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 How Much Training Are You or Your Tutors/Therapists Receiving?

- Saturday, August 07, 2010
An issue that I frequently encounter either through parent report, tutor report, or my own observation is a lack of training for parents and tutors. There are a few reasons why this is a big problem: leads to less effective intervention for the child, can hinder progress of the child, and it violates the BACB code of conduct (and the structure of the Autism Demonstration Project for military members). I will discuss each of these issues below as well as provide some reasons why I think a lack of training occurs, a description of what a lack of training looks like,  ways to address the issue.

Leads to less effective intervention for the child
Research in the field of behavior analysis and autism treatment in general indicates that parent training and tutor training are crucial to the success of an intervention package. Lynn and Robert Koegel have done an extensive amount of research on parent training and consistently show that parents serve well as the child's teacher and parent training leads to gains for both the child and the parent. I will provide summaries of other research regarding parent training at the end of this blog. 

Most children receiving behavior analysis services only receive a few hours of treatment per week (around 7-10) but the recommended intervention amount is 30-40 hours. If the parent does not receive proper training, you are looking at countless hours that are being wasted and possibly un-doing the work that the therapist is doing during her 7-10 hours with the child. If the tutor/therapist doesn't receive proper training, you are looking at even less progress for the child because the few hours of therapy that are being provided, are not as effective as they could be. Sometimes I will see children who make wonderful progress with poorly trained tutors/therapists and parents and it saddens me because they could be making at least double that progress if everyone was trained.

Can hinder the progress of the child
An even worse situation is when lack of training leads to hindering the progress of a child. Most of the time children who are receiving services require a very consistent and structured intervention package. If the tutor/therapist is following this package but the parent does not, all of the work that is being done during sessions could be counteracted when the session is over. For example, if a child is hitting himself for attention and the intervention plan consists of providing a thick schedule of attention throughout the session when the child is not hitting himself, gently blocking the hitting when it does occur, and not providing eye contact, talking, or other attention during the hitting; but the parents tell the child "NO HITTING" and provide a lot of attention every time the hitting occurs, you will have a behavior that not only doesn't decrease but might increase. This is is because the behavior is now on a variable reinforcement schedule, meaning sometimes it is reinforced (the child receives attention) and sometimes it is not (the hitting is blocked and ignored). Because the child never knows what reaction he will receive, he is going to continue to hit in the hopes that he gets attention and he might do it more intensely when he doesn't get attention to see if hitting harder will get him the attention he is wanting. 

Additionally, if the tutor/therapist hasn't received proper training on how to assess the function of a behavior, the therapist/tutor and the parent might be reinforcing the behavior. For example, some children will refuse to follow an instruction and a therapist/tutor will automatically provide escape extinction as a consequence. This means, the therapist/tutor will hand over hand guide the child to do the task. This also sometimes results in a physical struggle of trying to keep the child in the chair, trying to maintain the materials if the child is pushing them away, etc. I don't typically use this procedure even if the child is trying to escape a demand but that is a topic for a different blog. If no analysis is done and no data collection is kept to see how frequently the child is doing this behavior and whether or not the behavior is increasing/decreasing, the tutor/therapist will not know if the escape extinction intervention is effective. It is the job of the BCBA to train the therapist/tutor on how to collect this data, when to collect this data, and for the BCBA to devise a plan on how to intervene in order to decrease the behavior. If the child was not responding because he enjoys the physical prompting and struggle, the behavior will actually increase. 

Violates the BACB Guidelines for Responsible Conduct
Not providing training to parents or therapists/tutors results in the following violations of the BACB:

2.02 Accepting Clients - The behavior analyst accepts as clients only those individuals or entities (agencies, firms, etc.) whose behavior problems or requested service are commensurate with the behavior analyst’s education, training, and experience. In lieu of these conditions, the behavior analyst must function under the supervision of or in consultation with a behavior analyst whose credentials permit working with such behavior problems or services.
If the behavior analyst isn't providing training because he/she doesn't know how to intervene, then they are violating 2.02 because they should not be accepting clients whose service needs are outside their area of training without also seeking supervision from another behavior analyst who does have this training.

3.02 Functional Assessment of Behavior - (a) The behavior analyst conducts a functional assessment, as defined below, to provide the necessary data to develop an effective behavior change program.

(b) Functional assessment includes a variety of systematic information-gathering activities regarding factors influencing the occurrence of a behavior (e.g., antecedents, consequences, setting events, or motivating operations) including interview, direct observation, and experimental analysis.

If the behavior analyst has not trained the tutor/therapist how to collect data, nor collects data/analyzes the behavior herself, then she is violating 3.02 because the behavior is not being assessed for function. Additionally, if the behavior analyst trains the tutor how to collect data but never uses that data to develop an intervention plan, then she is violating 3.02 because the behavior is still not being analyzed

3.03 Explaining Assessment Results - behavior analysts ensure that an explanation of the results is provided using language that is reasonably understandable to the person assessed or to another legally authorized person on behalf of the client. Regardless of whether the interpretation is done by the behavior analyst, by assistants, or others, behavior analysts take reasonable steps to ensure that appropriate explanations of results are given.

If the behavior analyst doesn't analyze the behavior in the first place, then 3.03 would automatically be violated because you can't explain the results if you don't analyze the behavior. Sometimes the behavior analyst will analyze the behavior but will not explain the results thus violating 3.03. 

3.05 Describing Program Objectives - The behavior analyst describes, in writing, the objectives of the behavior change program to the client or client-surrogate (see below) before attempting to implement the program. And to the extent possible, a risk-benefit analysis should be conducted on the procedures to be implemented to reach the objective.

Again if 3.02, and 3.03 are violated then 3.0 is automatically violated. Sometimes though a behavior analyst will assess the behavior but not type up an intervention plan with objectives. If this is not done, it makes it very hard to train the tutor/therapist and parent and it violates 3.05. 

4.01 Describing conditions for Program Success - The behavior analyst describes to the client or client-surrogate the environmental conditions that are necessary for the program to be effective.

If the behavior analyst is not providing training, then he/she is not describing to the parent and tutor/therapist the conditions for success of the program. Typically, parent training and tutor/therapist training is one of the conditions that are necessary for the success of the program. 

4.04 Approving Interventions - The behavior analyst must obtain the client’s or client-surrogate’s approval in writing of the behavior intervention procedures before implementing them.

If the behavior analyst is not providing training to the parent, then he/she is not getting approval for the interventions because typically the interventions are just being done without the parent knowing what is happening. 

5.11 Training, Supervision and Safety - Behavior analysts provide proper training, supervision, and safety precautions to their employees or supervisees and take reasonable steps to see that such persons perform services responsibly, competently, and ethically. If institutional policies, procedures, or practices prevent fulfillment of this obligation, behavior analysts attempt to modify their role or to correct the situation to the extent feasible.

If the therapist/tutor is an employee or supervisee of the BCBA and the BCBA is not providing training, supervision and safety precautions, then 5.11 is being violated. 

In this section it is also important to note that the Tricare Autism Demonstration Project requires monthly parent training so if a child is receiving services through this project and the parent is not receiving parent training, the BCBA is violating the conditions set out by Tricare and violating another guideline 2.14 Accuracy in reports to those who pay for services (In their reports to those who pay for services or sources of research, project, or program funding, behavior analysts accurately state the nature of the research or service provided, the fees or charges, and where applicable, the identity of the provider, the findings, and other required descriptive data.). The Demonstration project also requires that tutors/therapists receive ongoing supervision and TRAINING as well. Most companies will come out to observe the tutor but not provide training. They need to do both in order to meet the requirements of the Demonstration project. 

Why the lack of training?

I think there are a few reasons for a lack of training:

1. For a lot of providers, the focus is on the child so they are typically caught up in doing what they can with the child while they are there. So the lack of training isn't purposeful or meant to hinder the child's progress, the provider is just so caught up in the child, that they don't realize training the tutors and parents is key to the child's progress.

2. Sometimes parents don't realize they need training and treat ABA intervention similar to speech or OT where a person comes and works with the child and then leaves. The principles, techniques, and programming laid out in an ABA intervention package have to be followed 24/7 or the intervention will not be as effective. Therefore, it is crucial that parents receive training. It is also important for the BCBA to lay out from the start of services that training is required.

3. Sometimes the BCBA is so booked with clients, that she does not have time to train the tutors/therapist. There is an easy fix for this one, include training time in your schedule and do not book so many clients. It is more important that your clients receive effective treatment then take on too many clients who receive mediocre intervention due to a lack of training.

4. Sometimes the BCBA does not know how to provide training. Some programs don't train BCBAs how to provide training to others on the interventions. There are certain techniques that work better than others when providing training. Behavior Skills Training is typically the most effective technique but not all BCBAs know what this is or how to do it so they just don't provide training. Some will provide training but it is poorly done so it is ineffective.

5. Sometimes the BCBA does not realize that training is a crucial part of the intervention package. The program that trained them didn't have much training or focus much on training so they don't realize it is something they need to be doing. 

6. Sometimes parents are resistant to training because it is not done well and they are trained on the wrong things. In my experience, it is best to train the parent using terminology that they understand, examples from their lives (hopefully related to their child), to not bog them down in understanding behavior analysis in the same way that we do, and to teach them how to follow the intervention within the natural environment. I very rarely have a parent sit down and do drills with a child (I very rarely do drills with a child). However, I will teach them how to intersperse targets during the daily routine and how to react/prevent challenging behavior within the daily routine. If a BCBA is trying to teach a parent how to run a session or make them learn all of our terminology in the same way we learn it, that is typically going to be a big turn off for parents and they won't want to participate in training. 

7. Second to last and almost as important, sometimes training does not occur because of limited funding. Sometimes parents can only afford the rate of the tutor and not the rate of the BCBA. In this situation a few things can and should be done. 1. If the BCBA still wants to provide services to the client, the rates could be lowered based on what the client is able to pay and a minimum amount of supervision/training should be set per either week or month. If the parents really cannot afford to pay the minimum should be at least 1 hour/month on site training with the parent and the tutor. And then the tutor should meet with the BCBA and receive feedback and training and then take that back to the child and train the parent but only if the tutor is experience enough to provide such training. 2. A budget should be made with the family where they receive x amount of tutor hours per month and then x amount of BCBA hours per month. This might mean not having as many sessions with the tutor so that the BCBA can still provide services at his standard rate but the overall effectiveness of therapy will benefit. 4. If these solutions will not work, the BCBA should refer the parent to a company that can use one of these solutions. Because training of the tutor and parent is key to providing effective treatment, if the BCBA cannot figure out a way to provide these in the amount that is necessary for the client either because of funding or time constraints, then the BCBA should not take on the client. Otherwise the client's money is being wasted and the child might receive counter productive services. 

8. Lastly, and most importantly sometimes the BCBA doesn't know how to handle the behavior or skill so they can't provide training. This is most important because in a situation like this, the BCBA should seek the supervision and consultation of another BCBA who does know how to handle the behavior or skill. With all of the message boards and internet pages for behavior analysis now a days, there is no excuse for not finding someone who can provide ideas/supervision/consultation to a BCBA who does not know how to handle a certain behavior. 

What Does a Lack of Training Look Like

There are some obvious signs and some not so obvious signs that adequate training is not occurring:

1. The BCBA never talks to the parent or therapist/tutor about the programming. The BCBA does not explain what programs are being done, what interventions are in place for challenging behaviors, how to practice these programs, and how to intervene for challenging behaviors. 

2. The child is continuously engaging in the same challenging behavior or having the same programming issue with acquiring certain skills. If the BCBA is providing proper training, these issues would be analyzed and the plans would be modified.

3. A treatment plan, behavior plan, or plan of intervention does not exist. It is basically impossible to provide training on a child's programming if there is not a treatment plan that outlines programming, reinforcement criteria, prompting criteria, other instructional techniques, and plans for reducing challenging behavior.

4. When the tutor/therapist or parent asks the BCBA to assist with a skill, the BCBA provides short answers (or sometimes no answers) but never sits down and trains the tutor/therapist or parent on the skill. Effective training typically consists of: explanation of the plan, modeling the technique, role playing the technique, providing feedback, and practicing the technique in the actual teaching/natural setting. 

5. There is not a system in place for monitoring the intervention with the tutor or parent. Integrity checklist are typically used to monitor whether or not an intervention is being implemented correctly. I don't use them for every little thing I do but when a reduction program is complicated or a new acquisition program requires multiple steps or a child really needs prompting done a certain way, I will use integrity checklists to show the tutor or parent how well they are following the plan. 

6. The parent or tutor/therapist thinks they really have no clue what to do with the child. 

Ways to address this issue

I have split this into two categories: one for behavior analysts and one for parents or tutors. 

If you are a BCBA who has difficulty training parents/tutors:

1. Make it part of your company's policy that parents and tutors participate in a minimum amount of training each WEEK. The minimum will depend on the client but I will do anywhere from 15 minutes to 1 hour and sometimes more. 

2. Schedule training into your session. Sometimes parents are very busy and use session time to get all of the things done that they need to get done. This is fine, but they still need to know how to interact with their child. Talk to the parent and tutor/therapist and set up specific days/times where training will occur.

3. Use behavior skills training. Google it and you will find tons of information. I also have a blog about it if you go here BST 

4. Provide the training specific to the client and make it understandable. Try to teach parents how to use behavioral techniques and follow the child's program within the context of the natural environment.

5. Have contingencies set up. If possible try to do a reinforcement contingency among all of your clients. You can catch parents, tutors/therapist doing a good job following the intervention plan and give them a ticket. At the end of the month a ticket is pulled for a prize. At the very least praise and reinforce parents or tutors/therapists when you see them doing a great job or at least trying to follow the intervention (don't forget to shape the behavior). Just as importantly, have a policy in place for parents or tutors/therapist who refuse to be trained or follow the protocol. If you are not able to provide effective services because of a lack of participation, you have to discontinue services. Have this in your company's policies. I do a three strikes and your out where I will tell the person 3 times how they are not participating and work with them to fix this: provide additional training, adjust the schedule, make the plan more feasible, etc and if they still don't comply, I have to terminate services. There are too many children who need services and are on waitlist to allow a parent to not participate in their child's programming. DO NOT however, just discontinue services without ever explaining to the parent that they are required to participate or giving them warnings and feedback and working with them to fix the issue first. I have worked at places where this happened and the parents were infuriated (rightfully so) because they didn't even know that there was an issue and the company just terminated services. 

6. Use integrity checklists. Contact me if you need more info on this but you have to monitor the performance of your parents and the tutors/therapists and give them positive and constructive feedback on how they can better follow the plans. 

If you are a parent or tutor/therapist who is not receiving proper training:

1. Ask your BCBA for more training. If the BCBA refuses or doesn't really respond print out a copy of this blog and ask them why they are not doing training. Make sure to point out to them that by not training you, they are in violation of the BACB Code of Conduct

2. Try to just observe sessions with your child (if you are a parent) or of other therapists (if you are a therapist). You can learn a lot by observing as long as the session is being done correctly.

3. Ask the BCBA what their training policy is and if they don't have one push them to create one. If you work for the company, offer to help create one. 

4. If the training is over your head or not relevant to you and your child (client), ask the BCBA to make it more relevant to you and to break it down more. Ask for a typed up plan and/or training packet and ask the BCBA to use behavior skills training to teach you the skills. 

5. If you are a tutor or parent who is paying out of pocket and the BCBA is not providing training to either of you because of this, talk to them and work out a situation where this can happen. Determine as a team how much supervision/training is necessary for this particular child and figure out a way to make that happen whether it means cutting down on some of the tutor time and convincing the BCBA to lower his rate because you are paying out of pocket. It is almost pointless to receive services from a tutor if you are not receiving adequate training/supervision from the BCBA. 


Here are some resources related to parent training and tutor/therapist training

-Most publications by Robert and Lynn Koegel include descriptions of how to train. Visit theirwebsite for more information

-For more information on the BACB Code of Conduct, click here 

Articles on Parent Training:

1. Lafaskas and Sturmey (2007)  studied the effects of using Behavior Skills Training to teach parents to use Discrete Trial Teaching. The parents learned the skill and the children acquired skills faster. 

2. Chaabane, Albar-Morgan, DeBar (2009)  studied the effects of training parents to teach their children to request items using PECS. The children acquired novel requests and the parents successfully implemented the protocol. 

3. Osborne and colleagues (2008)  studied the effects of stress on effectiveness of treatment. They found that parent stress counteracted the effectiveness of treatment. Therefore, when doing parent training it is important to identify stressors and help train the parents in a way that will reduce these stressors and increase the effectiveness of therapy. 

4. Iovanonne and colleagues (2003)  identified components of effective programming as: (a) individualized supports and services for students and families, (b) systematic instruction, (c) comprehensible/structured learning environments, (d) specialized curriculum content, (e) functional approach to problem behavior, and (f) family involvement.

5. Dawson and colleagues (2010) ) compared the effectiveness of the Early Start Denver Model, which is a developmental behavioral approach to intervention that consists mostly of training the parent and the tutors to a community model and found that the Denver model was more effective. 

I know that there is more research than this but I unfortunately cannot find where I saved the information and do not have time to look for more links. Please feel free to comment on additional research. 

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