Chapter 8 - Quality measurement in applied behavior analysis

Behavior analysis is the underclass of psychology. It is under-funded, under-taught, and underappreciated. A lot is happening that is positive, but just beneath the surface, there are grave dangers lurking that could significantly worsen our already poor status. I prefer to believe that most of these dangers are things we can control by our own behavior (itself a rather behavioral idea), and I offer this list of dangers in that spirit. As someone once said: if you always do what you always did, you'll always get what you always got. Behavior analysts need to appreciate the following six dangers and adapt to them. LOSS OF MISSION Behavior analysis was initially strategically committed to the field of animal learning, but from the beginning its ultimate purpose was an understanding of complex human behavior: importance of a science of behavior derives largely from the possibility of an eventual extension to human affairs (Skinner, Behavior of Organisms, 1938, p. 441). In the early decades that was merely a promise, but the arrival of applied behavior analysis turned it into a program. Over the years, however, both basic and applied behavior analysis have narrowed and that original vision is being lost. Applied behavior analysis is gradually becoming a subfield of developmental disabilities, as a glance at a recent issue of JABA will confirm. The depth of the risk this creates is covered over by methodological rigor and applied impact within that narrow domain. Basic behavior analysis clings largely to narrow and precise questions of self-stimulatory interest in the animal laboratory, even while animal laboratories are being closed one by one, and areas of research within behavior analysis are being opened up that require human research. The depth of the problem is covered over by the productivity of a few major behavioral laboratories and the emergence of a handful of international labs, where protection from political winds have allowed the old seeds to grow a few new sprouts. In some ways, all of the other dangers I list can be traced back to the following core concern. Behavior analysis was always a carom shot. Instead of approaching human complexity directly, it tried to develop conceptual tools based on simple behaviors in simple contexts with small non-human animals, and then to apply these to an analysis of virtually every form of complex human behavior. It was a bold and even slightly preposterous idea, and yet it was one that worked far beyond what anyone had a right to expect. Now, however, we seem to be on the verge of forgetting what the mission was in the first place. Many basic behavior analysts have begun to believe that basic behavior analysis is a subfield of animal learning or (perhaps worse) behavioral biology. Where are the experimental analyses of emotion, friendship, sexuality, health, reasoning, humor, intelligence, and so on? Interpretation is not enough--we need an experimental analysis of such behaviors. Without the basic account, applied behavior analysts either ignore these areas or build common sense approaches to them. TOOL POLISHING No field so enjoys principles as does behavior analysis. Principles of behavior are ways of speaking about the prediction and influence of the historically and currently situated actions of organisms that are precise, broadly applicable, and coherent in terms of the larger fabric of science. Principles are the intellectual tools of analysis. They are not, however, ends in themselves. Sometimes behavior analysts are like the watchmakers who decided to make a set of extremely fine tools before actually making some complicated new watches. Forgetting what the tools were for, the talented watchmakers did not build the watches and display them in a glass cabinet, but instead put the tools themselves in that cabinet, taking them out only to polish them and to show how they work. Basic behavior analysts are especially prone to this error. …

At its core, productive collaboration between speech-language pathologists and behavior analysts requires effective communication between both parties. Successful communication can be gained in par...

Background Autism is a disorder characterized by pervasive delays in the development of language and socialization, and the presence of stereotyped, repetitive behaviors or nonfunctional interests. Although a multitude of treatments for autism exist, very few have been the subject of scientific research. The only treatment that has been supported by substantial empirical research is treatment based on applied behavior analysis (ABA). Methods This article describes components of comprehensive ABA treatment programs, reviews research on effectiveness, and discusses issues related to collaboration between ABA and psychiatry. Results ABA has been supported by several hundred single case experiments and an increasing number of between-groups studies. Comprehensive ABA treatment programs are comprised of multiple intervention procedures, such as discrete trial instruction and natural environment training, and are founded on basic principles of learning and motivation, such as positive reinforcement, extinction, stimulus control, and generalization. Clinicians in the fields of ABA and psychiatry have similar goals regarding client outcome, and several ABA measurement and analysis procedures produce information that may be useful to psychiatrists. Conclusions ABA treatment programs for individuals with autism are supported by a significant amount of scientific evidence and are therefore recommended for use. Patient care would likely benefit from a greater degree of collaboration between practitioners in the fields of ABA and psychiatry.

Across many countries in Europe, the last decade has seen a rapid increase in the number of early intervention programmes for children with autism based on applied behaviour analysis, and a related growth in demand for competent behaviour analyst practitioners. There has also been a rapid growth in university-based courses that are focused solely on behaviour analysis, and these have all aligned their curriculum with the Behavior Analyst Certification Board task list. We describe the context of these developments and discuss some of the ways courses have been developed and some of the future challenges to be faced in developing an international profession of behaviour analysis. These have been positive moves for behaviour analysis in Europe. Now there is a solid foundation to continue this work, and to ensure that behaviour analysts play a central role in helping those who need their expertise.

There is an old Chinese curse that says you live in exciting and we as clinical psychologists are certainly living in exciting times these days. Most of us are aware of the increasing pressure community-based clinical psychologists are experiencing, although we are not necessarily sensitive to the impact this pressure is having on those practitioners or on our field. In large part, many of the changes and challenges we are facing are byproducts of the increasing financial limitations and time restrictions being place on community-based clinical psychologists and it has become apparent that there are a number of changes ahead that will greatly impact the field as we know it. Clinical behavior analysis has much to contribute to the field. On a fundamental level, we have the strength of an empirically grounded theory and a lengthy history of research demonstrating effective clinical work. Additionally, our historical roots in pragmatism allow for the adaptation and integration of techniques from other branches of clinical psychology, not traditionally seen as behavioral. We will need to be aware of the current context, however, if we are to effectively participate in the transition clinical psychology is undergoing. In addition, there are number of obstacles which make it difficult for CBA to be a part of this process; some of the variables controlling these trends are in our hands. First there is our isolation from other branches of psychology. We need to spend more time talking to clinical psychologists from alternative theoretical orientations. This is true for both academic psychologists and clinical behavior analysts. I work in a department of anesthesiology, a somewhat unusual setting for a clinical psychologists, and my various roles in the medical school are such that I have a foot in the clinical camp and a foot in the ivory towers of academia. In trying to balance these contingencies, it has become apparent to me that there is a schism between what academic clinicians are doing and what community-based clinicians are doing. If that schism grows, we may find that community-based clinical psychologists will pay less and less attention to the research we produce. There is already a general attitude ex- pressed by many of the clinical psychologists I encounter that much of what we do as researchers is not relevant to what they do as clinicians. It is vital that we attend to this issue. On a more practical level, we as clinical behavior analysts need to participate in dialogues with other clinicians if we want to play a role in the changes psychology is already undergoing. As CBA is largely performed by academic psychologists at this point, we don't often consider our role in the economic marketplace. Since the marketplace is largely oriented toward cognitive-behavioral therapy, it is wise for us to plan specifically how CBA will fit into the future marketplace. This has implications for attracting future behavior analysts into the field. Although applied behavior analysis has been highly successful in our work with the developmentally disabled and in closed communities/hospital settings, many have been reluctant to move into settings in which our influence over the functional contingencies is more limited and relies heavily on verbal and rule-governed behavior. Despite pioneering early work in the outpatient arena by Kanfer and Saslow (1965, 1966), Ferster (1973), Krasner (1978, 1988), and Rachlin (1988), the role of functional analysis in the outpatient treatment session and a more molar view of a client's life were largely unexplored. The more traditional treatment areas for behavior analysts do not represent the typical setting in which most clinical psychologists practice and when these behavioral treatments appear, they are similar to cognitive treatments (e. …

Supporting people with neurodevelopmental disabilities often requires interdisciplinary collaboration and effective partnerships with clients and their families. Behavior analysts receive intensive training and supervision in a variety of domains; however, expanding interdisciplinary training for behavior analysts is needed. Interdisciplinary training programs, such as the Leadership Education in Neurodevelopmental and Related Disabilities (LEND) programs, offer trainees the opportunity to hone their skills as advocates for people with neurodevelopmental disabilities and collaborators as part of an interdisciplinary team. Historically, many LEND programs have not offered training positions specifically to behavior analysis students or professionals, although some behavior analysts have participated as trainees in other disciplines such as psychology or special education. The benefits, barriers, and possible future directions of interdisciplinary training for behavior analysts within a LEND program are discussed through the experience of the University of Cincinnati LEND Program which added an Applied Behavior Analysis (ABA) training track in 2020.

Healthcare quality measures have a central role in monitoring and incentivizing the quality of surgical care. Payors and other stakeholders rely on consensus-based entities (CBEs) for the rigorous, independent evaluation and endorsement of quality measures. The aim of this study is to catalog current CBE-endorsed, surgery-related quality measures and to assess measure characteristics, gaps, and redundancies to inform prioritization of measure development efforts. The National Quality Forum Quality Positioning System and Battelle Partnership for Quality Measurement were reviewed to identify CBE-endorsed quality measures related to perioperative care. Identified measures were characterized in terms of their type (eg, structure, process and outcome), quality domain (eg, effectiveness and efficiency), focus (eg, complications, cost and improvement in functioning), and perioperative specialty (eg, general surgery and anesthesia). A total of 172 perioperative measures were identified, of which 79 were currently CBE-endorsed and 93 were previously endorsed. Among currently endorsed measures, 43 (54%) were clinical outcomes measures (eg, mortality and/or complications, readmissions), 8 (10%) were patient-reported outcomes measures, 20 (26%) were process measures, 4 (5%) were cost measures, and 4 (5%) were measures of structure. Measures specific to cardiothoracic (n = 40) and orthopedic (n = 11) surgery were the most common while 12 measures were relevant to multiple specialties. Despite the large number of surgery-related quality measures, most are concentrated on a small sample of quality domains for a few surgical specialties. Fewer measures are focused on patient-reported outcomes or experiences, low-value care (eg, unnecessary testing or imaging), healthcare structures, or processes that may lead to better outcomes.

To develop a comprehensive set of explicit process measures to assess the quality of health care for osteoarthritis and to describe the scientific evidence that supports each measure. Through a comprehensive literature review, we developed potential quality measures and a summary of existing data to support or refute the relationship between the processes of care proposed in the indicators and relevant clinical outcomes. The proposed measures and literature summary were presented to a multidisciplinary panel of experts in arthritis and pain. The panel rated each proposed measure for its validity as a measure of health care quality. Among 22 measures proposed for osteoarthritis, the expert panel rated 14 as valid measures of health care quality. Sufficient scientific evidence and expert consensus exist to support a comprehensive set of measures to assess the quality of heath care for osteoarthritis. These measures can be used to gain an understanding of the quality of care for patients with osteoarthritis.

Adapting interventions based on learner progress is paramount to the effectiveness of interventions in special education and applied behavior analysis. Although there is some research on effective methods for training practitioners to make general instructional decisions (e.g., modify an intervention) based on graphed performance data, research on training individuals to make specific decisions (e.g., how to modify an intervention) is more limited. Our purpose in this study was to evaluate the effects of a training package, consisting of a brief online training and a visual decision-making model, for increasing preservice teachers’ and behavior analysts’ accuracy in making specific instructional decisions based on graphed performance data. In a multiple baseline across participants design, all participants increased their decision-making accuracy on novel graphs during assessment sessions and maintained accuracy at 1-month follow-up. The implications of these findings for training and future research on data-based decision-making are discussed.

Functional assessment checklists and experimental functional analysis have become standard practice in applied behavior analysis. This chapter incudes an overview of existing methods and how they are utilized in various applied contexts. We discuss the standard functional analysis model first described by Iwata et al. (1982/1994) and significant variations on the standard model, such as trial-based functional analysis, interview-informed synthesized contingency analysis, among others. We also comment on the strengths and weaknesses of these methods and how they can complement one another during clinical decision-making. The article also discusses methods of analyzing functional assessments and assessment informed treatment. Finally, we discuss barriers and criticism of functional assessment and how these can be addressed by behavior analysts.

Monitoring Duration of Coverage in Medicaid and CHIP to Assess Program Performance and Quality

Examining behavior within the context of applied behavior analysis (ABA) from the perspective of acceptance and commitment training (ACTr), while understanding the role of relational framing and the transformation of stimulus function, can better equip behavior analysts to effectively address complex behavior that may be influenced by covert verbal behavior. This approach may lead to a more comprehensive analysis of behavior and result in more effective interventions for socially significant change. The aim of this article is to provide behavior analysts with information and guidance on using relational frame theory (RFT) and ACTr in behavior-analytic services. The article first provides a rationale for considering thoughts as behavior and outlines important components of RFT. Subsequently, the benefits of employing ACTr in ABA are highlighted, including brief descriptions and examples of the use of ACTr within ABA practice. The article highlights the importance of expanding the consideration of maintaining variables when attempting to address maladaptive covert verbal behavior and ultimately aims to encourage a greater number of behavior analysts to adopt RFT and ACTr practices in applied settings.

Applied Behavior Analysis (ABA) has long been recognized as an effective therapeutic approach for individuals with Autism Spectrum Disorder (ASD), primarily within clinical and educational settings. However, the potential of ABA principles extends beyond these traditional environments, offering valuable insights into the design of inclusive products tailored to the unique needs of autistic children. This paper explores the interdisciplinary application of ABA in the development of products such as adaptive toys, clothing, and footwear, aiming to enhance the daily experiences and developmental outcomes of children with ASD. The integration of ABA strategies into product design involves a meticulous understanding of behavioral patterns, sensory preferences, and reinforcement mechanisms. By aligning product features with these behavioral insights, designers can create items that not only accommodate sensory sensitivities but also promote engagement, learning, and independence. For instance, toys designed with ABA principles can reinforce positive behaviors and facilitate social interactions, while adaptive clothing can address sensory discomforts and support self-dressing skills. This paper conducts a comprehensive literature review of recent studies that exemplify the successful incorporation of ABA into product design for autistic children. The findings underscore the significance of a collaborative approach, bringing together behavior analysts, designers, and stakeholders to create products that are both functional and empathetic. By embracing the principles of ABA in product development, we can move towards a more inclusive society that recognizes and supports the diverse needs of children with autism.

The emergence of positive behav-ior support (PBS) has presented somechallenges and opportunities for ap-plied behavior analysis. In a recentreview and critique of positive behav-ior support, Johnston, Foxx, Jacob-son, Green, and Mulick (2006) ac-knowledge that the success of PBS ingarnering support in schools, agen-cies that service individuals with de-velopmental disabilities, and stateand federal agencies, and suggestsome behaviors to be emulated byapplied behavior analysis in order togarner similar support. However,they recommend that PBS shouldnot be embraced by behavior analystsbecause it poses a threat to the fieldand is less effective than appliedbehavior analysis. Before this recom-mendation is embraced by behavioranalysts, it is important to considerthe ramifications of a split betweenPBS and behavior analysis, particu-larly given that PBS has its origins inbehavior analysis and is conceptual-ized by prominent adherents of thePBS model to be a type of orextension of applied behavior analy-sis (Dunlap, 2006; Horner, 2000). Ipropose that PBS should not bedismissed but should be viewed asan opportunity by the field of appliedbehavior analysis to reach its goal oflarge-scale adoption. A continuedstrong relation between PBS andbehavior analysis may actually ac-complish the broadest disseminationand adoption of effective behavioraltechnology. It will also benefit PBSby keeping it grounded in the con-ceptual system that fostered its de-velopment.PBS is clearly still in its formativestages; in fact the executive board ofthe Association for Positive BehaviorSupport currently is working to de-velop a comprehensive definition ofPBS and to define the roles for theorganization (C. Anderson, personalcommunication, November 2, 2006).As is true in any organization—eventhe Association for Behavior Analy-sis—different members may espousedifferent perspectives on issues suchas the relation between PBS andother perspectives, training models,and so on. This in itself has been thesource of many challenges, and per-haps misunderstandings, for those inthe behavior analysis community.For example, Johnston et al. (2006)emphasize the negative views of PBSresearchers toward behavior analysis.However, many leaders, trainers, andresearchers in PBS have a favorableview of behavior analysis, considerthemselves to be behavior analysts,and continue to publish in behavioraljournals such as the Journal ofApplied Behavior Analysis and TheBehavior Analyst. Thus, although thissituation has been viewed pessimisti-cally by Johnston et al., I believe thatthere are significant grounds forhaving an optimistic view about thefuture relation between PBS andapplied behavior analysis. BecausePBS is in its formative stages and isrooted in behavior analysis, the field

Nine States' Use of Collaboratives to Improve Children's Health Care Quality in Medicaid and CHIP