ADVANCED CLINICAL
DECISION-MAKING
PART 1
LEARNING Objectives
At the completion of the lesson, clinicians will have learned:
- Best practices related to the development of appropriate targets
- Problem solving for lack of progress when targets are appropriate
- Rationale for focus on and reporting of goals met scores
AS A CLINICIAN AT CSD
INFO
Since the initial clinical decisions are made with the best available information, as additional data, observations, and information are gathered, the treatment plan should continually be evaluated (at least bi-weekly), to assess progress and determine the need for modification.
INFO
INFO
Deciding on the appropriate data collection method, intervention strategy, prompting level, target skill, and mastery criteria, are all common clinical determinations to be made.
You will be responsible for making a variety of clinical decisions to ensure optimal treatment outcomes.
Identify barriers in the treatment plan early and often by continually evaluating data and progress
It is recommended that Clinical Directors and Clinical Leaders meet with one another out of session at least one time per month per client to review, discuss, and modify as needed.
For regions whose payors only allow for direct billing, utilize time during overlaps to analyze fidelity of implementation and determine if modifications are needed
Clinicians in regions that allow for indirect billing should evaluate each clients’ data and treatment plan, at least bi-weekly.
Scheduling time for your clients in advance is a strategy to assist with calendar monthly projections.
deeper dive: case studies
scenario
- You are assigned a new client, Jane, who is 3 years old, recently diagnosed with ASD.
- The caregivers' main concern is that Jane does not engage in any type of play activities with her siblings and lacks functional play skills.
- You implement a treatment target for engaging in play activities
- Jane is demonstrating the ability to engage in this skill in 100% of opportunities during sessions with her clinical team
View
What would you do?
A. Continue to increase the duration of the non-preferred activities and target the goal with the Behavior Specialist only
B. Discontinue the goal since she has demonstrated that she can do this
C.Provide caregiver training so that the caregiver can implement the goal outside of sessions
D. Continue to increase the duration of the non-preferred activities and target the goal with siblings during session
We want to plan for generalization early and often, in this scenario sibling interaction is a caregiver concern, the clinical should support the caregivers in their ability to facilitate social interaction.
scenario
Caregivers report that their home has many toys available such as puzzles, blocks, dolls, and the television. Jane spends the majority of the time engaging in self-stimulatory behaviors such as rocking and clapping, rather than playing like her siblings.
What would you do?
A. Conduct a preference assessment to identify stimuli that are reinforcing to Jane and once identifying something she will play with, target parallel play
B. Target parallel play to teach Jane how to play with the puzzles and dolls like her siblings
C. Focus on a different domain since Jain isn't motivated to play
D. Recommend Jane for SSG to gain functional play skills.
The clinical team and caregivers should be aware of Jane's individual preferences and identify specific items, activities, and people that are reinforcing to her, then work on the next set of appropriate play skills.
What would you do?
A.Free operant
Since Jane lacks demonstration of scanning skills and toleration to relinquishing reinforcers, a preference assessment that might be appropriate for Jane is?
B. MSWO
C. Progressive Ratio
D. MSW
What would you do?
A.Place the self-injury on extinction and provide attention contingent on acceptable behavior (DRA) or non-occurrence of problem behavior (DRO)
Jane also engages in aggression toward others. Baseline frequency data has been gathered. The Behavior Specialist reported that she "does it all the time for attention." What is the appropriate best step to take?
B. Train the caregiver on extinction protocols.
C. Conduct a functional assessment to determine if the hypothesized attention function is accurate and develop appropriate antecedent and consequence strategies
D. Have the Behavior Specialist safety care trained so that appropriate response blocking can be implemented
What would you do?
A.Put the goal on hold until the next treatment period
Jane has two Behavior Specialists on her team. When analyzing the goal for manding for access to items, you observe high variability in the data. What would you do?
B. Reach out to the training department to have the Behavior Specialists retrained in data collection
C. Overlap a session with each of the Behavior Specialist to identify any differences in delivery, responding, and reinforcers available in the environment.
D. Request to scheduling that one Behavior Specialist is removed from the case
Clinical Directors and Clinical Leaders should overlap sessions to observe progress towards goals, data collection, and client responding. If there are barriers with implementation, training should be provided to the Behavior Specialist.
- Utilize BST whenever possible.
- Model the correct implementation and provide appropriate feedback.
- Collect IOA data and meet inside of session to review data collection.
- Ensure that every goal has complete instructional notes to support fidelity of implementation.
solving for caregiver concerns
scenario
- During your initial session with the client's caregiver, she reports that tantrums occur every time the family goes to the grocery store.
- She explains that her son will often bring preferred toys to the cart for purchase, when she says "no" he will stomp his feet, engage in loud vocalization and other tantrum behaviors until she allows him to put the item in the cart.
- The caregiver comes to you worried and frustrated by her limited ability to go to stores. She reports that his happens "Every time" and feels "stuck" because he "cries and cries until he gets what he wants."
What would you do?
What would be the most appropriate initial concept to review with the caregiver to address this concern and increase her understanding of the tantrum behavior?
A. Perspective taking
B. Premack Principle
C.ABC Data Collection
D. Differential Reinforcement
It is useful to provide caregivers with an understanding of antecedents that "Trigger" the behavior, the behavior itself, as well as consequences that maintain or stop the behavior. Understanding the relationship between consequences and future behavior, can help caregivers understand their role in challenging behavior and give them confidence that the behavior can be changed.
scenario
Your next client is a 19-year old who has been in ABA treatment for the past 4 years. The client is on track to meet all goals on the current treatment plan and the end of the authorization period is approaching in two month, you meet with caregiver to discuss next steps. The caregiver states that they cannot discharge right now because the client still needs support in loading the dishwasher, making his bed, and cooking his own meals.
What would you do?
A. You recommend one more authorization period of ABA because the caregiver has valid concerns since the client needs to be more independent at his age.
B. Conduct a reassessment to identify deficits and current skill level to determine if more ABA is needed.
C. Since the caregiver may be upset by discussing discharge you should avoid this conversation until it is time to submit the report. Continue with your recommendation for
D.Continue with your recommendation for discharge and provide the family with resources for ongoing support and Day Program's, regional center, and vocational centers.
ABA is an episodic treatment, meaning, it is recommended during specific times in a person’s life. Clinicians should speak openly and often to clinicians regarding anticipated discharge date. Consider least restrictive settings and programs that focus on quality of life for clients.
scenario
During your parent led session, the caregiver reports that your 12-year-old client finds activities with peers hard and avoids them whenever possible. Hanging out with other kids in social settings is difficult but the client is very interested in video games.
What would you do?
A. Recommend in person SSG to increase socialization with peers.
B. Recommend that the caregivers offer a new video game that requires social interaction with peers
C. Train the caregivers on leisure activities that the caregivers can play with the client
D.Recommend that the caregiver withhold video games so that client has to earn them since video games are the most preferred.
Take time during caregiver training to review motivation when discussing skill building. Explain that learning is difficult when the behavior is difficult to do or non-preferred. Since we know it's hard for the client to talk with peers in person and he does not enjoy it, we can suggest that if he is motivated to learn a new video game, he may be more likely to put himself in a social situation.
What would you do?
Your next client Paul is a 12-year-old male with diagnosis of Selective Mutism and ASD. You are a CL supporting the caregivers in a parent-led session.The caregiver says to the Paul, “Do you want to come to the table to talk with us?” Paul shrugs his shoulders and responds, “No.” The CL should model for the caregiver the response of:
A.Saying, “Thanks for letting me know. I see that you are not ready to come to talk with us.”
B. Providing a physical prompt to guide Paul to the table
C.Saying, “You really need to come to the table now.”
D. Ignoring Paul's response
Clinicians should model honoring assent and reinforcement-based procedures for caregivers.
scenario
Paul engages in elopement behavior that is maintained by attention. His mom implemented a token economy that allows Paul to earn tokens to exchange for backup reinforcers from a menu. Paul can exchange for iPad time, Legos, various edibles, going outside to play and free pass to opt out from doing various chores. Mom saw some reduction in problem behaviors but did not see a meaningful improvement in the past 6 months.
View
What would you recommend?
A. Mom should add different edibles to the menu
B.Mom should add a punishment component
C.Mom should add "playtime with mom" to the menu
D. Mom should discontinue the token economy system
Since the data indicates that the intervention being used, token economy, has not been effective at decreasing the behavior over the 6 months, in fact eloping has increased. This intervention should be discontinued since it is not having its intended effect and is not creating behavior change.
Problem solve for insufficient progress or outcomes and modify recommendations when the data indicates
Continuously evaluate client responding and progress, if progress is limited or not occurring, decide what modifications are appropriate to make to ensure that client goals are achievable and attainable within the authorization period and accurately reflect their progress.
scenario
Read more
How would you modify the treatment target?
A. Modify the goal to the current skill level- Client will mand for preferred items in 20% of opportunities presented across 3 consecutive sessions.
B.Modify the mastery criterion based on current rate of acquisition- Client will mand for preferred items in 40% of opportunities presented across 3 consecutive sessions.
C.Modify another aspect of the mastery criterion- Client will mand for preferred items in 80% of opportunities presented across 1 consecutive sessions.
D. Do not make any modifications, the goal should remain- Client will mand for preferred items in 80% of opportunities presented across 3 consecutive sessions.
Importance of the progress report
Caregivers and clinicians assess and observe progress regularly; however, the only opportunity payors have to assess progress is on the progress report.
Payors do not see the day-to-day responses that indicate skill acquisition in the same way it does for caregivers and clinicians.
Instead, clinicians need to assess progress from the payors lens, which may require zooming in on the current target to identify if the data collection method and measurement is appropriate based on current skill level and rate of acquisition.
Read more
We are here to help!
INFO
INFO
CONGRATULATIONS!
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Transcript
ADVANCED CLINICAL
DECISION-MAKING
PART 1
LEARNING Objectives
At the completion of the lesson, clinicians will have learned:
AS A CLINICIAN AT CSD
INFO
Since the initial clinical decisions are made with the best available information, as additional data, observations, and information are gathered, the treatment plan should continually be evaluated (at least bi-weekly), to assess progress and determine the need for modification.
INFO
INFO
Deciding on the appropriate data collection method, intervention strategy, prompting level, target skill, and mastery criteria, are all common clinical determinations to be made.
You will be responsible for making a variety of clinical decisions to ensure optimal treatment outcomes.
Identify barriers in the treatment plan early and often by continually evaluating data and progress
It is recommended that Clinical Directors and Clinical Leaders meet with one another out of session at least one time per month per client to review, discuss, and modify as needed.
For regions whose payors only allow for direct billing, utilize time during overlaps to analyze fidelity of implementation and determine if modifications are needed
Clinicians in regions that allow for indirect billing should evaluate each clients’ data and treatment plan, at least bi-weekly.
Scheduling time for your clients in advance is a strategy to assist with calendar monthly projections.
deeper dive: case studies
scenario
View
What would you do?
A. Continue to increase the duration of the non-preferred activities and target the goal with the Behavior Specialist only
B. Discontinue the goal since she has demonstrated that she can do this
C.Provide caregiver training so that the caregiver can implement the goal outside of sessions
D. Continue to increase the duration of the non-preferred activities and target the goal with siblings during session
We want to plan for generalization early and often, in this scenario sibling interaction is a caregiver concern, the clinical should support the caregivers in their ability to facilitate social interaction.
scenario
Caregivers report that their home has many toys available such as puzzles, blocks, dolls, and the television. Jane spends the majority of the time engaging in self-stimulatory behaviors such as rocking and clapping, rather than playing like her siblings.
What would you do?
A. Conduct a preference assessment to identify stimuli that are reinforcing to Jane and once identifying something she will play with, target parallel play
B. Target parallel play to teach Jane how to play with the puzzles and dolls like her siblings
C. Focus on a different domain since Jain isn't motivated to play
D. Recommend Jane for SSG to gain functional play skills.
The clinical team and caregivers should be aware of Jane's individual preferences and identify specific items, activities, and people that are reinforcing to her, then work on the next set of appropriate play skills.
What would you do?
A.Free operant
Since Jane lacks demonstration of scanning skills and toleration to relinquishing reinforcers, a preference assessment that might be appropriate for Jane is?
B. MSWO
C. Progressive Ratio
D. MSW
What would you do?
A.Place the self-injury on extinction and provide attention contingent on acceptable behavior (DRA) or non-occurrence of problem behavior (DRO)
Jane also engages in aggression toward others. Baseline frequency data has been gathered. The Behavior Specialist reported that she "does it all the time for attention." What is the appropriate best step to take?
B. Train the caregiver on extinction protocols.
C. Conduct a functional assessment to determine if the hypothesized attention function is accurate and develop appropriate antecedent and consequence strategies
D. Have the Behavior Specialist safety care trained so that appropriate response blocking can be implemented
What would you do?
A.Put the goal on hold until the next treatment period
Jane has two Behavior Specialists on her team. When analyzing the goal for manding for access to items, you observe high variability in the data. What would you do?
B. Reach out to the training department to have the Behavior Specialists retrained in data collection
C. Overlap a session with each of the Behavior Specialist to identify any differences in delivery, responding, and reinforcers available in the environment.
D. Request to scheduling that one Behavior Specialist is removed from the case
Clinical Directors and Clinical Leaders should overlap sessions to observe progress towards goals, data collection, and client responding. If there are barriers with implementation, training should be provided to the Behavior Specialist.
solving for caregiver concerns
scenario
What would you do?
What would be the most appropriate initial concept to review with the caregiver to address this concern and increase her understanding of the tantrum behavior?
A. Perspective taking
B. Premack Principle
C.ABC Data Collection
D. Differential Reinforcement
It is useful to provide caregivers with an understanding of antecedents that "Trigger" the behavior, the behavior itself, as well as consequences that maintain or stop the behavior. Understanding the relationship between consequences and future behavior, can help caregivers understand their role in challenging behavior and give them confidence that the behavior can be changed.
scenario
Your next client is a 19-year old who has been in ABA treatment for the past 4 years. The client is on track to meet all goals on the current treatment plan and the end of the authorization period is approaching in two month, you meet with caregiver to discuss next steps. The caregiver states that they cannot discharge right now because the client still needs support in loading the dishwasher, making his bed, and cooking his own meals.
What would you do?
A. You recommend one more authorization period of ABA because the caregiver has valid concerns since the client needs to be more independent at his age.
B. Conduct a reassessment to identify deficits and current skill level to determine if more ABA is needed.
C. Since the caregiver may be upset by discussing discharge you should avoid this conversation until it is time to submit the report. Continue with your recommendation for
D.Continue with your recommendation for discharge and provide the family with resources for ongoing support and Day Program's, regional center, and vocational centers.
ABA is an episodic treatment, meaning, it is recommended during specific times in a person’s life. Clinicians should speak openly and often to clinicians regarding anticipated discharge date. Consider least restrictive settings and programs that focus on quality of life for clients.
scenario
During your parent led session, the caregiver reports that your 12-year-old client finds activities with peers hard and avoids them whenever possible. Hanging out with other kids in social settings is difficult but the client is very interested in video games.
What would you do?
A. Recommend in person SSG to increase socialization with peers.
B. Recommend that the caregivers offer a new video game that requires social interaction with peers
C. Train the caregivers on leisure activities that the caregivers can play with the client
D.Recommend that the caregiver withhold video games so that client has to earn them since video games are the most preferred.
Take time during caregiver training to review motivation when discussing skill building. Explain that learning is difficult when the behavior is difficult to do or non-preferred. Since we know it's hard for the client to talk with peers in person and he does not enjoy it, we can suggest that if he is motivated to learn a new video game, he may be more likely to put himself in a social situation.
What would you do?
Your next client Paul is a 12-year-old male with diagnosis of Selective Mutism and ASD. You are a CL supporting the caregivers in a parent-led session.The caregiver says to the Paul, “Do you want to come to the table to talk with us?” Paul shrugs his shoulders and responds, “No.” The CL should model for the caregiver the response of:
A.Saying, “Thanks for letting me know. I see that you are not ready to come to talk with us.”
B. Providing a physical prompt to guide Paul to the table
C.Saying, “You really need to come to the table now.”
D. Ignoring Paul's response
Clinicians should model honoring assent and reinforcement-based procedures for caregivers.
scenario
Paul engages in elopement behavior that is maintained by attention. His mom implemented a token economy that allows Paul to earn tokens to exchange for backup reinforcers from a menu. Paul can exchange for iPad time, Legos, various edibles, going outside to play and free pass to opt out from doing various chores. Mom saw some reduction in problem behaviors but did not see a meaningful improvement in the past 6 months.
View
What would you recommend?
A. Mom should add different edibles to the menu
B.Mom should add a punishment component
C.Mom should add "playtime with mom" to the menu
D. Mom should discontinue the token economy system
Since the data indicates that the intervention being used, token economy, has not been effective at decreasing the behavior over the 6 months, in fact eloping has increased. This intervention should be discontinued since it is not having its intended effect and is not creating behavior change.
Problem solve for insufficient progress or outcomes and modify recommendations when the data indicates
Continuously evaluate client responding and progress, if progress is limited or not occurring, decide what modifications are appropriate to make to ensure that client goals are achievable and attainable within the authorization period and accurately reflect their progress.
scenario
Read more
How would you modify the treatment target?
A. Modify the goal to the current skill level- Client will mand for preferred items in 20% of opportunities presented across 3 consecutive sessions.
B.Modify the mastery criterion based on current rate of acquisition- Client will mand for preferred items in 40% of opportunities presented across 3 consecutive sessions.
C.Modify another aspect of the mastery criterion- Client will mand for preferred items in 80% of opportunities presented across 1 consecutive sessions.
D. Do not make any modifications, the goal should remain- Client will mand for preferred items in 80% of opportunities presented across 3 consecutive sessions.
Importance of the progress report
Caregivers and clinicians assess and observe progress regularly; however, the only opportunity payors have to assess progress is on the progress report.
Payors do not see the day-to-day responses that indicate skill acquisition in the same way it does for caregivers and clinicians.
Instead, clinicians need to assess progress from the payors lens, which may require zooming in on the current target to identify if the data collection method and measurement is appropriate based on current skill level and rate of acquisition.
Read more
We are here to help!
INFO
INFO
CONGRATULATIONS!