Epiphanies, Opportunities, and Reflections from the Field
An Interview with Carl Sundberg, PhD, BCBA-D, Hayleigh Kanzler, MA, CCCSLP, & Angela Seal, MOT, OTR, Behavior Analysis Center for Autism
By David Celiberti, PhD, BCBA-D & Patrick O’Leary, MA, BCBA
We want to thank you all for participating in this group interview. Meaningful and effective multi-disciplinary collaboration is something that may not come easily for many teams, particularly when there are different views about the relevance of science in the treatment of autism. We are very grateful for the opportunity to showcase the model used at the Behavior Analysis Center for Autism.
Q: Dr. Sundberg, please describe how BACA came to include OTs and SLPs.
Carl Sundberg: In the years before BACA was established, I consulted for families who were doing in-home ABA programs. In most cases, the child was also receiving speech and/or OT services through the school or another provider. It was often difficult to coordinate services between the various providers. In many cases where the child was receiving speech services, the speech language pathologist (SLP) involved would also target general language acquisition. Sometimes these recommendations/programs would differ from the recommendations/programs made and established by the ABA provider. About 10 years ago, when I was working for an ABA center, I had suggested that we begin contracting with an SLP so that we would all clearly be on the same page. We would create the language programs based on the principles of applied behavior analysis (ABA) and the SLP would focus on issues related to vocalization, articulation, feeding, swallowing, etc. We then started contracting with an occupational therapist (OT) and eventually hired an SLP and OT full time. BACA now employs three SLPs and two OTs.
Q: Our experiences have been similar with providers working on similar targets but in different ways, and, in many cases, those divergent methods were not necessarily compatible or complementary. In many cases, there may actually be an absence of communication and coordination altogether. We can see how having providers onsite has the potential to promote consistency and synergy. Was the hiring process challenging?
Carl Sundberg: The hiring was a bit tricky. We needed to find people who would fully embrace ABA and especially Skinner’s analysis of verbal behavior, commit to data-based decision making, as well as agree to focus on more narrow objectives relating to the mechanics of speech, articulation, and feeding. For the OT, we needed to find someone who could help us with our OT needs yet not be a major supporter of sensory integration. Once hired our SLPs and OTs participate in the same trainings as our other clinical staff, beginning with the training required to become a Registered Behavior Technician. They attend all in house training and are sent to behavioral conferences and workshops as well. One of our SLPs has finished her BCBA coursework, sat for and passed the exam while working at BACA.
Q: Sounds like the expectations are in place that promote consistency across members of the team. Can you tell our readers a bit more about how OTs are deployed at BACA? Do you use OTs with every child, or only the ones who have significant gross or fine motor issues?
Carl Sundberg: Not every child is in need of OT services. Those who do receive services vary in need. Our OTs will assess our clients’ gross and fine motor skills, and design, oversee, and train staff on programs (exercises) to improve any weaknesses. Our OTs also assess the need and make recommendations for adaptive equipment (such as special scissors, shoes or wrist guard to help with writing, etc.) and program equipment (such as swings, balance beams, large balls, etc.).
Q: When you use an SLP in a program, what does he or she typically address that a BCBA cannot?
Carl Sundberg: Before we worked closely with SLPs, we already had an understanding of how to use the methods of ABA such as stimulus stimulus pairing, differential reinforcement, and shaping to attempt to produce new sounds, to establish echoic responding, and to improve articulation. However, we were lacking a true mechanical and developmental understanding that an SLP can provide. An SLP can devise specific programs with specific targets that can greatly enhance success when it comes to establishing and enhancing vocalizations. In addition, an SLP can give us a better understanding of the child’s probability of becoming a functional speaker. This is a critical variable when deciding on a response form for a student, if continuing with vocalizations is feasible, when to fade out sign language, other forms of augmentative communication, etc. The input provided by our SLPs related to these areas has been invaluable to us.
Q: Thank you for sharing these experiences as I know that many programs for individuals with autism have grappled with how to create synergy through effective multi-disciplinary collaboration and coordination. We have the good fortune to have Hayleigh Kanzler available to answer some questions. Hayleigh, how do you incorporate ABA into your therapy sessions when focusing on communication skills?
Hayleigh Kanzler: My work is heavily guided by ABA principles and, in fact, I use reinforcement strategies all the time in therapy! I have found that the students I work with respond well and will work harder if there is a tangible reward at the end. I also use transfer trials for teaching generalization. More specifically, we use ECTER: error (child makes an error), correction (correct error with prompt), transfer (take away that prompt for a correct response), expansion (have the child do something else), and return (come back to the target). That system of teaching really allows the child to be successful, but also take that skill beyond just knowing how to answer in a specific situation. It allows learners to transfer the skill beyond that one moment in time when they know the answer- they have to do other things that distract them from the correct answer and come back to it. Obviously, it would start with one, small expansion, but the expansion time and number of expansion activities increases! I think the greatest asset we have as SLPs at an ABA center is having a behavior technician with us during therapy. I am constantly asking questions to promote consistency and also teaching how to implement my speech goals within their daily practice. The great thing is that the behavior technicians follow through with practice, so I see faster progress than I typically would if this carryover was not part of the culture.
Q: Do you work in a consultative capacity or are you typically working one-on-one with children? In other words, do you provide exercises for line therapists to use, or do you do all the work directly with the children?
Hayleigh Kanzler: To answer that question, yes and yes! I do see children for direct therapy (one-to-one), but also have the flexibility to do some consultations with children who are not on my caseload. Sometimes a consultation will include helping to create vocal goals for children who are just starting at BACA and sometimes it can be with a child on my caseload to help brainstorm with that child’s team. I see around 25 children per week for direct services and then I leave exercises to be practiced until I see them the next week. It’s a great model for daily practice and since I am often in the same building, I am there to train and answer any questions the behavior technicians may have.
Q: What are some underpinnings of ABA that can guide the practice of SLPs involved with individuals with autism?
Hayleigh Kanzler: Coming from a research background, I appreciate the data-driven nature of ABA programming. I do think SLPs can implement many ABA techniques to increase success in working with kids with autism. Many SLPs already use reinforcement naturally but not necessarily as intentionally or systematically as they could! Other behavior analytic teaching techniques- such as errorless learning, transfer trials are also great tools to have as an SLP when working with students with autism.
Q: What advice do you have for BCBAs on school based teams who are trying to make inroads with OTs and SLPs?
Hayleigh Kanzler: The biggest thing with collaboration is to realize that we are all working for the same thing- for the good of the child. SLPs, OTs, and BCBAs may disagree with some things, but these can often be worked through in a professional and open manner. Every member of the team benefits when each person has an open mind to the others’ specialties. Each professional has knowledge and instead of getting frustrated, ask “why” something is being done a certain way and, then, actually listen. These discussions are enhanced when research is incorporated and data are used to back up assertions being made.
Q: Last, but not least, we wanted to bring Angela Seal into the conversation in her role as an OT at BACA. How do you incorporate ABA into your therapy sessions when focusing on skills?
Angela Seal: Primarily, I use reinforcement procedures to strengthen the skills that I am teaching our clients. I also rely on shaping and fading procedures to teach skills. I utilized these procedures before I joined the Behavior Analysis Center for Autism; however, with guidance from our clinical staff, I have been able to refine my skill level in implementing these procedures.
Q: Do you work in a consultative capacity or are you typically working one-on-one with children?
Angela Seal: The majority of my time is spent one-on-one with clients with brief consultations following with behavior therapists to teach and discuss activities that will support the child’s program. When a client is not on my caseload, one of our BCBAs can request a consult with an OT. Usually during these consults, I give recommendations related to specific questions related to fine or gross motor skills, daily living skills or feeding.
Q: What are some underpinnings of ABA that can guide the practice of OTs involved with individuals with autism?
Angela Seal: In my opinion, the basic underpinning is the careful analysis of antecedent and consequences through the collection of ABC data. OTs should be analyzing what is happening before and after a client’s behaviors, specifically what a therapist’s response is to the behavior. The OT must understand how various modes of attention, such as eye contact, proximity to client, physical touch, etc., can reinforce a behavior (adaptive or maladaptive).
Q: As you know, your skill building approach to OT is not universally shared. For many students with autism, OT services are defined by the delivery of sensory experiences. What are your views on sensory integration therapy?
Angela Seal: I would not consider myself an expert in sensory integration theory as I don’t use it personally. I would be more inclined to utilize sensory integration if there was a strong base of research to support it. I have also observed fellow OTs who are misapplying this theory. In many cases, utilizing sensory integration techniques during behaviors has the potential to reinforce that behavior. For example, placing a child on a swing to calm the child during a maladaptive behavior only teaches him or her that initiation of the maladaptive behavior is one way in which he or she can access the swing. Therefore, instead of utilizing a mand for the swing, a child will learn to exhibit a maladaptive behavior to access the swing.
Q: What advice do you have for BCBAs on school based teams who are trying to make inroads with OTs and SLPs?
Angela Seal: As professionals, we all want respect for the profession to which we chose to devote our lives. So, my number one piece of advice: respect the OT and SLP you work with in the school system. Listen to them and let them describe what frames of references they are working from when they are treating their clients – whether it be SIT, neuromuscular, cognitive, etc. Discuss deficits and strengths of mutual clients. Ask how the OT and/or SLP focus on strengthening the deficits, and then offer insight on how principles of applied behavior analysis may impact or enhance that plan. Share information about ABA, how it can be utilized to strengthen skills, and how data collection can be used to objectively measure progress. I would like to think that most professionals in the school system are there for the good of the clients. The strength of a client’s program often lies in the strength of the relationships of those who are creating the program. Those relationships are built on a mutual understanding and respect, as well as collaboration.
Q: What can behavior analysts learn from OTs? What can OTs learn from behavior analysts?
Angela Seal: OTs are able to teach behavior analysts how to identify basic deficits for common tasks and then common activities or exercises to address those deficits. For example, clients who have difficulty maintaining a grasp on a toothbrush most likely have strength deficits within the hand. There are common activities and exercises that would strengthen the hand, such as animal walks or playing with resistive materials. It would still be advantageous to request a consult from an OT because there could be underlying issues but these activities could be utilized until that consult could take place.
Another example would include feeding in which I would assess muscle tone; strength; oral motor skills; feeding skills (can the child use a fork or spoon); tolerance to certain textures, temperatures, tastes, feeding equipment; and/or positioning (does the child require special support, is the child in a chair where he or she is stabilized with feet on the ground). I would also consider whether the child or family have certain foods that should be avoided (for example, certain faiths do not allow pork to be eaten). Once areas of concern have been identified, I can offer recommendations to the behavior analyst that may include positioning; types of utensils to utilize; methods in which to focus on desensitization to textures, temperatures and tastes; and oral motor strengthening exercises (often times this is in collaboration with Speech Therapy). Together, the behavior analyst and I can create a feeding protocol reflecting our respective areas of expertise. In sum, a behavior analyst can learn about underlying deficits preventing skill acquisition and basic ways in which to address the deficits.
Behavior analysts are obviously skilled in the analysis of behavior, more specifically the function of the behavior. I have learned valuable lessons from behavioral analysts when observing them complete a functional analysis of the behavior. After we have discussed the results and they have given recommendations on behavior protocols, I have been more successful in my treatment of the child.
Thank you all for a wonderful interview. We are very grateful that you were able to share your experiences and hope that the elements of your model can be considered by others. It takes a village to help a person with autism realize their fullest potential and a strong multi-disciplinary team that relies on science and is grounded and guided by data is essential.
Citation for this article:
Celiberti, D. & O’ Leary, P. (2015). Related Services in an ABA Setting: Epiphanies, Opportunities, and Reflections from the Field An Interview with Carl Sundberg, Hayleigh Kanzler, & Angela Seal, Behavior Analysis Center for Autism Science in Autism Treatment, 12(2), 5-10