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 Highlights from ABAI: Potty Training, the Next Step in Motivation, Ethical Issues and More!

NBC Admin - Wednesday, June 02, 2010
The annual Applied Behavior Analysis International Conference was this past weekend in San Antonio, TX. I thoroughly enjoyed a few presentations and of course networking/picking the brains of behavior analysts that I admire and aspire to be like. Below is a summary of a few of the topics that I learned more about this weekend:

The Next Step in Motivation
The workshop presented by Robert Schramm on instructional control was by far my favorite presentation of the conference. I have already read his book and had been incorporating procedures similar to his for a few years but he has been doing this longer and has refined the technique. In the workshop we learned how to decrease escape and noncompliance without using force, blocking, or nagging. The basic idea is to withhold reinforcement completely and wait the child out. The child's learning environment should be an "oasis of fun" so the child should be so motivated within the environment that he/she doesn't try to leave but if he/she does, that is fine you just stop the oasis of fun until the child returns. Following the 7 steps of instructional control along with a few other techniques not only decreases noncompliance and escape behaviors but it results in a willing and motivated learner. I will write much much more on this topic in future blogs as I will be doing a review of Robert's book. I call this the next step in motivation because pioneers such as Jack Michael, Dr. Sundberg, Dr. Partington, and Dr. Carbone all recognized that the "traditional" method of sitting at a table and plowing away wasn't working. They devised current motivational procedures of pairing the table and therapist with reinforcers and focusing heavily on developing a fun relationship with the child where they see you as a walking m&m. Robert's approach is taking this one step further by not just saying that the therapist or parent should pair with the child but providing more direction on what this pairing should look like, how much of it should occur, and what should happen when the child doesn't want to interact and pair. Most people would say when the child doesn't want to do the demand, force them to but this counteracts all of that pairing you were doing. If you are forced to do something, you don't generally enjoy it and you aren't as motivated. My favorite video that Robert showed was one of a therapist pairing with a little girl who loved music. In most ABA sessions you might see a therapist play music and sing along and the child may or may not enjoy it or even notice the therapist is sitting there, but this is considered pairing. In the video Robert showed, the therapist was swinging the little girl around (which the little girl enjoyed but not as much as she enjoyed the music) and the little girl would sometimes walk away from the therapist. It was ok for this to happen, but the music was paused if the child was not interacting with the therapist. Then when the little girl rejoined the therapist, the music was turned back on. This truly pairs the therapist with the music and it motivates an interaction. This is HUGE when looking at autistic children who are severely delayed with social interactions. If they can only have their preferred items when interacting socially with someone, then the reinforcing value of social interactions will increase greatly. I highly recommend attending a workshop by Robert, reading his book or visiting his website. His book is Educate Toward Recovery and his website is www.knospe-aba.com

Potty Training
I thought I knew everything there was to know about potty training but the informative presentation done by Patrick Friman and Ennio Cipani taught me a few things:
1. Never use aversive methods for accidents when potty training. This point was made by Patrick Friman. I personally have never used aversive methods but I know people who do. The method doesn't even have to be intended to be aversive but if a child finds it aversive, then it is. For instance I had a client who started crying when we praised him for peeing in the potty. We were trying to reinforce him but he did not like it so we had to stop throwing a party while he was peeing. Some places will have you require the child to clean themselves up or help clean themselves up after an accident, some will do positive practice where you take the child back and forth the the potty from the spot of the accident. These are designed to have a consequence for accidents but should not be aversive, if they are then they should be discontinued because you don't want the potty training to be aversive. 
2. Pants Off! while potty training. This was discussed by both Patrick Friman and Ennio Cipani. While I myself have had this idea before I had never thought to phrase it the way they did. For those of you who are behavior analysts out there think about the child's history with peeing. Prior to potty training, peeing is done when pants are on so Pants on is a Sd for peeing. Whereas if the child might try to pee without their pants on while their diaper is being changed, parents might punish that or quickly throw the diaper on. Therefore, pants off is a S delta for peeing, meaning the child has learned when my pants are off I should not pee. This relationship obviously needs to be reversed to have successful potty training. This method is not necessary for all children but should be considered when you have a child who doesn't pee in the potty and literally does not pee until you put their pants/diaper/etc back on after hours of a potty protocol. I have definitely worked with clients who sat on the potty contently for 10 min or longer and would not go so we would put their clothes back on and within seconds they would pee. Clearly they were under the impression that this is where they should pee. The recommended procedure was to keep pants off during the training. As soon as the child goes in the potty, put their pants on for 5 minutes because they shouldn't pee again right after peeing. Then take their pants back off until they pee again. Increase the amount of time with pants on each time the child is successful in the potty. So it would look like this: pants are off, take child to potty every 15 minutes, child pees in the potty, put pants on for 5 minutes, take pants off, take child to potty after 15 minutes, child pees in the potty, put pants on for 6 minutes, take pants off, etc. This whole time you follow the standard potty training procedure described by Azrin and Foxx of scheduled trips to the potty, frequent liquids, and reinforcement for peeing in the potty.

Ethical Issues
I talked at length with numerous behavior analysts about issues regarding supervision and oversight by the BACB. While a good number of behavior analysts are trained well and provide stellar work, the high demand in our field is resulting in an issue with proper training at the newer behavior analysis programs and the online programs. The good news is a lot of BCBAs are aware of this issue and are hounding the board about it and everyone who is concerned agrees changes need to be made regarding supervision requirements/monitoring. The bad news is that a lot of the people in charge of making the decisions live in a little bubble where they are not exposed to some of the issues that others experience on a daily basis. It was good to see people at least talking about these issues and trying to come up with solutions. 

Psychotropics and Exercise
One of the other talks I went to that was rather interesting was about psychotropics. I haven't attended any talks on psychotropics so this was rather interesting. I do not recall who all presented but the main message was that most psychotropics don't work, they are over prescribed, and a lot of the reasons given for needing them are false. For instance, I thought it was well established that depression and/or schizophrenia are caused by chemical imbalances. There is actually NO evidence to indicate this and it is still merely a theory that has yet to even come close to being proven. Yet, pharmaceutical companies imply links in their commercials and get the psychiatrists on board to prescribe the meds. This isn't to say that some people don't need meds but MOST people do not. There was also discussion about the lack of effectiveness of meds and the side effects. For instance Zyprexa is not very effective, led to serious side effects in 22% of the clients and 20 people died. Yet psychiatrist down play these side effects. Also to become FDA approved the drug companies only have to prove some effect and they can do this by doing as many studies as they want. So they might do 10,000 studies and only have 2 that show an effect and become FDA approved. They also will stop studies in the preliminary stages if they are not seeing the results they want. And they pay half the cost of the FDA approval process. On the other hand one person presented on the effectiveness of exercise to decrease depression, anxiety, and other mood disorders. In one study more than half of the participants no longer had depression after following the exercise protocol. This is definitely an area of interest to me but I am still in love with autism more than anything else.


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