Chapter 6 Section 2: Responsibility in Practice From the beginning stages of our field, it became clear that behavior could be influenced through the implementation of strategies and procedures previously employed and developed within more traditional laboratory settings. However, it was not yet clear in whose best interest these behavior changes were to occur. In many cases, the focus was placed on the interest of the employers of the behavior analysts. That is, the “client” was not necessarily the individual being directly impacted by the goals of intervention. Instead, goals were focused on the needs of the group or institution that hired the behavior analyst. Thus, while the challenging behavior of such learners may have been reduced, these behavior changes were facilitated to better serve the environment within which the learner resided, rather than for the increased autonomy, independence, or quality of life of the learner (Bailey & Burch, 2016). Though behavior analysts had the ability to manipulate the environments to serve the interests of institutions, it became more apparent that without the individual’s best interest as the paramount focus, effective intervention could also be harmful and abusive. From this change in perspective, there was a structural shift in which behavior analytic strategies were applied, with the most vulnerable individual identified as the primary client and direct focal point of service. By dedicating clinical efforts toward the individual who was least able to advocate for themselves, behavior analysts were able to institute meaningful change not only in the life of the person but also for those collaterally involved (Leaf et al., 2021). Section 2 of the Behavior Analyst Certification Board (BACB) Ethics Code (2020b) emphasizes the practices and procedures behavior analysts may take in best assuring the interests of learners are of highest priority and that appropriate stakeholders are involved and invested throughout the process to inform beneficial decisionmaking and intervention strategies. To facilitate a responsible practice that includes learners and those immediately affected by behavior-analytic intervention, independent data related to the behavior in question must be collected. Much of the information received by behavior analysts is based on anecdotal accounts from those who have direct interaction with learners. For example, parents may report a concern related to a particularly challenging behavior, teachers may describe a skill deficit that is interfering with a student’s learning, and employers may note issues related to overall workflow and productivity. While this information is extremely important and should not be dismissed, a behavior analyst must not rely solely on these subjective statements when determining areas of need and when developing intervention plans. Without observing the target behavior and related corresponding variables, a behavior analyst may inadvertently implement intervention strategies that are inappropriate, ineffective, and/or unnecessary (Tarbox et al., 2011). A Workbook of Ethical Case Scenarios in Applied Behavior Analysis, Second Edition. https://doi.org/10.1016/B978-0-323-98813-1.00006-2 Copyright © 2022 Elsevier Inc. All rights reserved. 57 An aspect that distinguishes applied behavior analysis (ABA) from other related fields is its reliance on data collection to make informed decisions regarding behavioral strategies and interventions. Assessing behavior involves record review, indirect assessment through interviews and questionnaires, and direct assessment via observation, including the collection of baseline data to demonstrate preintervention levels of the target behavior. Additionally, once an intervention is in place, ongoing assessment occurs through continued data collection that depicts the effects of the intervention (Tarbox et al., 2011). By conducting a comprehensive assessment prior to and during implementation, behavior analysts are better able to take responsibility in accounting for any behavior change that may result from the intervention. As not all individuals involved with the behavior-analytic intervention will have the time or skill set to evaluate the information gathered, it becomes increasingly important for behavior analysts to explain and discuss assessment findings in a manner that is easily understandable and meaningful. Even the most well-researched and thorough interventions can fail before they begin if those directly involved in the intervention lack understanding of their direction, purpose, or practice. Furthermore, in order to ensure practices are socially valid, it is essential to take a collaborative approach with clients when identifying intervention goals and developing intervention plans. The voices, preferences, and wishes of those that will be served must be heard and addressed in order to actualize an intervention approach that demonstrates compassionate care (Taylor et al., 2019), does no harm, and demonstrates cultural humility. Perhaps one of the more controversial aspects of interventions based in ABA is the use and implementation of restrictive or punishment-based procedures. Such strategies focus on the elimination or reduction of a specified behavior through the presentation or removal of a particular stimulus. In many cases, the presented stimulus may be considered aversive to the individual who engages in the targeted behavior identified for reduction. Likewise, the stimulus removed is likely one that is valued or preferred by the individual. Punishment-based strategies are often effective in quickly eliminating targeted behaviors, and when consistently implemented, have the potential of maintaining the reduction (Cooper et al., 2020). Unfortunately, punishment can be reinforcing for the individual implementing the punishment-based procedure, resulting in the use of punishment strategies instead of reinforcement-based procedures that focus on the development of adaptive and appropriate replacement behavior and skills. As these strategies become more inherent, the individual implementing the punishment-based procedure may increase the frequency or intensity of the punishment as a means of maintaining the behavior change. Similarly, the use of punishment-based procedures may generalize across other behaviors viewed as requiring reduction. Utilizing punishment-based procedures may also continue to be reinforced as their implementation may result in a reduction of stress and increase in satisfaction as the individual employing the punishment-based strategy experiences a sense of personal responsibility for affecting the behavior change and an assumption that they have taken active control of the challenging situation (Dawson, 2004). Behavior analysts have learned that behavior can be effectively altered through reliance on reinforcement strategies. Yet, both the appeal and risk of including punishment procedures are important to acknowledge and address. Doing so suggests the use of punishment strategies only when absolutely clinically necessary and requires the behavior analyst to actively reflect on their rationale for including punishment procedures within behavior-change programs prior to implementation. As such, it is explicitly noted within Section 2 of the Code that reinforcement procedures are used and recommended whenever possible, and any inclusion of punishment interventions are only incorporated following the use of reinforcement strategies as an adjunctive strategy with reinforcement procedures when (1) desired results have not been obtained through less intrusive means; (2) the risk of harm to the learner is more prominent than the risk of implementing the punishment-based strategy; (3) required review processes have been followed; (4) data collection and observation is conducted to ensure appropriate implementation, effectiveness, and necessity of the strategy; and (5) the punishment-based procedure is modified or discontinued when no longer necessary or has been determined to be ineffective (BACB, 2020b). 58 6. Section 2: Responsibility in Practice CASE 38: NO “I” IN TEAM Anvi is the Board Certified Behavior Analyst (BCBA) representative on a multidisciplinary Individualized Education Plan (IEP) team. At each IEP meeting, one of the other professionals consistently recommends strategies that are not supported by research. Though Anvi advocates for evidence-based interventions, the rest of the IEP team is considering including one of the nonevidence-based suggestions within the student’s IEP, which would require Anvi’s staff to be responsible for implementing and collecting data on the intervention. Case 38: No “I” in Team 59 CASE 39: WALKING BILLBOARD Advanced Autism Services is a nonpublic agency, providing ABA services for children, teens, and adults diagnosed with Autism Spectrum Disorder (ASD) and other developmental disabilities (DDs) within the clinic, home, school, and community settings. When providing clinic-based services, staff members are asked by management to wear an agency uniform (either a collared shirt or agency t-shirt) that has the agency’s logo prominently displayed on the front. Staff are told that the uniform helps to ensure that staff are dressed appropriately and professionally in clothing that allows them to address any clinical need or manage challenging behavior, as well as helping the learners identify who they may access for assistance. Many of the staff provide services to individuals completely within the clinic setting; however, others provide services to several individuals in different locations depending on the learner and the time of day. Out of convenience, many staff remain within their agency uniform as they provide services to learners outside of the clinic setting, such as in the community or within schools. 60 6. Section 2: Responsibility in Practice CASE 40: WORD OF MOUTH Carlos, a BCBA, is conducting an observation of a learner named Chase in the school setting when approached by the parent of another student in Chase’s class. The parent told Carlos that she is interested in starting ABA services for her daughter and has been looking for an agency. She mentioned that the teacher told her to speak with Carlos since he is a BCBA supervising Chase’s program. She asked for Carlos’s business card so she could speak to him about initiating services with his agency. Case 40: Word of Mouth 61 CASE 41: HOLIDAY SPIRIT Over the holiday season, Asha, a BCBA-D and owner of Kids Konnect Behavioral Services, receives several holiday cards with pictures of the children and families to whom her company provides ABA services. As a demonstration of appreciation, Asha displays the cards in the waiting room of the front office on the “Kids Konnect Announcements” bulletin board. 62 6. Section 2: Responsibility in Practice CASE 42: COFFEE TALK Hector is a BCBA supervising home-based services for Sonia. Hector typically conducts treatment team meetings and supervision for the direct staff members who work with Sonia within the family’s home. However, due to changes in scheduling, home meetings are no longer an option. If meetings are held within Hector’s office, one or more staff members will likely be unable to attend. Hector has found a coffee shop that is centrally located for all the staff and plans to hold meetings at this location, since everyone will be able to attend, until Sonia’s parents are able to host meetings at their home again. Case 42: Coffee Talk 63 CASE 43: DECORATION DILEMMA Kira is a BCBA who is remodeling the office space at her ABA agency, as well as updating her company’s website and social media pages. She wants to give the company a more personal feel by showcasing pictures of staff and learners across her internet platforms and within her office space. She asks the Registered Behavior Technicians (RBTs) to text her pictures of learners taken on their phones during their sessions. 64 6. Section 2: Responsibility in Practice CASE 44: SCAM LIKELY Greg, a BCBA, receives a telephone call while at his office from Sally, who states that she works for the Student Services Department at the local university. Sally is calling to confirm John, a new student, receives ABA services from Greg so that she may enroll him in the university’s available resource groups and collaborate with Greg about John’s services. Greg has been supporting John in transitioning to his new school and has encouraged him to contact the university’s programs but was not aware John had followed through with the recommendation. Case 44: Scam Likely 65 CASE 45: MY PASSWORD IS “PASSWORD” Sally, an RBT, had her car broken into while parked at a local coffee shop between clients. In addition to several personal items missing, Sally’s company’s tablet, which contained learner data, contact information, and programming details, was stolen from her front seat. The tablet requires a four-digit passcode to unlock the device and a personalized password to access learner records. 66 6. Section 2: Responsibility in Practice CASE 46: NEED A NAP Trisha is a BCBA working at an ABA agency within the clinic setting. Most of the individuals she works with at the clinic are dropped off in the mornings and receive services continuously throughout the day, depending on their needs. Some of the learners Trisha supervises are young children who take naps. Trisha and her staff typically record when naps occur and when active instruction is taking place. This information is provided to the company’s administrative department. After reviewing the funding authorization requests for several of the individuals on her caseload, Trisha noticed that her agency bills the entire day, including the times when the learners are napping, as active intervention. Case 46: Need a Nap 67 CASE 47: BILLING BLUNDER Tarik is a BCBA who works at a large ABA agency with multiple departments that provide various behaviorbased services to individuals with DDs including ABA intervention, parent support groups, family therapy, and respite services. Tarik received an audit from the funding organization for one of the individuals on his caseload. In reviewing his documentation and the billing information submitted, Tarik noticed consistent weekly occurrences when his company billed for ABA services that were not provided to the learner. In researching the discrepancy, Tarik found that the company did provide respite services, which are not part of the family’s authorized funding, during those times that were billed as intervention based in ABA. Tarik knows how much the family has benefited from the support and relief the respite services have provided. 68 6. Section 2: Responsibility in Practice CASE 48: HIDDEN FEES Penny, a BCBA, is in the process of completing the introductory paperwork and intake process for a new learner. While confirming the family’s insurance information and coverage, Penny noticed the family has a particularly high copayment responsibility. She is concerned this expectation may be a barrier for the family to participate in services. Penny is hopeful that her company will be able to work out an alternative option once services are initiated. Since the family did not specifically ask about copayments during the initial meetings, Penny decided not to mention the fee. Case 48: Hidden Fees 69 CASE 49: MONOLINGUAL MESS Krissy, a BCBA, recently started working with Jasmin, a new learner. Jasmin and her family speak Spanish as the primary language within their home. The parents have expressed a preference for intervention to be conducted in Spanish, as they believe this will assist Jasmin in communicating and connecting with her family and will allow for family support and involvement in learning objectives. While Krissy does speak Spanish and is able to communicate effectively with Jasmin’s family, she does not currently have any available RBTs who speak Spanish to join Jasmin’s team. Given the lack of available Spanish-speaking staff and that Jasmin will be enrolled in an English-speaking school, Krissy informs the family that she and her team will be conducting all intervention programming in English. 70 6. Section 2: Responsibility in Practice CASE 50: IDENTITY FIRST Elton participates in ABA services with Janel, a BCBA. Although he has repeatedly told the members of his ABA team that he prefers to be referred to as “autistic” rather than a “person with autism,” Janel and her team continue to introduce Elton using person-first language. Elton’s behavior intervention plan includes “Stereotypical Behaviors” as a target for reduction. Elton has discussed with his team that he understands he may engage in some finger-pointing behavior, particularly when he is having difficulty with school assignments, but does not believe the behavior is an issue for concern. Elton’s plan lists the behavior under the heading “Problem Behaviors” along with “Noncompliance” and “Vocal Protest.” Case 50: Identity First 71 CASE 51: SAFETY FIRST Sonja is a BCBA providing consultative services for individuals who engage in severe or persistent dangerous behaviors within an adult inpatient hospital setting. She received a request to develop a behavior support plan to assist in the reduction of self-injurious head banging for an adult patient in the hospital. Based on the preliminary hospital staff report, head banging has increased significantly over the last 2 months. The hospital staff have attempted to stop the behavior when it occurs, but the patient is also very aggressive toward others, resulting in several staff injuries. The hospital staff have not yet attempted preventative strategies beyond offering the use of a padded helmet, which the patient refuses or promptly removes once placed. Hospital records indicate that the patient has a drainage shunt inserted in her head to assist with hydrocephalus. However, the patient has missed her last several appointments to assess the shunt due to aggressive behavior during transport to the medical professional. 72 6. Section 2: Responsibility in Practice CASE 52: PREEMPTIVE PLAN Antoine is a BCBA working within a residential facility for adults with developmental disabilities (DDs). One of his cases, Derek, has begun engaging in more frequent and severe episodes of aggressive behavior, resulting in several staff injuries and causing one other learner at the facility to require significant medical attention. Antoine has heard from the hospital staff that Derek rarely seeks out others to engage in aggression and only aggresses when others are near him. Antoine develops a behavior plan that focuses on the staff decreasing their direct contact with Derek and reducing expectations. The plan includes teaching strategies aimed at increasing Derek’s appropriate requests to ask for breaks or to receive space and provides reactive strategies should Derek engage in aggression. The behavior plan also includes crisis management techniques to increase staff and peer safety in the event an aggressive incident occurs. After discussing and receiving approval for the plan by Derek and his guardians, Antoine trains staff and implements the plan within the residential setting. Case 52: Preemptive Plan 73 CASE 53: CTRL-C/CTRL-V Anika is a BCBA supervising Yoshiko, a Board Certified Assistant Behavior Analyst (BCaBA), accumulating supervised hours toward her BCBA credential. Anika and Yoshiko follow the BACB’s Task List and consistently document their experience and supervision hours. While meeting, Anika provides Yoshiko with her timesaving strategies and tips for maintaining a caseload. Anika shows Yoshiko how she generates behavior support plans based on a learner’s functioning from a skeleton template of previously developed plans that she has written. Anika matches the function with the correct initial generic template and adds the learner’s name and initiation date to the already developed behavior plan, allowing her to complete the support plan in less time. Once implemented, she may make adjustments to the plan, if necessary. 74 6. Section 2: Responsibility in Practice CASE 54: RUNNING ON EMPTY Aki is a BCBA who recently started providing services to a new learner who was transferred from another agency. After reviewing the learner’s records, Aki observed that the learner’s most recent behavior support plan targeting reduction of aggressive behaviors included contingent exercise (i.e., one lap around his house whenever he aggresses). The data Aki has been provided demonstrate a reduction of aggressive behaviors coinciding with the initiation of the current plan. Aki decides to continue the behavior support plan as written to ease the transition to the new agency and staff. Case 54: Running on Empty 75 CASE 55: SWEET TOOTH Meredith is a BCBA supervising the intervention of Mai, a 19-year-old learner diagnosed with a DD. Staff are having an extremely difficult time increasing Mai’s participation in programs. Meredith conducted a preference assessment since the staff have reported that they “cannot find anything to get Mai to attend during teaching sessions.” The assessment shows that Mai’s highest preferred items include fast food and candy. Meredith has begun integrating these items as reinforcers within Mai’s treatment. 76 6. Section 2: Responsibility in Practice CASE 56: PUNITIVE MEASURES Olivia works as a BCBA at an ABA agency with several other BCBAs on staff. Often, if one of her colleagues is sick or on vacation, arrangements are made for supervision coverage with the other BCBAs. Olivia has been asked to cover Jaylan’s cases while he is off for the week. While reviewing a behavior plan at a team meeting for one of Jaylan’s cases, Olivia notices little documentation or direction for how the staff members should respond if the learner engages in a replacement behavior. The behavior plan only specifically states that staff should sternly say “No!” and use response-blocking techniques should the learner engage in a targeted challenging behavior. Case 56: Punitive Measures 77 CASE 57: LET’S MOVE Lana is a BCBA supervising the behavioral intervention of an adult, Marcus, diagnosed with a DD. Staff have reported that whenever they give a directive to participate in new activities, Marcus begins to bite his hand. The biting has become so severe that Marcus now has constant grooves and red marks on his skin and has required bandages on several occasions. As part of her assessment, Lana asked Marcus’s parents if they had also observed hand biting. Similar to the staff members’ reports, it appears that Marcus engages in the behavior when asked to perform new or nonpreferred activities. Based on her assessments and discussion with the staff and parents, Lana develops a behavior intervention plan to reduce hand biting maintained by contingent escape. Lana includes several proactive strategies to prevent the likelihood of the behavior occurring and incorporates reactive strategies for managing the behavior should it occur. The behavior plan also implements strategies that promote appropriate replacement behaviors. Given the significant nature of the behavior and that Marcus has already caused damage to his skin that may be long-lasting, Lana implements the behavior plan at her observation session the following day. She intends to review and discuss the plan with Marcus and his family at the team meeting later in the week. 78 6. Section 2: Responsibility in Practice CASE 58: ALL IN THE FAMILY Mike is an RBT who provides services within the home of Miguel, a 10-year-old boy diagnosed with ASD. Miguel has two younger brothers, ages 6 and 4, living in the home. The younger brothers often play in the vicinity of the session, sometimes joining in for different activities. Mike normally doesn’t take issue and is usually able to practice a lot of social skills, sibling play, and coping and tolerance with the brothers. Recently though, the parents will leave Mike alone with all three brothers for 20–30 min at a time while they go inside and make dinner, do household chores, or take phone calls. Mike often feels like he is “babysitting” all three boys rather than holding an intervention session with Miguel. Case 58: All in the Family 79 CASE 59: COMMUNITY INTEGRATION Sierra is an RBT working with a 17-year-old learner within the home setting. A major aspect of the learner’s current programming goals focuses on social interaction and comfort within the community. After several months of the learner’s parents not planning or participating in community outings, Ling, the supervising BCBA, discussed the importance of increasing community opportunities and addressed the lack of progress on related goals. The family addressed any challenges and agreed to increase community outings. The first experience at a local hangout was very successful, leading to several additional community sessions at various locations, many at the request of the parents. While Sierra has noticed several positive developments with the increased outings, she is also aware that only a small portion of the actual time spent on these trips is dedicated toward program goals, with the rest spent waiting for the parents to complete their personal errands. 80 6. Section 2: Responsibility in Practice CASE 60: SUPPLIES WITH LEGS Juanita is one of three RBTs working within the home of Ishmael, a young child with an intellectual disability. Her agency provides supplies for use during intervention sessions, including games, flashcards, and various toys. The materials are stored in a suggested location in the family’s home so that the behavior technicians can access the items during their sessions. All of the materials are marked with the agency’s name with the intention of being returned to the agency after the supplies are no longer needed for intervention purposes. Over the last several weeks, Juanita has noticed different items missing from the supply box. The other RBTs working within the home have noticed the same issue. Juanita mentioned the missing supplies to Ishmael’s parents. After a very brief discussion, she was asked to leave the house before her session was complete. Case 60: Supplies With Legs 81 CASE 61: ALL BOOKED UP Sylvie is a BCBA working with Ravonna, a 3-year-old diagnosed with ASD. Based on assessment results, interviews and observations conducted, strengths identified, and areas of need detected, Sylvie has developed a treatment plan with individualized goals and objectives. Sylvie recommends 30 hours per week of direct behavioral intervention to appropriately work toward the items included within the intervention plan. Ravonna’s parents have reviewed the intervention plan and approve of all of the focus areas; however, they informed Sylvie that Ravonna would only be available to participate in 10 hours per week of intervention. What factors would you recommend Sylvie consider if she were to determine that she could not work with Ravonna given Ravonna’s limited availability? 82 6. Section 2: Responsibility in Practice CASE 62: UNLOCKED AND UNLOADED During her home-based session with Dwight, an RBT, Jodi, saw a handgun placed on a high shelf in Dwight’s parents’ office. Although the firearm was directly out of reach to Dwight, it could still be accessed if he stood on the chair in the office. It did not appear the handgun was locked in a safe while on the shelf. Jodi immediately asked Dwight’s parents if they were aware of the gun and if they could place the gun in a secured location. Jodi was told not to worry about the gun since the family keeps the bullets in a separate location. Case 62: Unlocked and Unloaded 83 CASE 63: CAN YOU HEAR ME NOW? Celia is a BCBA working with an ABA agency in a small rural town. One of her current learners and their family are moving significantly farther away from the agency’s office location. Despite the distance, Celia’s agency is still the closest service provider. However, given the distance, Celia is unable to find staff who can consistently travel to the learner’s home, and the family has safety concerns with driving the learner to the agency’s office. Celia has extensive experience delivering services via telehealth modalities and determined that continued service through video streaming would be an appropriate option for this learner. After several in-person trainings with the learner’s parents, Celia transitions to telehealth sessions. Unfortunately, as a result of the home’s poor internet, each session has been interrupted due to dropped connections and choppy feeds. 84 6. Section 2: Responsibility in Practice CASE 64: ZOOMING INTO TREATMENT Due to health and safety concerns, James, an 11-year-old diagnosed with ASD, is not able to participate in faceto-face ABA services. James has consistently benefited from his involvement in his ABA program. He has shown an increase across skill development targets and an overall reduction in aggressive and self-injurious behaviors within sessions. Darlene, the BCBA working with James, would like to continue to provide ABA services. She has asked James’s parents to switch to participating in telehealth services in which one of the parents would sit with James at the computer while Darlene implements James’s current treatment protocols and programs through a video platform. During the telehealth sessions, James’s parents will be expected to ensure all supplies are available and redirect any interfering behaviors. Given the immediacy of the health concern, Darlene plans to train James’s parents to address and minimize dangerous behaviors, as these continue to occur in the home setting without staff present during their first several telehealth sessions. Case 64: Zooming Into Treatment 85 CASE 65: PROMISES, PROMISES Ailani, a BCBA, has started providing services to a new learner at her ABA agency. The learner had received behavioral services prior to starting with Ailani’s agency but stopped due to a change in available funding. The learner’s previous program was based on the procedures of Floortime. Ailani met with the parents and discussed ABA services and her agency’s foundation and approach. The parents were very invested and interested but were also very happy with their previous agency and were apprehensive about all the changes. Ailani assured the parents that she would be heavily involved in the transition and provide as much parent education and support as possible. She also promised to integrate the preferred aspects of the learner’s previous treatment plan and strategies to ease the change and appease the parents. 86 6. Section 2: Responsibility in Practice
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