I am a BCBA collaborating on a case with an occupational therapist. The OT recommended a weighted vest. I know this is not an evidence-based practice, but I fear that if I’m not open to her suggestions, it will hurt our collaborative efforts and reinforce possible perceptions that behavior analysts are close-minded. How can I ensure that I am adhering to the BACB’s Professional and Ethical Compliance Code while still maintaining our professional relationship and ensuring that we are both making decisions in the best interest of the client?

Answered by Adriane Miliotis, MA, BCBA, LBA and Mary Jane Weiss, PhD, BCBA-D
Association for Science in Autism Treatment

Collaborating with service providerFirst, we would like to applaud you for reaching out with this question. Thanks to a combination of factors leading to growth in the field of applied behavior analysis (ABA) in recent years, Board Certified Behavior Analysts (BCBAs) are increasingly working within interprofessional and multidisciplinary teams (Brodhead, 2015; LaFrance et al., 2019). On average BCBAs receive little or no formal training in collaboration (Kelly & Tincani, 2013) despite the increased demand for the services of behavior analysts, evidence that collaboration can improve outcomes (Hunt, et al., 2003), and an ethical obligation to effectively and respectfully collaborate with colleagues (BACB, 2020).

Furthermore, this lack of training is often compounded by an additional tenet of the current and future ethics codes (BACB 2014, 2020) that require BCBAs to promote only scientifically supported, most-effective treatment procedures. The obligation to follow an evidence-based practice (EBP) process and employ data-based decision-making across all services is not only designated in the Code, but is also rooted in the graduate training of most behavior analysts. Within the science of ABA, the scientist-practitioner model (SPM), also known as the Boulder Model, is an integral component of the field (Shawler, et al., 2018; Weiss, 2018).

When all of these factors are put together, it is no surprise that behavior analysts like yourself are struggling when it comes to how to best collaborate with other professionals. For those BCBAs who are highly committed to a conservative interpretation of the Code, it is easy to conclude that one must never support a non evidence-based procedure. However, behavior analysts who function as part of a team may conclude that application of the Code is more nuanced and must be considered within each individual context. They may have insight into the potential pitfalls of strict adherence to the code, including harm to collaborative efforts and damage to professional relationships with colleagues. Nevertheless, there are also significantly dangerous and known ineffective treatments that must be advocated against; at times, the team needs to be educated about the harm or ineffectiveness of an intervention. In general, regardless of the collaborative challenge, behavior analysts need more explicit training on strategies for navigating nonbehavioral treatment recommendations.

One such strategy, as laid out by Brodhead (2015) proposes a “decision making model to help BCBAs problem-solve the ethical dilemma that may arise when a nonbehavioral treatment is proposed by a nonbehavioral colleague” (p. 72). In this model, Brodhead outlines one possible way for assessing nonbehavioral treatments by advocating for client safety, becoming familiar with the treatment, taking the perspective of the nonbehavioral colleague, and analyzing the treatment’s potential negative effects to the client. Below, we will briefly summarize Broadhead’s guidelines for assessing nonbehavioral treatments. Readers who are interested in learning more are encouraged to read the source document, which can be found here.

Broadhead’s model begins with the assumption that a nonbehavioral colleague has recommended a nonbehavioral treatment. Once a nonbehavioral treatment has been identified, the steps for assessing the treatment are as follows:

  • Is Client Safety at Risk? The safety of the client should always be the primary focus of the interdisciplinary team. This includes both physical harm as well as short- and long-term psychological harm. If the BCBA determines that the proposed nonbehavioral treatment does pose a risk to client safety, he or she should address the proposed treatment with the nonbehavioral colleague.
  • Are You Familiar with the Treatment? BCBAs should seek to move beyond their initial understanding of a treatment. This can be accomplished by searching for literature that has empirically tested the efficacy of nonbehavioral treatments on individuals with developmental disabilities, consulting with another professional from the same field as the nonbehavioral colleague, and exploring research that is not traditionally published in behavior-analytic journals.
  • Revisit Client Safety. It is possible that after becoming familiar with the treatment, the BCBA may uncover possible harmful side effects that were unknown prior to the review. If the BCBA determines client safety is at risk, the proposed treatment should be addressed with the nonbehavioral colleague.
  • Is Treatment Success Possible When the Nonbehavioral Treatment is Translated into Behavioral Principles? In this step, the BCBA should attempt to translate the proposed nonbehavioral treatment into behavior-analytic terminology. If the BCBA determines that the treatment is likely to be successful when translated into behavioral principles, no further action is necessary and the BCBA can avoid a situation where questioning a nonbehavioral treatment recommendation may potentially harm the collaborative relationship.
  • Will the Treatment Negatively Interfere with the Goals of the Client? The BCBA should determine if the intervention may negatively impact the overall goals of the client by interfering with already established goals or introducing inconsistency into the instructional approach. If the proposed nonbehavioral treatment is likely to negatively interfere with the goals of the client, the recommendation should be addressed.
  • Consult the Checklist for Analyzing Proposed Treatments (CAPT). The CAPT is a tool designed to help the BCBA put the relative negative impacts of a treatment into perspective. It is possible that the proposed treatment may have minimal negative interference, in which case it may not be worth addressing, especially if doing so could damage the professional relationship.
  • Are the Impacts to the Client Sufficient to Justify the Possibility of Compromising the Professional Relationship? A nonbehavioral treatment that has the potential to significantly interfere with the goals of the client should be addressed with the nonbehavioral colleague regardless of the impacts on the professional relationship.

Taken together, the steps of the above decision-making model represent one strategy a BCBA may use when deciding whether or not to address a nonbehavioral colleague’s nonbehavioral treatment recommendation.

Another option available to behavior analysts for navigating nonbehavioral treatment recommendations relies on the relative strength of the field in designing and implementing single subject experimental designs (SSED). Amongst the other allied health professions (e.g., occupational therapy, physical therapy, speech language pathology), BCBAs are uniquely positioned to work with their colleagues to conduct single subject research to evaluate the efficacy of a proposed intervention for an individual learner. An advantage of using SSED over other decision-making processes is that it provides evidence specific to the child being treated.

Alternating treatment designs, in particular, are a simple strategy to help nonbehavioral colleagues compare the effectiveness of two therapies or to compare treatment versus non-treatment on the behavior of a child. Kay and Vyse (2005) describe the steps for designing and implementing an alternating treatments design in the context of evaluating a nonbehavioral treatment recommendation, including: identifying the target behavior, designing the test, developing decision rules, collecting the data, and evaluating the results and making a decision. Using their training as a scientist-practitioner, behavior analysts can help guide the team to make decisions to continue, discontinue or modify the procedure based on such data.

In addition to the options presented above, we also refer you to the section of ASAT’s website “Learn More About Specific Treatments” as well as Autism NJ’s “Framework for Understanding What Is Evidence-Based.”. ASAT categorizes treatments under “what works,” “what needs more research,” and “what doesn’t work or is untested.” Autism NJ uses a stoplight analogy to categorize treatments as green, yellow, or red. Behavior analysts who are questioning whether or not to proceed with a nonbehavioral treatment can consult these two sources to first determine if a proposed intervention is one that warrants advocacy against its implementation.

Additional helpful resources include position statements from professional organizations, which may recommend for or against certain interventions. It is helpful to stay abreast of these, as they provide additional expert opinion on the value of designated interventions. The American Academy of Pediatrics and the American Speech and Hearing Association have numerous position statements on interventions that are commonly suggested (e.g., Facilitated Communication, Rapid Prompting Method, Auditory Integration Training, Sensory Integration Therapies). These resources also provide some interdisciplinary perspectives on the risks and benefits associated with procedures.

Finally, we cannot end a discussion on this topic without reiterating that not all proposed nonbehavioral treatments should be considered within a collaborative model. Ultimately, BCBAs are obligated to operate in the best interest of the client and in some instances, this will mean advocating against the implementation of an inappropriate nonbehavioral treatment (Brodhead, 2015). When there is documented harm, documentation of ineffectiveness, elements of pseudoscience or anti-science, and when position statements exist warning against their use, clinicians should voice their objection to the intervention, and should not implement it.

As the field of behavior analysis continues to grow, the mandate for BCBAs to work collaboratively becomes more pressing by the day. While graduate training programs are starting to answer the call, BCBAs who are already working in the field should familiarize themselves with current research on collaboration, avail themselves of relevant continuing education opportunities, and seek out consultation and mentorship from more experienced behavior analysts when necessary. They should also stay current with various resources that could assist in the process of determining the evidence base for a suggested intervention. With respect to disseminating evidence-based practices, behavior analysts have both a duty and an obligation to “play nice in the sandbox” to the extent that promoting positive professional relationships will ultimately lead to increased access to evidence-based treatment and improved outcomes for individuals with disabilities. There is also an obligation to uphold the tenets of science. Balancing these obligations is a nuanced skill set, but can be strengthened with the strategies and resources reviewed above.

References

Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for behavior analysts. Author.

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. Author.

Brodhead, M. (2015). Maintaining professional relationships in an interdisciplinary setting: Strategies for navigating nonbehavioral treatment recommendations for individuals with autism. Behavior Analysis in Practice, 8, 70-78. https://dx.doi.org/10.1007%2Fs40617-015-0042-7

Hunt, P., Soto, G., Maier, J., & Doering, K. (2003). Collaborative teaming to support students at risk and students with severe disabilities in general education classrooms. Exceptional Children, 69(3), 315-332. https://doi.org/10.1177/001440290306900304

Kay, S., & Vyse, S. (2005). Helping parents separate the wheat from the chaff. Putting autism treatments to the test. In J. W. Jacobson, R. M. Foxx, & Mulick, J. A. (Eds.), Controversial therapies for developmental disabilities: Fads, fashion, and science in professional practice (265-277). Lawrence Erlbaum Associates, Inc.

Kelly, A., & Tincani, M. (2013). Collaborative training and practice among applied behavior analysts who support individuals with autism spectrum disorder. Education and Training in Autism and Developmental Disabilities, 2013, 48(1), 120–131.

LaFrance, D. L., Weiss, M. J., Kazemi, E., Gerenser, J., & Dobres, J. (2019). Multidisciplinary teaming: Enhancing collaboration through increased understanding. Behavior Analysis in Practice, 12, 709-726. https://doi.org/10.1007/s40617-019-00331-y

Shawler, L. A., Blair, B. J., Harper, J. M., & Dorsey, M. F. (2018). A survey of the current state of the scientist-practitioner model in applied behavior analysis. Education and Treatment of Children, 41(3), 277-297. https://doi:10.1353/etc.2018.0014

Weiss, M. J. (2018). The concept of the scientist practitioner and its extension to behavior analysis. Education and Treatment of Children, 3, 385-394. https://doi.org/10.1353/etc.2018.0021

Citation for this article:

Miliotis, A., & Weiss, M. J. (2021). Clinical Corner: What are some ethical and practical considerations when collaborating with nonbehavioral service providers? Science in Autism Treatment, 18(7).

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