Conducted by Adriane Miliotis, MA, BCBA, LBA and David Celiberti, PhD, BCBA-D

Recently, we had the pleasure of speaking with ASAT Professional Advisory Board Member, Tracie Lindblad, MSc., SLP, MEd, BCBA, to learn about her journey to becoming a dually certified SLP-BCBA and to discuss her thoughts on interprofessional collaboration. 

Adriane and David: Please share some details about your career path and how you became involved in autism treatment.

Tracie Lindblad, MSc, MEd, SLP, BCBA

Tracie: The journey has been long and circuitous. In my second year of university in Canada, I took a course through the Speech Language Pathology (SLP) department called Communication Disorders. The next year, I took a course through the Psychology Department called Psychopathologies of Childhood. I was aiming to become a Paediatrician so both courses ticked the necessary boxes: they were easy (good marks to help with my GPA) and related to my chosen field. In both of those courses, there was a lecture on “Classical Autism” which intrigued me since it was so rare (3 in 10,000 births) at that time. As I completed my university coursework, I began to realize I wanted to study Speech Language Pathology (SLP) instead of medicine.

Upon graduation with my shiny new degree, there were a shortage of jobs and no hospital openings in the paediatric department. So, I headed to the local school board for my first professional role. As the new person in the department, I was the lucky recipient of a caseload that was extremely challenging. I was assigned to the special education classrooms where most of the individuals had complex needs and were non-verbal. I loved it! These students required all my new knowledge and then some. Since there was little to guide my practice, it enabled me to be creative, try new things, and reach out to mentors, parents, and researchers. I was young, inquisitive, and probably a little naïve, which gave me the gumption to reach out for clarification and mentorship by simply writing authors directly. It afforded me an introduction to passionate people who were also on a quest to determine the best treatment for individuals with autism spectrum disorder (ASD) and other complex communication needs. One of the first people I wrote to, in the late 80s/early 90s, was Dr. Andy Bondy. He was, and continues to be, extremely helpful in guiding my practice as a Speech Language Pathologist (SLP).

As the schools in Ontario, Canada changed from direct treatment to assessment and consultation only, I knew that it was time for me to switch to private practice to continue to develop my treatment skills. I opened a private practice and have almost exclusively treated children with ASD and complex communication needs for the last 25+ years.

Adriane and David: What an incredible journey that has been. It is wonderful how you reached out to experienced professionals when needed. What led you to pursue additional certification in behavior analysis?  How has that guided your work as an SLP?

Tracie: In my private practice in the mid- to late-90s, I had two separate clients who had engaged Applied Behavior Analysis (ABA) services from the USA. I was invited to attend the trainings and reluctantly agreed to go. It was during these trainings that I realized how general my goals were, how much my data collection lacked, and that I didn’t have the analytic skills necessary to truly be confident in what I was teaching and how I was teaching it. It also gave me the opportunity to begin to understand how to assess, analyze, and change behaviours which interfered with the therapy sessions.

This was a pivotal time in my professional career; I began to explore the science of ABA and apply it within my SLP practice. The application of ABA to my practice could immediately be seen in many areas such as goal development, goal writing, data collection, data analysis, materials selected to meet specific treatment goals, parent coaching/feedback, and addressing the barriers to learning (i.e., interfering behaviours). I also began to limit and eventually stop my overreliance on marketed treatment materials since I could now determine what to teach, how to teach it, and when to tweak the goals and/or materials.

Many aspects of speech and language pathology utilize the principles of ABA. However, many SLPs (I included at that time) are unaware of the science of ABA at work during our sessions. I became more aware that within my speech and language intervention, some of the elements of the science of ABA were embedded throughout. SLPs are taught to provide opportunities to ‘sabotage the environment’ to promote opportunities for increased communication. When I was ‘sabotaging the environment’, I was increasing motivation, contriving and capturing opportunities, and providing prompts to shape the target behaviour. Shaping, chaining, prompting, and reinforcement (i.e., operant learning principles) are implemented by SLPs but often without the explicit knowledge regarding the underlying principles and the empirical support for each of those components.

Thank you for so articulately sharing how ABA has enhanced your clinical work. As a dually certified SLP-BCBA, you have a unique perspective on the relationship between the two disciplines. Why is collaboration important and what can each field offer the other?

Tracie: As someone who “wears two hats,” it is readily apparent how each field can assist the other.

SLPs have extensive knowledge and scope of practice (i.e., formal education and training) in standardized (i.e., norm-referenced, criterion-referenced, and diagnostic) assessment practices, child language development, phonology (the sound system of language), neurology, physiology of the speech mechanism, and speech, language, and communication disorders including swallowing, dysfluencies, and voice problems.

BCBAs have extensive knowledge and scope of practice in the assessment of the environmental variables which may be controlling a behaviour (i.e., speech, language, and communication are considered behaviours as you can observe them and effect changes). They also know how to differentiate function versus form in the behaviours one observes and have knowledge regarding how to effectively break down a complex behaviour into stepwise targets. Further, BCBAs have experience in writing measurable goals and collecting data to both assess and demonstrate a causal relationship between the treatment and the goal outcome, and they know how to systematically and effectively teach through carefully controlled lessons which progress to more ‘loose teaching’ to ensure acquisition, fluency, generalization, and maintenance of the specific skill. They use reinforcement to strengthen behaviours, and they assess and treat barriers to learning (i.e., problem behaviours) or those behaviours which negatively impact the client’s quality of life and are socially significant.

Collaboration is for the betterment of the client; neither field has the scope of practice (i.e., the breadth of training) that is necessary to effectively treat the whole person. Together, clinicians can choose appropriate goals, develop materials to promote acquisition and generalization, and systematically implement treatment with data obtained to allow for error analysis and modification such that the client achieves the skills and effectively uses them within their natural environments.

Adriane and David: You recently authored an article that was published in Behavior Analysis in Practice in January 2021 titled, Ethical Considerations in Clinical Supervision: Components of Effective Clinical Supervision Across an Interprofessional Team. What motivated you to produce scholarly work on the topic of interprofessional collaboration?

Tracie: Interprofessional collaboration and practice allows clients with ASD and other complex needs to achieve the best outcomes. Without the joining of fields, the client suffers. A piecemeal approach to treatment, usually characterized by competing goals, inconsistencies in techniques, varying messages resulting in confusion for the client and their caregivers, skills taught which may hinder optimal functioning and must later be ‘undone,’ and ineffective and misused resources (time, money, items, etc.) does not result in a better outcome for the client. I went into the field of speech pathology to be able to effect a positive change for the client and their family. I was only truly able to realize that goal when I added ABA to my practice and when I collaborated beyond both of those fields by adding other professionals as needed to the team.

Human behaviour is complex, and we’ve only revealed the tip of the iceberg in what we know about the brain and the human body. It doesn’t make sense to assume that one profession is equipped to handle issues and effect the changes required when the human system is so multifaceted. It takes a well-trained and diverse team to address the needs of such clients.

It is also much more rewarding and fun to work with colleagues who inspire learning and are dedicated to maximizing the outcomes of their clients. It is always best to work with those who are motivating, receptive to ideas, and are willing to share their knowledge, helping you to achieve something that you couldn’t achieve on your own.

Adriane and David: Teams with these qualities can create incredible learning opportunities for all. We’d like to shift gears a bit and discuss the promotion of science. As this can be a very challenging endeavor, how can we better promote science to teams comprised of multiple disciplines?

Tracie: It is a difficult time in our world to promote science. There is so much skepticism of the scientific process. People are questioning the motivations of those involved in science, the cost and the ability to realize profit from science, the misapplications in the name of science, and the inequities in the access to science. Often, multidisciplinary teams are competing within their own workplace and across workplaces. The competition for jobs is fierce and the need to not be seen as expendable has negative impacts across professional departments within a work setting.

Promoting science must start in education and training programs. Universities must begin to utilize a case-based team approach to teaching professionals to work together. A model which demonstrates that a collaborative team is required to determine the optimal treatment plan for the client would lead to an increase in the use of the scientific process across all members of the team.

In programs where there is strong interprofessional education designed in the curriculum, professors nurture respect and teamwork and shape the skills required to function effectively in such an environment. We need to look to other areas where solutions to complex problems require a highly skilled team of professionals such as those that tackle environmental problems, technological innovation, and global crises. These team members do not see themselves in competition with each other but rather as necessary collaborative members in a process where everyone is valued and required in order to solve the problem at hand.

Adriane and David: You raise such important points. What was autism treatment like twenty-five years ago?  What would you like to see twenty-five years from now?

It is my hope that twenty-five years from now we have answers or greater clarity to some of the unknowns about ASD that can lead to better treatment options:

  • Diagnostics that can be reliably made as soon as possible (i.e., neonatal, or under 1 year of age) for earlier treatment options.
  • Genetic information that may guide treatment for specific subtypes of ASD.
  • Comparison research which can demonstrate what works, for whom, for what profiles, and when.
  • An increased use of technology for better teaching such as the use of virtual reality to teach safety skills ‘safely’, artificial intelligence/machine learning to assist with the design of individualized curriculum, which is tweaked depending on the learner’s responses, etc.
  • Dissemination of treatments around the globe which are accessible, affordable, and effective.
  • The acceptance of treatment for those on the spectrum who wish to improve their quality of life and/or their skills; and
  • A greater understanding and awareness of possible negative aspects or outcomes of some of the treatments currently available with discontinuation of those in the future.

Adriane and David: There are several studies that have evaluated intensive early behavior intervention (EIBI) versus an eclectic model (e.g., Eikeseth et al., 2002; Howard et al., 2005). In these studies, participants who received EIBI had better outcomes than those who received eclectic intervention. How does working within an interprofessional team differ from an eclectic model and is there any empirical evidence that a collaborative approach is better than EIBI alone?

Tracie: Within EIBI it has been documented in the Eikeseth et al., 2002 and Howard et al., 2005 studies that eclectic treatment did not result in the same positive effects as only EIBI services which were delivered by those trained in ABA. The ‘eclectic’ services in those studies were ‘treatment as usual’, meaning the participants received ABA services delivered by those trained in ABA concurrently with a combination of other therapies such as Project TEACCH, sensory-motor therapies, speech and language therapy, special education, etc.

Delivering services via an interprofessional team, however, differs significantly from multidisciplinary services (i.e., eclectic treatment). With multidisciplinary services, each discipline assesses the individual, determines appropriate goals, and provides treatment based on their theoretical underpinnings, scope of practice, and competency for the client. All goals and outcomes are reported separately.

With interprofessional services, the team acts as a unified whole where the baseline assessment serves as the starting point for a discussion about all possible goals, the appropriateness of specific goals, and the prioritization of goals. The goals are developed as a team with consensus determined around sequence and priority as well as the specific procedures to be employed, data to be collected, and mastery criteria. Under an interprofessional services model, the team leader, the Clinical Supervisor, is tasked with guiding the team through this process so that the team can develop the best treatment plan that meets the needs of the client.

To my knowledge, there are no empirical studies which have directly compared outcomes for interprofessional services vs. ABA services only (i.e., EIBI or comprehensive ABA) for ASD treatment specifically. There is a study in 2015 which examined an interprofessional care model for ASD assessment (Koushik et al., 2015). The authors found that there was a significantly reduced time to diagnosis which they felt was likely associated with better care coordination. They also found that the establishment of the clinic enabled them to connect these specific low-income clients to community-based resources in a timely manner, potentially reducing disparities in ASD diagnosis and intervention for this segment of children.

There are good indications from other studies involving complex care clients such as those requiring cardiac and neonatal care. These studies have supported that an interprofessional model results in better outcomes. However, there are drawbacks regarding the cost of resources with respect to the professional’s time (i.e., meetings, large teams, etc.). Nevertheless, the extension of those studies as applied to individuals with ASD has led to more recent discussions and interprofessional practice for children with ASD.

Adriane and David: In your paper, you talk about the behavior analyst assuming the role of interprofessional clinical supervisor. In a field fraught with turf wars and accusations of scope encroachment, it’s not surprising that there’s already been some pushback against this idea. While you offer many practical suggestions for the behavior-analytic clinical supervisor with regards to strengthening the collaborative skills of team members, they all require an openness to the behavior analyst as interprofessional clinical supervisor in the first place. What advice can you offer to the behavior analyst in this role working with a team or team member who is unwilling to accept the behavior analyst in this position?

Tracie: The skills required to be the interprofessional clinical supervisor align very closely with the scope of practice within the field of ABA. Specifically, behaviour analysts are trained to observe human behaviour, shape skills, use the principles of reinforcement, and collect data to determine the outcomes. All of these activities are in the purview of the behaviour analyst and are not solely to be used for clients with challenges but rather can be utilized within a workplace or human services team. There is an entire subset of the field, Organizational Behaviour Management (OBM), which applies the principles of ABA to systems and organizations. The interprofessional team is a system tasked with an outcome. The team members are variables within that system that will have a direct impact on achieving the desired outcome – which is optimal functioning of the client. A skilled behaviour analyst with the specific competencies required to lead a team of professionals from various backgrounds should possess the proficiencies necessary to evaluate the team members, determine the activities necessary to strengthen the team (i.e., shape individual team members or shape the workings of the team as a whole), provide reinforcement contingencies to increase the desired behaviour(s), and analyse the outcomes of the entire team towards meeting the goal. For behaviour analysts who are not yet proficient in these areas yet wish to take on the role of interprofessional clinical supervisor, the Behavior Analyst Certification Board (BACB) has issued guidance entitled Recommendations for Respecializing in a New ABA Practice Area (2020).

I agree that the idea of the behaviour analyst assuming the role of clinical supervisor may be looked upon as adding fuel to the fire regarding the current turf wars and encroachment messages that have been raised largely in the social media realm.  However, I examine the suggestion of behaviour analyst as team leader and the overall team composition with a slightly different lens. It’s true that behaviour analysts often don’t even have a seat at the interprofessional table and so it may then seem presumptuous to suggest that they lead the team without first coming up through the ranks and meeting their dues as a team member. However, I would offer that by leading the team they would, in fact, be functioning more like the impartial chair of a committee rather than a contributing/fully functioning member of the team where the possibility exists that any suggestions from the behaviour analyst may further add to the feelings of turf wars and encroachment issues from team members who have had past negative experiences, feel in competition for their own job, and/or have been impacted by the messages on social media. Thus, their role would be one tasked with ensuring optimal team functioning, coordination of services, education with respect to crafting succinct measurable goals, problem solving and conflict resolution, data analysis, etc., and less about direct recommendation for ABA services within the client treatment plan.

By working to shape the team to achieve optimal outcomes for the client, the behaviour analyst can demonstrate the application of an evidence-based practice process, guide the selection of targets/goals which are functional in nature and socially significant, assist with determining appropriate data collection and assist in the overall analysis of data to determine treatment effectiveness. Further, they can facilitate the access and understanding of empirical literature from across the disciplines, and bring to the fore discussions regarding the role of motivation and reinforcement within the treatment procedures to ensure that changes to functioning are possible.

In the role of the clinical supervisor utilizing OBM strategies, the behaviour analyst may become the valued and respected member of the interprofessional team who assists in shaping the team to achieve a positive outcome for the client.

Adriane and David: The two sections of your paper that really resonated the most were the discussions of Evidence-Based Practice and Data-Based Decision Making. As behavior analysts, we can often be quick to dismiss a practice as “not evidence-based,” which closes to the door to any possibility for collaboration. However, we are ethically bound to promote only “scientifically supported, most-effective treatment procedures” (Behavior Analyst Certification Board, 2014). How can we reconcile these two competing forces, especially if, as the interprofessional clinical supervisor, we are accountable for shared team decisions?

Tracie: Graduate training in the field of behaviour analysis is based on the Boulder Model, also known as the scientist-practitioner model (Shawler, et al., 2018). It is because of this training, which contrasts with the biopsychosocial or medical model of our other allied health practitioner team members, that behaviour analysts operate differently and tend to focus on and uphold the core tenets of this model [which are also embedded within the Professional and Ethical Compliance Code for Behavior Analysts (BACB, 2014), as well as the Ethical Code for Behavior Analysts (2020)]. Thus, behaviour analysts are obligated to follow an evidence-based practice (EBP) process and employ data-based decision-making paradigms within all services. However, the interprofessional team is comprised of various members from diverse backgrounds where the standards for EBP and data collection and analysis differ. This discrepancy often impacts on successful collaboration, as you have highlighted, since the behaviour analyst is ethically bound to comply with the standards of the code.

I would posit that there also can be other interpretations to the definition of ‘evidence-based’ and “scientifically supported, most effective treatment procedures” (BACB, 2014) which may provide some leeway and flexibility for the behaviour analyst in satisfying their obligation to meet this section of the code. Behaviour analysts are well trained in single subject experimental design (SSED) and the evidence-based practice process. Any planned treatment can be implemented in a way which can satisfy the code and meet the criteria for ‘evidence-based practice’ as well as ‘scientifically supported’ and ‘effective treatment’, if:

  • the goal is well defined (observable, measurable, achievable);
  • the treatment is implemented with fidelity (technologically sound and manualized/written in sufficient detail); and
  • data are collected and analyzed against the set criteria.

There are also many areas of practice where there is little research (i.e., scientific support) to guide the practitioners in treatment – either for the specific problem area, the unique characteristics of the client, and/or the intervention setting(s) (which may include the families wishes and the wider community). In these cases, the practitioner (or interprofessional team) must take clinical experience and recommendations into account when choosing a possible treatment option. As offered in the paper, there are also tools that the clinical supervisor can employ to assist the team in making sound decisions with respect to specific treatment recommendations. The use of these processes does enable the behaviour analyst, as the clinical supervisor or as a lone practitioner collaborating with other professionals, to meet their obligations under the code and develop respected and trusting relationships with other professionals for the ultimate benefit of the client.

Adriane and David: One more question! We are delighted to have you serve on our Professional Advisory Board.  Given your busy schedule, can you share a bit about your decision to support our work?

Tracie: It has been an extremely easy decision to support the work of ASAT through the Professional Advisory Board as well as through direct, personal, and local initiatives such as sharing the website links, resources, and wealth of information that ASAT produces. For me, ASAT is the trusted and unbiased source of information about autism treatment for parents, practitioners, and professionals. With the sheer volume of information currently available through social media channels, it is extremely difficult for those who are new to this diagnosis or new to practicing in this area not to become overwhelmed by the choices and messages out there. ASAT provides the information in one place. In addition, ASAT advocates for clear and accurate reporting of information based on science. With the onslaught of the anti-science campaigns of recent times, ASAT’s role is becoming increasingly more valuable and needed to ensure that accurate information is disseminated, that journalists are held accountable for the content of their messages, and that scientists have an avenue for disseminating their research findings to the public in understandable language for parents and professionals alike.

Adriane and David: Well, of course, we couldn’t agree more! We appreciate that, and thank you again for taking the time to discuss your own professional journey and to answer our questions regarding your recent publication on interprofessional collaboration. There is still much work to be done in this area and we hope we can keep this conversation going. 

References:

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

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. Littleton, CO: Author.

Behavior Analyst Certification Board. (2020). Recommendations for respecializing in a new ABA practice area. Littleton, CO: Author

Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7- year-old children with autism. A 1-year comparison controlled study. Behavior Modification, 26(1), 49-68. https://doi.org/10.1177/0145445502026001004

Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Research in Developmental Disabilities, 26(4), 359-383. https://doi.org/10.1016/j.ridd.2004.09.005

Koushik, N. S., Bacon, B., & Stancin, T. (2015). An interprofessional care model for evaluating autism spectrum disorders (ASDs) among low-income children. Clinical Practice in Pediatric Psychology, 3(2), 108–119. https://doi.org/10.1037/cpp0000093

Lindblad, T. L. (2021). Ethical considerations in clinical supervision: Components of effective clinical supervision across an interprofessional team. Behavior Analysis in Practice. https://doi.org/10.1007/s40617-020-00514-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

Citation for this article:

Miliotis, A., & Celiberti, D. (2021). An interview with Tracie Lindblad. Science in Autism Treatment, 18(6).

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