Gasiewski, K., Weiss, M., Leaf, J. B., & Labowitz, J. (2021). Collaboration between behavior analysts and occupational therapists in autism service provision: Bridging the gap. Behavior Analysis in Practice, DOI: 10.1007/s40617-021-00619-y

 

Reviewed by Beatriz Querol-Cintrón, MS, BCBA, LABA(MA)
Association for Science in Autism Treatment 

A review of Collaboration between behavior analysts andThe increasing prevalence and complexity of autism spectrum disorder (ASD) have driven the need for effective, evidence-based treatments involving the following goals: a) skill acquisition, b) removal of barriers to learning, and c) improvement in functional living skills and quality of life (Centers for Disease Control & Prevention [CDC], 2019; Anagnostou et al., 2014). Due to a wide variety of ASD practitioners and a recurrent overlapping of their responsibilities (i.e., Board Certified Behavior Analysts [BCBAs], occupational therapists [OTs], physical therapists [PTs], social workers, and speech language pathologists [SLPs]), Gasiewski and colleagues (2021) highlighted the importance of collaboration to facilitate shared accountability in treatment to further improve client outcomes (Friend & Cook, 2007). As such, if various professionals work with a single learner, forming an alliance aimed at unifying and enhancing therapeutic goals is key.

While various disciplines provide treatments for ASD, Welch and Polatajko (2016) noted that both occupational therapy (OT) and applied behavior analysis (ABA) are heavily involved in targeting similar skills. More specifically, OT addresses self-care, play, school, and job skills, while ABA targets the same areas as OT in addition to behavior reduction and skill development in activities of daily living, motor movement, communication, and socialization. However, to date, pieces written on OT-ABA collaboration have been limited. Therefore, this article is a very important addition to the current literature base, particularly given that we have seen an increasing number of published works written about the BCBA-SLP relationship (Koenig & Gerenser, 2006; Spencer et al., 2020; Morgan, 2020), and the role of BCBAs within interdisciplinary settings (Kelly & Tincani, 2013; Brodhead, 2015; Greenwald et al., 2015; Summers et al., 2021).

ABA and OT 

Gasiewski and colleagues (2021) proficiently discussed histories, similar and contradicting foundational concepts, and practical applications between ABA and OT. Furthermore, they examined both fields’ views on the implementation of sensory interventions as touched upon briefly below.

ABA, a field that emerged in the late 1950s and 1960s, is the science of understanding human behavior that uses behavior principles to generate socially significant change (Baer et al., 1968; 1987). While ABA helps individuals access their surroundings more effectively through consistent instruction and reinforcement, OT, established in 1917, teaches skills needed for independence and participation in daily living activities within environmental and cultural contexts (Occupational Therapy Practice Framework, 4th Edition [OTPF-4], 2020). Despite their integrated focus on skill acquisition, behavior regulation, and meaningful, real-world outcomes, considerable disagreement exists between both fields. Gasiewski and colleagues (2021) assert that this disagreement stems from the theory behind, and application of, sensory interventions – processes that allow the nervous system to interpret senses and as a result produce motor and behavioral responses. Ayres sensory integration (ASI; Ayres, 1979) and sensory-based interventions (SBIs; Bodison & Parham, 2018) are two discrete interventions that lack evidence for their effectiveness (Smith et al., 2016), as shown through their inability to replicate intervention protocols and assess sensory motor factors.

Given limited or inconclusive empirical evidence, Gasiewski and colleagues (2021) posit that OTs should pair sensory interventions with functional tasks and use them sparingly with individuals with sensory processing issues (Bodison & Parham, 2018). Furthermore, the authors contend that OTs tend to gravitate toward outcomes and performance in practice, compared to BCBAs who employ objective data collection highlighting their process-oriented approach. Although both professions hold client outcomes in high regard, BCBAs rely on continuous data collection, data-based decision making, and quantitative analysis. 

Evidence-Based Practice for ASD 

Effective interventions require empirically validated treatment (Zane et al., 2016). Gasiewski and colleagues (2021) emphasized the complexity of ASD as it necessitates expertise from many disciplines via interdisciplinary collaboration – a combination of each field’s strengths to maximize best client outcomes (Brodhead, 2015; LaFrance et al., 2019). However, the authors stress that coordinated care presents as a challenge to most clinicians because of differing philosophies, perspectives, and definitions of what constitutes evidence-based practice (EBP). 

Barriers to Collaboration 

Behavior analytic care, although evidence-based, tends to be one-dimensional when utilized as a stand-alone form of treatment. Many large ABA organizations solely offer behavior analytic services, even while striving to improve on collaborative efforts as set forth by the Ethics Code for Behavior Analysts (Behavior Analyst Certification Board® [BACB®], 2020). Without interprofessional collaboration, disjointed care could lead to inefficient, or worse, counterproductive service delivery, negatively impacting learners with ASD. Therefore, the authors present six evident barriers to collaboration between ABA and OT as outlined below: 

    1. Evidence-based practice and misperceptions. Driven by the Ethics Code in ABA and its addendum on collaboration (BACB®, 2020), Gasiewski and colleagues (2021) claim that most BCBAs maintain that their ethical duty requires them to question and identify nonevidence-based interventions as ineffective (Stephenson & Costello, 2020). Misperceptions in the use of EBP in OT heavily impede successful, effective collaboration between OTs and BCBAs. As professionals deeply invested in EBP, Gasiewski et al. (2021) suggest that BCBAs may need to recognize a concerted effort within the OT discipline that attempts to employ EBP in practice as evidenced in their OTPF-4 (2020). Additionally, the authors add that OTs see themselves as doers, disinterested in demonstrating practical benefits or discussing theoretical frameworks behind interventions (Christiansen & Haertl, 2019).
    1. Differences in terminology. Through the years, the use of behavior analytic terminology across disciplines has acted as a deterrent to effective collaboration due to unfamiliarity and inconvenience expressed by specialists from other fields while communicating. As such, the authors endorsed a recommendation forwarded by Critchfield et al. (2017) that BCBAs proactively lessen their use of jargon especially when attempting to build professional relationships with OTs.
    1. Reputation of ABA. Gasiewski and colleagues (2021) discussed misconceptions of each discipline as a contributing factor to disruptive collaboration (Welch & Polatajko, 2016). Most practitioners outside the field of ABA view the practice as: a) highly focused on discrete trial instruction (DTI; Cooper et al., 2020); b) unable to plan for generalization (Matson et al., 2012); and c) incapable of considering client preferences in evaluation and treatment (Welch & Polatajko, 2016).
      On the contrary, BCBAs utilize teaching strategies aside from DTI, plan for skill maintenance and generalization before treatment, and prioritize individualization and client input in goal development.
    1. Reputation of OT. Similarly, as reported by Gasiewski and colleagues (2021), clinicians outside the field of OT assume that OTs mostly utilize sensory interventions (Welch & Polatajko, 2016), which have been described as “complementary or alternative medicine, with limited and inconclusive evidence” in ASD literature (Brondino et al., 2015). Gratefully, a trend has surfaced in that newer OTs recommend sensory interventions much less than their older counterparts because of the greater push for EBP within the OT profession (Thompson-Hodgetts & Magill-Evan, 2018).
    1. Obstacles during interactions. Gasiewski and colleagues (2021) mention that between OTs and BCBAs, disagreements stem from the following areas: a) utilization of interventions for both skill deficits and behavioral excesses; b) goal development; and c) role assumptions due to overlapping scopes of practice (Kelly & Tincani, 2013).When compared to OTs, BCBAs do not typically receive training on collaboration through their coursework (Scheibel & Watling, 2016). Nevertheless, the trend has changed as seen in a few universities offering a wide range of ABA degree concentrations (e.g., Endicott College’s ABA and Childhood Clinical Disorders, ABA and Mental Health; Eastern University’s Counseling with ABA; University of Northern Colorado’s Special Education and ABA; School Psychology and ABA), and in some BACB® Authorized Continuing Education (ACE) Providers establishing virtual training opportunities on interprofessional collaboration (e.g., Special Learning, Inc.’s Multidisciplinary Collaboration Series).
    1. Collaboration versus eclectic intervention. Per Gasiewski and colleagues (2021), collaboration should not be equated with eclectic intervention, as the former involves the infusion of expertise unavailable within one discipline. Despite differing philosophical underpinnings, the authors forwarded a suggestion made by Odom et al. (2012) to combine the following approaches: a) EBP; b) individualization in goal development; and c) treatment fidelity. 

Models and Strategies for Improving Collaboration

To facilitate effective collaboration between OTs and BCBAs, Gasiewski and colleagues (2021) compiled suggestions from fellow researchers and enumerated the following models and strategies:

    • A combination of developmental and behavior science while considering respective discipline’s ethical codes (Welch & Polatajko, 2016). Some BCBAs begin their practice with limited knowledge and little to no training in developmental psychopathology, which could be beneficial when writing up age-appropriate and contextually sound goals for their learners.
    • Creation of a collaborative cross-disciplinary decision tree (that currently is non-existent). As a field that highly values data-based decision making, BCBAs could certainly learn from a carefully laid out visual on collaborative best practices, and therefore best adapt to changes in the Ethics Code (BACB, 2020).
    • Development of an interdisciplinary code of ethics (Cox, 2012). A unified code that considers each field’s clinical strengths and weaknesses could lead to significant improvements in interprofessional collaboration and communication.
    • Evaluation of the quality of intervention proposals and their implementation, emphasizing safety protocols, like a decision-making tree for BCBAs to collaborate with medical professionals (Newhouse-Oisten et al., 2017). With program evaluation being at the center of behavior analytic practice, BCBAs could assimilate a great deal of expertise in quality control from medical professionals.
    • Application of a decision-making model for behavior analysts when faced with a nonbehavioral intervention proposal via the Checklist for Analyzing Proposed Treatments (CAPT; Brodhead, 2015). This tool could tremendously inform and assist BCBAs in teasing out interventions based on evidence versus those that lack scientific rigor.
    • Clarification of roles (Luiselli, 2015). Aligned with the Ethics Code (BACB, 2020), all practitioners should be mindful of practicing within their scope of competence. 

Getting to decision making within teams. Unquestionably, there are more benefits to collaborative practice than there are drawbacks as outlined above. BCBAs need not limit themselves to their own circle of influence. Reaching out to and learning from other practitioners could build on their clinical expertise and consequently, contribute to well-rounded, robust behavior analytic services. Gasiewski and colleagues (2021) bring up Brodhead’s (2015) CAPT which welcomes and enables all practitioners to evaluate a proposed intervention’s safety, risk, and ability to translate into individualized treatment, a huge step toward improving collaboration efforts. Furthermore, the authors promoted Stephenson and Costello’s (2020) recommendation that OTs need to communicate the evidence behind their practice to individuals they collaborate with, more specifically BCBAs. 

Additional strategies. Koenig and Gerenser’s (2006) work on ABA-SLP collaboration may be expanded to other disciplines, according to Gasiewski and colleagues (2021), inspiring professionals to share their respective research by way of conferences, journals, or even listservs with the goal of developing constructive professional disagreement while stimulating new and improved forms of treatment. Moreover, the authors mention that OTs need to increase their research base to include individuals with ASD to be able to advance studies implemented through ABA (Welch & Polatajko, 2016). To strengthen this point, they encourage professionals to jumpstart that dialogue regarding professional roles, boundaries, and overlaps while continuously observing each other, jointly delivering treatment, and facilitating case conferences that could potentially reinforce clinical collaboration within teams. 

Benefits of collaboration. Gasiewski and colleagues (2021) elaborated that improved collaboration brings about the following advantages:

    • Enriched learner outcomes due to comprehensive assessments and interventions (LaFrance et al., 2019);
    • Built shared scope of practice and fundamental knowledge to deliver highly integrated supports (Koenig & Gerenser, 2006);
    • Appropriate goal development for clients (e.g., the use of alternative sensory activities and the use of contingent or noncontingent reinforcement to address automatic or sensory-based behaviors);
    • Creation and refinement of EBPs (Koenig & Gerenser, 2006);
    • Maximized outcomes without having to duplicate work (Koenig & Gerenser, 2006); and
    • Enhanced professional respect and development of functional, effective work environments. 

Areas for Training, Implications, and Future Research

Given the limited scope and range of literature on interprofessional collaborative practice amongst BCBAs, Gasiewski and colleagues (2021) suggest the following items as areas for training and future research:

    • Adaptation of decision-making models for interprofessional collaboration;
    • Recognition and establishment of a common ground between OTs and BCBAs;
    • Further examination of the types of collaboration between OTs and BCBAs and corresponding strategies; and
    • Development of soft skills to further enhance OT-ABA collaboration.

Gasiewski and colleagues (2021) are among many writers (i.e., Brodhead, 2015; Greenwald et al., 2015; Kelly & Tincani, 2013; Koenig & Gerenser, 2006; Morgan, 2020; Spencer et al., 2020; Summers et al., 2021) investigating the value of interdisciplinary collaboration in pursuance of optimal outcomes in autism treatment. As they have shown, there are many great benefits to working with others who utilize evidence-based treatments drawn from fields outside of one’s own. BCBAs and OTs should attempt to be in continuous communication about interventions and goals for their shared clients. Both fields will benefit from richer knowledge about autism treatment and will understand their clients with greater depth. While producing meaningful outcomes for clients, practitioners from any field will foster deeper respect towards members of their interdisciplinary teams and advance the work done in their respective fields.

Citation for this article review:

Querol-Cintron, B. (2021). Review of Collaboration between behavior analysts and occupational therapists in autism service provision: Bridging the gap. Science in Autism Treatment, 18(12).

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