by Jane Sevier
For some children and adolescents with developmental disabilities, severe behavior problems threaten their success in school and society. By unraveling the causes of those behaviors and developing treatments tailored for them, teams at Vanderbilt University’s Behavior Analysis Clinic (BAC) offer lifelines for those children and their families.
“Our interventions are relatively straightforward,” said clinic director Joe Lambert, assistant professor of the practice in the Department of Special Education at Vanderbilt’s Peabody College of education and human development. “We want to stop undesirable behavior, encourage acceptable behavior and help clients tolerate situations when they can’t immediately have what they want.
“We provide all of our instruction in the contexts in which problem behavior is most likely to occur and teach our clients socially sanctioned strategies for getting what they want or need. Then, we give them practice interacting with others for brief periods of time when said strategies are ineffective and they must wait to get what they want or need. As evidence of success mounts, we systematically increase the amount of time that clients spend in these less-desirable situations,” he said.
Lambert works hand in glove with Nea Houchins-Juárez, Applied Behavior Analysis program student coordinator for the Department of Special Education and behavior analysis consulting services coordinator for the Vanderbilt Kennedy Center’s Treatment and Research Institute for Autism Spectrum Disorders (TRIAD).
Last year, they launched a refined, refocused Behavior Analysis Clinic intended to enhance the systematic approaches to providing high-quality training to students and the clinic’s vital role in Peabody’s Applied Behavior Analysis (ABA) training program that Houchins-Juárez developed during her decade at the clinic’s helm.
The team limited the number of clients they work with each semester to three and increased the duration of their treatment to 4–6 hours per week across 12–16 weeks. They augmented the scope of interventions to include comprehensive skill assessments, analysis of the function of each severe problem behavior, and comprehensive evaluation of treatment efficacy. The new iteration of the clinic, which falls under the TRIAD umbrella, is a joint venture among Peabody College, the Vanderbilt Kennedy Center, and Vanderbilt University Medical Center, and launched in January 2014.
“The primary focus of assessment in our clinic is to identify the function of problem behavior,” Lambert said. “What are this child’s triggers? What does he need and how is he getting it? We don’t really conceptualize behavior as good or bad; just effective or ineffective. We use assessment outcomes to structure the rest of therapy. We insist on teaching exclusively in situations under which motivation to engage in proper behavior is high because intervention outcomes are valid only if they alter the probability of problem behavior in the presence of its triggers. Our goal is always to eliminate problem behavior in the contexts that have historically guaranteed it,” he said.
“The amount of time a child has to wait for what he or she wants can be age-dependent, too,” said Houchins-Juárez. “If you’re talking about a 3-year-old, five minutes is probably good. With a middle schooler, that can be up to 30 minutes by the end of the intervention.”
The clinic also trains parents and other care providers to deliver the interventions themselves.
“Once we identify an intervention that works and figure out how to change the child’s behavior, then we have to change the parents’ behavior,” Houchins-Juárez said. “The way we’ve set up the clinic works well for parents. For a little while, they may wonder what’s going on, but by the end of the intervention, we hope they’ve bought in and can continue the intervention at home. It comes down to compromise.”
At the BAC, Lambert and Houchins-Juárez supervise the teams of interns, working with a graduate case manager who has gone through the internship the previous semester and who serves as team leader. In the last 10 years, the clinic has trained 135 students.
Finding the right intervention
Last fall, Carmen Caruthers (M.Ed.’14) served as a graduate case manager at the clinic. Now a behavior therapist with the Carolina Center for ABA and Autism Treatment, Caruthers applies the skills she gained to her work with children with Autism Spectrum Disorders (ASD). With her BAC supervisors, Caruthers guided a team of four graduate-student interns working with a 5-year-old child with ASD to mitigate problem behaviors that included aggression and noncompliance.
“She would hit, bite, kick—the usual things that you see,” Caruthers said. “Noncompliance was part of that, so as a team, we decided we would look at it as a tantrum. With behavior analysis, every intervention is function based. If you have two different behaviors that serve two different functions, you have to address each individually. Ideally, we want an intervention that is comprehensive, so it may have many different components but with the same end goal of decreasing the problem behavior.”
As case manager, Caruthers was responsible for conceptualizing the case, creating a plan of action for each week’s treatment, and helping train her team in data collection. She also designed the functional analysis, which identifies the purpose (or function) of the client’s problem behavior, and orchestrated an intervention that corresponded to those functions. Throughout the semester, she worked with her team and supervisors to tweak the intervention as needed.
“The function of this client’s problem behavior was escape, so she often engaged in aggression to get out of a demand or social situation,” Caruthers said. “We refer to our intervention as functional communication training with discrimination training. With that, we teach the client to appropriately ask for a break instead of engaging in the problem behavior. We wear a bracelet to signal to the client if requesting a break is or is not available and systematically increase the amount of time that requesting breaks is not available.
“We added Mom into the intervention because that’s ultimately her primary caregiver, and that’s who she would have to listen to. We had to be sure the client was performing just as well if not better with Mom as she did with us. Mom was able to learn to carry out the intervention properly and saw decreases in her child’s behavior without us around,” she said.
After a semester of treatment, the 5-year-old’s problem behavior had been completely eliminated during appointments at home and in the clinic and had been reduced considerably outside appointments throughout the rest of her day. All the teams working with children last year saw 100 percent reduction during appointments.
Caruthers’ ultimate goal is to become a school psychologist.
“I will be entering a doctoral program in school psychology in the fall,” she said. “I hope to use this training to provide both behavior analytic and psychological services to children in urban areas.”
Becoming scientist-practicioners
Master’s degree and doctoral special education students concentrating in early childhood, high incidence or severe disabilities may apply to the Applied Behavior Analysis (ABA) training program, and all those accepted are required to work at the Behavior Analysis Clinic. Lambert, who directs the ABA program, increased the size of student-led teams that serve each client from two or three to four or five. Interns must spend an equal amount of time out of session analyzing, summarizing and responding to data, presenting problems, debating solutions and modifying intervention programs accordingly to ensure the effectiveness of clinical appointments.
“Many applied behavior analysts consider themselves scientist-practitioners and approach the presenting problems of their clients as if each were a research experiment,” Lambert said. “That method often leads to incredibly effective clinical practice and is a standard we wish to instill in our students. Thus, to the extent possible, we expect our interns to apply single-subject research methodology to establish experimental control for any intervention we claim will influence a client’s behavior. Our data protect our clients from our egos.”
Students’ clinic work exposes them to flaws in current best practices and encourages them to ask questions that can lead to research directly relevant to clinical practice. The BAC’s tradition of rigorous data-collection standards and frequent procedural fidelity checks and evaluations has yielded information that contributes to knowledge in the field. Since January 2014 alone, one clinic study has been accepted for publication, five are under review, and four are being prepared for submission. In addition, seven different students presented BAC research at the Tennessee Association for Behavior Analysis Conference last October, and six will present at the Association for Behavior Analysis International Conference in San Antonio in May.
“We’re one of the primary rotation sites for interns as they go through the behavior analysis program,” TRIAD Associate Director Pablo Juárez, a behavior analyst and an alumnus of Peabody’s ABA program, said. “Many of them wind up working with our behavior analysts within the Division of Developmental Medicine and working with those in the Behavior Analysis Clinic, so they’ll get to see the full range of services. They can also provide ongoing support to families as they need to within that medical model. Families who need more-intense services that may not be covered well under pediatrics, we refer to the clinic.
“We’re building a continuum of services. Our experiences in the Behavior Analysis Clinic help us develop programming within the Division of Developmental Medicine in pediatrics. It’s an important learning model being developed, a strong collaboration between TRIAD and Special Education,” he said.