The Intersection of Autism and Trauma

Dr. Camille Kolu, Ph.D., BCBA-D Author

04/19/2022 Added

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Tri State Webinar

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[00:00:02.910]Hi, everyone.
[00:00:04.930]Welcome to my talk on the Intersection of Autism
[00:00:09.100]and Trauma and Applied Behavior Analysis.
[00:00:12.320]And I'm just really excited to be joining you today.
[00:00:15.760]And I look forward to all the questions at the end,
[00:00:18.160]and even during this talk.
[00:00:20.260]So my name is Dr. Camille Kolu,
[00:00:22.250]and I have a private practice
[00:00:24.060]that allows me to look at this topic every day.
[00:00:27.250]I just wanna share a few of the ideas
[00:00:29.620]that I've come up with with you,
[00:00:31.680]but I'll also share with you a lot of resources
[00:00:34.330]and some ideas about how you might expand
[00:00:37.180]your own boundaries of competence as we go
[00:00:40.030]in order to start honoring the important experience
[00:00:43.410]that your clients bring to the table.
[00:00:45.620]Now, my big idea that I wanna share with you first
[00:00:49.180]is that I don't think trauma-informed behavior analysis
[00:00:53.150]is any different
[00:00:54.410]than doing great behavior analysis already, okay?
[00:00:57.840]But I do believe it's very important
[00:01:01.270]to document the history somebody goes through
[00:01:03.960]and really to appreciate that history,
[00:01:07.520]even in our functional behavior assessments
[00:01:09.890]in a way that some of us in the field
[00:01:11.700]are only just starting to appreciate.
[00:01:15.040]When someone goes through trauma,
[00:01:16.700]those pieces of their history do confer important risks,
[00:01:21.550]and they sort of change the way practice needs to happen.
[00:01:24.860]And I'll share with you a few examples
[00:01:27.240]as we get deeper into this.
[00:01:29.817]And the last thing I'll say about this
[00:01:31.050]is just how important good team collaboration
[00:01:35.000]is going to be.
[00:01:36.410]It's to the extent that all of my successes
[00:01:39.140]I have to attribute to the collaboration
[00:01:42.120]with many diverse professionals.
[00:01:44.470]They are sometimes behavioral.
[00:01:46.430]Sometimes I'm the only behavior analyst on the team
[00:01:49.820]in a team of about 30 to 40 people.
[00:01:51.930]So this, I cannot emphasize enough.
[00:01:54.830]We have to do this together.
[00:01:57.620]In terms of our learning objectives,
[00:01:59.420]we will discover four different areas today
[00:02:02.920]that really have informed my own practice
[00:02:05.550]and hopefully can confer something useful to yours too.
[00:02:10.010]But we'll sort of go back and forth between a lot of these.
[00:02:13.230]One thing I'm going to do with repertoire components
[00:02:16.170]is highlight some of the work other individuals
[00:02:18.740]in our field, or in behavior analysis,
[00:02:21.960]how some of those works can be intersecting
[00:02:24.820]with what you do.
[00:02:25.830]So we're gonna look at this from a perspective
[00:02:28.380]of what other people have contributed.
[00:02:31.870]Now, I think it's going to help
[00:02:33.420]to understand the literature too.
[00:02:35.250]So in the past five or so years, for example,
[00:02:38.650]researchers are finally starting
[00:02:40.710]to look more into this important intersection.
[00:02:43.350]And we'll hear from a little bit of those later.
[00:02:46.460]I think even those so-called experts
[00:02:49.260]are still only beginning to understand
[00:02:51.980]that hearing from autistic voices is critical too,
[00:02:56.090]and there are more and more
[00:02:57.160]of those opportunities out there.
[00:02:58.980]So please compliment this session with consultation,
[00:03:04.110]continuing education, and training,
[00:03:07.230]and seek out experts who are also autistic.
[00:03:09.970]Learn what assent can mean to your practice
[00:03:12.580]and ask those difficult questions.
[00:03:15.860]I think it will pay a off for your practice,
[00:03:19.470]but also to share this with your administrators
[00:03:22.420]and teachers and any therapists
[00:03:24.630]that disagree with the possibility
[00:03:26.620]that this is so important.
[00:03:28.130]Can they just start that openness?
[00:03:29.640]So how might your clients have been harmed in the past,
[00:03:33.780]or what painful or aversive experiences have they endured?
[00:03:37.320]What have you struggled with?
[00:03:39.190]You know, how have your staff or the parents
[00:03:41.880]that might be difficult,
[00:03:43.070]how have they struggled?
[00:03:44.870]And what do you bring to your role from your own history?
[00:03:47.740]So if you're really open and curious about these questions,
[00:03:51.760]you'll discover a lot
[00:03:53.100]about how your practice might be able to grow.
[00:03:57.420]To do this, we're going to cover autism and trauma
[00:04:00.570]and children, but really critical to let you know,
[00:04:05.150]is that it applies to adults too,
[00:04:07.320]and autistic adults.
[00:04:08.700]Maybe some of your staff are autistic adults,
[00:04:11.340]maybe you are, or maybe you're a staff person
[00:04:14.430]or parent just now realizing
[00:04:16.410]that trauma was a part of your own history
[00:04:18.750]or at your ABA company,
[00:04:21.410]or maybe somewhere you were trained,
[00:04:23.230]that there were practices
[00:04:24.360]that nowadays would be considered traumatic themselves
[00:04:27.870]or inappropriate now that we know more.
[00:04:30.450]So what I mean to do is to open lines of communication
[00:04:33.950]and really provide some tools.
[00:04:37.380]I'd like to examine this overlap
[00:04:40.200]and just share with you a few statistics.
[00:04:43.350]And I think this will help you
[00:04:44.990]look at your target population if you're a clinician.
[00:04:48.630]But it might also help you understand
[00:04:50.890]what somebody near to you needs,
[00:04:53.610]somebody like your child
[00:04:55.720]or your advocacy client or yourself,
[00:04:58.200]and to really look at the risks
[00:04:59.790]that somebody with autism faces
[00:05:01.940]when they've also been affected by trauma.
[00:05:05.670]So let's take a look at some of these areas of overlap.
[00:05:10.840]There are several different studies
[00:05:13.840]that I could cite about this one fact,
[00:05:15.650]that autism spectrum disorders do co-occur with trauma.
[00:05:20.820]And if you have autism,
[00:05:23.890]well, about 50% of you may have already experienced trauma,
[00:05:28.070]and this number might grow
[00:05:30.120]as you tap into other populations,
[00:05:31.900]like autism and aging or autism and seizure disorder,
[00:05:36.910]other things that we can talk about later.
[00:05:39.320]Now, there are some behaviors that are more likely
[00:05:42.510]in clients with autism and trauma experiences,
[00:05:45.680]and Brenner, Pan, and Mazefsky in 2018
[00:05:50.010]have looked directly at what behaviors are more likely.
[00:05:53.390]And they mentioned, this is so urgent,
[00:05:55.360]we need to urge practitioners to do screenings for trauma
[00:06:00.000]to support this big group
[00:06:01.610]where this overlap is particularly important.
[00:06:06.230]Autism is a risk factor itself for experiencing trauma
[00:06:10.600]and children with autism are about 2 1/2 times
[00:06:15.270]more likely to experience foster care.
[00:06:18.640]And that's another intersection
[00:06:20.360]between trauma and experience.
[00:06:24.210]So it's a risk factor either way.
[00:06:26.930]If you have autism, that's a risk factor for trauma.
[00:06:29.600]If you're exposed to foster care, that's a risk factor.
[00:06:32.570]And the area of overlap is even greater.
[00:06:35.080]Now, as I sort of mentioned before,
[00:06:37.150]there are unique risks
[00:06:39.020]for people with autism who face trauma,
[00:06:41.300]but this is also true for people with autism
[00:06:44.470]who are adopted or involved in child protection.
[00:06:48.300]And so this is really, really important to understand.
[00:06:52.360]And this is one reason that I have adopted
[00:06:54.810]and generated some screening tools,
[00:06:57.130]which we'll see a little bit later.
[00:06:58.890]There's so many reasons
[00:07:00.680]for this increased likelihood of trauma
[00:07:02.950]if you've experienced autism.
[00:07:04.980]And some of those reasons
[00:07:06.200]are related to the behaviors themselves
[00:07:08.370]that clients with autism use,
[00:07:10.720]but they can also be related to what caregivers have
[00:07:14.550]and what our education system has to offer.
[00:07:18.430]And so we're gonna see examples of all of those
[00:07:21.140]in a few minutes.
[00:07:23.710]On this area of overlap,
[00:07:25.760]your clients with autism might be at risk
[00:07:28.850]of facing social isolation.
[00:07:30.820]So this could be true for all children.
[00:07:34.270]Of course, we all face difficulties,
[00:07:36.390]but we're talking risks of additional challenges
[00:07:38.680]specific to having autism, risks of being excluded,
[00:07:42.660]risks of being educated in isolated environments,
[00:07:46.520]which also relate to the availability
[00:07:49.990]of trauma-related factors.
[00:07:51.350]So we'll talk about that more later too.
[00:07:53.600]A strong social network can really confer protection
[00:07:57.450]against those inevitable challenges with peers,
[00:08:00.560]but people with autism are at greater risk
[00:08:02.850]of lacking that kind of important support.
[00:08:05.630]And the research shows us that this can be very protective
[00:08:09.560]in such a way that I encourage people
[00:08:11.800]to do some training just in this
[00:08:15.369]so that this is an area of protection,
[00:08:18.510]it helps against bullying,
[00:08:20.350]it helps against trauma though too
[00:08:22.870]from a medical perspective.
[00:08:24.780]And we'll see a little bit of research later
[00:08:27.060]by somebody named Nadine Burke Harris,
[00:08:29.770]who has done some of the research on buffering factors,
[00:08:33.010]including social support.
[00:08:35.250]And third, we've all heard about tragedies,
[00:08:39.870]like somebody trying to report abuse or bullying,
[00:08:43.580]or even trying to respond to trauma,
[00:08:46.010]but finding that their listeners just do not understand,
[00:08:49.490]or maybe adults fail a student
[00:08:51.590]and misinterpret these heroic attempts as misbehaviors.
[00:08:56.220]So some of these are feeding into the next thing here,
[00:09:01.530]and a higher rate of mental health challenges
[00:09:03.850]and psychopathology symptoms.
[00:09:05.960]So all of these can kind of start to interact
[00:09:09.230]when somebody has autism
[00:09:11.090]and just confer real challenges to education
[00:09:15.610]and to their accessing the world and their social network.
[00:09:21.150]Interestingly, I thought, children with ASD
[00:09:24.070]who attended full inclusion classrooms
[00:09:26.300]were at even higher risk
[00:09:27.840]than self-contained classroom students
[00:09:29.760]when you actually look at the literature.
[00:09:31.740]And as I mentioned,
[00:09:32.670]the literature is sort of in this fledgling state right now,
[00:09:35.790]but people are starting to do it.
[00:09:38.810]So as you can see,
[00:09:41.460]this is so important for the population
[00:09:43.810]with whom both you and I do a lot of our work
[00:09:47.570]and the population that perhaps you or I are a part of.
[00:09:52.580]So it's so important for us
[00:09:54.050]as behavior support professionals or related staff,
[00:09:58.030]to be able to know what do we need
[00:10:00.640]in terms of our repertoires.
[00:10:02.710]So that's what objective one is all about.
[00:10:05.260]I think it's so crucial when autism is involved
[00:10:08.140]because the very behaviors that come with autism
[00:10:11.500]can be risk factors themselves.
[00:10:13.750]You know, having behavioral needs
[00:10:15.130]can mean that we're at risk for experiencing things
[00:10:18.470]like seclusion or experiencing the system
[00:10:22.500]or experiencing inappropriate prompting.
[00:10:26.240]And as a consultant, you know,
[00:10:28.230]I've seen the second problem a lot.
[00:10:30.320]So people who use so-called challenging behaviors,
[00:10:33.810]they're at risk for going through inappropriate prompting,
[00:10:36.950]but also this more sinister prompting
[00:10:39.790]that might border on abuse,
[00:10:41.300]or that might be experienced as aversive
[00:10:44.620]or even traumatic by somebody who's got other trauma
[00:10:48.310]in their history.
[00:10:50.810]This is an example of a client that I had worked with.
[00:10:54.340]And I'm just going to layer some thoughts
[00:10:56.590]that she might be thinking here.
[00:10:58.920]So at first you see her at school.
[00:11:01.380]She says, "I'm really distracted in class today.
[00:11:04.460]I keep zoning out.
[00:11:06.130]I'm not sleeping at night.
[00:11:07.840]We have a new foster brother, he's molesting me.
[00:11:10.410]I don't know how to tell.
[00:11:11.810]I don't know how to ask for help."
[00:11:14.490]So the client must be exhausted, as you can imagine.
[00:11:17.450]And just be under this terrible strain and stress
[00:11:21.420]of the trauma that they cannot communicate.
[00:11:24.490]So the client tries to say no, it doesn't work.
[00:11:28.140]So let's suppose a paraeducator is there
[00:11:30.660]trying to do her job for the day.
[00:11:33.060]And she doesn't know let's realize
[00:11:35.000]what's going on at home.
[00:11:37.260]So she continues to try to communicate with the para.
[00:11:41.140]She thinks, "Oh my God,
[00:11:43.050]is she going to start hurting me too?
[00:11:45.080]Now she's grabbing me."
[00:11:46.500]Perhaps the para from her perspective
[00:11:48.480]is prompting right now.
[00:11:51.300]This is still not working, what should she do?
[00:11:53.660]The para keeps prompting.
[00:11:55.310]The client has to up the ante.
[00:11:57.380]Do you notice that?
[00:11:58.810]They're probably being flooded with sensory experiences,
[00:12:02.110]paired with the assaults going on
[00:12:03.830]in that different environment.
[00:12:06.040]And she hates this.
[00:12:07.100]She says, "At least before,
[00:12:08.680]I was gonna get my favorite book,
[00:12:10.280]and now everything is ruined.
[00:12:11.650]I'm crying, I'm so embarrassed."
[00:12:13.860]The kids are all staring at her.
[00:12:16.260]The client gives up,
[00:12:18.010]and restraint and seclusion are imminent.
[00:12:20.890]And whoa, you know, stop to take that in for a second.
[00:12:24.520]You may be experiencing some distress just watching this.
[00:12:28.140]Can you feel the hopelessness of the autistic person?
[00:12:32.040]Can you feel their shame
[00:12:33.430]in being exposed to this situation?
[00:12:36.420]As we clicked through this slide,
[00:12:38.550]I was trying to describe a progression that I witnessed
[00:12:41.750]in a client I knew was going through trauma.
[00:12:45.200]And I was watching in a therapy situation
[00:12:47.740]for a company who insisted trauma doesn't matter.
[00:12:51.300]Well, all they cared about
[00:12:53.200]was knowing the function of behavior in the moment.
[00:12:55.970]Is that best in this situation?
[00:12:58.570]The commentary and my words are my own,
[00:13:01.260]but I hope you can see
[00:13:03.780]there's a lot going on there.
[00:13:05.040]There's history, and there's a well-meaning paraeducator.
[00:13:09.309]And there are conditioned responses to respondent
[00:13:11.750]and physiological stimuli and sensory experiences,
[00:13:16.080]there are operant learning histories.
[00:13:16.953]There's so much going on, right?
[00:13:20.930]So yes, they're at risk for experiencing the system
[00:13:24.750]and inappropriate prompting,
[00:13:26.730]also for being exposed to restraint or seclusion.
[00:13:30.950]What behaviors did you read about?
[00:13:32.750]They were pushing a hand away.
[00:13:35.140]So the client was saying no, the client was kicking.
[00:13:37.970]The client was biting themselves.
[00:13:39.610]We learned they were about to scream and fall down.
[00:13:42.700]Well, perhaps the plan said if those behaviors occur
[00:13:46.840]and you cannot prompt the behavior of compliance
[00:13:50.280]at that point, you go to restraint or seclusion.
[00:13:54.210]So in my example, maybe the system
[00:13:56.620]is the child welfare system or adult protective services
[00:14:00.600]or the educational system.
[00:14:03.820]I've basically seen this happen across all of them.
[00:14:06.690]Somebody uses a so-called challenging behavior.
[00:14:09.810]It increases their likelihood of being exposed
[00:14:12.640]to a series of cascading interventions
[00:14:15.750]incorporating restraint or seclusion.
[00:14:18.580]Could be a timeout room, a calm down area,
[00:14:21.370]being restrained by hands or even by medications.
[00:14:25.300]So I know we're not talking much about solutions right now,
[00:14:29.140]but you might wanna start looking at your checklist
[00:14:32.030]called Safer Autism that I've provided
[00:14:35.730]along with this training.
[00:14:38.470]So you are also at more risk
[00:14:40.900]of programming experiences that might include
[00:14:44.730]either inappropriate procedures or targets.
[00:14:47.350]So first I want you to know
[00:14:49.670]that none of these would be inappropriate all the time,
[00:14:53.260]just as none of these are appropriate
[00:14:56.490]all the time, okay?
[00:14:59.520]So a behavior analytic trainer
[00:15:01.810]or somebody in a classroom who's an educator
[00:15:04.370]with behavioral expertise,
[00:15:06.790]you know, we need to know
[00:15:07.790]that this should happen on an individualized basis.
[00:15:10.560]There should be no behavioral plans that are boilerplate.
[00:15:15.510]Now, imagine that you're a paraeducator
[00:15:18.010]who knows that student we described earlier.
[00:15:21.800]And here's what she said to me.
[00:15:23.070]She said, "Should it matter that Cindra just got back
[00:15:27.010]from being sex trafficked?"
[00:15:29.200]She said, "Do I still have to start on
[00:15:31.380]with following instructions today?
[00:15:33.720]I mean, she seems really upset.
[00:15:36.210]Can't I just sort of get to know her again?"
[00:15:38.980]And this question sort of stunned everybody
[00:15:41.490]when the paraeducator brought this to their attention,
[00:15:45.160]because some staff knew the real reasons for her absence,
[00:15:47.840]but there was a behavior analyst who was unaware
[00:15:50.680]and that person had been focused on function in the moment.
[00:15:54.700]And the staff is trying to say
[00:15:56.370]I'm uncomfortable with this program.
[00:15:58.930]So what do you think?
[00:16:03.500]So some of these targets might not be appropriate
[00:16:07.550]on a really hard day.
[00:16:09.040]And that's what I want you to come away with
[00:16:11.700]is that as behaviorist or as supporters
[00:16:15.400]of students' behavior, we need to be thinking
[00:16:18.130]what's the best case scenario for this client
[00:16:21.880]who is going through the worst case scenario for them?
[00:16:25.460]We've got to avoid cookie-cutter plans like the plague.
[00:16:28.970]And you know, it's not just about
[00:16:31.210]avoiding certain procedures.
[00:16:32.480]It's the fact that when you really individualize,
[00:16:35.360]it might look different than what you thought.
[00:16:37.980]So we can't make assumptions.
[00:16:40.060]You have probably seen this article already
[00:16:42.980]if you're a behavior analyst,
[00:16:44.600]but just take a look at this title for a second,
[00:16:48.500]On the Effectiveness and Preference
[00:16:50.700]for Punishment and Extinction Components
[00:16:54.090]of Function-Based Interventions.
[00:16:56.160]Check that out for a second.
[00:16:57.370]This is sort of mind-blowing.
[00:16:59.690]I find it pretty darn interesting that when we assume,
[00:17:02.770]even when we think we're using best practices,
[00:17:05.780]we're often wrong for individuals.
[00:17:08.530]And this finding by Greg Hanley
[00:17:11.190]and Piazza and Fisher and Maglieri
[00:17:13.990]is pretty unexpected if you haven't seen it.
[00:17:16.360]So they say this findings,
[00:17:19.950]and this is in their abstract,
[00:17:21.960]these findings suggest that the treatment selection process
[00:17:25.660]may be guided by person-centered and evidence-based values.
[00:17:30.090]In other words, you don't have to give one up.
[00:17:32.090]You don't have to choose between evidence-based
[00:17:34.750]and person-centered.
[00:17:35.920]You can do both.
[00:17:37.830]So they evaluated client's preference for these components
[00:17:40.700]and they found some clients preferred something
[00:17:43.780]that you would've thought, or I would've thought
[00:17:46.080]is aversive, but it wasn't to that client.
[00:17:48.969]So check this study out
[00:17:50.870]and then understand its implications
[00:17:52.530]for individualizing treatment.
[00:17:55.470]Now, when you don't individualize programs,
[00:17:57.870]you end up with things that look the same for everybody
[00:18:00.290]and work for maybe the majority,
[00:18:02.260]but are very harmful to one or two students
[00:18:05.840]in your classroom, or even more,
[00:18:08.130]with the rates of trauma as they are.
[00:18:09.970]This could apply to token systems, level systems,
[00:18:14.020]using the same prompt hierarchy for everybody,
[00:18:16.610]using the same behavior reduction program for everybody.
[00:18:22.010]And I think that there are a few behavior analysts,
[00:18:25.010]one of them is gonna be Greg Hanley,
[00:18:27.610]the guy who was the lead author
[00:18:30.150]of that paper I just mentioned, who sort of get it.
[00:18:34.470]And one of these other guys are Pat Friman,
[00:18:37.910]Dr. Pat Friman.
[00:18:39.700]And I'm also gonna mention Dr. Kim Crosland
[00:18:42.560]and a few others.
[00:18:43.520]So each of these people have contributed something
[00:18:47.080]to behavior analysis that I would call
[00:18:49.880]pretty trauma-informed.
[00:18:52.350]Dr. Greg Hanley's approach
[00:18:54.380]is you might remember the happy, relaxed, engaged learner.
[00:18:58.590]If you're on Facebook, you can find a PFA, SCA,
[00:19:02.800]which refers to synthesized contingency analysis.
[00:19:07.290]You can find a Facebook group for that
[00:19:09.090]with lots of fantastic resources
[00:19:11.530]and guiding professionals who do this.
[00:19:15.130]And Dr. Friman piloted
[00:19:17.320]sort of the circumstances view of behavior
[00:19:20.020]and made that more popular with his TED Talk.
[00:19:22.650]I'll also talk a little bit here about Kim Crosland.
[00:19:26.550]And so she works in Florida,
[00:19:28.390]and I was just in awe
[00:19:29.860]when I saw her functional analysis paper
[00:19:32.890]on teen runaway behavior.
[00:19:35.000]So if you're looking for articles
[00:19:37.040]within the trauma population and behavior analysis,
[00:19:40.370]you can find them, but they might not
[00:19:42.470]always be in behavior analytic journals.
[00:19:45.250]And for Kim Crosland, you're gonna find some of her work
[00:19:48.170]in social work journals.
[00:19:50.920]Other behavior analysts just really continue
[00:19:53.400]to transform our approach.
[00:19:55.280]And one of these people is Dr. Jeannie Golden.
[00:19:58.460]I love some of her papers with Walter Prather.
[00:20:02.320]You notice that on this screen,
[00:20:04.350]everybody that I'm mentioning here has a slide beside them.
[00:20:07.740]And that's because I've done screen grabs here
[00:20:11.550]from Association for Behavior Analysis International
[00:20:16.140]and their trauma-related talks.
[00:20:19.140]So the one in the middle, Dr. T.V. Joe Layng,
[00:20:22.070]was not specifically talking about trauma,
[00:20:25.170]the other two are, and the next slide I'll show are.
[00:20:28.880]But all of these are continuing
[00:20:30.410]to offer something really impactful
[00:20:33.130]with respect to how we treat trauma in behavior analysis.
[00:20:36.850]We've also got Elizabeth Houck,
[00:20:39.220]who's at University of North Texas
[00:20:41.130]and is looking at trauma
[00:20:43.497]and how it changes the behavior of people
[00:20:46.410]out in state school environments,
[00:20:49.240]people who have intellectual differences.
[00:20:52.300]Then we've got Paula Flanders.
[00:20:54.150]I watched her incredible talk
[00:20:56.340]and she spoke a lot about how she changes her practice
[00:20:59.900]of behavior analysis
[00:21:01.890]if she knows somebody has been through trauma.
[00:21:04.300]The important thing about her professional background
[00:21:07.330]is that she's also a social-emotional support therapist,
[00:21:10.820]and I really loved her work.
[00:21:12.220]So any of these people that are on your screen
[00:21:16.080]are great to follow if you're going to conferences
[00:21:19.100]and you wanna see some of their work.
[00:21:21.840]So I'm gonna use these ideas
[00:21:23.760]and then kind of parse them out
[00:21:25.040]in terms of repertoire components.
[00:21:27.120]The first person I'm mentioning is Joe Layng.
[00:21:29.490]You saw one of his slides a second ago.
[00:21:32.100]He often works with Dr. Paul Andronis
[00:21:34.087]and they were both students of their mentor,
[00:21:37.270]Dr. Izzy Goldiamond.
[00:21:39.280]Their constructional approach,
[00:21:41.690]or what you might have heard
[00:21:43.000]as nonlinear contingency analysis
[00:21:46.440]has been a real life changer for my own practice,
[00:21:50.260]and we'll see a slide about what that is in a moment.
[00:21:53.190]In it, we don't just look at the function of behavior
[00:21:56.010]in the moment, we look at alternative sets of contingencies.
[00:22:00.410]And so in other words, what somebody's going through now,
[00:22:03.950]and if they have the ability
[00:22:05.610]to switch over to something else that's effective
[00:22:08.680]and what they did in the past,
[00:22:10.250]and how those things worked out for them.
[00:22:13.230]As a resource, you might check out their new book
[00:22:16.660]on "Nonlinear Contingency Analysis,"
[00:22:19.270]and it really levels up your practice
[00:22:21.550]if you haven't seen it before.
[00:22:23.630]If you haven't seen it before,
[00:22:25.130]this is Joe Layng on the top,
[00:22:27.030]while his mentor, Goldiamond, is on the bottom there,
[00:22:29.760]and the book is great,
[00:22:31.460]but there are some foundational papers
[00:22:33.210]as well in the literature like this one.
[00:22:36.460]So one thing I love about it is that,
[00:22:39.450]so I'm gonna contrast nonlinear analysis here on the right
[00:22:43.870]with linear analysis on the left.
[00:22:46.400]One thing I love about it
[00:22:47.510]is that you just don't have to look at behavior
[00:22:50.220]in terms of its consequences,
[00:22:51.930]in terms of its immediate antecedents
[00:22:54.830]and payoffs, in other words.
[00:22:56.740]When you're doing basic linear analysis,
[00:22:58.880]you're looking at the ABCs of behavior,
[00:23:00.860]nothing wrong with that, except it's limited.
[00:23:03.700]It doesn't look into the past.
[00:23:05.580]It doesn't look at a bunch of alternatives for the person
[00:23:09.120]and why those aren't being utilized now.
[00:23:11.930]It doesn't look at what history brings.
[00:23:14.340]Nonlinear analysis on the right side does.
[00:23:18.090]Nonlinear analysis views behavior
[00:23:20.400]in terms of its history too,
[00:23:22.530]and the history of its alternatives.
[00:23:25.490]And it's very powerful
[00:23:27.690]in terms of transforming your view,
[00:23:29.660]I find, of a client.
[00:23:32.030]And so Joe Layng says this about client's behavior.
[00:23:35.530]He says, "If you look at it through this perspective,
[00:23:39.530]you can see that behavior is not maladaptive.
[00:23:42.410]It's not dysfunctional,
[00:23:44.040]it's functional and highly adaptive."
[00:23:47.000]They even go so far as to quote a social worker,
[00:23:51.030]Eileen Gambrill, I think her name is,
[00:23:53.990]who talked about the true heroic nature of clients
[00:23:58.180]and how we can finally reveal that nature
[00:24:00.570]if we look at behavior
[00:24:02.470]in terms of its history and the contingencies.
[00:24:05.680]And so this is a beautiful way
[00:24:07.560]to conceptualize behavior after trauma.
[00:24:11.210]Some more behavioral repertoire components
[00:24:14.280]that I think Greg Hanley contributes
[00:24:16.290]is we have to be able to learn a contingency analysis
[00:24:21.000]that takes more into account.
[00:24:22.930]Have you ever seen somebody's work
[00:24:25.960]and you think, "Well, okay,
[00:24:27.410]they did a great functional analysis.
[00:24:29.200]They pinpointed attention,
[00:24:30.420]but I know this student really well,
[00:24:32.900]and I sort of think that it's mixed.
[00:24:35.860]It's several different things
[00:24:37.210]contributing to their behavior in the moment."
[00:24:39.080]And you know what?
[00:24:39.913]It changes, it changes on different days.
[00:24:42.520]It's not always a function of escape.
[00:24:45.090]It's a function of lots of things.
[00:24:46.490]Well, if you've had that conversation
[00:24:48.500]with yourself or others, you're really going to appreciate
[00:24:52.000]what Dr. Greg Hanley offers
[00:24:53.490]and look at his practicalfunctionalassessment.com site,
[00:24:58.480]or to get just a flavor of it,
[00:25:00.880]check out his interview with Matt Cicoria.
[00:25:03.140]Matt has "The Behavioral Observations Podcast,"
[00:25:05.650]and I find it super interesting all the time,
[00:25:08.840]but Greg Hanley's episode is great.
[00:25:12.480]Now, some people believe,
[00:25:14.570]as Dr. Greg Hanley states here,
[00:25:16.720]that ABA is already trauma-informed,
[00:25:19.200]and he goes through a few ideas
[00:25:21.290]for why this is and how it could be.
[00:25:23.980]So for instance, you know,
[00:25:25.320]when we build and maintain trust,
[00:25:27.870]when we follow the client's lead,
[00:25:30.430]when we work on listening to them
[00:25:32.750]and not working people through noncompliance,
[00:25:36.330]all of those things are wonderful.
[00:25:38.770]They're parts of making sure ABA is trauma-informed.
[00:25:43.520]I am going to disagree that that's all that TIBA is though,
[00:25:48.030]because I really needed to bring other pieces to the table
[00:25:51.210]to minimize risks my clients have gone through.
[00:25:53.860]And I'll talk about what I add to this idea
[00:25:55.980]a little bit later.
[00:25:57.880]Behavioral Repertoire Components brought by Pat Friman,
[00:26:03.390]you may have seen his paper
[00:26:04.570]about why we have to study emotion.
[00:26:06.760]It's a little bit older now, but it's really important.
[00:26:09.890]I also love his idea about look at behavior
[00:26:12.920]in terms of the circumstances somebody's going through.
[00:26:16.400]It's not just behavior that's appropriate or inappropriate,
[00:26:20.010]but what is the person going through?
[00:26:22.320]And he's got a great article about this now,
[00:26:25.970]but he's also got a TED Talk out about it.
[00:26:28.130]So you could Google him and find either of these.
[00:26:30.920]This is what the article is called in "JABA"
[00:26:34.320]if you're looking for it right now.
[00:26:35.547]"There's no such thing as a bad boy,
[00:26:37.460]the circumstances view of problem behavior."
[00:26:42.830]In terms of additional repertoire components,
[00:26:45.450]I'm going to combine a couple now.
[00:26:48.250]Neither of these are strict behavior analysts,
[00:26:50.600]Dr. Karen Weigle does behavior analytic work.
[00:26:53.670]Dr. Bruce Perry is a psychiatrist.
[00:26:56.220]Basically they teach us
[00:26:58.490]that we have to learn to help somebody move forward
[00:27:02.600]without presenting demands.
[00:27:04.510]This is important for when you're building rapport
[00:27:07.430]with somebody after trauma,
[00:27:09.540]demands function differently for everybody.
[00:27:12.740]And I think that this means
[00:27:16.330]for me, I need to learn how to operationalize demands
[00:27:20.600]individually in people's behavior plan.
[00:27:23.480]So if my presence functions as a demand for my client,
[00:27:28.390]or if saying, "Great work sitting in your chair nicely,"
[00:27:32.350]if that functions as a demand for one of my clients,
[00:27:35.670]I need to know that, and I need to put that in the plan.
[00:27:38.550]Well, you might also enjoy this resource,
[00:27:41.390]Dr. Bruce Perry's book with Maia Szalavitz.
[00:27:44.550]This is a great book if you haven't read it already,
[00:27:47.037]"The Boy Who Was Raised As A Dog,"
[00:27:49.240]to understand stories
[00:27:51.070]from a child psychiatrist's perspective
[00:27:53.300]on how they treat trauma.
[00:27:55.260]Again, I wanted to emphasize that we don't,
[00:27:58.550]you know, behavior analysts are not treating the trauma.
[00:28:00.980]We're treating behavior after trauma.
[00:28:03.930]But you're gonna learn a lot
[00:28:05.840]by looking through how somebody else approaches trauma.
[00:28:10.060]Dr. Jeannie Golden is somebody who sees trauma differently.
[00:28:14.090]You know, she was someone who adopted a child
[00:28:17.440]who had been from a foster background
[00:28:19.450]and had been through a lot of trauma-related experiences.
[00:28:23.580]She describes that child's progress
[00:28:25.920]and some of the wonderful lessons
[00:28:27.520]she learned along the way being her parent.
[00:28:30.820]And a couple that I always take from her
[00:28:33.310]when I listen to Dr. Golden's brilliant talks
[00:28:36.220]is that you gotta be able to do microshaping,
[00:28:39.000]understand tiny amounts of progress.
[00:28:41.890]And what that means is you've got to learn to appreciate it
[00:28:45.000]so you can catch it and reinforce it,
[00:28:47.540]but you've also gotta be safe.
[00:28:50.030]You've gotta be a safe person.
[00:28:51.430]And this is gonna come into play later
[00:28:53.290]when we try to provide or even rebuild relationships
[00:28:57.730]for somebody that doesn't have attachment,
[00:29:00.100]or that has some attachment-related challenges.
[00:29:04.200]She just embodies empathy.
[00:29:05.890]But that's crucial, you know,
[00:29:07.650]being able to be empathetic
[00:29:09.640]when there's challenging behavior going on,
[00:29:12.350]being able to be very consistent is huge.
[00:29:16.300]And a couple of her works I think are great
[00:29:20.680]in terms of breaking down these ideas of attachment
[00:29:23.800]in terms of behavior analysis.
[00:29:25.940]And if you haven't already seen them,
[00:29:27.630]you can just Google her name plus Walter Prather,
[00:29:31.140]he's one of our frequent co-authors in this area.
[00:29:35.660]Now, I mentioned a moment ago, Dr. Nadine Burke Harris.
[00:29:39.520]She's a pediatrician, not a behavior analyst.
[00:29:42.730]But she was going to be our B.F. Skinner lecturer,
[00:29:45.140]and she's the California Surgeon General.
[00:29:48.250]She has done some monumental work
[00:29:51.040]on looking at childhood adversity
[00:29:53.160]and how it changes the body,
[00:29:55.590]how it changes the stress response,
[00:29:57.850]how it changes the trajectory of medical problems
[00:30:01.720]for somebody's lifetime.
[00:30:04.220]And she taught me how trauma can function
[00:30:07.050]as a medical variable.
[00:30:09.090]And so at this point, I'm gonna add some of my own ideas.
[00:30:12.200]I think it's so important that we look at what she found,
[00:30:16.520]but also how this can be interpreted
[00:30:19.220]in terms of behavior analysis.
[00:30:21.010]So she speaks about how prolonged inescapable stress
[00:30:25.360]impacts the body.
[00:30:26.940]This is her book over here, "The Deepest Well,"
[00:30:29.470]but you can also find her TED Talk,
[00:30:31.630]you can find lots of papers in medical journals,
[00:30:34.720]like papers in pediatrics.
[00:30:36.970]And she learned all this
[00:30:39.030]from doing practice as a pediatrician,
[00:30:42.480]starting with this little guy named Diego
[00:30:44.650]who absolutely stopped growing
[00:30:47.380]after being sexually assaulted.
[00:30:49.520]And she started tracking this problem in other patients.
[00:30:52.880]She is the one who taught me
[00:30:54.840]that it was so important to screen for trauma.
[00:30:58.290]If you haven't began to screen for trauma
[00:31:00.660]in your behavioral practice, or with the kids you teach,
[00:31:04.000]look at all of these medical problems
[00:31:06.830]that can be related to trauma
[00:31:08.420]and think about how those intersect with behavior.
[00:31:13.290]So if you need more on this,
[00:31:14.580]I hope you'll look up some of her work on that connection.
[00:31:18.620]Now, I have found that trauma does function
[00:31:23.020]as a medical variable.
[00:31:24.640]What I'm trying to bring to the table
[00:31:26.130]is how to operationalize this and how to document it,
[00:31:29.350]why it's important to document it,
[00:31:31.580]how to analyze its interaction
[00:31:33.560]with other behavioral stimuli
[00:31:35.200]and other environmental variables,
[00:31:38.620]and how to document the risks related to it
[00:31:42.040]and communicate with other medical providers,
[00:31:44.940]but also, you know, all kinds of therapists
[00:31:48.470]and educators and social workers
[00:31:50.750]and all kinds of collaborators.
[00:31:54.030]So we've got to understand how trauma functions this way.
[00:31:57.260]This is so important to me
[00:32:00.090]that I made the SAFE-T model just to do it, you know,
[00:32:04.500]just to make sure people know
[00:32:06.890]that providing supervision on a case affected by trauma
[00:32:09.910]is so critical, because if I don't have this experience,
[00:32:13.610]if I don't know how to operationalize
[00:32:15.360]those trauma-related and medical-related concerns,
[00:32:19.500]you can really do some medical damage to someone.
[00:32:23.220]This is so important to assess and document risks
[00:32:27.510]and to do the FBA on not just immediate functions,
[00:32:31.260]but the historical components of behavior,
[00:32:35.050]and to also do better evaluation.
[00:32:37.700]Look at the environment.
[00:32:39.160]Now, I do all of these things
[00:32:42.710]just to make sure clients are safe receiving ABA,
[00:32:45.920]and in some cases I do them instead.
[00:32:49.080]I do them before we ever get to the T in the model,
[00:32:52.700]which is doing behavior analytic training,
[00:32:56.210]doing treatment and triage,
[00:32:58.640]which is just coming together
[00:33:00.380]to really prioritize somebody's needs and treat them.
[00:33:04.720]Sometimes it's more important
[00:33:06.110]to make sure someone's sleeping safely at night
[00:33:09.010]or that they have food on the table
[00:33:10.960]or the transportation to their job
[00:33:13.130]before we do behavior analysis,
[00:33:15.620]or before we try to change behavior, I should say.
[00:33:18.760]So this is kind of a revolutionary look
[00:33:21.040]at what behavior analysis can be
[00:33:23.200]when we do all these things.
[00:33:25.270]Now, there's such an important intersection
[00:33:27.720]for our clientele.
[00:33:29.550]You know, somebody who has ASD
[00:33:31.940]is already exposed to difficult tasks
[00:33:34.900]in education or therapy.
[00:33:36.400]And we already talked about
[00:33:38.130]how somebody might be at increased risk of trauma
[00:33:43.070]just by virtue of having ASD.
[00:33:45.710]They have difficulties or differences with communication.
[00:33:49.760]The importance here is that I'm trying to highlight
[00:33:53.110]how it intersects with things like medical concerns,
[00:33:56.830]and this could be slides and slides,
[00:33:59.620]but I've tried to be limited here
[00:34:01.530]and just mention a couple of them.
[00:34:03.450]And so something like tuberous sclerosis,
[00:34:06.930]which is little tumors all over, including in the skin.
[00:34:10.860]About 45% of folks with TS also have as ASD.
[00:34:16.650]And so that's looking at it
[00:34:17.840]from kind of a different perspective.
[00:34:19.680]They have to deal with painful medical procedures
[00:34:22.900]and things that can produce medical trauma.
[00:34:26.320]So looking at it from a different perspective here,
[00:34:29.120]we've also got co-occurrence of ASD
[00:34:31.390]with all kinds of genetic disorders.
[00:34:33.830]Some examples that I work commonly with
[00:34:35.850]are Angelman syndrome, Fragile X,
[00:34:39.110]Prader-Willi, Rett syndrome, and seizures.
[00:34:44.090]What the second bullet here on the middle
[00:34:46.010]is really highlighting is that ASD does commonly occur,
[00:34:49.710]not all the time, but it commonly occurs with seizures.
[00:34:52.710]Well, often that's with another medical
[00:34:56.140]or genetic challenge.
[00:34:57.780]And then understand that so many people who have ASD
[00:35:02.300]will also end up taking at least one drug.
[00:35:05.300]So in terms of behavioral pharmacology,
[00:35:08.420]we're saying at least 40 to 50% of persons with ASD
[00:35:12.440]will also take at least one
[00:35:14.600]psychopharmacological intervention.
[00:35:17.820]Well, looking at trauma now,
[00:35:20.220]did you know that there are some drug side effects
[00:35:24.940]that will increase your exposure
[00:35:27.010]to punitive or aversive situations,
[00:35:29.870]but also have behavioral effects
[00:35:32.310]that can reduce your likelihood to be able to escape
[00:35:36.380]or to want to escape an aversive situation?
[00:35:40.420]So this is just one example
[00:35:43.920]of a critical intersection for our clientele.
[00:35:46.760]And we're gonna highlight an example
[00:35:49.010]at the intersection of all these things.
[00:35:51.820]Okay, suppose a client has epilepsy and autism,
[00:35:55.910]and unknown to his ABA team,
[00:35:58.390]he's going through abuse in his foster care at home.
[00:36:01.740]Let's say he's learning to follow adult instructions
[00:36:05.620]and he gets hands-on prompting
[00:36:07.400]when he doesn't follow instructions,
[00:36:09.680]but he's on a seizure medication
[00:36:12.500]and a behavioral effect of that drug
[00:36:14.960]is that it decreases his escape behavior
[00:36:18.550]from aversive situations.
[00:36:20.220]Wow, so that would be really dangerous, wouldn't it?
[00:36:25.210]Okay, so here's an example with just anticonvulsants
[00:36:28.750]and you could do this for any drug your client is on,
[00:36:31.307]and this is really important.
[00:36:33.190]Look at the behavioral effects of this drug.
[00:36:35.700]It can act as an establishing operation for sleep.
[00:36:39.120]Have you ever had a student extra sleepy in a classroom?
[00:36:43.970]It can act as an abolishing operation,
[00:36:46.130]in other words, decreased motivation for effort.
[00:36:49.810]It can decrease alertness.
[00:36:53.030]It can decrease speech clarity
[00:36:56.890]and create or even enhance memory issues.
[00:37:00.190]So let's say our child or our student
[00:37:02.810]is going through epilepsy, and it's epilepsy
[00:37:05.670]that targets the memory areas already.
[00:37:07.910]So the drug he's taking, an anticonvulsant
[00:37:11.100]to try to combat the seizures,
[00:37:13.400]is having these behavioral effects
[00:37:15.420]that are really important.
[00:37:16.560]Imagine if you did not know he was on the drug.
[00:37:19.550]Imagine what behavioral providers might do
[00:37:23.670]to try to change his environment
[00:37:25.260]not knowing that all of this is happening physiologically.
[00:37:29.980]So let's imagine it's a regular Wednesday morning
[00:37:33.170]in this school, and the child
[00:37:35.410]is about to have a seizure in here.
[00:37:37.150]Fortunately, this is in place.
[00:37:39.060]There's documentation.
[00:37:40.820]His history of seizures is documented in their chart.
[00:37:44.500]The drugs they take are listed.
[00:37:46.180]The side effects are categorized.
[00:37:48.350]The behavioral side effects are listed.
[00:37:51.130]Other side effects
[00:37:52.140]that change his medical outlook are listed.
[00:37:56.570]And these areas are all highlighted in the chart.
[00:37:58.990]At the same time, there's staff training.
[00:38:01.480]So staff are informed in his history.
[00:38:03.650]They know how his seizures
[00:38:05.000]relate to his current environment.
[00:38:07.550]If he has seizures triggered by bright lights,
[00:38:10.330]they know about that.
[00:38:11.670]They are trained to keep the students safe.
[00:38:13.810]They know how to respond to the antecedents of this seizure.
[00:38:19.150]They are trained in what those antecedents look like,
[00:38:21.190]how to prevent them, what the student will do
[00:38:24.300]and look like during the seizure.
[00:38:25.890]And they're trained to document what happens in the seizure,
[00:38:29.730]how today's events interacted with educational tasks.
[00:38:33.590]And think about this as an outcome,
[00:38:35.300]the student is not gonna fail a test
[00:38:37.600]he was about to take when he started having a seizure.
[00:38:41.610]So we've got team support as well.
[00:38:43.300]Let's say the team members have talked and they've planned,
[00:38:46.680]and they're gonna support the student
[00:38:48.220]in learning and practicing a repertoire of SAFE-T skills.
[00:38:52.500]So for example, the student is learning
[00:38:55.190]to label the different components of her symptoms
[00:38:58.740]to report them, to do safe things or request supports
[00:39:02.600]like naming the antecedent they feel,
[00:39:04.990]or saying, "I need to sit down,"
[00:39:07.010]when a seizure's coming.
[00:39:08.770]And also for the team,
[00:39:09.880]there's a designated safe person
[00:39:12.130]or somebody who's ready to support
[00:39:14.000]and do follow-up training.
[00:39:16.030]Now, the student is supported to do what they need to do
[00:39:19.740]to remain safe.
[00:39:20.910]They might need to eat something
[00:39:22.340]or sit down or close their eyes or lay down
[00:39:25.450]depending on what's happening medically, right?
[00:39:28.520]And they know important members of their team
[00:39:30.700]and who to go to, who's gonna be ready to help
[00:39:33.610]in the moment of need.
[00:39:35.220]But there's one thing I wanna mention
[00:39:37.240]that we don't always consider.
[00:39:38.670]What about peer information?
[00:39:40.250]Well, in this case, everybody around the student
[00:39:43.540]knows what it's like to have a seizure.
[00:39:46.230]They don't feel embarrassed
[00:39:47.350]because it's just a medical thing
[00:39:49.140]some of their friends have,
[00:39:50.610]the way some students have an EpiPen
[00:39:52.510]and they can't touch eggs.
[00:39:54.470]And the peers are supported to do things
[00:39:56.960]that would help keep their friends safe
[00:39:58.360]if there was no teacher available nearby.
[00:40:01.950]So here we have documentation, staff training,
[00:40:04.540]and team support.
[00:40:05.950]Everybody's ready, right?
[00:40:08.800]So the student has all of these skills.
[00:40:12.300]They can tact signs a seizure's coming.
[00:40:14.620]They can request help any time.
[00:40:16.600]They don't have to ask nicely.
[00:40:19.620]Would you look for a second at what you feel,
[00:40:22.760]how it's different if it's a medical trauma
[00:40:25.990]rather than maybe a psychological one?
[00:40:29.520]Do you see what supports could be in place
[00:40:31.790]and how the world could change
[00:40:33.170]if the student had all of these
[00:40:35.150]when it's an emotional issue, not just a medical one?
[00:40:40.110]So what if these things are not present?
[00:40:41.900]Why might that matter?
[00:40:43.630]Well, I think it's easier to see
[00:40:45.640]why it matters for a medical concern.
[00:40:48.610]We looked at that intersection for many of our clients,
[00:40:51.270]but the thing is, some of these factors can be invisible.
[00:40:55.620]So first there's ASD and then there's medical factors
[00:40:59.800]and then there's trauma.
[00:41:01.370]I'm gonna highlight an example
[00:41:02.540]of the intersection of those.
[00:41:05.540]This is the negative example now.
[00:41:07.130]So in documentation,
[00:41:09.300]let's suppose there's no history of trauma
[00:41:11.770]mentioned in the FBA.
[00:41:13.530]He's taking medications,
[00:41:15.760]but those side effects are not listed.
[00:41:18.550]They've been through trauma,
[00:41:19.500]it's linked to medical problems they're having,
[00:41:21.900]but this wasn't included or considered in the FBA
[00:41:25.290]for Staff training.
[00:41:27.320]Staff are not informed about history.
[00:41:29.610]They're not trained to look at antecedents
[00:41:31.570]and consequences that are removed.
[00:41:34.540]So they're trained to look at it in the moment,
[00:41:36.410]but not about history.
[00:41:38.100]They often speculate about what mental illnesses
[00:41:41.020]the client might have
[00:41:42.750]since the behavioral approach doesn't seem to be working.
[00:41:47.410]But when something happens out of the blue,
[00:41:49.220]they just try to desensitize the person
[00:41:51.590]to the antecedent that they saw.
[00:41:54.890]When a trauma-related behavior happens,
[00:41:57.620]they just respond as if it's a typical behavior to decrease.
[00:42:00.700]And all the team members take kind of a similar approach
[00:42:04.030]to all their students at the clinic.
[00:42:06.120]So they've heard there might be some trauma,
[00:42:07.870]but they haven't discussed it as a team,
[00:42:10.510]and they haven't talked about how that interacts
[00:42:12.650]with the SAFE-T skills.
[00:42:13.880]So the student has some good days,
[00:42:17.000]but there are also challenges out of the blue
[00:42:19.640]and they have an emergency plan in their book,
[00:42:22.490]but it's the same as every other student.
[00:42:25.610]In terms of peer information,
[00:42:27.510]her peers are not sure why the student has a hard time
[00:42:30.480]and they've been taught by the teachers
[00:42:32.570]to just try to ignore her behaviors
[00:42:34.550]and the emotional difficulty she has.
[00:42:37.190]Maybe her peers can tell that she gets really upset
[00:42:40.930]when someone else is restrained,
[00:42:42.810]but there's no change in the staff toward her.
[00:42:45.340]They just act like it's no big deal.
[00:42:47.830]So we can see
[00:42:48.990]this is a pretty untherapeutic classroom, right?
[00:42:52.720]Well, what could we do?
[00:42:55.130]I think in terms of behavior and trauma and medical issues,
[00:42:59.330]it's a little easier to see, right?
[00:43:01.720]We might use an assessment or list of questions.
[00:43:04.370]We might screen regularly for changes in skin,
[00:43:07.770]eating, toileting, sleeping,
[00:43:09.750]alertness, behavior, speech, and medical changes.
[00:43:13.590]Well, this can be really important
[00:43:16.450]because we are the closest ones sometimes to our student
[00:43:20.170]and their changing needs.
[00:43:22.270]But all of this stuff could be true for trauma too.
[00:43:24.840]Maybe there are changes in behavior
[00:43:26.430]that seem kinda subtle that nobody picks up on
[00:43:29.150]or takes her to the doctor for.
[00:43:31.670]So what do you do?
[00:43:33.570]Well, we need to begin with a list of questions and screen,
[00:43:37.960]but we also do nonlinear and historical analysis.
[00:43:42.980]So we repeat this when things change.
[00:43:44.990]We update the FBA in terms of what's going on,
[00:43:48.750]how does that affect the present?
[00:43:51.510]You know, what did she go through in the past
[00:43:52.843]that might be contributing to it?
[00:43:55.100]I'm going to show you a little bit later
[00:43:56.820]a couple of tools that I use to do this.
[00:43:58.820]I'll just pre-queue that one of those
[00:44:01.090]is going to be the IPASS,
[00:44:02.910]and one is a screening tool.
[00:44:05.930]Now this goes right along with F1 in our task list.
[00:44:10.030]We have to review records and available data
[00:44:12.700]at the outset of the case.
[00:44:14.120]We should be taking history into account.
[00:44:16.250]It is our role to do that.
[00:44:19.400]I think to do the analysis that I just mentioned though,
[00:44:22.350]we have to be able to fulfill
[00:44:24.570]what is objective two in our talk today.
[00:44:26.820]So now we're gonna move on to some possible ways
[00:44:30.690]that trauma-related terms could be operationalized
[00:44:34.150]in a way that's conceptually consistent
[00:44:36.830]with behavior analysis.
[00:44:39.160]So to start, you might think about
[00:44:41.660]how Jeannie Golden does it,
[00:44:43.390]and she does this for attachment
[00:44:45.580]in that article I mentioned with Walter Prather.
[00:44:48.740]One thing she focuses on is that history that someone has
[00:44:52.890]is not just their experiences.
[00:44:55.230]Yeah, it's their direct experiences,
[00:44:57.370]their contingency-shaped behaviors,
[00:45:00.220]but it's also about verbal behavior.
[00:45:03.130]It's about socially transmitted experiences.
[00:45:06.890]It's about rule-following behaviors.
[00:45:09.040]It's about the things that your community went through.
[00:45:14.000]It's about historical abuse and neglect
[00:45:17.480]maybe that has been entrenched in a culture of racism.
[00:45:22.010]It's about observational learning,
[00:45:23.780]modeling by caregivers and community members.
[00:45:26.620]All of these things I've just mentioned
[00:45:28.780]can confer trauma-related variables to our client's history.
[00:45:33.450]So I'm gonna show you some pictures.
[00:45:35.270]Think about how these different situations
[00:45:37.210]might signal danger and evoke avoidance behaviors
[00:45:41.920]if you had an abusive or aversive history.
[00:45:44.720]Maybe if you've never been pulled over by a cop,
[00:45:47.560]it doesn't bother you to see those headlights.
[00:45:50.690]Perhaps if you've never experienced abuse by a priest,
[00:45:53.870]it doesn't bother you to see a cross.
[00:45:57.270]How might that change though?
[00:45:58.800]So engage in some private verbal behavior,
[00:46:01.840]think about how these ideas might be relevant
[00:46:04.440]to somebody who has been abused by a parent figure
[00:46:08.090]or a person who has been abused by an authority figure
[00:46:12.710]or a person who has been a member
[00:46:15.040]of an historically marginalized community.
[00:46:18.080]So here, we're thinking about
[00:46:19.580]Jeannie Golden's contributions,
[00:46:21.220]and we're talking about conditions
[00:46:23.630]that could disrupt attachment.
[00:46:25.260]So in other words, that's my shorthand
[00:46:27.790]for regularly approaching and having your needs met
[00:46:31.260]by a familiar caregiver.
[00:46:33.460]So what are are some effects
[00:46:35.370]and what are those caused by?
[00:46:37.200]Well, early unpredictable interactions
[00:46:40.320]with your familiar adults might be abuse,
[00:46:44.060]might be neglect, might be abandonment,
[00:46:46.390]might also be something that wasn't their fault
[00:46:48.910]like living in a war zone,
[00:46:50.990]living through immigration as a very young child.
[00:46:54.850]Well, what does this do behaviorally?
[00:46:57.720]It results in discrimination training.
[00:46:59.770]In other words, you learn that you can approach others
[00:47:02.950]when you have needs,
[00:47:04.230]but that's going to be extinguished or even punished.
[00:47:07.430]And at the same time,
[00:47:08.820]taking action to meet your needs
[00:47:11.390]is reinforced by necessity,
[00:47:13.230]and that can breed some kind of bizarre looking behaviors
[00:47:16.450]if somebody doesn't know
[00:47:18.050]that you were actually trying to meet your needs,
[00:47:20.900]as a child who was neglected for example,
[00:47:23.250]and foraging through the trash can.
[00:47:26.730]So when this happens after this kind of history
[00:47:30.310]of discrimination training,
[00:47:32.320]behaviors can emerge that are not appropriate,
[00:47:34.690]quote unquote, "When an adult caregiver is present,
[00:47:38.420]you may see typical development being interrupted
[00:47:41.830]because the behavior stream has to shift
[00:47:44.550]to survival-related behaviors
[00:47:46.630]instead of growth and learning-related behaviors."
[00:47:51.050]So we're gonna look at some downstream effects of those.
[00:47:54.260]There can be conditioning of long-lasting
[00:47:57.040]and harmful condition-motivating operations.
[00:48:00.980]And this occurs via contact with your reinforcers
[00:48:04.250]for unproductive or harmful behaviors.
[00:48:07.240]So could be drugs, could be alcohol,
[00:48:09.630]could be sexual risk behaviors, any of those things.
[00:48:14.340]What are the outcomes here?
[00:48:16.020]Adults may become S-deltas for approach.
[00:48:19.440]If you're not incredibly familiar with an S-delta,
[00:48:22.900]it's simply a stimulus that acts as sort of a signal
[00:48:27.730]that reinforcement is not available right now.
[00:48:30.890]In other words, approach is not gonna be reinforced.
[00:48:34.780]So it's sort of a signal to walk away
[00:48:36.900]if an adult's coming your way.
[00:48:38.500]You got any students who do that?
[00:48:41.610]Another possible outcome is approach from adults
[00:48:44.810]may be not only neutral, but conditioned as aversive,
[00:48:49.470]and the onset of their approach,
[00:48:51.460]you know, when somebody starts to notice your behavior
[00:48:53.750]and come over to you,
[00:48:55.540]that may be established as an SD,
[00:48:58.290]or in other words, a signal
[00:48:59.950]that means threat-related behaviors
[00:49:02.600]are gonna be reinforced.
[00:49:04.720]So what does that mean?
[00:49:06.120]Avoidance is gonna be more likely
[00:49:08.540]in the presence of an adult paired with this.
[00:49:11.970]There may be environmental changes
[00:49:13.910]that are correlated with the adult's approach
[00:49:16.660]that kind of enter into new relations
[00:49:19.500]with other aspects of the environment,
[00:49:21.170]even things you didn't expect to be related
[00:49:24.000]start to get roped in to this relationship.
[00:49:27.780]So how do these functions layer and combine
[00:49:30.820]for somebody who's got both autism and trauma?
[00:49:35.570]I'm gonna share an example,
[00:49:36.710]but first I want you to think
[00:49:38.040]only about the regular functions of behavior.
[00:49:41.640]So we're gonna do that with an example
[00:49:44.550]about a child I'm calling Aniyah.
[00:49:48.253]And for this student, we're gonna think
[00:49:49.940]what would change if we knew the historical content
[00:49:53.470]of Aniyah's behavior?
[00:49:54.760]How could context add meaning in other words?
[00:49:58.660]And how would it change what you chose to do
[00:50:02.130]about the behavior as an educator or a therapist?
[00:50:06.210]Well, here is her example.
[00:50:10.090]She's a girl with autism.
[00:50:11.700]She's described by her teachers as spirited and helpful,
[00:50:15.800]but as somebody who also struggles
[00:50:18.100]when people other than her team members try to help
[00:50:20.880]and a BCBA is often called to the class.
[00:50:23.920]Well, today they see her lying under a desk,
[00:50:26.540]she's banging her head and she's screaming.
[00:50:30.810]Now, more context.
[00:50:32.170]It's a holiday, her regular teacher's gone.
[00:50:34.690]There's a male substitute teacher.
[00:50:36.780]They've been in the class all week.
[00:50:38.080]Things have been getting worse.
[00:50:39.370]Now she's avoiding all demands by screaming.
[00:50:43.580]Today, apparently her screaming escalated
[00:50:46.200]and the male teacher says
[00:50:47.710]he tried to put a worksheet on her desk
[00:50:50.080]instead of just walk away.
[00:50:51.920]She started to throw things, destroyed property,
[00:50:54.810]she's hitting herself.
[00:50:56.180]The security guard enters the room,
[00:50:58.520]he restrains her, but eventually the team
[00:51:01.140]has to just back out.
[00:51:02.400]They call a police escort.
[00:51:03.780]She goes to the hospital.
[00:51:05.320]Her medications are stabilized
[00:51:07.450]and she skips school for the rest of the week.
[00:51:10.000]Okay, what are the behaviors?
[00:51:12.300]Screaming, property damage,
[00:51:14.450]there was self injury.
[00:51:17.540]What are the functions?
[00:51:18.540]What are the treatment options?
[00:51:19.810]That's what I want you to think about right now.
[00:51:21.650]So let's look at some of the evidence from the example.
[00:51:24.240]We saw she skips the rest of the week.
[00:51:27.870]She's avoiding demands, security guards rush in,
[00:51:32.680]there's a hospital visit.
[00:51:33.860]Okay, so the first of those two bullets
[00:51:36.670]look like avoidance, and maybe the second two bullets
[00:51:40.980]over here, they look like attention, all right.
[00:51:43.880]So what are we gonna do?
[00:51:44.880]We have some treatment options.
[00:51:46.220]Maybe we try to tell the substitute,
[00:51:49.117]"Well, you should've been following through on demands."
[00:51:51.740]And it's a lot easier to look back
[00:51:53.690]and say what he should have been doing, right?
[00:51:56.380]Maybe we need to go back
[00:51:57.570]to functional communication training
[00:52:00.110]and really start to honor appropriate asking.
[00:52:02.710]Maybe she just needed to ask appropriately for a break.
[00:52:06.440]Or maybe we should bring her school demands
[00:52:09.140]to the hospital and continue them.
[00:52:12.310]Okay, recall these features and functions
[00:52:15.700]of trauma-related stimuli
[00:52:17.570]that I mentioned a few minutes ago.
[00:52:19.570]So discrimination training led to adults
[00:52:22.900]being S-deltas for approach and SDs for avoidance.
[00:52:27.280]And adult approach was aversive,
[00:52:29.780]maybe even an occasion-setter for inappropriate behavior.
[00:52:33.760]The adult approach was an SD for threat-related behaviors.
[00:52:37.130]Okay, we're seeing that.
[00:52:39.090]Maybe this is all accompanied
[00:52:40.600]by conditioned physiological responses.
[00:52:43.440]Have you started to think about the stress Aniyah is under?
[00:52:47.900]Maybe there's conditioning of long-lasting MO's,
[00:52:51.220]have you heard of CMOs?
[00:52:54.150]Well, Aniyah says, "What if you knew something about me
[00:52:56.970]that my school record doesn't show?"
[00:52:59.670]So here, in this example,
[00:53:01.700]I'm just gonna focus on the surrogate CMO,
[00:53:04.980]because these are a little tricky, a little complicated,
[00:53:07.940]but with a great example, you can see the logic in them.
[00:53:11.180]So we're gonna do that for a CMO surrogate.
[00:53:14.700]Okay, so this is pretty simple.
[00:53:17.890]In the past, it was paired with an MO,
[00:53:21.650]and now it's a stimulus that has the same effects
[00:53:24.860]as that MO did.
[00:53:26.490]Does that sound confusing?
[00:53:27.640]Let's work the example.
[00:53:30.730]So again, what if you knew something about her?
[00:53:33.150]What if you knew this?
[00:53:34.740]In the past, Aniyah was abused by a guard
[00:53:39.210]and that guard had striking physical features.
[00:53:42.650]She got away, but only after
[00:53:45.190]she injured herself severely, okay?
[00:53:49.690]Now, when she sees Mike, which is her school guard,
[00:53:53.500]he looks very similar to that guy.
[00:53:56.740]And Aniyah uses unsafe behavior
[00:53:59.150]that occasions a medical emergency.
[00:54:02.290]And so here is someone who maybe is flagged
[00:54:05.240]as overusing medical equipment and services.
[00:54:09.900]This is in her chart.
[00:54:11.030]What's not in her chart is this assault
[00:54:13.420]that she experienced a long time ago.
[00:54:15.710]Well, when she uses unsafe behavior,
[00:54:18.420]she has a medical emergency
[00:54:20.200]and the guard is replaced by the EMT team.
[00:54:23.670]They handle the emergency.
[00:54:25.640]So over time, even a substitute teacher
[00:54:28.320]might kinda act as a stimulus
[00:54:30.160]that's been paired with this kinda situation
[00:54:32.690]and can set off the behaviors even without school demands.
[00:54:35.920]So let's break it down.
[00:54:36.840]Here's Mike, he comes in, she uses behavior.
[00:54:40.670]She has a medical emergency.
[00:54:42.860]Mike leaves, guard is no longer needed,
[00:54:45.210]Aniyah is sedated and hospitalized.
[00:54:48.660]Okay, so back to the example,
[00:54:50.230]here's the environmental condition, Mike walks in.
[00:54:53.640]And in our case, maybe now we're talking
[00:54:55.450]about the substitute teacher as Mike.
[00:54:58.240]So a CMO has two effects.
[00:55:00.110]Number one, it's got a temporary effect on a reinforcer.
[00:55:05.080]So all of a sudden, anything that makes Mike leave,
[00:55:09.050]it's more reinforcing.
[00:55:11.020]What that means is the second effect is on behavior.
[00:55:14.320]There's a temporary increase in behavior
[00:55:16.690]that's been reinforced by that stimulus.
[00:55:19.080]So there's a temporary increase in unsafe behavior
[00:55:22.810]that results in medical emergencies, wow.
[00:55:27.430]So you remember these feature and functions
[00:55:30.610]and even this second one,
[00:55:32.160]there's also relational frame theory ideas here.
[00:55:35.690]So adults and adult approach and adult-related stimuli,
[00:55:40.240]like instructions, like praise, like demands, like touch,
[00:55:44.400]all these can enter into relational frames
[00:55:47.020]with new stimuli that were not even related
[00:55:49.770]to the original threat, wow.
[00:55:53.710]So we could put all these terms into practice
[00:55:56.720]and really help somebody like Aniyah,
[00:55:59.020]and help them be as free from coercion as possible.
[00:56:03.000]But we would need to be able to fulfill objective three,
[00:56:06.360]which was what are the behavioral cusps that we need?
[00:56:09.640]What do need to do differently?
[00:56:11.320]What does Aniyah need to do differently?
[00:56:15.560]So do you think that Aniyah was really free
[00:56:17.770]to do the right thing, or was she doing her best?
[00:56:22.020]You know, she was staying safe.
[00:56:23.750]She was about to get out of that classroom.
[00:56:26.130]Her system perceived all of that as a threat.
[00:56:28.590]I know, I know your educational classroom
[00:56:30.820]is not threatening, but it can be pretty coercive.
[00:56:34.470]It can be compliance-riddled.
[00:56:36.210]It can be unsafe for somebody
[00:56:38.320]who doesn't have any other experience to draw on.
[00:56:42.460]On that note, I just wanted to mention
[00:56:44.830]Amelia Bowler's new book.
[00:56:46.530]Now, this isn't technically out yet, I have read the PDF.
[00:56:50.780]And it's called, "The Teacher's Guide
[00:56:52.360]to Oppositional Defiant Disorder."
[00:56:54.050]Amelia is a BCBA who's also a parent,
[00:56:57.730]and is a school consultant.
[00:56:59.340]And I found it super helpful
[00:57:03.170]in talking of about coercive systems
[00:57:05.050]and what to do differently.
[00:57:07.240]But going back to Aniyah,
[00:57:08.970]she was doing her best in a coercive system
[00:57:11.140]that was uninformed about her history.
[00:57:14.180]Well, let's say you're interested
[00:57:15.940]in how you can give more freedom to your client yourself?
[00:57:19.400]So it might help to ask this kind of question.
[00:57:23.960]Are you looking at all the contingencies?
[00:57:26.550]And so for Aniyah, are you looking at how
[00:57:29.740]her escape behavior paid off in the past,
[00:57:32.630]not just in the moment?
[00:57:35.510]Are you looking at the alternatives she has to switch to?
[00:57:39.180]Maybe asking for a break was never gonna cut it.
[00:57:42.570]Maybe she really needs new skills to calm down
[00:57:45.640]and to de-stress herself
[00:57:48.490]and to be safe in an environment
[00:57:51.100]where there are triggers all around her.
[00:57:54.250]Does she need to be more fluent
[00:57:56.130]at switching to those alternatives
[00:57:57.880]when she's really stressed?
[00:58:00.410]Is she fluent at the alternative she has?
[00:58:02.790]And so these are different things by the way,
[00:58:04.310]fluent at switching and then fluent
[00:58:06.630]at using those alternatives.
[00:58:09.530]Are any alternatives she has, are they reinforcing?
[00:58:12.890]So maybe she's able to ask for a break,
[00:58:15.550]but no one honors that.
[00:58:17.350]Maybe the substitute teacher is not well-Versed
[00:58:20.040]in all of her quote, unquote, alternative skills.
[00:58:24.840]Big question here, are you selecting and programming
[00:58:28.350]behavioral cusps for your teams and clients?
[00:58:31.480]In other words,
[00:58:32.313]things that are gonna make a huge difference,
[00:58:34.310]not just a difference in this very moment?
[00:58:39.200]Okay, as I walked you through those questions,
[00:58:43.240]did you recognize that as nonlinear thinking,
[00:58:46.130]as constructional thinking?
[00:58:49.580]This is Dr. Jesus Rosales-Ruiz,
[00:58:52.380]and he was one of my mentors.
[00:58:55.700]This is one of his mentors, Dr. Don Baer.
[00:58:58.450]And they collectively came up with this idea
[00:59:01.270]of the behavioral cusp, actually they popularized it.
[00:59:06.190]The behavioral cusp was originally talked about
[00:59:08.680]by Dr. Sid Bijou.
[00:59:11.360]He was a KU, Kansas University developmental psychologist.
[00:59:15.620]So what I'm talking about is not simply behavioral.
[00:59:19.110]It takes development and history into account,
[00:59:21.700]and I love that.
[00:59:24.060]They clarified the concept
[00:59:25.450]and they wrote a 1997 paper,
[00:59:28.740]and it helps connect development with behavioral analysis.
[00:59:32.170]Now, haven't you often felt
[00:59:33.840]that that's a missing connection?
[00:59:35.560]If you're like me, you kinda have,
[00:59:37.010]and you love this idea of a cusp.
[00:59:39.920]A cusp is simply a behavior change
[00:59:42.730]that is crucial to what happens next.
[00:59:45.290]So in other words,
[00:59:46.960]it's something that connects you to future events.
[00:59:50.540]It's a change that gives you access to new reinforcement.
[00:59:54.210]So I use it when I'm selecting
[00:59:56.750]what am I going to target as a goal?
[00:59:58.700]The really important behavior changes.
[01:00:01.010]Jesus and his colleagues and students
[01:00:04.440]have generated some papers
[01:00:06.650]that talk about examples of cusps,
[01:00:08.340]maybe learning to ask questions for a client with autism.
[01:00:12.010]Learning to read, that's a huge cusp.
[01:00:15.120]So here's some examples.
[01:00:16.240]If you have a client after trauma who needs to move forward,
[01:00:21.450]we often need to have somebody be able to describe a person,
[01:00:25.540]tact body parts, successfully request assistance.
[01:00:30.700]This is bigger than it sounds.
[01:00:32.330]You know, there's a lot of components here,
[01:00:34.270]identifying who to ask, get their attention,
[01:00:36.990]be assertive, repeat it if they didn't hear you,
[01:00:40.020]wait until there is a response,
[01:00:42.860]use skills that help them remain in the present.
[01:00:45.670]And by the way, noticing and cognitive flexibility
[01:00:49.650]are both act-related skills that are huge after trauma.
[01:00:53.630]And so I found that like Nadine Burke Harris has found,
[01:00:57.600]if somebody has the skills
[01:00:59.340]to get out of a stressful situation
[01:01:01.870]and just be present, they are often able to heal
[01:01:04.990]more effectively and quicker after trauma.
[01:01:08.920]There are cusps that you need as a team member too.
[01:01:12.350]And some of those that I have really found helpful
[01:01:15.240]are being able to detect and document risk,
[01:01:18.700]being able to screen for trauma,
[01:01:21.170]talking about risks with teams,
[01:01:23.380]asking for resources, and talk about trauma
[01:01:27.050]with your other professionals on your team.
[01:01:29.530]This is so huge.
[01:01:31.440]And you've probably thought of a million reasons
[01:01:33.530]why it matters to you, it matters to me too.
[01:01:36.590]I find everything I do with the SAFE-T model
[01:01:39.360]is just to help other professionals
[01:01:41.350]with this array of skills.
[01:01:43.140]So as a resource, if you need a screening tool,
[01:01:47.170]it can be found in my SAFE-T checklist.
[01:01:49.730]And I can share pieces of this with you if needed.
[01:01:52.350]I also wanna give you additional resources
[01:01:54.960]to enhance your competence in this area.
[01:01:56.670]So we're gonna see a few of those on the screen.
[01:01:59.030]So let's put it all together, okay?
[01:02:00.660]So why does it matter, and where in your students' chart
[01:02:04.600]and in their plan, where does it matter?
[01:02:07.200]Well, with respect to medical and behavioral history,
[01:02:11.480]if we miss trauma there, we run the risk
[01:02:14.050]of contributing to medical errors.
[01:02:16.730]I know behavior analysts are not the ones
[01:02:19.220]making the medical errors,
[01:02:21.330]but we can certainly make them more likely
[01:02:23.480]or make them worse if we don't refer out
[01:02:26.440]or ask for a medical check or a second opinion.
[01:02:29.770]And it's not only misdiagnosis,
[01:02:32.320]it could be much, much worse.
[01:02:34.140]Behavior after trauma can be a really important sign
[01:02:37.180]of a medical problem related to the trauma.
[01:02:41.920]Another huge problem
[01:02:43.380]is that if the FBA doesn't mention trauma,
[01:02:47.260]all of our assessments might be wrong.
[01:02:49.810]And if it's wrong, then we might miss a lot of the risks
[01:02:53.540]that are conferred by the trauma
[01:02:55.030]that we never caught.
[01:02:56.540]And so our behavior plan is never gonna get around
[01:02:59.090]to addressing the problem,
[01:03:00.900]but it's doing something isn't it?
[01:03:03.050]It might be providing a whole lot of more trauma
[01:03:06.510]or a whole lot of function-related treatment
[01:03:10.230]that's at the wrong function.
[01:03:12.380]And we can miss mental health needs,
[01:03:14.410]we can do overmedication, We can miss opportunities
[01:03:17.760]to earn the trust of our clients,
[01:03:19.380]the problems snowball, it just goes on and on.
[01:03:22.700]Now, the news is not all bad.
[01:03:24.500]What if we looked at it from another perspective, okay?
[01:03:26.900]So when we do start to integrate trauma
[01:03:30.250]and trauma-related variables
[01:03:31.650]as an important contextual piece of an assessment,
[01:03:35.530]then we could be spotting a trauma-related illness,
[01:03:39.640]saving a life,
[01:03:40.610]steering somebody toward a lifetime of better health.
[01:03:44.220]And in behavioral terms,
[01:03:46.060]we're informing the real reasons for the challenges.
[01:03:49.350]There are real immediate payoffs too.
[01:03:51.610]The behavior plan can be more effective and compassionate,
[01:03:55.280]more person-centered.
[01:03:56.700]Now, I've even seen cases
[01:03:58.160]where soon the behavior plan is not even needed,
[01:04:00.880]and we simply have a little safety plan.
[01:04:03.830]Medications can be used only when needed now.
[01:04:06.440]And the trauma-informed team are helping
[01:04:09.070]and being preventive and supportive.
[01:04:11.650]So how might we do things differently
[01:04:14.390]if we knew trauma was a part?
[01:04:18.610]Well, we could screen for trauma.
[01:04:21.420]I'm showing you now just a brief part of the SAFE-T model.
[01:04:25.100]Here, it's a screening tool.
[01:04:26.670]And on the left side, you've got behaviors I screen for.
[01:04:30.380]On the right side, you've got situations I screen for.
[01:04:34.200]And sometimes you don't have both.
[01:04:36.170]You don't have the access to information
[01:04:37.950]about both of these things,
[01:04:39.920]but often you do have information about behavior
[01:04:43.010]in the referral.
[01:04:44.400]So referral concerns are problems
[01:04:46.970]that the person is presenting.
[01:04:48.750]Situations might be things that the client was exposed to,
[01:04:52.870]but maybe it's also something like a teacher says,
[01:04:56.207]"You know what, his everyday response to my praise
[01:05:00.590]is to get really mad and maybe he blows up."
[01:05:03.750]So everyday caregiving situations
[01:05:06.380]seem to make the client worse.
[01:05:08.760]So that would be a situation that can let us know
[01:05:11.110]about possible adverse experience in the past.
[01:05:14.350]Well, we screen, and if we need to,
[01:05:16.750]we move on to a more complex and more robust tool
[01:05:20.470]for looking at the actual risk conferred
[01:05:23.320]by these trauma-related factors.
[01:05:27.070]If we need to, we could document hidden triggers.
[01:05:30.730]The IPASS is one way that I do that.
[01:05:33.300]It just stands for inventory of potential aversive
[01:05:37.320]stimuli and setting events,
[01:05:39.000]and it goes through the five senses,
[01:05:41.550]our auditory stimuli, visual stimuli,
[01:05:44.510]olfactory stimuli, things they smell,
[01:05:47.680]even vestibular stimuli,
[01:05:49.330]you know, how the body's positioned in time.
[01:05:52.330]I had a client once that I was really mystified
[01:05:55.890]as to why she was having outbursts.
[01:05:57.840]This is what her mental institution called them.
[01:06:00.430]And I realized by doing something like this,
[01:06:03.400]where we're documenting the before,
[01:06:05.837]and the pieces of the environment,
[01:06:08.150]and the afters, what's going on,
[01:06:10.560]I realized it was a trigger for her to be laying on her back
[01:06:13.670]when there was a ceiling fan going on.
[01:06:16.780]I might never have really noticed that as an antecedent,
[01:06:19.490]because there was almost always a ceiling fan
[01:06:21.640]going in her room.
[01:06:23.160]But by looking at it systematically,
[01:06:25.290]like this sheet helps me to do,
[01:06:27.770]I was finally able to pinpoint this relationship
[01:06:30.820]between a trigger and her challenging behavior,
[01:06:34.080]or so to speak.
[01:06:36.800]We could also really individualize reinforcers
[01:06:40.800]and learn how stimuli function for individuals
[01:06:44.270]and not just make assumptions.
[01:06:45.420]Like praise should be a reinforcer.
[01:06:47.470]We know it's not, right?
[01:06:48.680]We know it's not always, it has to be conditioned
[01:06:51.430]for praise to be a reinforcer.
[01:06:53.380]Well, if somebody is exposed
[01:06:54.930]to a lot of adult-delivered aversive stimuli,
[01:06:58.740]praise could just be another clue that you're not safe,
[01:07:02.590]you're just looking for me to mess up
[01:07:04.170]or do something good.
[01:07:05.110]In either case, it's not good to be noticed.
[01:07:08.220]So if you wanna use this, it's a very easy, simple tool
[01:07:12.690]to try to canvas helpers around the person
[01:07:14.920]and see what's helpful.
[01:07:16.640]Is it helpful when I praise?
[01:07:18.210]Is it helpful when I maybe just give them
[01:07:20.900]a thumbs up instead?
[01:07:22.200]What are some alternatives?
[01:07:24.190]And we can get the students' input.
[01:07:25.950]We can get adults' input.
[01:07:27.740]I call this the adult attention preference assessment.
[01:07:30.210]It's very simple.
[01:07:32.960]And when needed, we could start to move on
[01:07:36.360]and actually document risks
[01:07:38.010]related to the trauma somebody experienced.
[01:07:40.640]So if we do know what somebody went through,
[01:07:44.520]then we can go ahead and move on to the SAFE-T checklist,
[01:07:47.650]which again is not documenting trauma per se,
[01:07:51.400]but it's documenting a lot of variables
[01:07:53.150]that might be helpful to know about.
[01:07:55.090]For instance, section A of the SAFE-T checklist
[01:07:58.880]is all about what professionals are surrounding the person.
[01:08:02.070]And it helps me understand
[01:08:03.620]whether a team is really robustly collaborating.
[01:08:08.410]It has six different domains.
[01:08:10.170]You can see them here.
[01:08:11.800]We record about 200 different items in the Family Variables
[01:08:16.380]and Professional Support sections.
[01:08:18.200]We make referrals when needed.
[01:08:21.080]In the Behaviors of Concern section,
[01:08:23.200]we note things that the person is doing
[01:08:25.940]or not doing that might be a concern.
[01:08:29.070]But also in section D
[01:08:30.700]we look at how their development's happening
[01:08:32.820]and if they have some repertoire gaps
[01:08:35.140]or there was learning history
[01:08:36.380]we should have taken into account,
[01:08:38.280]and how it looks when they interact with caregivers.
[01:08:41.480]Finally, in section F we look at their possible exposure
[01:08:45.260]to adverse circumstances,
[01:08:47.060]and then we try to integrate the results in FBAs and plans
[01:08:50.760]and training documents.
[01:08:52.830]So you're gonna see another domain here.
[01:08:54.540]This is section D.
[01:08:56.520]As you can see, we're just trying to put all this stuff,
[01:08:59.740]I'm gonna say on one page,
[01:09:01.160]it's actually several pages long,
[01:09:02.830]but we can use it in Google Sheets
[01:09:04.920]in order to really keep it all together
[01:09:07.250]and have diverse professionals just put in the components
[01:09:10.820]that they know about,
[01:09:12.050]and then we can be much more on the same page
[01:09:15.070]for our client.
[01:09:17.250]Now, the reason we do all of that
[01:09:19.260]is because we want to make risk mitigation plans.
[01:09:22.840]We can plan for clusters of risks
[01:09:24.910]that our client experienced.
[01:09:27.480]And so for instance,
[01:09:29.230]you remember there was section E
[01:09:31.400]that was all about caregiver interaction?
[01:09:33.630]Well, all of those can be put into clusters.
[01:09:37.540]This first section is all about evidence
[01:09:40.270]that maybe a caregiver needs some special support
[01:09:42.750]for behavior management.
[01:09:45.360]If we select things from the second cluster here,
[01:09:48.570]it tells me that we need trauma-related support
[01:09:51.527]and education in that family, or for that caregiver.
[01:09:56.460]If this third one down is flagged,
[01:10:00.550]then I know that maybe some family members
[01:10:02.490]were paired with adverse conditioning experiences
[01:10:05.590]and would benefit from some techniques to remediate that,
[01:10:09.470]and so on and so forth.
[01:10:10.850]So all of these were clues
[01:10:13.800]that caregivers needed special support,
[01:10:16.020]and we can do this for so many different risks clusters
[01:10:19.530]that I assess for in the SAFE-T checklist.
[01:10:23.280]We have these for educational teams too.
[01:10:25.540]And I just wanted to highlight this one.
[01:10:27.590]Often there are huge unaddressed educational needs.
[01:10:32.090]And sometimes that is because somebody after trauma
[01:10:35.710]has been involved in so many different educational systems.
[01:10:39.430]There are areas of education
[01:10:41.430]that they're not fluent in at all.
[01:10:43.400]There are missing records from their families moving around
[01:10:46.730]or from being in foster care or from being hospitalized
[01:10:49.780]and lacking educational opportunities.
[01:10:51.950]So there are so many intersections here for education,
[01:10:55.770]trauma, autism, and many more.
[01:11:00.710]We use all this information.
[01:11:02.460]So now we're finally getting to objective four.
[01:11:05.460]We use all this information
[01:11:07.580]to try to do no harm or at least minimize harm.
[01:11:11.280]And I'm talking about counter-indicated procedures here.
[01:11:15.390]On the top of your screen
[01:11:16.380]you can just see the name of my blog post on this topic.
[01:11:20.290]Basically, I'm gonna share with you
[01:11:22.480]six different situations from trauma
[01:11:24.900]that my clients with autism have faced.
[01:11:27.550]For every single one of these there is a procedure
[01:11:31.810]that we might wanna I look very carefully at
[01:11:34.550]that might be counter-indicated given their history.
[01:11:37.890]So if after food insecurity,
[01:11:40.500]I wanna be really careful with doing edible reinforcement.
[01:11:44.530]After sexual abuse, I wanna be really careful
[01:11:48.000]about oversight or about one-on-one
[01:11:52.160]and make sure that I have some oversight there.
[01:11:54.250]Similar, if somebody's been through sexual abuse,
[01:11:57.740]I wanna be really careful with toilet training.
[01:12:00.640]As you can tell from all of these,
[01:12:03.930]they are not things you wanna do or not do
[01:12:07.290]in every situation.
[01:12:08.610]I'm still gonna use edible reinforcement.
[01:12:10.480]Sometimes, maybe I'm still gonna toilet train,
[01:12:13.900]but I'm gonna be very careful.
[01:12:15.800]And so by taking special care,
[01:12:17.720]what I mean is do a risk versus benefit analysis.
[01:12:22.650]Sections 2.14 and 2.15 in the ethics code
[01:12:27.770]talk about minimizing risks and the way to do that
[01:12:31.680]in terms of doing a risk versus benefit analysis.
[01:12:34.720]I have a lot of resources for this
[01:12:36.520]that I have shared with you all today as well,
[01:12:39.390]and that are available in your packet.
[01:12:42.760]Okay, so we're just gonna take extra care.
[01:12:45.340]We're not going to say
[01:12:46.570]I can never use extinction with a client.
[01:12:50.150]And for a second, if that kinda threw you off
[01:12:53.060]or threw you for a loop and you're thinking about trauma,
[01:12:55.780]well, it's also extinction
[01:12:58.300]when my client finally learns to not freeze
[01:13:02.110]or what we might call space out or run away,
[01:13:07.930]extinction is going on in helping her
[01:13:10.170]to learn to be in the moment again
[01:13:12.900]in an environment that used to be paired with abuse,
[01:13:15.760]but is no longer.
[01:13:17.040]And so if she was abused in educational settings,
[01:13:20.120]I need extinction to take place
[01:13:21.790]for her to be able to enter the building again, right?
[01:13:24.807]And so there's conditioned components of that too.
[01:13:27.980]If you think about respondent behavior,
[01:13:29.910]you'll understand nothing is all good or all bad, right?
[01:13:34.860]And that goes for things like reinforcement and extinction,
[01:13:38.030]there's a place for everything,
[01:13:39.950]but it's got to be individualized.
[01:13:42.430]What there really shouldn't be a place for
[01:13:44.130]is severe deprivation and bribery
[01:13:46.520]and manipulation and coercion.
[01:13:49.970]Well, what might we do differently
[01:13:51.610]if we knew that there was trauma?
[01:13:54.100]We first ask why, and then we're gonna ask what,
[01:13:58.670]so we would avoid doing harm.
[01:14:00.670]We would assess risks before they happen.
[01:14:03.210]We wanna match clients with agencies better,
[01:14:05.300]or clients with therapists or therapists with behaviors.
[01:14:10.190]We could better match needs with procedures,
[01:14:13.040]minimize counter-indicated procedures,
[01:14:15.990]make a huge difference, and feel better about working.
[01:14:21.120]And I think our FBA and BIP,
[01:14:23.620]or behavior intervention plan
[01:14:25.320]might look a little bit different too.
[01:14:26.820]So on the next slides,
[01:14:28.760]I'm gonna show you just a little taste
[01:14:31.470]of what the trauma-informed behavior intervention plan
[01:14:35.320]or FBA might have.
[01:14:37.530]So here are six components that I really love
[01:14:40.250]for supportive timing and delivery.
[01:14:42.900]After trauma, I try to make sure
[01:14:45.330]we are not making key stimuli dependent on asking nicely.
[01:14:49.950]In other words, I've got preventive schedules
[01:14:52.270]going on in my classroom all the time.
[01:14:55.000]We document historic relationships
[01:14:57.830]between trauma and the person's current behaviors.
[01:15:00.570]And if there are medical needs, we put that in there
[01:15:03.420]and we make sure the whole team is trained on it.
[01:15:05.960]I also love to document important times for the person
[01:15:09.610]because there could be important past or present schedules
[01:15:12.810]or times of day, times of year,
[01:15:15.220]holidays that were really important historically, and why.
[01:15:20.270]This kind of relates to triggers,
[01:15:22.140]and just the fact that we need to document those.
[01:15:25.610]And remember how in a seizure,
[01:15:28.300]in a classroom that's supporting a student after a seizure,
[01:15:31.230]you wanna minimize a trigger,
[01:15:32.590]not just present it all the time, right?
[01:15:34.910]Well, in behavior analysis, we have kind of missed this.
[01:15:37.730]Sometimes we focus too heavily on,
[01:15:40.267]"Oh, I'm going to present that antecedent
[01:15:42.280]and teach him to not respond inappropriately."
[01:15:44.970]But if it was trauma,
[01:15:46.600]we really need to be sensitive to this
[01:15:49.260]and try to minimize
[01:15:51.060]what's aversive for the person and adverse.
[01:15:53.890]So I'm sure you've seen preference assessments.
[01:15:56.800]Have you included aversive assessments though?
[01:16:00.680]You know, have you really documented
[01:16:02.440]what's aversive to the person and why?
[01:16:04.920]So those are things
[01:16:05.780]that I love putting in a trauma-informed FBA.
[01:16:08.340]We do the similar thing in a trauma-informed behavior plan.
[01:16:13.350]So I wanna teach all my teachers
[01:16:16.030]and all the staff and all the therapists
[01:16:18.000]how to do preventive time-in.
[01:16:20.360]They don't have to ask first
[01:16:21.700]for this kind of preventive time-in.
[01:16:24.180]It's an antecedent strategy, in other words.
[01:16:26.640]It's not contingent on acting out.
[01:16:28.950]Now, high level attention
[01:16:31.240]might be interactions with a principal
[01:16:33.750]or even interactions with a medical professional
[01:16:36.660]or a security guard.
[01:16:38.610]We also look at building relationships
[01:16:40.590]and we put that in the plan.
[01:16:41.910]If there's no safe person,
[01:16:43.600]then we start with building relationships
[01:16:45.610]with important people.
[01:16:47.830]If there are medical important factors in the FBA,
[01:16:50.840]then we provide some support in the behavior plan
[01:16:53.640]to honor that.
[01:16:54.850]There's preventive procedures for hard times.
[01:16:58.000]We need to focus on building repertoires
[01:17:00.570]towards the values the person has.
[01:17:03.690]And we work on a designated safe person
[01:17:06.890]who's building relationships all the time
[01:17:08.660]and practicing check-ins about how things are going
[01:17:12.750]so that we're not just doing this
[01:17:14.980]in a responsive or a reactive way.
[01:17:17.690]There's just a little bit more information about this,
[01:17:20.327]and I have a handout that goes over this with you.
[01:17:25.220]Basically, we wanna include things
[01:17:27.340]that the research guides us on.
[01:17:29.460]So for buffering items, those are the six things
[01:17:32.400]that Dr. Harris suggested protects after trauma,
[01:17:36.630]sleep, exercise, nutrition,
[01:17:38.640]relationships, mental health support,
[01:17:40.640]and often these are things
[01:17:41.870]that behavioral analysts can fulfill
[01:17:44.580]when we start doing behavioral skills training
[01:17:46.580]or using ACT to complement our work.
[01:17:50.170]Just a couple of notes on procedures
[01:17:52.060]that would target appropriate repertoire development
[01:17:55.950]are here, and there's a few examples of curricula
[01:17:59.990]that can do this, like the IISCA work by Greg Hanley
[01:18:03.610]down at the bottom here,
[01:18:05.070]or the AIM work that kind of brings ACT into the picture
[01:18:09.160]by Mark Dixon, or the work on TAPS,
[01:18:12.990]which is talk aloud problem solving by Joanne Robbins,
[01:18:16.670]who's the principal of a fluency-based training school.
[01:18:20.140]Anyway, there's so much that we can do
[01:18:22.070]if we wanna be trauma-informed.
[01:18:24.960]Now, you saw on the previous page,
[01:18:27.010]it said use trauma-informed practices
[01:18:29.130]to select needed skills.
[01:18:30.920]Well, what if somebody has been through trauma
[01:18:34.110]and has autism and is receiving behavior services?
[01:18:37.350]So some of the needed skills might look like this,
[01:18:42.110]and here, I'm gonna focus on this intersection.
[01:18:44.110]I'm gonna change medical though,
[01:18:45.840]remember it said medical before,
[01:18:47.610]I'm changing that to sexuality
[01:18:49.870]and how that might intersect with trauma and autism.
[01:18:53.340]So in this intersection, if you have autism,
[01:18:56.680]you're more likely to experience isolation in education.
[01:19:00.860]Maybe there are skilled differences,
[01:19:02.560]like challenges being assertive.
[01:19:05.000]Maybe you're not viewed as credible
[01:19:06.700]or as an accurate reporter.
[01:19:08.350]And at the same time, there's a lack of models,
[01:19:11.320]a lack of explicit teaching on important skills.
[01:19:15.040]Maybe you don't receive any sexual education,
[01:19:17.640]maybe there's excessive power differentials
[01:19:20.440]between you and your therapist
[01:19:22.130]or your boss or your educators.
[01:19:24.610]And in terms of trauma,
[01:19:25.750]there's an increased rate of experiencing exploitation.
[01:19:30.180]And there's this culture I've already mentioned
[01:19:32.080]of compliance, being socialized to just comply.
[01:19:36.320]Well, you might find it interesting
[01:19:38.380]to look up some work by Dr. Robin Moyher,
[01:19:41.170]who has looked into the culture of consent.
[01:19:44.480]I find that some of her suggestions on skills
[01:19:47.790]are really helpful, so I'll go over that in a second.
[01:19:51.150]Think about this student here.
[01:19:53.510]She says, "I think I'm supposed to say okay to all adults."
[01:19:57.620]You know, she's been socialized to be compliant.
[01:20:00.640]And then she says, "My CASA volunteer."
[01:20:03.150]If you haven't heard of that, by the way,
[01:20:05.760]court appointed special advocate.
[01:20:07.750]It's a volunteer that all my clients have
[01:20:09.960]if they are in the foster care system.
[01:20:12.150]She says, "My volunteer gives me all these presents
[01:20:15.210]and hugs me, and it makes me feel kinda weird.
[01:20:18.910]And we go in their car.
[01:20:20.190]We have all these confusing interactions."
[01:20:22.970]Okay, so look at how a typical
[01:20:26.120]autism support learning history,
[01:20:28.470]and then assuming that all adults are safe
[01:20:31.440]could really set up confusion for this student.
[01:20:34.220]So thinking about Dr. Robin Moyher's suggestions,
[01:20:38.010]she suggests these are good topics to do preventive teaching
[01:20:42.500]for TIBA and sex and autism, where these intersect.
[01:20:46.840]Here's some examples of the skills under these categories.
[01:20:50.160]She teaches body parts, their functions,
[01:20:52.050]their actual names, who to touch, how can they touch,
[01:20:55.970]where can they touch, when is it okay?
[01:20:58.550]Do this for all categories of people.
[01:21:01.180]You know, I had a case where a CASA volunteer
[01:21:03.620]actually did seem to be giving really big presents,
[01:21:07.430]touching my client inappropriately.
[01:21:09.660]They were grooming my client.
[01:21:11.770]They were eventually fired from their volunteer position,
[01:21:14.750]but we had not thought about training
[01:21:17.180]for volunteers, you know?
[01:21:20.520]So good touch, bad touch, what's confusing touch?
[01:21:23.680]Don't have any secrets about touch.
[01:21:26.290]In terms of boundaries,
[01:21:27.670]Dr. Moyher suggests training on consent,
[01:21:30.760]on giving and getting consent, on refusal,
[01:21:33.880]including what can you do if you're nonverbal,
[01:21:36.700]what are the cues you can use and respond to,
[01:21:39.260]respect for boundaries, and discrimination training
[01:21:42.920]for both consensual and nonconsensual scenarios,
[01:21:47.160]and of course, boundaries in public and in privacy.
[01:21:51.200]She also goes over what to teach about your relationships.
[01:21:54.690]You know, how to build skills related to that
[01:21:57.100]such as autonomy, self-advocacy, self-regulation,
[01:22:01.380]emotion regulation, detecting emotions.
[01:22:04.870]And I love this focus too that she has on media influences,
[01:22:09.130]on healthy relationships and unhealthy relationships.
[01:22:12.780]Oh, I'm gonna go back because I love this resource,
[01:22:15.540]sexaba.com.
[01:22:17.290]And we have a conference coming up speaking at SEXABA.
[01:22:21.270]This is something that Barb Gross and Worner Leland
[01:22:23.870]have put together, and there's some wonderful trainings
[01:22:26.480]that are coming out of this.
[01:22:29.312]Just like we looked at the intersections
[01:22:31.400]of autism, trauma, and sex,
[01:22:33.780]and listed some skills that were important to teach,
[01:22:36.480]we can do this for any combination of factors
[01:22:39.220]our clients face.
[01:22:44.070]So here, we're looking at the intersection
[01:22:46.260]I mentioned earlier on where trauma and autism
[01:22:49.310]intersect with medical factors.
[01:22:51.840]Here, I have a few medical need-related skills,
[01:22:54.870]like taking medications or holding one's arm still
[01:22:58.930]during a blood draw.
[01:23:00.880]And some related procedures we might use
[01:23:03.580]are collaborating with professionals,
[01:23:06.310]especially medical ones,
[01:23:07.940]documenting and assessing for medical variables,
[01:23:11.880]and really doing task analysis.
[01:23:13.520]You can see how that would be important
[01:23:15.560]as you try to break down
[01:23:16.640]how does somebody hold their arm still during a blood draw?
[01:23:19.870]And notice, I didn't write tolerate all medical procedures.
[01:23:23.870]Please be subtle and individualize.
[01:23:26.110]Don't go back to the culture of compliance
[01:23:28.880]with all instructions.
[01:23:30.090]Instead, teach assent, refusal, negotiation, et cetera.
[01:23:35.210]When someone has more control over what's about to happen,
[01:23:38.550]if they can say, "I want to do my arm draw
[01:23:41.780]in one minute, not right now,"
[01:23:44.290]this has brought me a lot of support
[01:23:47.530]in the medical field
[01:23:48.920]as I'm collaborating with all the nurses and professionals
[01:23:52.040]who are experiencing challenging behaviors
[01:23:54.570]from the clients they're trying to treat.
[01:23:57.640]Now, you really need to be able
[01:23:59.110]to apply the great resources out there
[01:24:02.230]on assent and consent.
[01:24:04.550]And so I just wanted to mention
[01:24:06.210]one of my colleagues, Cassi Breaux,
[01:24:08.430]who works in this area, and you can find their stuff online.
[01:24:12.960]They do a lot of assent workshops.
[01:24:16.120]So remember that all of our clients
[01:24:19.140]might be facing not only autism,
[01:24:22.490]but all kinds of additional trauma-related events.
[01:24:26.560]And that's so important.
[01:24:30.390]So as a review, just to bring us back to our objectives,
[01:24:34.560]we need to practice within our boundaries,
[01:24:36.860]but we grow them too.
[01:24:39.140]And as you collaborate with others,
[01:24:40.860]it's going to be super helpful
[01:24:42.900]for you to learn how to operationalize important concepts
[01:24:45.870]in their areas like trauma and attachment
[01:24:49.250]and medical variables.
[01:24:52.060]It will help us to select and teach behavioral cusps,
[01:24:56.740]not only for your clients, but your team members too.
[01:25:00.180]And I've given a few examples of repertoire components
[01:25:03.600]and behavioral cusps that I program for clients with trauma,
[01:25:07.530]and for my team members that are working in the area.
[01:25:10.150]Finally, when we look at procedures
[01:25:12.560]that are contraindicated, this is why it's so important
[01:25:16.150]to use a risk versus benefit tool
[01:25:18.710]to select a procedure for your individual.
[01:25:24.030]I like to use the SAFE-T model to do all of this,
[01:25:26.880]to screen, to do risk assessment and document risks.
[01:25:31.200]And I'm gonna share with you what happened with Aniyah
[01:25:33.970]when we used this approach.
[01:25:36.310]And so you'll recall in Aniyah's example,
[01:25:40.780]we had not originally identified
[01:25:43.270]the hidden trauma in her life,
[01:25:44.710]and she was experiencing a really hard time in school.
[01:25:47.810]Now, after we used the SAFE-T approach,
[01:25:51.010]our screening did identify that trauma
[01:25:52.980]and we outlined the risks very clearly in her plan.
[01:25:56.390]Some procedures we decided to put on hold,
[01:25:59.550]and one of these was requiring appropriate requests.
[01:26:03.380]And so instead of following through
[01:26:04.720]on all demands for the moment
[01:26:06.360]or requiring appropriate requests,
[01:26:08.050]before we let her leave,
[01:26:09.810]we changed this to noncontingent reinforcement.
[01:26:13.320]And we used that schedule for escape,
[01:26:16.000]which was a really important behavior for her.
[01:26:18.500]It was a really important skill
[01:26:20.170]and it was crucial in her survival in the past.
[01:26:23.520]Well, this turns out to be a very important procedure
[01:26:27.090]in the literature.
[01:26:28.140]And, you know, you can do a schedule for escape
[01:26:32.440]without extinction.
[01:26:34.690]I wanted to share with you a Ricciardi paper.
[01:26:37.150]So here it is, Ricciardi, Luiselli, and Camare
[01:26:40.440]used this for an intervention with phobia.
[01:26:44.460]So learning to approach challenging toys,
[01:26:47.710]something that the child had found
[01:26:50.120]evoked a lot of fear responses,
[01:26:52.360]and they did this without extinction.
[01:26:55.700]Although it doesn't mention trauma,
[01:26:57.060]I think it's a good precedent paper
[01:26:58.810]for acknowledging the role of emotion,
[01:27:00.930]a fear in a child with autism
[01:27:02.920]and using a procedure to shape but without preventing escape
[01:27:06.920]from the thing they find so aversive.
[01:27:09.380]In other words, if the child needed to leave the room,
[01:27:11.810]he could, and so could Aniyah,
[01:27:14.220]and she began to get better when it was noncontingent.
[01:27:18.310]So why do we do all this?
[01:27:20.040]You know, as we end,
[01:27:21.010]I wanted to share a few things with you
[01:27:23.130]because our clients with autism and trauma
[01:27:24.880]do have differences clinically.
[01:27:27.630]Each of these headers here, I've got five of them,
[01:27:30.270]correspond to a few specific differences
[01:27:33.710]that I'll write more about in your notes packet.
[01:27:36.390]So we actually do see differences clinically
[01:27:39.940]between our typical populations we're treating
[01:27:42.810]in early intervention and later on with ASD,
[01:27:46.070]and that same population when our individual
[01:27:48.970]has been affected by adverse childhood experiences.
[01:27:53.320]I think you may enjoy spending more time
[01:27:55.100]with the next few slides too in your packet after this talk.
[01:27:58.880]Here, I'm trying to highlight some of the beautiful
[01:28:01.940]but challenging parts of life that come with trauma.
[01:28:05.730]It doesn't erase your personhood
[01:28:07.620]or desires or needs or capabilities,
[01:28:10.770]but it does put someone at risk for more trauma.
[01:28:14.350]And I've noted in yellow, some needs your client has
[01:28:19.810]may be outside the realm of behavior analysis.
[01:28:23.450]And that's why collaboration will be so important.
[01:28:28.330]After trauma, somebody may have skill gaps
[01:28:31.070]that need healing or use behaviors
[01:28:33.620]that are difficult for you to see,
[01:28:35.600]but that were once their only hope.
[01:28:37.540]And that one in particular is where I find it so useful
[01:28:41.430]and compassionate to use the nonlinear approach
[01:28:44.950]that Joe Layng advocates
[01:28:47.210]in looking at the past contingencies for behavior
[01:28:49.830]like we did for Aniya,
[01:28:51.420]and how that behavior was once functional for your client.
[01:28:54.970]Finally, note this place that I've listed again in yellow,
[01:28:58.740]behavior analysis may even have been part of the trauma
[01:29:01.740]your client experienced.
[01:29:03.340]Let's acknowledge that and begin to heal,
[01:29:05.930]not continue to do harm.
[01:29:09.490]So I am very hopeful for the field
[01:29:12.420]and all of my clients with trauma and autism.
[01:29:15.730]I wanna move us from TIBA,
[01:29:18.310]or just trauma-informed behavior analysis
[01:29:21.860]toward the practice of behavior analysis
[01:29:23.387]that's actually trauma-healing.
[01:29:26.540]And I think together when we use these principles
[01:29:29.320]and we learn from our collaborators across different fields
[01:29:32.880]that we can do that.
[01:29:36.320]Thank you so much to the Autism Support Network
[01:29:40.580]and ATBS, and especially everybody providing support,
[01:29:45.750]but of course we could not do this
[01:29:48.230]without all the people we are entrusted to support,
[01:29:51.530]so thank you to each one.
[01:29:54.500]I've listed many references,
[01:29:56.190]and the first few are going to be most specific
[01:29:59.100]to this talk.
[01:30:00.340]You've also got my website up there, cuspemergence.com,
[01:30:03.800]for a series of blogs on this subject,
[01:30:07.320]but also some interesting articles
[01:30:09.210]like the one on behavior cusp
[01:30:10.800]and the great article by Joe Layng on nonlinear thinking.
[01:30:15.950]Finally, these are the books that I mentioned today.
[01:30:19.017]"The Boy Who Was Raised as a Dog" and "The Deepest Well,"
[01:30:22.010]but I also want to shout-out
[01:30:23.710]to James Luiselli's guidebook,
[01:30:25.810]which has a great chapter, chapter five,
[01:30:28.480]on behavioral screening.
[01:30:30.000]It's not trauma-informed,
[01:30:31.600]but it does discuss risk mitigation,
[01:30:33.810]and it does a great job describing how to do this.
[01:30:37.680]There's a few other articles and selected reading for you,
[01:30:40.970]and everything here will also be in your notes packet.
[01:30:46.270]So I am just thrilled to speak with you all
[01:30:49.130]and address any questions that have come up for you
[01:30:51.940]during the talk.
[01:30:53.200]Thank you so much for listening.

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The Intersection of Autism and Trauma

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