right?
So a setting event though makes an antecedent more or less likely to elicit the behavior, right?
And so if you think about setting events, like if you think about this, like for little kids, right?
If you know that a kid has missed their nap, right, or they didn't have breakfast or they didn't take their medicine, right?
Or if you had a fight with your partner this morning, then if I took my cup of coffee, right.
And I'm really, really, really, really tired, seeing my cup of coffee is gonna be way more likely to elicit my behavior of drinking the coffee, right?
If seeing the McDonald's sign is the behavior for ordering a Big Mac, if I miss breakfast, right?
That's gonna be a setting event that makes it more likely that the antecedent of seeing the McDonald's sign is gonna get me to order a burger.
If I had just thrown up, because I have the flu, that's a setting event, that's gonna make it less likely that seeing the McDonald's sign is gonna cause me to order a Big Mac, right?
And so some of these things are directly related, right?
I'm tired, I'm gonna be more likely to do things that are gonna get me asleep.
Sometimes these setting events just make a junkie, right?
If I'm tired, I'm gonna be less resilient.
And so like, anything is gonna cause me to be more likely to tantrum.
We should always be looking at setting events, right?
Or antecedents, right, we all know that, but we should also be looking at setting events.
And we often forget that when we write our behavior plans, when we write our IEPs, we're always like, make sure the room is quiet and make sure we stand between exits and make sure they, you know, you give a quiet space, right?
But we just throw things at the wall.
We're not intentional about it.
And so that's, what's really important here.
So is everybody like clear?
You know, I know we have like a variety of experiences here, but is everybody like on-board with all these categories.
Is anybody like so miserable 'cause I just explained, and you like hate me and you're gonna run away now?
I know you're not gonna actually put that in the chat, but no mystery at all, thank you.
See, I just needed some like validation there.
Sometimes though I missed it, it went away.
Okay, but I am sure somebody said something really important just now, okay cool.
All right, thank you for my validation.
I actually hate that I can't see people and interact with people like in their faces in these webinars.
So sometimes I just need to know that everyone is like here with me.
Oh, thank you, Anam, I think, says that I'm doing great, so thank you.
So we're looking at an example of Markos here.
So this chart is really big and really overwhelming.
So try to like look at it for a second, unless you have like a big, giant screen, you're not gonna really be able to appreciate it, but we're gonna look at it in like a smaller bit here.
I promise you, it's gonna look like that, so don't stress out, but I just want you to look at it in its whole picture right now.
So this whole picture is ultimately what your entire intervention is gonna be mapped out in.
Okay and so I just wanna super quickly, you guys can see my arrow, right?
Yes, okay, cool.
Okay, so what we're gonna map out in this is just these boxes here and these boxes here in this training, okay?
But there's two other trainings which we're gonna do on the next two.
So we're gonna do this one in the next training two and we're gonna do this one in training three.
And so by the very end, you're gonna have an entire comprehensive intervention.
So what we just talked about just now though, is our antecedents, our behaviors, our consequences and our functions, right, and our setting events.
And so ultimately when you have your entire intervention, I'm gonna go through this really fast.
It's probably gonna be overwhelming if you're not into this, but I'm just gonna say it super fast for some context and we'll move on and it'll make sense later.
But basically what it is is that we have our things, right?
We have our setting events, our triggers, our behaviors, all of that and then below here, are gonna be all of our interventions, right?
In this row here, is all of our interventions.
And at each step here, we have the opportunity to interrupt the interventions.
And once one doesn't work, we'll move to the next and this is how we're gonna be able to implement our entire plan here.
It's really cool, it's super awesome.
So we are gonna look at Markos here.
So we're gonna follow three friends throughout this entire workshop and so Markos is one of our friends.
And so the information actually that we have on Markos, is that he's four years old, with two vocal words, he can say pee-pee and cookie.
He's potty trained, he's ambulatory and he's got age-appropriate motor skills and he's diagnosed with autism.
When he sees a cookie, he jumps up and down and screams and his mom gives him a cookie and the data shows that it's more likely to occur if he skipped breakfast.
You don't have to memorize all that, but just some background.
So we know that when Markos sees a cookie, he jumps up and down and screams and he hits his mom, and his mom gives him a cookie, right?
So we fill that out in our form here.
And again, these are kind of copied and pasted sort of out of order but just so they fit here.
So we know here, he sees a cookie, we moved our behavior down there so it would fit.
He jumps up and down and screams.
He gets his cookie and presumably, his function is access, right, 'cause he wants this cookie.
So we know that he's more likely to do it if he missed breakfast, right?
So it's set up here, this is a very basic.
so now we need to think about what our interventions are.
So we wanna make sure we put in an antecedent and an intervention, right?
The easiest antecedent and intervention is if the antecedent is he sees cookies is hide the cookies.
All right, it's super simple, make sure there's no cookies out and then he's not gonna see the cookies and jump up and down or scream, right?
I went to a therapist, so I was observing and he was super good and he was working with this kid and then he was running goals and they were doing something fun and the kid just kept grabbing his water bottle and he kept moving the water bottle and moving it out of the way and doing things.
Suddenly I was like, hey, why don't you just take the water bottle away?
And it was such an easy thing and we just forget, right?
So hide the cookies, we're good to go, right?
And if you do that, well, that may just be the end of it and we may no longer have behaviors and we just keep the cookies out of sight, right?
The other thing is though, he missed breakfast.
If we have an IEP, that's like, make sure he's out of reach of people who can kick him and stay in the headphones and all of that.
Well, that doesn't really address what the issue is, right?
The issue is, is he missed breakfast.
So let's put in a plan that makes sure that he has breakfast and so right here it says, feed him breakfast, right?
But really you should have things in place that are gonna make sure that happens, right?
So what are some things we could do to make sure this kid has breakfast that can be part of our intervention?
Amy, yeah, there are copies of this presentation that will be handed out.
Yeah, so wake up on time is what Emily says.
So what we would wanna specifically say is set an alarm, at X, Y, Z, so there's time to eat.
Yep, Elizabeth, exactly, feed breakfast at school.
Yep, ask the family before the day starts if he's had breakfast.
Makes sure the family has resources to feed, exactly.
And so if our issue, right, give preferred foods.
So if our issue really is that he's Hungary, we'll just feed him breakfast and if we feed him breakfast, maybe that's just gonna address our problem.
And then we're not gonna have any behaviors of him jumping up and down and screaming.
Now what we'll talk about next time is like, we still have to address the fact, when he wants a cookie, he's hitting his mom and we can remediate that skill and we can teach him how to say cookie and all of that stuff, right?
Like all of a sudden, he still needs to have language to say cookie, right?
But we're not gonna have to teach him how to say cookie while he's hitting his mom because now we've addressed the two reasons that he's hitting his mom.
And so now potentially we've just, gotten rid of the problem behavior and we don't have to have sticker charts.
So we don't have to have interventions and we don't have to have, you know, physical management, and we don't have to have any of that nonsense 'cause all we had to do was put the cookies in the cupboard and make sure the kid has cereal.
Good, we're groovy, super cool.
So Chelsea says we can't remove cookies from the whole world.
No, this isn't a forever intervention.
Because like I said in the next training, we're gonna talk about remediating skills, right?
But for right now, our behavior chain, is he sees the cookie in his kitchen.
And the idea is to prevent behaviors.
So you can remediate skills versus having to remediate skills while the crisis is still happening.
'Cause whatever, you can have crisis over here and remediate skills over here, we do that forever.
But like you don't have to.
All right, so let's look at Hawa.
So Hawa's 10 years old and speaks in full sentences.
She has delays in emotional regulation and sensory integration, she's got a diagnosis of fetal alcohol syndrome.
When she's asked to clean her room, she runs from the room.
The majority of the time the babysitter says, "Fine, I'll do it, nevermind." We observe that when she slept for only three hours, this increases the likelihood of the behavior.
So up here, Hawa has to clean her room.
She runs from the room, the babysitter says, "Fine, I'll do it, nevermind." What is the antecedent?
Asked to clean her room, that's right, behavior.
Runs, runs, runs, runs, runs consequence.
Yep, babysitter says she doesn't have to do it.
Right, function is escape, right?
escape, shouldn't that do it?
That's the official word escape, right?
Same thing, doesn't have to do it, whatever, escape.
Okay, so do we all remember what it said?
That her setting event was, does anyone remember what that was?
I can go back to the page if people don't remember.
Lack of sleep, yeah, three hours of sleep, okay.?
So what would be a simple antecedent intervention for her?
So we know the antecedent is she's asked to clean her room.
What are some things that we could do for the antecedent intervention?
So the time, yeah, that would be for the setting event intervention.
So we're getting stuck on the setting event.
So we want to go with the antecedent first.
So we want an antecedent intervention.
So the antecedent is cleaning the room.
It's super common to mix these up, which is why we're doing it, but we really wanna separate them out, so that we don't conflate them in our interventions.
Right, so Emily said, don't ask her to clean her room.
That's always an option, right?
You never have to clean your room again, right?
Nick says, don't ask her if she hasn't slept.
So that's interesting, yeah, Cassie, I would probably give her smaller steps.
Right, break it down in the small parts.
Again, it would on her, but probably I would do small steps, offer to help her, do it with her.
Yeah, checklists are useful, a timer is useful and say, you know, let's do it with this.
Ask her to pick up three things, right?
Yeah, as the antecedent and intervention has to do it in smaller steps.
Visual, make sure you're not interrupting preferred activities, backwards chains, yep.
So all of these are really, really good examples, right?
And so the antecedent is go clean your room, right?
Which is a big task, maybe we need to back it all the way up to she doesn't have to clean a room, but probably a more useful intervention for the purposes of this is to start it off with something more functional that she can do in small steps.
So now all y'all who are super excited about setting events, which I love is that we know she gets tired.
She's sleepy, three hours of sleep, so how can we address that setting event with an intervention?
Sleep routine, yep, napping.
Earlier bed time, yeah, napping is so tricky though 'cause then once they start napping, then they don't go to bed at night and then check for a medical reason, sleep hygiene is so important.
I have a kid with insomnia and getting her to do her sleep hygiene like now that she's 12, she finally realizes like what a difference it makes.
Another thing too that you can do for an intervention is make sure that they get exercise during the day 'cause that can help them sleep.
Cassandra absolutely, ask her why she's not sleeping.
But yeah, you know, make sure electronics are off by a certain time.
Yeah, so you guys get to the deal, right?
We're doing an intervention to help sleep, right.
'Cause again, if we can remove her being tired, then maybe she's gonna be more resilient when we ask her to do her room, because again, being tired can affect your executive functioning too, right?
And so if cleaning her room is difficult with executive functioning skills and again, then you have your antecedent interventions of your visual checklists or things like that, which can support if she has a medical reason for insomnia or things like that.
Right, so they go together.
And so if your setting intervention doesn't work, then you can possibly catch it with your antecedent interventions.
All right, last friend, Brendan.
Brendan is six and developmentally on track.
He's diagnosed with generalized anxiety disorder.
When he's asked to wear a mask, he shouts, cries and throws up.
His father lets him stay at home.
It appears the issue is wearing the mask and not the location they're traveling to.
We have observed that this occurs more frequently when it is hot outside.
So you guys can put this all in one line, 'cause you were becoming experts here.
What is put in A for antecedent and then the word B for behavior, C for consequence.
And you can just shorthand it.
Asked to wear mask is our antecedent, that he can just throw up, behaviors, and everybody doesn't have to be both, you can just pick your favorite.
Shouts, cries, throws up is our behavior, escapes.
Yep, doesn't have to go home.
And our function is, escape.
I saw a question that says, what's the process of assessing the antecedent?
So what you do is you like actually take data and it's really hard for families to do.
But you have to do it in order to get it accurate because people remember things terribly and so literally, what you do is like every time he shouts and cries and throws up, somebody has to write down what happened right before.
So if you've decided that the behavior is throwing up, like, oh my gosh, this kid, you know, does this thing.
You know, Markos kicks and hits me.
Okay, well, all right, every time he kicks and hits you let's see what happens.
And so then I would write down, asking for a cookie.
He saw a cookie, he kicked me and I gave him the cookie.
And so we would write those down in like patterns and like, see what happens and then we would look for the pattern because then you need to see, is it frequently because you can hit and kick me.
You can see a cookie and hit and kick me.
That doesn't mean that you're hitting and kicking me to get the cookie.
It could mean that you're hitting and kicking me for my attention.
It could mean that you're hitting and kicking me in order to get the cookie.
It could mean you're doing it because you're trying to get sent to time out and escape whatever's happening in the kitchen.
Or it could be you're doing it because it feels good.
There's some sort of sensory need that's being met there, it would be pressure or something.
The only way you'll know is if you track what happens immediately afterward and what is the pattern from there.
So if afterwards the majority of the time I yell at the kid and say, stop hitting me for cookies, well then it's probably actually attention.
If the majority of the time I give them a cookie, it's probably access to the cookies.
If the majority of the time I sent him to timeout, then it's probably escape from whatever it is in the kitchen and if really neither of those happen or it's kind of inconsistent or if he's sort of just kind of doing it in all situations, that actually may be a sensory thing.
And so that's the way that you figure that out.
I do have to tell you though, it's really, really hard to ask parents this.
And this is a problem that BCBAs do is can we just say like, parents write all those things down and your behavior intervention is gonna be a complete failure if you don't do this.
And this is my job, right?
I am a BCBA, I am a good BCBA, like, you all have heard me talk and you probably have a good sense that I'm like super good at my job.
I have four kids, right?
Three have special needs, two have fetal alcohol syndrome and one has a physical disability.
And I had a BCBA come to work with my littlest kid when she was one for like early intervention for, not autism, it was weird, she was way too young for it.
It was before, I would not do that now.
And sort of one-year-old, a two-year-old and two five-year-olds and they all disappeared in my house, right?
I hadn't really given birth to three of them and she says to me, I need you to take data, I got this.
And three days in, I had my hands in one girl's hair, 'cause three of them are black so you have to, you know, really, really take care of the hair.
It's very important, so I had one of the girls, my hands in one of the girl's hair and I had two kids fighting each other.
So I had my like, leg over them and then I had another kid like crying on the ground and I was supposed to be taking data on behavior.
And I like burst into tears and I was like, I'm a failure as a mom, I'm a failure as a BCPA.
And so the BCBA came over and I was like, I can't take data.
And she was like, well, I have four kids and I was able to.
And I said to her, I was like, well, how old are they?
And she's like, well, the youngest was nine and the oldest was 16 and I just walked away and I told my husband, I was like, I'm never gonna talk to this woman again.
And so again, I'm glad that happened to me because it made me a better clinician.
But parents are not clinicians, they're human beings.
And so we have to just be careful and our teachers, right?
Are all of the people that we're asking to take data, we have to figure out ways to do this.
And so a good way to do it is to have like circles on the data sheets.
If you like generally know what could be, like causing these things to happen.
Like, you know, you can guess, right?
I think this kid is probably hitting his mom for cookies, but like, we're not sure, we really need to do our due diligence and make sure.
And so you can have little things to circle, like, am I yelling at him and I doing this?
And we also have to give permission to teachers and parents to be making mistakes because they have to answer honestly.
So if I'm yelling at my kid, because they're crying for a cookie, like I have to feel safe enough to be able to admit that to you, even though I know I'm supposed to be like telling them, I understand they have sad feelings in their heart.
So anyway, that's a bit of a tangent, but I'm super glad you asked that question because typically when I do this training, people have that background and so recognizing that some people may not have that background was really helpful.
So Brendan, and he's actually a really good example here of how we can get a little bit more in depth into this, because now at this point, so I talked a lot.
So do we remember what his setting event was or should I go back?
It was hot, yep, Emily.
So it was the one that's hot outside, he was more likely to do this.
Yeah, so what could be an antecedent and intervention for us to do with Brendan?
And obviously it could be, he doesn't have to wear a mask, but let's assume this is a medically, necessary thing because of COVID.
So what are some things that we could do besides telling him to not wear a mask?
Social stories about masks, different types of masks.
So Michelle, that's really the key here.
There's lots of different things that could, so Melissa dressing appropriately for the weather would be more of your setting event intervention, because that's about talking about heat.
Heather, same thing about masks in the fridge.
Nobody has suggested that before, that's actually a really cool but that would also be around the heat because that's addressing the heat issue.
But now I lost track of who said, about the choosing the masks, again, that's the number one thing that we should be doing right?
Is we should be looking at what is it about the mask, right?
What is the problem, is it the type of mask?
Is it the smell, is it the detergent?
Like, there's gotta be something about the mask.
Somebody just said, try it over the mouth and not the nose.
So that would be more of like the behavior intervention, because that would be like shaping the behavior.
So that would be something that would go over there.
So setting times during the day to take it on and off, again, that would be more of your behavior interventions.
So you wanna think about what are we gonna do when we say you have to put your mask on.
So this is gonna be something to address the initial, it's time to wear your mask.
And so we know he's asked to wear his mask, so how are we gonna address that thing there?
And so it's the problem with wearing the mask.
So what is the issue with the mask is what we're trying to address?
Yep, give them choices.
Right, somebody said a shield, that is potentially an option.
Turn it into a game is an option.
Right, instead of asking him to turn on a mask, put on a mask, do the put on a mask game.
That's a really good one, too.
Y'all are super creative, I need to do more of these trainings without BCBAs, they're all boring, you all have fun things.
So then now yes.
Talking about why he needs to wear masks, yep.
Texture thing, yep.
So now if we're looking at the setting events.
So we know the setting event is he's hot, so then how are we gonna address the setting events?
So we had somebody talk about putting the mask in the like refrigerator, which is super cool, I love that idea, I kind of want like a mask in the refrigerator now, a mini-fan, I like that.
So a cool treat would be a consequence intervention.
And so that's what we would do as like a reinforcer.
Yeah, cool compress to cool him down.
Somebody else said earlier, weather appropriate clothes.
And this is why we can go through these things, right?
It's 'cause people are like, this is a great idea and they are great ideas, right?
But we wanna make sure we put them in the right category because if we have an intervention that's like here and here and here and here, then we miss targeting each of these steps, where we can interrupt the behavior as we go.
Corey suggests putting the mask on, like inside where it's cool, which yeah.
So anyway, so you guys understand the point here.
So now let's talk about exactly what a trauma event is.
So trauma on its own is a real thing and it can be defined.
Something that's interesting I just thought was worth noting is that trauma and PTSD are two different things.
So PTSD has a diagnostic criteria on the DSM and the DSM-IV and the DSM-V are different.
The majority of kids that we're gonna be working with, actually, aren't gonna qualify for PTSD on the DSM-V, but it doesn't matter as far as us working with them.
All of these same things would apply, but many of them would have qualified under the DSM-IV and one of the main things is that, to qualify for PTSD people have to have had exposure to actual or threatened death, serious injury or sexual violence and more of the following ways.
So it's directly experiencing it, witnessing it, learning about it, that occurred to a close family member or friend and experiencing repeated or extreme exposure to the details of a traumatic event, but that would be like for a first responder or something.
So not really like a child, but that does not include media.
Whereas in the DSM-IV it included people who felt like they were at risk, whether or not they actually were.
And that was a difference and also you could, because we had kids who were experiencing media things.
We had kids who were, you know, experiencing particularly populations we work with, who had these moments where they felt like they were in life-threatening danger, but now they won't qualify for PTSD if they like weren't actually.
So it's an interesting change, it was quite controversial.
And then intense helplessness was another one that was there before, that's not there anymore.
According to the National Child Traumatic Stress Network, trauma events are defined in sort of the obvious ways that you would expect, right?
Abandonment, life-threatening the loss of a caregiver, domestic violence, bullying, life-threatening health situations, witnessing community violence, loss of a close adult, police activity of a close relative, loss of a caregiver, chronically chaotic environments.
All of these things that, you know, would sort of go on the list if you thought, like what was trauma.
The highlighted things, so I think are really important to recognize because those are things that all of our kids have experienced with COVID, or potentially experienced or have most likely experienced, particularly when things shut down.
And I don't know how much it looked out in Canada, but I suspect it looked very similar, but you know, the day things shut down, it was one day with no notice and it was just down.
Yeah, so it was a lot and really, with this collective trauma that our kids have experienced, it's really what's given me the opportunity to be able to reach a wider audience with this messaging, because not only has it given me these online platforms that I wouldn't have had, it's also given the network of providers the opportunity to see and realize what trauma is doing to our kids.
Yes and definitely it is still going on for sure.
It was just that everybody experienced it in one second.
Yeah, and so not having your needs met because of communication skills, 100%.
And I think that this is like a controversial thing and they haven't done any studies here, but I think it's really important to note that the definition of neglect, early childhood neglect, is not having your needs met as an infant, when you are communicating your needs.
And if we have children who have communication disorders, who we're trying to communicate with even their most devoted caregivers and those caregivers couldn't understand what those communications were, it is not unlikely that those children experienced some level of experiences of neglect.
And so I think that that's an important thing.
Yeah, this carries over to all populations and actually, Corey, I'm really glad that you brought that up.
So this is a thing as I talked about, like everybody can continue to grow all the time.
There is a problem in our field that we infantilize people with autism.
I mostly work with children, I actually started my career with adults but I work with children.
So when I talk, I tend to talk about children, but we shouldn't be, we should be saying people.
And I constantly have to remember and constantly fail to talk about people with autism as children.
And they're not children, it's a full range of ages, just like the whole rest of the world and so it is something that we should all keep in mind.
The other thing on this list here is chronically chaotic environments.
This is something also I wanna point out to people is that our field, the education field, ABA, all of that is a field dominated by white women.
And as a result, what we bring to that is our cultural values and biases.
And that can refer to what we assume may be baby traumatic spaces for the kids that we work with.
And it's really important that we're aware of that as we come into spaces and that we're not making assumptions about the experiences that the clients we're working with or the students we're working with are experiencing.
And so it's just really, really important that you're thinking about that and thinking about those lenses, even if, maybe you're not in that, you know, if you're a part of that, you know, population and that your programming isn't focusing on social skills and coping skills that are for a middle-class white woman and that they're actually appropriate for the age and demographic of the student that you're working with.
Yeah, Amanda, it's a good point.
She says, it's a white woman dominated in practice and white men dominated in the research world.
And it's all problematic.
I mean, the entire point is that we need to be sure that we're actually creating programming that's appropriate to the clients that we're working with.
So trauma isn't observable, but trauma events are.
So we need to think about how we're just determining, how we are defining trauma events when we're looking at programming.
And so one of the ways to do that is with the ACE scores.
Are any of you all using ACE scores?
Okay, so it seems like there's a mix.
So ACE scores are interesting so you don't have to have like a special like certification or anything, they're available from the CDC, they're useful.
And I think some people are like, yes, I use them.
And some people are like, I don't like to calculate them or whatever.
Yeah, I don't actually like do the number either, but I kind of sort of keep them in the back of my mind when I'm working with clients.
They're not perfect, they have some like assumptions in them that I don't think are great but they are a tool to kind of have like a baseline for what trauma is.
It is an assessment that lays out sort of the risk of trauma and risk factors.
And there are a lot of studies associated with it that are really interesting.
And so basically it's a list of several questions that sort of list out like it's yes or no, have you experienced these trauma events?
And so there are things that you would expect, right?
Like, has a parent or adult in your household, you know, grabbed, slapped, pushed or thrown something at you?
Have you felt like nobody loved you?
Did you often have food to eat or had dirty clothes or whatnot?
You know, some of the things like number nine is, "Was a household member depressed or mentally ill?" All right, which I think is problematic because you can have a family member with mental illness who's completely stable.
So that's not necessarily a traumatic risk factor at this point, but nonetheless, it gives a normalized standard for things.
The thing about the ACE scores though that's really interesting is that it is tied though, specifically to long-term health, the poor long-term health outcomes.
And it's got some of the things that you would expect from, you know, trauma such as like, you know, an increase in, you know, injuries, but also there's an increase over time that the higher your ACE score is the more likely you're going to engage in alcoholism, drug use and smoking, but also medical conditions, obesity, diabetes, heart disease, cancer.
And then it also affects achievement as far as both academic success and then attendance time at work as well.
And so obviously this doesn't correlate to an individual human, my ACE score is very high, but I am a very successful human, but it's really important data to recognize that individual trauma events, do have long-term affects on people that is measurable.
And that we should be aware of that.
The neat thing about this though, is that as a field, we are able to, be a part of this and support.
And so as BCBAs but also as clinicians, I see that there are things coming up in the chat, they're coming too quickly for me to read them.
So I may need you to like repeat those later.
That the CDC has strategies and approaches for how to address the issues in the ACEs.
And, you know, they're not like identifiable treatment goals that we can put into behavior plans or IEPs or any of those things but I think it's really exciting because it indicates that what we're doing can have real effects on these longterm projections for people who have high ACE scores.
And so some of the things here that jump out is that, we hid all of these categories under the Teach category, that the CDC lists out.
And so one of the things that, for example, right?
Is that it says that one of the strategies is to promote social norms that protect against violence and adversity.
And so, you know, we obviously don't like specifically have men and boys are allies and in prevention, right?
That's not like a program we have.
However, we have the opportunity to create social skills programs for our men and boys, around social skills goals that are culturally and age-appropriate around being kind humans, right?
And around having the social values that match what their parents and what their communities want that can prevent continuing the cycles of abuse and trauma in their communities.
We also, you know, this ensures a strong start for children.
We are this category, right?
We have the opportunity to do these early interventions that help parents to learn the skills to stop generational trauma and also to give kids the skills so that they can improve and have additional opportunities for growth, to address any skill deficits or needs that they may have from early trauma and also to prevent any effects that future trauma may have, and also just to build up skills that they may have from any of the situations they may have experienced.
And so you can see that it sort of continues with that as we go through these categories.
And so I just think that that's super exciting, that we're involved in this, you know, that we're a part of the system already.
Okay, anybody have any questions or anything before I jump into the next section?
I actually can look back and see what people were saying here.
- [Shelly] Saundra, it's Shelly.
I think one of the questions I noted toward the end was around consent requirements, so if you're thinking about using the ACE assessment, are there specific requirements around, you know, written consent from caregivers and that type of thing that you're aware of?
- So with the ACE assessment, that would just be, I mean, anytime you assess a child, you have to get parent consent, but almost always we do the ACE through the parent.
So yeah, but yeah, at least here we can't do any assessment on a kid without a parent consent.
You would use this, Corey, you would use this for adults.
Your ACE score is based on what happened to you before 18.
So the long-term effects for your like, long-term health effects and all of those things, are based on what happens to you before you're 18.
But like I said, I don't use this, like with what I do intakes, like I will ask families directly, like, have you had like, you know, interactions with foster care?
Like, is there a history of, you know, I'll ask a couple of questions around like, you know, any issues with like, you know, abuse or neglect or whatever?
But I don't like ask all 10 of these questions and you'll be amazed how often parents will be like, oh yeah, I know the kid was in foster care for two years and like they'd never mentioned it otherwise, but then when you ask directly, they'll be like, oh yeah.
Okay, we on board, we're good?
Is this new information to people, this trauma stuff?
Or did you come in and all-knowing about the trauma stuff?
Okay, cool, all right, so we have variety here.
All right, so Applications to ABA and Behaviorism.
So this is gonna like tie it all together.
Okay, so combining ABA and trauma-informed practices is we're calling them, so trauma events are also setting events, right?
So that's this thing that like makes it all work magically in this ABA thing and so we call it a TESE.
So basically it's the trauma trigger.
The trauma trigger, TESE, trauma trigger.
If I was doing this in an ABA conference, I could only call it the Trauma Event Setting Event, or everybody would be all like dramatic.
If you're a BCBA, please just let me say trauma triggers.
So everybody's not a BCBA, it doesn't get all like confused and not know words, such as trauma trigger.
So I'm gonna like go like a little bit back and forth between those terms but that's basically what we're talking about here.
So, remember a setting event makes a behavior more or less likely to occur and you have to be aware of them or your interventions are a waste of time, right?
Because if I haven't slept, then I'm just gonna kick you no matter what, because I'm tired, no matter what you do.
So examples of Trauma Event Setting Events, right?
So the trauma triggers, might be that you were, or like the trauma events that you've seen in the past, are witnessing domestic violence, right?
Being hit by a parent, being in a car crash, right?
The day school shut down, all of those things we just talked about on the other sheets, right?
But these are discrete events when we're talking about this, because I'm not a trauma therapist, right?
This isn't, you know, trauma informed CBT, right?
This is not psychotherapy, this is behavioral therapy.
So we're still engaging in observable behavior, observable events, so I am not saying, this kid had trauma in a broad sense, right?
I am saying this kid had a traumatic event.
There was an event that happened and that event was they were not fed for five because their mom didn't come home, right?
Or the event was that they saw their dad hit their mom and send her to the hospital.
Now we're not always gonna know the specific details.
We're not gonna know what day they didn't get fed, right?
We're just gonna know that they came into foster care and it was neglect because the file's not full.
But when we talk about this as a concept, it's important to recognize that, that's what we're talking about though, because we don't wanna get stuck and be too mentalistic, because this is still our science, this is still behavior analytics science, because otherwise we can't write effective interventions.
And so again though, be sure you're consulting with your mental health providers when you're doing these interventions.
So we wanna make sure that we're doing our antecedent interventions related to our setting events, regardless of if it's trauma, but particularly when it's trauma, right?
So one way to do a setting event intervention, right, is to make sure the setting event doesn't occur.
Right, so we did that already, we talked about that.
So you make sure the setting event is that they don't take their medicine, then you make sure they have their medicine, right?
You can teach the kid how to do that.
We'll talk about that with the behavior stuff.
We can also do things though, like calming strategies right?
So if our setting event is the kid is super anxious, they're super worried, they're really just off the hook, a setting event intervention can be to, you know, be calm and safe.
It can be taking deep breaths, or it can be sorry, it's things that we do.
So it can be building a relationship with the kid.
It can be making sure that we are calm and safe, it can be posting rules up.
It's not things that they do, it's things that we do.
We can also changed the environment.
So we can reduce stimulation.
We can remove access to harmful things, right?
So these are all antecedent interventions that we could do related to any setting events but they can also apply to the trauma events.
So with our kids, who've experienced trauma, the setting event interventions are way more important than any kind of intervention that we can do.
Because if I've experienced food deprivation, you could give me as many stickers as I want to, I am gonna fight you for food.
You can do any kind of follow through.
You can tell me that I need to sit down and clap my hands.
If I have had a history of not being fed, and you do not have an intervention in place to support that anxiety and to support that need, we're gonna be wasting our lives.
Before you do any of these interventions though, you must rule out any medical issues, because we may think that the kid is acting out because they had food deprivation issues, but maybe they have an ulcer.
So we really need to be not get stuck on trauma, we need to make sure there's not a medical issue first.
Okay, so let's look at these TESE antecedent interventions for Markos, okay?
So we'll remember that the first person or that Marcos was our first friend, he's four years old with two vocal words.
He says pee-pee and cookie.
He's potty-trained ambulatory, and has age-appropriate motor skills and he's diagnosed with autism.
When Markos sees cookies, he jumps up and down and screams and his mom gives him a cookie.
The data show that he is more likely to occur if he didn't eat breakfast.
We have just learned that Markos experienced early food deprivation.
So his trauma event, right, is food deprivation.
So some Trauma Event Setting Event interventions, right?
So some interventions we can put in place to deal with this trauma setting event, are things like we could create a food schedule for him.
Right, so he's gonna know exactly what he's gonna eat and we could put out an any time food, so you can have free access to veggies.
So now that there's gonna be less anxiety around food and he's not gonna need to fight over a cookie because there's gonna be less of a need to be concerned about food.
We needed to address the history of the lack of access to food and it'll reduce the uncertainty, but the food will be available.
And so these are kind of two examples.
And so this is kind of what at any-time-food thing looks, this particular kid really liked orange food.
And then this is kind of an example of what a food chart could look like.
Questions about that?
Okay, so let's look at, real quick you guys can do this, so we just learned that Hawa is in foster care and experienced parentification.
So that means she had to take care of her whole family.
Cook and clean, do all of those things.
She was responsible for caring for her two younger siblings, feeding them, taking care of the house and getting them to school.
So what is her trauma of it?
Yeah, caring for a family.
And so what are some examples of setting event antecedent interventions?
So antecedent interventions that we could do to address that trauma for her, that we could put in place.
So remember, these are the things that we do.
They're nothing she does, they're things that we do to address that trauma and prevent it from feeling and causing that anxiety for her.
Yep, so make sure that the requests are appropriate, make sure there's a schedule of what she's responsible for and a schedule for what the staff is responsible for or her parents.
Yep, exactly, a job chart.
We used to have a mommy chart, daddy chart, mommy jobs, daddy jobs and kid jobs.
Now, the thing about that though, that's really important, is you need to make sure that if you put something on the adult chart you have to do it.
So if you're somebody who like never sweeps, just don't put sweeping on the chart, you could have an unswept house, that's fine.
But don't put sweeping on your chart if you're not gonna actually sweep, because then it's gonna cause the anxiety 'cause the job's not getting done.
Okay, so Brendan has experienced a worldwide pandemic and he's lost access to his school, his friends and his nanny in one day, plus his grandmother died of COVID.
So what's his setting event?
What's his trauma setting event?
Yep, COVID, loss, the pandemic, Everything that's awful in the whole wide world that we're all dealing with, right?
And so what's a way that we could address that, right?
This one's a hard one, it's hard for us 'cause we're all in the middle of it too.
But what are some things we could do to help address this?
Validate it, yeah.
Talk about it, so Cassandra, what are we gonna talk about?
And Emily, what's your social story gonna talk about?
Talk about what we can do to say safe, calming strategies.
Talk about hope, yeah, so think about this, right?
He's gone through that, review things he can control, yes.
So social stories are great.
We can talk about, yes, keep routines as normal as possible.
Talk about COVID, right, we have just spent the last year, you know, whatever telling him he's gonna die if he goes outside, right?
Like I wouldn't want to go outside.
I like went to a barbecue and like, there were like five friends and I like left after 30 minutes 'cause I got scared, right?
Like we've drilled into these kids that they can't like go anywhere and so it makes sense if somebody is like anxious about it.
So we can talk about COVID, right?
And how you can be safe and how you cannot, which I think somebody mentioned.
You know, give him control in other areas of his life, absolutely.
Talking about how it makes sense to be nervous.
One of my kids, you know, she decided she wanted to move her room around, but she wanted to move it in a way that was just like physically impossible.
Like the stuff wouldn't fit and she threw a fit.
She just like destroyed her room, it was awful and like from a behavior analytic standpoint, you would think, oh, well maybe we can get her new comforters or paint her walls, but it wasn't about her room, right?
It was about the world had shut down and she lost everything and she wanted to control something.
And so we went ahead and let her like choose what bedtime was and she picked from 7:30 to 7:46 and to this day it's been 18 months and the bedtime is 7:46, it's very important.
And so, yeah, so again, that that's gonna be just like a really, really important thing.
And so with all of these kids, right, if we weren't addressing that trauma trigger, we're not gonna be able to target the intervention, right?
If Marcos was worried about not eating, you're not gonna be able to move forward with an intervention.
If Hawa is worried about parenting you, she's not gonna clean her room and if Brendan thinks he's gonna die if he leaves the house, it doesn't matter what you do, he's not gonna put that mask on and he's working himself up so much, he's throwing up.
But by putting these three interventions in place, you know, by addressing the antecedent, the setting event and the trauma setting event, it's possible, we'll just stop the behavior in its tracks.
And that's really cool.
So Tanya, you don't always need to know the exact trauma trigger, right?
Because we generally know the history of our kid, right?
We generally know a bit of their background and not always but we call it, trauma-informed basic precautions, right?
And when we talk about it later, we'll talk about the consequences and how we can do trauma informed consequences, 'cause you know what, whatever, we can have the best intervention in place.
And I could like not, you know, I could do all of that, I could have the anytime food and I could put away the cookies and I could make sure he takes his nap and he could still hit me in the face.
And so then we still have a consequence intervention after that, that can address that, right?
But we still generally know, right?
This kid was in foster care, this kid used to be held down all the time at his old school, you know?
This kid has, you know, communication delays, right?
We generally know what the deal is with our students, even if we don't know like exactly, exactly, and we're able to sort of place these interventions, which we are gonna do right now.
And so if you can take a kid that you're thinking about, and maybe you can make it work.
So let's try it and if you get stuck, maybe we can walk through it.
So we are gonna look at our own kid right now.
So if you could take out a piece of paper, this is gonna be ideal.
Actually no, your best bet is to do it in the chat right now and then you can write it down on a piece of paper later and so what we're gonna do is I want you to think about a kid, right?
Spend like one minute, 'cause we are close on time, but it's okay, we have enough time.
When you think about a kid on your caseload or human on your caseload, somebody you're working with, if you don't have a caseload right now, be your like own child but we shouldn't do therapy on your kid because it sets you up for failure, but you know, or think of an imaginary person, but think about a kid, think about their deal, right?
Think about the behavior you wanna target.
I haven't taken data on it right now, so we're gonna be estimating on this, but it'll be okay.
So I want you to in the chat right now, please do not put any identifying information in here.
As you feel comfortable, you can either write it down on your paper if you want to but it's helpful if you put it into the chat.
I'm gonna start asking what's the behavior, what's the antecedent and I'm gonna start correcting things?
I'll be like, oh no, that's not a behavior, that's consequences, I'm gonna go through this real quick.
I'm gonna go through it quickly and by the end, you're gonna have a really good understanding of this and it's gonna be applicable to a kid you work with.
All right, let's go, so people throw out what behaviors that are we talking about right now?
Fighting, hitting, hating private instruction.
Okay, Corey, just be sure you define what sleep hygiene is, as far as like in your head, you don't have to tell me, but make sure you know what that means as you're addressing it.
Okay cool, all right, throw out your antecedents and consequences and functions.
If you need to break it down one by one, that's fine.
Heather, if you can break down demand more specifically, that's gonna help make this easier for you, but if you know it in your head, that's fine.
Laura, antecedent and setting events might be confined but if you can kind of think about, so your antecedent's gonna be like literally what happened and your setting event is gonna be like some outside factor that makes it more likely to happen in the future.
So like, if that thing wasn't there, then the behavior would be less likely to occur.
And it could be completely unrelated, right?
Like I had a bad day at work yesterday, so I yelled at my kid, that had nothing to do with, like I found out she stole a candy bar.
Me having a bad day at work had nothing to do with her stealing a candy bar.
Okay, awesome, all right, great.
Okay, so now have your antecedent interventions.
So throw your antecedent in with the antecedent intervention next to it.
So like Angelica, you've got being asked to put a toy away and then what's your idea like, so type that in and then write antecedent intervention, what you would do as your intervention.
Okay, Chelsea good, Chelsea has staff close, antecedent and intervention, staff keep a distance.
Okay cool, all right, so setting events.
Okay and if there's anything that you guys are like, I really need help on this one, you guys can put it in the Q&A, so I don't lose it.
Okay, so now do the same thing and do setting event and then next to it, do your intervention.
Your setting event intervention, not the trauma one, do your regular one.
So somebody asked about ignoring a dangerous behavior.
So that is consequence intervention.
So that would be not an antecedent intervention.
Remember an antecedent intervention prevents the behavior from occurring.
It's not a response to a behavior.
So we're not there yet.
Lots of tired kids.
Okay, rough morning with parents, check in with feelings.
Yep and so that one, so Cassandra has got that, she had a rough morning with the parents and then like a check-in with feelings.
The other thing you could do with that too, is like a little bit of free time in the morning, like downtime too, it's just like a remove instructions for a period of time in the morning, so if that would be helpful for the kid, to just like reintegrate, so things like that.
Okay, all right and so then now the last two is our Trauma Event Setting Events and our antecedent intervention there.
And so this one here is you're gonna lay out what your trauma event is, now again, it may be vague.
Okay, so Chelsea, go away with pecks as a behavior.
So if they couldn't communicate when they were alone for our antecedent interventions, that would be something like a rules card that says like in our house, everybody can ask for their needs or a wall of communication or making sure they have the ACE board.
And so it's a tool that we're giving them.
It's a small distinction, but it's an important one.
Yep, so attachment breaks and losses, providing lots of love, snowball time, yep.
Yeah, food deprivation, younger kids eat first.
Yeah, Dana, one of my kids used to steal food, but to give it to their little sister.
The loss in ability to access things, allow access within reason with specific timeframes outlined, yep.
Exactly Vanessa, a posted schedule is really great around what is available when, so there's no uncertainty study around it.
Great, yeah, so again we're at time I see people jumping out of the chat now and so yeah, So this is exactly how it looks.
And so this is the initial.
Yeah, and so Dana, this is the kind of thing that like, it starts like getting these wheels flowing about, like how can we like think about this a little differently?
And so, yeah, so anyways, you can just like, you can use this piece, start thinking about things and you know, some of the stuff you can implement right away and we'll talk more at the next meeting.