One of the tenets of ABA is to provide evidence-based practice. The best way to help us do this is to keep up with the literature! Each month, Sam Blanco, PhD, LBA, BCBA will select one journal article and provide discussion questions for professionals working within the ABA community. The following week another ABA professional will respond to Sam’s questions and provide further insight and a different perspective on the piece.
- The researchers trained caregivers on a university campus using the BST model prior to home visits. In your current work, would this be a possibility for you? If not, how could you provide this type of training to caregivers? What obstacles can you predict, and how might you address them?
The majority of my clinical practice is primarily situated in home-based settings. Delivering behavior analytic services in home-based settings presents with a multitude of circumstances contributing to variable rates of success in teaching new skills for both the client and caregivers. Two variables contributing to such challenges in service delivery is caregiver accessibility and limited service hours allotted, particularly if the services are funded through insurance-based sources. Formal Behavior Skills Training (BST) often requires time intensive performance and competency- based components, creating a challenge to implement in the home setting at times. With careful planning and caregiver commitment to participation, BST training in the home setting is quite “do-able”.
To address time constraints, a ‘train the trainer’ model or pyramidal training (Pence, St. Peter, & Tetreault, 2012), may be a beneficial strategy to assist in training multiple caregivers as well as contribute to increased proficiency in treatment fidelity. A pyramidal training model involves a senior trainer (e.g., a behavior analyst) training a small group of staff or caregivers who in turn train other staff or caregivers. This type of training model may be particularly beneficial to clinicians working in settings where time constraints may be a factor (such as residential services).
- Discuss the multiple baseline design used in the study. How does it demonstrate experimental control? What can you determine from a visual analysis of the data?
The researchers in this study utilized a concurrent multiple-baseline-across-modules design to analyze the effects of the BST module training delivered to parents to teach their children mands. Concurrent multiple-baseline-across modules design allows for simultaneous measurement to occur for all clients. Research suggests concurrent measurement controls better for threats to internal validity and result in somewhat stronger inferences than do nonconcurrent designs (Watson and Workman, 1981). Multiple baseline designs are appropriate when target behaviors are not reversible. Use of a concurrent multiple-baseline design to evaluate treatment effectiveness minimizes the ethical concerns related to a withdrawal design. Training skills sequentially using a multiple-baseline-across-modules design is beneficial since it allows trainers to teach skills gradually and gave trainees repeated rehearsal opportunities on previously trained skills. The trainer could also monitor ongoing caregiver performance and make decisions to advance caregivers through the training based on the consistency and accuracy of their performance on trained skills. Researchers of the study required caregivers to reach specific mastery criterion rates to advance to additional modules in the BST to assess the maintenance of the caregiver’s accuracy of procedural integrity and the child’s mands.
Upon visual analysis of the data, results of the study support effects of a BST model for training caregivers to implement mand training procedures. In addition, after training, caregivers did not exhibit difficulties generalizing the skills to implement mand training procedures to the child. Additional training was provided to caregivers during sessions with the child when mastery criterion was not achieved. The researchers found by staggering the training across modules, caregivers learned to capture and contrive motivating operations contributing to the emergence of spontaneous mands.
- Part of this study included a measure of whether a competently trained parent could teach their spouse how to implement mand training. Why is this important? Have you implemented similar strategies in your own work?
Training caregivers to effectively generalize behavior analytic treatment strategies and interventions to the child outside of training sessions is one of the goals of family support behavior analytic services. Strategies to fade out the necessity of behavior analytic services is developed in the client’s treatment plan at the initiation of services. Delivering BST to a caregiver who demonstrates proficiency of the designated steps is invaluable in the treatment process. Through BST, trained caregivers who have demonstrated mastery of a skill, have the ability to train additional caregivers (e.g., grandparents and siblings) in the client’s environment, facilitating generalization of treatment effects.
In addition, research has supported the finding that providing caregivers with training and education to increase their family member’s functional skills (such as communication) may reduce caregiver stress by increasing the caregiver’s confidence levels (Bebko et al. 1987). Researchers have also found that parents who reported high levels of confidence in managing their child’s major difficulties and perceived others in the family as similarly successful also reported lower stress rates (Sharpley and Bitsika 1997).
In my practice, I utilize BST to teach caregivers skills related to communication and socialization training and areas of daily living such as toileting, dressing, toothbrushing and community safety. I recently utilized BST to teach a modified PECS (Picture Exchange Communication System) to a client’s caregivers. After reaching fluency criteria for each step of the target skill, the trained caregiver was capable of effectively training the modified PECS procedure to the second caregiver. Success rates for each steps of the BST procedure were measured by observation, data collection and data analysis of procedural integrity demonstrated by the second parent during sessions with the client. Success rates were also measured by data analysis of the client’s rate of progress in reaching various communication targets via use of the modified PECS taught by caregivers.
- This study did include maintenance data. Why is this data valuable? Do you collect maintenance data on the caregiver training you provide?
According to Alberto & Troutman, 2013, ‘maintenance’ is defined as “performing a response over time, even after systematic applied behavior procedures have been withdrawn”. Maintenance is demonstrated over time when the skill continues to occur after all direct teaching of the particular skill has been discontinued.
Maintenance data could also be utilized to assist in shaping additional skills. For example, prior to teaching a client receptive discrimination skills related to picture identification in a field of 3 stimuli, it is important to evaluate the presence or absence of certain prerequisite skills such as attending, gesturing (i.e., pointing or eye gaze), following direction and ability to identify objects depicted in the array. Without information gathered from maintenance skill probes (i.e., attending, pointing, tact repertoire, etc.), teaching the skill of receptive discrimination may not be possible if the client has not exhibited mastery of specific prerequisite skills first.
During skill acquisition training, I typically teach a targeted behavior until the recipient exhibits fluency in exhibiting that behavior. The computer- generated data system I utilize in my practice includes pre-set monitoring schedules of maintenance data based upon a timed schedule. Maintenance probes are automatically scheduled in a staggered fashion. For example, if the client exhibits proficiency in engaging in a specific skill during baseline, that skill is automatically scheduled for a maintenance probe on a monthly basis. If a client reaches fluency of a specific skill after commencement of treatment, the target is scheduled for maintenance in a staggered time frame (i.e., weekly, bi-weekly, monthly, bi-monthly and annually). After the client reaches mastery criterion for annual maintenance, the target is considered ‘closed’. If at any time the target fails maintenance, the target is added back into treatment.
If a clinician is teaching skills to fluency, the necessity of relying on maintenance data to determine if the skill remains in that client’s behavior repertoire becomes less relevant.
- Consider a particular skill you are teaching one or more clients. What would BST look like to teach caregivers how to implement the necessary procedures for teaching that skill?
A particular skill BST could be utilized to teach is use of utensils during mealtime.
Instruction – For this step, if a client exhibits adequate receptive skills related to vocal/verbal instruction, one may say to the client, “When you eat certain foods, such as spaghetti or vegetables, you use a fork to pick the food up. You wouldn’t use a fork to eat foods such as cereal or pudding.”
If the client does not exhibit adequate receptive language skills, one may describe the skill to the caregiver. For example: “We teach the skill of eating with utensils to assist with independent functioning. We will practice this skill first, with a fork and upon reach specific mastery criteria, we will proceed in teaching use of additional utensils, such as a spoon. It’s best to practice this skill when motivation to eat is high in order to increase rate of reinforcement and eventually, acquisition of mastery criteria (i.e., if the client is hungry, his motivation to follow the rule to use a fork to eat may be higher compared to times when he is not hungry). Reinforcement for use of the fork is naturally built in, as the food he eats with the fork will serve as reinforcement for the targeted behavior.”
Along with vocal/verbal instruction of the BST steps, I may also provide the caregiver with written steps to the procedure to assist with fluency.
Modeling – For this step, during mealtime, I model the steps described above to the caregiver. I provide a description of each step as the step is being performed to the caregiver.
Rehearsal –For this step, encourage the caregiver to implement the steps to practice the skill. During these practice sessions, data recording is critical to determine fluency of the practice of the targeted skill.
Feedback – Prior to this step, I discuss with the caregiver the form of feedback they prefer to receive (in-situ feedback or feedback after each trial session has ended). Throughout my career I have learned the importance of tailoring my delivery of feedback to individual preference (some caregivers prefer feedback while they are performing the step, while others prefer to receive feedback after they have completed the step). Once I have determined the timing of my feedback, I deliver the feedback in the context agreed upon.
- The article states, “General instructions were provided prior to baseline, but parents were only able to implement the procedures effectively when full instructions, modeling, rehearsal and feedback were used to train to mastery.” How can you change your current practice to ensure that you are providing the necessary steps to help caregivers master skills they have selected for parent training?
To streamline the often time-intensive process BST requires, I typically stagger the trainings across multiple sessions. Delivery of insurance-based family training services is generally provided in a time intensive and structured fashion. To meet these stringent guidelines and to ensure I deliver the most effective and efficient services, I provide the caregiver with written and verbal steps to BST across several consecutive sessions. I review each step with the caregiver and assign weekly assignments to practice specific steps. During each family training visit, I review and model the steps and request the caregiver to perform the step they worked on the week prior. After the caregivers reach specific fluency rates in responding accurately, additional steps are introduced.
One method of training I may consider including in my caregiver trainings when delivering BST, is use of video modeling. Video modeling is a teaching procedure that involves an individual viewing a videotaped sample of a model performing a specific, scripted activity or task. Immediately following having viewed the video-based model, the individual is directed to perform the activity or script he or she observed in the video (e.g., MacDonald, Clark, Garrigan, & Vangala, 2005). Use of video modeling may further address time constraints to training that is often a barrier in delivery of home-based services. Video modeling may also assist in in higher rates of procedural integrity when working with caregivers who learn more effectively through use of visual guides as opposed to textual guides only.
BST is an incredibly invaluable method of teaching new skills. With careful planning and commitment to learning, caregivers have a unique opportunity to actively participate in their family member’s treatment to help them engage in socially meaningful ways.
References
Alberto, P., & Troutman, A. C. (2013). Applied behavior analysis for teachers. Boston: Pearson.
Bebko JM, Konstantareas MM, Springer J. Parent and professional evaluations of family stress associated with characteristics of autism. Journal of Autism and Developmental Disorders. 1987; 17:565–576.
MacDonald, R., Clark, M., Garrigan, E., &Vangala, M. (2005) Using video modeling to teach pretend play to children with autism. Behavioral Interventions, 20, 225-238.
Parsons M. B., Rollyson J. H., Reid D. H. Evidence-based staff training: A guide for practitioners. Behavior Analysis in Practice. 2012; 5:2–11.
Parsons, M. B., Rollyson, J. H., & Reid, D. H. (2013). Teaching Practitioners to Conduct Behavioral Skills Training: A Pyramidal Approach for Training Multiple Human Service Staff. Behavior analysis in practice, 6(2), 4–16. doi:10.1007/BF03391798.
Pence S. T., St. Peter C. C., Tetreault A. S. Increasing accurate preference assessment implementation through pyramidal training. Journal of Applied Behavior Analysis. 2012;45:345–359.
Sharpley, C. F., & Bitsika, V. (1997). Influence of gender, parental health, and perceived expertise of assistance upon stress, anxiety, and depression among parents of children with autism. Journal of Intellectual and Developmental Disability, 22, 19–29.
Watson, Paul & A. Workman, Edward. (1981). The non-concurrent multiple baseline across-individuals design: An extension of the traditional multiple baseline design. Journal of behavior therapy and experimental psychiatry. 12. 257-9.
Elizabeth A. Drago, M.A., BCBA, LBA, is a Board Certified and Licensed Behavior Analyst and a consultant at Proud Moments Therapy located on Long Island, New York and Comprehensive Behavior Supports, located in Brooklyn, NY. She has over 15 years’ experience working with individuals with developmental and related disabilities and has advanced training in areas of autism, behavior disorders, sleep disorders, intellectual disabilities and positive behavior supports. As a consultant in home and educational settings, she clinically oversees client cases, provides parent training, implements comprehensive skill assessments and programming goals for children diagnosed with ASD, conducts staff trainings for effective performance improvement practices and behavior analytic practices and procedures. She holds professional memberships in organizations such as New York State Association for Applied Behavior Analysis, Association for Behavior Analysis International, Association of Professional Behavior Analysis.
Elizabeth is a Board member of the New York State Association for Behavior Analysis (NYSABA), serving the role of Representative at Large. She is also an active member of NYSABA’s Legislative Committee, focusing on efforts to remove the licensure scope of practice restriction in Behavior Analysis in New York State. Elizabeth has contributed significantly to disseminating information related to the scope restriction in Behavior Analysis in NYS. Some of Elizabeth’s achievements in these efforts include developing initiatives such as the video series entitled, ‘This is ABA’. The purpose of the video series is to highlight the effectiveness and applicability of the practice of Behavior Analysis to individuals of varying diagnoses, not only for those diagnosed with an Autism Spectrum Disorder. This video series is currently featured on the NYSABA website. Elizabeth also works collaboratively with NYSABA’s Executive Director, Mari Wantanbe-Rose in the development and oversight of NYSABA’s Inaugural ABA Ambassador Award. The NYSABA ABA Ambassador Award recognizes future behavior analysts, or students, who help to disseminate the usefulness and versatility of behavior analysis in various settings.
Elizabeth has presented at NYSABA’s annual professional conference on the topics of Systematic Desensitization (2017) and Self-Care for the Behavior Analyst (2018). She has been invited as a speaker at a roundtable meeting at Proud Moments ABA, presenting on the topic of the use of technical jargon when interacting with caregivers. Elizabeth has also been featured in a newsletter (August 2018 edition) generated by Comprehensive Behavior Supports in recognition of the many significant contributions to the agency and families she serves across Long Island as a Licensed and Board Certified Behavior Analyst. Elizabeth has been a guest speaker on a Behavior Analytic podcase, ‘Behaviorbabe’, hosted by Dr. Amanda Kelly, discussing the NYS licensure law scope restriction on the practice of Behavior Analysis in NYS. Elizabeth received a Bachelor’s Degree in Clinical Psychology from St. John’s University, graduating Summa Cum Laude. She continued her education, earning her Master’s Degree in Clinical Psychology at Teacher’s College, Columbia University, where she received an honors certificate in education and teaching and was a member of Kappa Delta Phi- Honor Society in Education. Elizabeth attended post-graduate studies at Penn State University, where she completed coursework in Applied Behavior Analysis. She earned her BCBA certification and licensure in Behavior Analysis in 2014.