Dr. Kolu BCBA-D Cusp Emergence Blog Post 8.26.2021
https://cuspemergence.com/
have difficulties calming down when under pressure
have difficulties using “appropriate” behaviors even after years of programmed reinforcement for using them
have mental health concerns that have never been appropriately addressed because my behavior masks my needs
have medical problems that are going unaddressed because my providers have never asked me about my trauma history, despite it being a fact that it confers serious medical risks. (See the incomparable Nadine Burke Harris talk about her work on this, and the amazing takeaways, in her classic TED Talk– or see some of her research and outcomes on using screening tools)
be more likely to use certain “challenging behaviors”
and find it more reinforcing, even important, to use behaviors you would describe as challenging
use behaviors that are more resistant to change than you are used to as an instructor, therapist, parent, supervisor or friend
find some kinds of social interactions difficult or painful
have trouble controlling some of my bodily functions, but may not be able to describe to you why
experience “triggers” in the environment that you can’t see (but that an experienced provider could locate, document, and learn to help me explore or move with, as appropriate)
experience some times of the day, week, month, or year that are marked by aversive events for me that you won’t know about
may not be able to explain WHY this time is difficult or why I am using an “old pattern of behavior”
find it more difficult to perform, or to learn and remember new things than others of my age, skill level, or occupation – even if “on a good day” I can do this just fine. (By the way, have you read The Four Agreements? Do you know how important it is to take nothing personally and know that others are doing their best (and how critical it is for you to do the same)? If not go check it out.
use occasional behavior that is mistaken as “ADHD” or “ODD”, or more, but that is actually related to how I was mistreated
have been given misdiagnoses, treatments that didn’t work, or medications that made my problems worse or that interacted with each other in harmful ways that hurt my body and cognitive function
attempt to advocate but get ignored when I try to communicate pain, mistreatment, or a medical concern
be more likely to experience FUTURE trauma because of what I faced before
lack a reinforcing and useful repertoire (e.g., full complement of skills and things to enjoy), especially if I faced treatments that just tried to “teach me a replacement behavior” for a few challenging things I did, instead of understand and grow me as a person in the context of my own community, needs and desires for my future
be part of a long line of marginalized people or one of multiple generations exposed to trauma
have a chance to change our lineage… if you help
Prather, W., & Golden, J. A. (2009). A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. International Journal of Behavioral Consultation and Therapy, 5(1), 56-74. http://dx.doi.org/10.1037/h0100872
Rajaraman, A., Austin, J.L., Gover, H.C., Cammilleri, A.P., Donnelly, D.R. and Hanley, G.P. (2022), Toward trauma-informed applications of behavior analysis. Jnl of Applied Behav Analysis, 55: 40-61. https://doi.org/10.1002/jaba.881
" First, behavior analysts may be hesitant to discuss trauma due to conceptual confusion and interpretive difficulty regarding the phenomenon. As with physical trauma, the causes of psychological trauma are extrinsic to the individual. However, the effect of experiencing traumatic events is generally conceptualized as an internal response to an aversive external event (DeCandia et al., 2014)"
"A second difficulty in incorporating trauma into a behavior analytic account has to do with our conceptualization of causes. As with anxiety, processes such as stimulus equivalence, derived relational responding, and stimulus generalization (Friman et al., 1998a; Friman & Dymond, 2020) may prove useful in explaining the persistence of trauma responses (e.g., emotional outbursts, blunted affect, -) months or years after the traumatic event(s). However, interpreting trauma through a behavior analytic lens and applying that interpretation in practice are two different behavioral repertoires, and it is possible that we are better at the former than the latter."
"The third potential barrier to incorporating trauma into behavior analytic research and practice has to do with evidence"
Rajaraman, A., Austin, J.L., Gover, H.C., Cammilleri, A.P., Donnelly, D.R. and Hanley, G.P. (2022), Toward trauma-informed applications of behavior analysis. Jnl of Applied Behav Analysis, 55: 40-61. https://doi.org/10.1002/jaba.881
"Clients may also routinely experience potentially traumatizing events during the course of ABA treatment. Some examples include transitioning to a residential facility away from home, staff and peer turnover in service settings, or being repeatedly physically restrained or secluded during episodes of dangerous behavior. Behavior analysts may not currently have methods to ascertain pervasive behavioral impacts of such events, but they all may constitute traumatic experiences." Rajaraman, 2022)
"...clients receiving ABA services may have undocumented histories of trauma. The overwhelming majority of practicing behavior analysts (78%) provide services to individuals diagnosed with intellectual and developmental disabilities (Behavior Analyst Certification Board®, 2020; LeBlanc et al., 2012). Given (a) the high prevalence of ACEs among children (Darnell et al., 2019); (b) the differentially greater risk for trauma among individuals with intellectual and developmental disabilities (Hibbard et al., 2007; Kerns et al., 2015); (c) the notion that communication deficits are a core feature of developmental disabilities like autism spectrum disorder (Ahearn & Tiger, 2013); and (d) the fact that most contemporary measures of trauma involve some form of verbal report (e.g., Cocozza et al., 2005; Morrissey et al., 2005), it is both possible and probable that there are clients who arrive at the doorstep of ABA services with a history of trauma that will remain unknown to the service provider." (Rajaraman, 2022)
What is important to the client?
History of reinforcement and Punishment
Any Medical Needs
Aversive Experiences
Familial Changes or Experiences
Barriers to treatment
Barriers between members in the support network
Barriers in the way of learning or using their skills
ABC skill access day
Any trauma, illness, or change with their caregiver?
When did they eat last?
Do they need the bathroom?
What sensations might be occurring?
Itchy, Cold, or Hot
Was there a medication change?
Did they sleep the night before?
Are they in pain?
Is a member of their support network sick or injured?
Consider the context they are in
Was there a new adult in their environment (substitute teacher, new therapist)
Transparent
Inviting
Collaborative
Friendly
Ask their opinion!
"Massive behavior challenges that can erupt seemingly out of “nowhere” when a client faces a trigger". -Dr. Kolu
Screaming
Flinching, cower, freeze, grimace
Close their eyes
"Zone" out
Run away
Play repetitively with toys
https://cuspemergence.com/2020/09/08/contraindicated-behavioral-procedures-after-trauma/
For a client who has experienced previous food insecurity, food related abuse or neglect, and/or severe food deprivation: One potentially contraindicated procedure is using edible reinforcers.
For a client who has been involved in previous sexual abuse (including when the client also makes allegations): One contraindicated procedure is assigning a 1:1 without additional oversight.
For a client who has experienced medical complications from sexual or physical trauma (e.g., this could include incontinence, fecal smearing or related concerns, etc): One contraindicated procedure is conducting toilet training without oversight from a medical professional, additional training or consultation by someone with expertise in this circumstance, etc.
For a client who has experienced previous neglect or adverse circumstances (such as deaths of parents, removal from unsafe conditions, or experiencing war, dangerous immigration or poverty related issues), resulting in deprivation of basic needs and social interaction: Some potentially contraindicated procedures involve attention related extinction, differential reinforcement of appropriate versus inappropriate requests, or time out from attention reinforcement.
For a client who has been affected by physical and/or sexual abuse, behaviors and circumstances consistent with reactive attachment disorder, or multiple and changing caregivers in childhood: One potentially contraindicated procedure might be contingent praise statements to establish compliance related behaviors.
Autonomy
Assent, Consent, and Assent Withdrawal
Set them up for success
Talk Out Loud
"my hands are on you until --- to keep you safe"
"I hear you"
Listen to what their behavior might be saying
Antecedent Strategies
Avoid Extinction
Develop an authentic relationship
What should be considered?
How can you manage behavior and be trauma informed?
What should be considered?
How can you manage behavior and be trauma informed?
“The Circumstances View of problem behavior attributes the source of the problem not to the person him or herself but to what has happened to the person over the course of their life up to the occurrence of the behavior(s) of concern. Therefore, the Circumstances View guides its adherents not to fix the blame upon a person but to fix the problem(s) (i.e., the behavior) by altering the circumstances.” (Friman, 2021)
Friman, P.C. (2021), There is no such thing as a bad boy: The Circumstances View of problem behavior. Jnl of Applied Behav Analysis, 54: 636-653. https://doi.org/10.1002/jaba.816
The “TIC” “(a) acknowledging the potential trauma experienced by clients and assuming a universal sensitivity to trauma; (b) curating environments that ensure safety and trust by building and maintaining rapport with clients and identifying alternatives to intrusive restraint procedures (whenever possible), thereby reducing potential retraumatization; (c) promoting client autonomy and shared governance by arranging choice-making opportunities and methods of client validation throughout client intake and treatment development; and (d) choosing intervention options that teach adaptive skills whenever possible.” (Rajaraman et al., 2022)
Rajaraman, A., Austin, J.L., Gover, H.C., Cammilleri, A.P., Donnelly, D.R. and Hanley, G.P. (2022), Toward trauma-informed applications of behavior analysis. Jnl of Applied Behav Analysis. https://doi.org/10.1002/jaba.881
Human
Trauma and Learning History (Circumstances and TIC)
Mental Health
Culture
Value
Context
Other Services (interdisciplinary collaboration)
Assessment
Principles
Tactics
Measurement
Curriculum
Ethics
Intervention
Monitor Progress
Artistry
We will be talking a lot about how Trauma Informed Care interacts with our Ethics in the RBT Ethics section!
This training program is based on the RBT Task List (2nd ed.) and is designed to meet the 40-hour training requirement for RBT certification. The program is offered independent of the BACB.