bcba slp - strategies for increased interprofessional ... · teresa cardon, phd ccc -slp, bcba-d...

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Strategies for Increased Interprofessional Collaboration between Behavior Analysts and Speech Pathologists to Support Children with

Communication Needs (aka – Collaboration Blind Spots!)

Teresa Cardon, PhD., CCC-SLP, BCBA-DThe Chicago School of Professional Psychology

Teresa Cardon, PhD CCC-SLP, BCBA-D

Agenda

• Disclosures• Collaboration Blind Spots• Theories• Interventions• Interprofessional Collaboration• Ten Tips!


Disclosures


Two disciplines – one goal!


Why is collaboration so important?

• Effective collaboration can support improved outcomes for clients (e.g., Kelly and Tincani, 2013; Hunt, Soto, Maier, Doering, 2003; Sheridan & Colton, 1994)

• Limited hours and limited access to professionals makes collaboration essential for clients to access effective intervention.


Why can collaboration be so tricky?


The Collaboration Blind Spot

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What is the collaboration blind spot?(Kwan, 2019 – HBR)• Groups who are asked to collaborate and work together often feel

threatened by the “other”• “Especially when those groups are being told to break down walls,

divulge information, sacrifice autonomy, share resources, or even cede responsibilities that define them as a group”• “Groups that have been asked to collaborate often retreat into

themselves and reflexively assume a defensive posture. Their top priorities: Guard the territory, minimize the threat”


Is it contagious?

YES - Collaboration Blind Spots lead to collaboration bias!

What you say and do can impact others and their perceptions!


SLPs and BCBAs are experiencing collaboration blind spots!• Each discipline brings unique strengths to the relationship!• We have a lot more to learn from each other if we take the time to

listen. • ”Turf wars” only hurt our professions and our clients!• Be aware of your own collaborationblind spots!

Teresa Cardon, PhD CCC-SLP, BCBA-D Teresa Cardon, PhD CCC-SLP, BCBA-D

Professional Practice Survey (2017)

• SLPs, BCBAs, SLP-BCBAs• Scenario based• Based on many interactions and conversations with both SLPs and

Behavior Analysts• Cardon, T. (2017). Speech language pathologists & behavior analysts:

Perspectives regarding theories and treatment of autism spectrum disorder. Perspectives: Language, Learning, and Education. Perspectives of the ASHA Special Interest Groups, 2 (SIG 1), 4. doi:10.1044/persp2.SIG1.4


Survey Results (Cardon, 2017):

Theory % of SLPs (n= 100) % of BAs (n= 34) % of SLP-BCBAs (n= 13)

Behavioral Approach (Skinner)

14% 91% 77%

Cognitive/SemanticApproach (Bloom)

41% 3% 15%

Constructivist/Social Approach (Vygotsky)

10% 3% 8%

Psycholinguistic/Syntactic Approach (Chomsky)

15% 3% 0%

Pragmatic Approach (Bruner)

13% 0% 0%


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Behavioral Approach (Skinner, 1957)

• Verbal behavior is defined as, “behavior reinforced through the mediation of other people” where the listener’s response “has been conditioned precisely in order to reinforce the behavior of the speaker” (Skinner, 1957, p.2). • Language is viewed from the strict constructs of behaviorism, where a

stimulus produces a response which in turn produces a consequence(Sr + R + C). • Skinner’s focus was on the functional control of the verbal behavior

as opposed to the form, use, and content of communication.• New – Relational Frame Theory (2015)


Cognitive/Semantic (Bloom, 1970)

• A child’s knowledge base comes from experiences and they begin to talk about what they know

• Children then begin to map the form and function of their language based on their experiences


Constructivist/Social (Vygotsky, 1962)

• Social Development Theory argues that social interaction precedes development; consciousness and cognition are the end product of socialization and social behavior• Vygotsky focused on the connections between people and the

sociocultural context in which they act and interact in shared experiences• Also known for zones of proximal development


Psycholinguistic/Syntactic (Chomsky, 1957)

• Brain is “pre-wired” for language and readily available to apply a set of rules to the particular language a child is exposed to

• Language acquisition device –children are born with the “device” they need to acquire language

• Current research (2016), questioning validity of theory!


Pragmatic Approach (Bruner, 1974)

• Development of language from a social context

• Bruner indicated that relationships and social interactions are the motivation for a child to acquire language


Survey Results: What does it all mean?

Theory % of SLPs (n= 100) % of BAs (n= 34) % of SLP-BCBAs (n= 113)

Behavioral Approach (Skinner)

14% 91% 77%

Cognitive/SemanticApproach (Bloom)

41% 3% 15%

Constructivist/Social Approach (Vygotsky)

10% 3% 8%

Psycholinguistic/Syntactic Approach (Chomsky)

15% 3% 0%

Pragmatic Approach (Bruner)

13% 0% 0%


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Theoretical Differences

Nature

• Chomsky

Nurture• Skinner• Bruner

Both Nature & Nurture• Vygotsky• Bloom


What theory(ies) guide your practice?

Let’s talk about the theories that guide our practice!


Remember two disciplines. . . .

ONE GOAL:

To support individuals with autism!


A quick overview …

FCTPRT

ESDM

VBJASPER

PECS

SGDs


Functional Communication Training (FCT)

• Based on the idea that problem behavior(s) may function as a means for communicating

1. IF a challenging behavior has a particular communicative function2. THEN we can teach a socially acceptable means (communication of some

type!) of achieving the same function

• Both SLPs and BCBAs implement FCT• Terminology and data tracking may be different


Steps to FCT:

• Teachers/practitioners identify:• An inappropriate behavior (e.g., hitting, grunting, falling to the floor) that is

serving some type of communicative function and that is being reinforced (perhaps unknowingly) so that it occurs on a regular basis; or

• A subtle communicative attempt that can be replaced with a more socially accepted form of communication.


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Common Reasons/Functions• Communication• Avoidance • Attention • Fear • Boredom• Transitions• SensoryØKEY – You must know the function of the

behavior before you will EVER be able to change or manipulate the behavior!


These are common – but not the only reasons! Many people stop here!

STEP 1: Identify the Target BehaviorSTEP 2: Functional Behavior Analysis

• Operationally define the target behavior• Observable & Measureable

• Take Data• Track the target behavior

• When does it occur?• How long does it last?• How long between target behaviors?• How intense is the target behavior?

• Look for a Pattern• What happened right before the behavior occurred?

• Antecedent• How did you respond?

• Consequence


Step 3. Identify the Replacement Behavior

• Choose a replacement behavior that is efficient & effective• The replacement behavior should be simple enough to:

• Be taught in a short amount of time; and• Allow the learner to quickly acquire the behavior and gain access to the reinforcement.

• Teachers/practitioners identify a replacement behavior that is acceptable and appropriate for both the environment and the learner.• Choose a replacement behavior that is recognized by multiple

communicative partners.


To Teach Replacement Behaviors• Teach a functionally equivalent behavior

• It must help them get the same thing or it is not a replacement behavior! It can’t be a new skill you hope they will pick up on!

• Follow through consistently across all settings

• Provide opportunities to practice the new behavior

• Make the replacement behavior more EFFICIENT & more EFFECTIVE than the problem behavior• Or it won’t work!!!!• (e.g. Suzy and math worksheets!)


Choosing & Learning to Protest:


Ineffective Strategies, What NOT to do…

Function Ineffective Strategy…

Avoid a Task Time – Out/ Removal

Escape a Task Time – Out/ Removal

Gain Attention Verbally Reprimand

Obtain a Tangible Handing Over Object


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Step 4. Track the Data

• Antecedents• Prompts required to produce the replacement behavior• Frequency of the replacement behaviors• Frequency of the interfering behaviors• Consequences of the behavior


Step 5. Create Environments for Success

• Think about ANTECEDENTS!!!• Where does it occur?• Are there visual supports you can create?• Do you need special reinforcers?


Step 6. Prompt for SuccessFull Physical

Prompt

Model Prompt/Verbal

Prompt

Direction

Comment

Time Delay


Step 7. Reinforcement

• Reinforce the correct behavior• Immediate• Naturalistic• Often

• DO NOT reinforce the incorrect behavior• Remember, it may get worse before it gets better

• Extinction Burst


One type of FCT:Used by MANY different practitioners!


Common Replacement Strategies for Functional Communication: SLPs• Picture Exchange

Communication System (PECS)• Sign• Gestures• Verbal Language• AAC

BCBAs• Picture Exchange

Communication System (PECS)• AAC• Verbal Behavior


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What is “Verbal Behavior”

• BF Skinner spent over 20 years developing his analysis of language• “Behavior reinforced through the mediation of other persons” but these

other persons “must be responding in ways which have been conditioned precisely in order to reinforce the behavior of the speaker” (Skinner, p. 2 and p. 225)

• His main premise was that language constitutes learned behavior acquired and maintained by environmental contingencies

• Verbal behavior is central to many critical aspects of human behavior (e.g., language acquisition, relationships, intelligence, academics)


Cooper, Heron, & Heward (2019)

Verbal Behavior focuses on Function overall (with Form often being addressed via “tacts”)

Form• Topography of the verbal

response (e.g. speech, sign language, text, icons)• Phonemes• Morphemes• Lexicon • Syntax• Grammar

Function• Causes of the verbal response• The immediate and historical

environmental contingencies that elicit and provide consequences for speaker and listener behavior• Focus of verbal behavior was to

identify these environmental contingencies


Cooper, Heron, & Heward (2019)

How can we work collaboratively to support FCT?

How can different practitioners can support each other within FCT?

How would this work in different settings?


Example: You have a 5-year-old client who is trying to gain access to his favorite crackers by crying and screaming. You talk with his parents about several options to change this behavior. Choose the option below that you think provides the BEST option. (Choose all that you would consider)

Answer: SLP (n=100) BA(n=34)

SLP-BCBA(n=13)

Teach the child to sign “more” 42 (42%) 6 (18%) 0

Teach the parents to ignore the child when he cries for crackers 6 (6%) 14 (41%) 3 (23%)

Use a differential reinforcement procedure 28 (28%) 28 (82%) 7 (54%)

Picture Exchange Communication System 81 (81%) 23 (68%) 9 (69%)

Remove the crackers from the house 0 0 0

None of the above 3 (3%) 0 0

Other 16 (16%) 11 (32%) 6 (46%)

(Cardon, 2017)

Scenario #3: A six-year-old child on your caseload is struggling to learn the steps of the morning routine at his new school. To assist him in learning the routine, choose what you would determine to be the most effective and efficient treatment plan from those listed (Choose the best answer):


SLP-BCBA(n=13)

Video Model of Routine 25 (25%) 14 (41%) 2 (15%)

Written task analysis 4 (4%) 9 (26%) 2 (15%)

Picture schedule 90 (90%) 24 (71%) 8 (62%)

Social Story 22 (22%) 3 (9%) 0

Premack Principle 2 (2%) 7 (21%) 1 (8%)

Physical Prompt 3 (3%) 6 (18%) 2 (15%)

Self Management 2 (2%) 3 (9%) 0

Other 4 (4%) 5 (15%) 0


American Speech-Language-Hearing Association (ASHA):• SLPs are responsible for “consulting and collaborating with other

professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate." (Practice Portal, 2016)• SLPs are charged to "share responsibility with other professionals for

creating a collaborative culture. Collaboration requires joint communication and shared decision making among all members of the team, including the individual and family, to accomplish improved service delivery and functional outcomes for the individuals served." (Scope of Practice, 2016)

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Behavior Analyst Certification Board

• 2.03 Consultation. • (a) Behavior analysts arrange for appropriate consultations and

referrals based principally on the best interests of their clients, with appropriate consent, and subject to other relevant considerations, including applicable law and contractual obligations. • (b) When indicated and professionally appropriate, behavior analysts

cooperate with other professionals, in a manner that is consistent with the philosophical assumptions and principles of behavior analysis, in order to effectively and appropriately serve their clients.


Pivotal Response Treatments

• The Koegel’s• Bob = Behavior Analyst• Lynn = Speech Language Pathologist

• Together = AWESOME!!!


PRT (Koegel & Koegel)

• PRT is a behavioral approach that includes a child’s caregiver in a natural setting using motivational procedures

• Research behind PRT indicates that if certain pivotal skills are taught to a child, learning those pivotal skills will affect other areas of a child’s development

• PRT is one strategy that has been successfully used to teach many children with autism to use verbal communication


PRT Components• Clinician should:

• Be clear, uninterrupted, and appropriate to tasks• Be interspersed with maintenance tasks• Include child-choice• Include multiple components when appropriate

• Reinforcement should:• Be contingent upon behavior• Follow any reasonable attempt

to respond• Be related to desired behavior

in a direct way

Teresa Cardon, PhD CCC-SLP, BCBA-Dh t t p :/ / w e b .t e a c h t o w n .c o m / im a g e s / r e s e a r c h / t t _ r e s e a r c h _ m e t h o d _ p o v it a lR e s p o n s e _ 4 5 0 x 3 0 0 .jp g

Step 1: Natural Environment & Caregivers

• The environment should be arranged to increase a child’s opportunities for communication.

• Caregivers should be a part of intervention!• How can you make this a reality in your setting?


How does PRT work? Step 2: Motivation

• Child choice should start the interaction!

• A child must be motivated enough to continue trying to get the object or activity.

• Talking is not easy and the child must be willing to persist!


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Step 3: Instruction & Response

• Instruction should be delivered clearly while the child is attending to the task.

• The child’s response should be clear, directed and appropriate to the task.

• Be sure you do not reinforce “behaviors” that you do not mean to be reinforcing.


Step 4: Maintenance Tasks

• Because talking is hard, be sure to intersperse new tasks with something the child is really good at and already knows how to do.

• Think of an 80/20 or 70/30 rule. 70-80% of the time work on new tasks (like talking) and 20-30% of the time let the child do something they have already mastered!


Step 5: Contingency

• If the child produces a vocalization, then the child gets the object or activity.

• Be sure to be consistent once you have set up the opportunity.

• If you set it up, then you must follow through or the child will learn that there are exceptions to the rule!


Step 6: Reinforce Attempts

• Reasonable attempts should IMMEDIATLEY be reinforced.

• A reasonable attempt initially is any sound that is directed and related to the task.

• As vocalizations become more consistent, different sounds and words become the focus.


Step 7: Direct & Natural Reinforcers

• Reinforcement should be directly and functionally related.

• If a child is interested in a ball, share control of the ball and use it as the direct and natural reinforcer.

• When the child verbalizes a reasonable attempt, reinforce the child with the ball!


Some important questions to ask when working on first words are:

1. Do I have the child’s attention?2. Am I using clear, short direct instructions?3. Am I following the child’s lead or choice of activity?4. Am I giving a mixture of already learned and still to be learned

tasks?5. Am I reinforcing/rewarding good trying?6. Am I reinforcing/rewarding with a built-in, natural reward – one that

the child is asking for?7. Am I reinforcing/rewarding RIGHT away?


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PRT in action!


PRT vs. DTT


DTT PRT

Breaks into smaller parts Naturalistic opportunities

Teaches 1 sub-skill at a time Multiple cues, multiple skills

Artificial reinforcement Task specific reinforcement

Prompt fading and shaping Prompt fading and shaping

Mass-trialing Increases natural reinforcement repertoires

Generalization after mastery Generalization at onset and throughout

Therapist directed Child directed

Both are ABA based, but…..

How can PRT work collaboratively?

How can various practitioners can support each other within PRT?

How can this work in different settings?


Early Start Denver Model (ESDM)• Great example of collaborative

practice – many practitioners involved

• Research driven & evidence based

• Developmentally based

• Applied Behavior Analysis

• Socially driven goals

• Family support & training


Biggest differences between SLPS & BCBAs

• Assessments • VBMAPP vs. Language Assessments• VBMAPP vs. Articulation & Motor

Planning Assessments

• Implementation• Science of contingencies &

reinforcement

• Data Collection• Single Subject Designs regular part of

BCBA protocol• Frequency, Variable, Ratio, etc.


ABA & SLPs –National Joint Committee for the Communication Needs of Persons with Severe Disabilities (NJC)

• “Bottom Line: Applied behavior analysis (ABA) is a set of procedures drawn from the discipline of behavior analysis that allows for understanding of the reasons that certain behaviors may occur. As part of interdisciplinary practice, SLPs may find application of ABA techniques within natural training contexts to be effective complements to their own communication interventions.”

• “Descriptions of ABA as a training methodology appear throughout the seminal literature of speech-language pathology. Today's practitioners can choose from permutations of ABA that include strict applications of the techniques mentioned above (e.g., discrete trial training) to more naturalistic technique applications (e.g., hybrid, milieu, or contemporary ABA training).”

• https://www.asha.org/NJC/Applied-Behavior-Analysis-and-Communication-Services/?fbclid=IwAR2yTJBVjZ4P_XyxicuH-bpIYoK5DYCPz3w7GP1hajQZax_HWNSaSM5WI7k


https://www.asha.org/NJC/Applied-Behavior-Analysis-and-Communication-Services/?fbclid=IwAR2yTJBVjZ4P_XyxicuH-bpIYoK5DYCPz3w7GP1hajQZax_HWNSaSM5WI7k

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ABA principles have been researched and used by SLPs for years!• During the period between 1950

and 1975, the application of behavioral strategies to clinical practice was frequently reported in the SLP literature:• Disorders of articulation

(e.g.,McReynolds, 1966; Sommers et• Fluency (e.g., Brookshire & Martin,

1967; Brutten & Shoemaker, 1967) al., 1966)• Voice (e.g., Shriberg, 1971)

• Stimulus presentation and reinforcement (e.g., Enquist & Wagner, 1950)• Response shaping and modeling

(e.g., Backus & Beasley, 1951; Bloodstein, 1950)• Child language (e.g., Baer & Guess,

1971; Holland & Harris, 1968; Sailor & Tackman, 1972; Schiefelbush, 1978)• ASHA Monographs (1970) A

Functional Analysis Approach to Speech and Language

Teresa Cardon, PhD CCC-SLP, BCBA-DCredit: Nikia Dower; Koenig & Gerenser, 2006, p. 3)

What’s in a word? Many ABA based strategies have been used for years by SLPs!

ABA Term ”Other” Terms

Shaping/Chaining Successive approximation; Scaffolding;

Premack Principle First/Then Board

Extinction Escape; Attention; Avoidance;

Reinforcement Praise; Prize Box; Stickers; Treats;

Token Economy Sticker Chart; Star Chart; Tokens


NOTE: THIS IS NOT AN EXHAUSTIVE LIST!!!!

Teresa Cardon, PhD CCC-SLP, BCBA-D Teresa Cardon, PhD CCC-SLP, BCBA-D

How can you collaborate with SLPs and other practitioners?

How can different practitioners collaborate on various cases. What are areas of strength? Areas of need?

How would this work in different settings?


Scenario #6a: A four-year-old child that you are working with is very hard to understand. They pronounce multiple words incorrectly. The child can imitate sounds in isolation when you work with them, but when they try to say complete words and sentences, the sound errors return. What would you do to evaluate the child’s sound errors? (Choose all that you would consider)


SLP-BCBA(n=13)

VBMAPP 1 (1%) 16 (47%) 0

Goldman-Fristoe 71 (71%) 0 10 (77%)

Language Sample 67 (67%) 10 (29%) 9 (69%)

Phonological Mean Length of Utterance 16 (16%) 5 (15%) 3 (23%)

Kaufman Speech Praxis Test 70 (70%) 6 (18%) 6 (46%)

Refer to another practitioner 1 (1%) 18 (53%) 0

Other 18 (18%) 1 (3) 4 (30%)


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Example: A 10-year-old on your caseload has started spitting. Mom reports he is spitting at home “all the time” and his classroom teacher confirms that she has noticed an increase in his spitting at school. What would you do to evaluate the new spitting behavior? Check all that apply.


SLP-BCBA(n=13)

Conduct a descriptive, Functional Behavior Analysis 69 (69%) 30 (88%) 11 (85%)

Ask the teacher to document when he spits 62 (62%) 23 (68%) 9 (69%)

Conduct an Experimental Functional Analysis 5 (5%) 17 (50%) 5 (38%)

Observe the client in multiple environments for 15 minutes at a time 58 (58%) 19 (56%) 9 (69%)

Implement a time out procedure 3 (3%) 0 0 Refer to another practitioner 17 (17%) 1 (3%) 1 (8%)Other 9 (9%) 2 (6%) 1 (8%)

(Cardon, 2017)

Interprofessional Collaboration

• The goal of interprofessional education is to support collaboration between disciplines to improve service delivery and outcomes for clients (Hammick, Freeth, Koppel, Reeves, & Barr, 2007)

• Effective collaboration can support improved outcomes for clients! (e.g., Kelly and Tincani, 2013; Hunt, Soto, Maier, Doering, 2003; Sheridan & Colton, 1994)


Tips for interprofessional collaboration Koenig and Gersener (2006)

• Share treatment efficacy data • Share innovative teaching procedures • Share basic information about his or her discipline • Share experiences of successful collaboration • Share key articles in professional journals • Share concerns about particular shared practice events • Share lunch


Have you uncovered any of your blind spots?


The Collaboration Blind Spot

Ten things you can do right now to help a child with autism communicate:

1. Create opportunities 2. Motivation3. Make yourself a valid part of the

interaction4. Multiple opportunities across multiple

contexts5. Make it visual6. Pair verbal with a speech generating

device 7. Create communication environments8. Early, early, early!9. Intensive10. Consult


1. Create opportunities – turn off your “helper” instincts


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To support communication development:• Avoid anticipating needs – turn off your

HELPER instincts!

• Give them a reason to communicate!

• STOP talking and asking so many questions!


2. Motivation – communicating is hard work!


How do I discover what motivates my client?

• The art of OBSERVATION!• Watch at their level to observe what they are REALLY interested in doing

• Remember that sensory components may be at work here

• What they do when the play alone• What interests them• Let them take the lead• Give your client some control


Preference Assessments!

• Formal and informal ways to determine what is motivating!


3. Make yourself a valid part of the interaction when possible• Follow your client’s lead and join

in the activity -• Imitate what your client is

doing• Add something new to the

activity • Reciprocal Imitation Training

• Create predictable turns• Turn the activity into an

interaction!

• Parts vs. Wholes• Find activities that have a lot of

different parts • Shared control

• Creative Stupidity• Forget key items• Be silly

• Batteries Required• And so are you!


What if my client’s interests are “different”?

• Again - think sensory!• Your client’s “play” skills may be atypical because they are not sure

what else to do!• Remember imitate them and add something new!

• Your client may take notice of you in a VERY different way!

When should you NOT follow your client’s lead?


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4. Multiple opportunities across multiple contexts

More opportunities to learn & generalize!

church

schoolhome


5. Make it Visual - Make it Clear!• “Let’s go to the Park!”


6. Pair verbal with a speech generating device


• Children who began intervention with SGD integrated into NBDI produced more spontaneous communicative utterances than children who started with NBDI and spoken language only

• Children showed increases in spontaneous communication, including different types of words and functions beyond requesting

• Adults were contingently responsive to a child attempts at communication and provided expansion of language through models that matched the child’s communicative intent

7. Create communication environments


Give them a reason to communicate!

8. Early, early, early!

• Gaps in development are less pronounced • neuroplasticity

• Begin appropriate INTERVENTION early to minimize/close the gaps

• SCREENING – MCHAT • https://www.m-chat.org/

• Refer for assessment


9. Intensive – Increased hours of engagement! (30-ish hours that are intentional!)


Siblings School

Social skills groups

Grandparents

https://www.m-chat.org/

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10. Consult & COLLABORATE!

SLP• Language• Motor

planning

BCBA• FBA• ABA based

intervention

MD• Health

Issues• Medication

Educator• Peers• Curriculum

Teresa Cardon, PhD CCC-SLP, BCBA-DClearly, this is not an exhaustive list!- OT, PT, Parents, SW, etc.

For every discipline . . .Evidence Based Practice!



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