Sleepy time struggles- Daily Drip #4

Sleepy time struggles- A discussion about caregiver rapport

Caregiver training. Caregiver buy-in. Treatment fidelity. I would argue that these three concepts represent the most important aspects of any behavior analytic treatment plans. I would go as far to argue that even with a non-function based behavior plan and poor reinforcement, you will still get more progress with a bought-in caregiver willing to implement intervention consistently than with a perfect behavior plan and a caregiver who you have no relationship with. 

As far as I know, there is not a lot of research on this. Sure, there are plenty of interventions that look at how to GET caregiver fidelity, but research is sparse on what happens when you do not have fidelity. The closest we get to this type of research is analyses of intervention effects of DRA vs. NRA when there are less than ideal treatment integrity conditions, but even that research does not take into account the multiple different variables involved in a caregiver relationship. (Effects of treatment integrity failures during differential reinforcement of alternative behavior: a translational model - PubMed (nih.gov))
As one of the key pieces that can make or break your case, I think it is important to give each one attention. Breaking down each of these challenges allows us to become a little bit better right away at each one.

Note, a lot of this also applies to the clients. For the sake of the post, we are going to focus on caregiver rapport, but know that client rapport is even more important.

Treatment integrity- Let's start here because the changes that you can make to your intervention before even starting the training relationship are crucial to building a sustainable intervention.

• Tip #1- Begin with the end in mind. This is a common phrase, but nonetheless it is exceedingly powerful. Before you even start designing an intervention, take an honest examination of the current environment and what it can support. For example, is your client in a group home setting where there is one staff to every six clients? A multicomponent intervention is never going to work. Is the client in school with a 1-1 and at home with a stay-at-home caregiver and no siblings? Perhaps the intervention can support more components!
• Tip #2- Begin to develop fidelity checks and data collection systems naturally into the intervention. I cannot stress this enough, but the power of permanent product data collection that is seamlessly integrated into the intervention is amazing. A keyway to monitor fidelity and progress is of course through data. Therefore, every intervention needs a way to be monitored, and that monitoring method needs to persist past the termination of services. A technician taking data during a session is not going to cut it. One great way to do this is by teaching self-monitoring to your client, so they can report on their own progress at the end of their routine. Then, all you have to do is print out a stack of paper and monitor the data. Even better, set up the intervention so that the final step in a chain of ADLs is clearly signaled by a stimulus. For example, after brushing your teeth, put your toothbrush in the “done” cup.
• Tip #3- Use component analyses! This powerful piece of single case design research is crucial for going from a complex, multi-step intervention to a lean intervention that only uses the components that are absolutely needed. You can do this by starting with a multi-component intervention and peeling off one piece at a time and assessing data, or you can start with a single component and add until behavior change occurs. 

Caregiver buy-in- Now that there is a lean intervention, let's present it to the caregiver… Except that caregiver hates ABA and hates you, so why are we even bothering presenting it? The buy-in from the caregiver into ABA services is crucial to long lasting interventions, and it comes down (in my opinion) primarily to trust.

• Tip #1- Actually be a human and form relationships. I want to be clear, there is a difference between forming dual relationships and good working relationships with caregivers. My personal line in the sand is “Could I discharge you and could you fire me without lasting emotional distress?” However, you absolutely can be friendly, engage with the caregivers, not as an ABA Robot. “What is the ABC??” and take an interest in their culture, family and friend dynamic, even their hobbies, as that all can lead into a more personalized intervention.
• Tip #2- Be honest about what are barriers to intervention. This is something that I used to screw up all the time. I would be working with a caregiver who told me, “No matter what, grandma gives snacks whenever the client gets aggressive.” I then hemmed and hawed, and instead of just being honest and meeting the challenge head on, I pretended like it wasn’t a problem. I am not advocating for us as behaviorists not being flexible and working around the realistic day-to-day routine, but I am saying we need to be honest about potential challenges and address them instead of sweeping them under the rug.

Treatment Fidelity- So, your intervention is lean, and the caregivers are happy to see you. Now let's get to the good part. Actually implementing the intervention. Luckily, there IS a lot of research on this piece, so I will be recommending some search terms or articles as I go.

• Tip #1- Understand renewal and renewal mitigation. There is SOO much research on resurgence, but not nearly as much on renewal, the sneaky cousin. If you remember your definitions, resurgence is when a previously extinguished behavior occurs when a different behavior is put on extinction. Renewal is when the behavior reoccurs after a change in environment. While resurgence is important in the conversation, renewal often causes more interventions to go haywire. Renewal mitigation strategies are simply different techniques to reduce or prevent the spike in behavior following a transition to a new context. All of these strategies generally go back to fading. Fade in new components (like a caregiver) and fade out old components (like a technician) slowly and systematically. More on renewal and resurgence-> Relapse during the treatment of pediatric feeding disorders - PubMed (nih.gov)
• Tip #2- Check early and often, then modify. This part is perhaps the most crucial tip of them all. In order to maintain fidelity, you need to have some way of tracking it. When tracking integrity, don’t forget to make decisions to simply or modify the intervention based on that information. Consider the video above and the situation with my toddler. Imagine if an analyst came in and told me to push bedtime back to 12:30 AM and do spaced visits. I texted them two days later and tell them that I wasn’t able to do 12:30 AM, instead he was still in bed at 9 PM. How pissed do you think I would be as the parent if the analyst responded, “Hm, well, we need him to be up til 12:30 AM so keep trying!” No, instead, the analyst needs to take into account the realistic boundaries put in place by the caregiver's ability and design an intervention around that. I am not saying don’t challenge the caregiver, but for goodness sakes if it is consistently low fidelity, do something different, don’t just blame the caregiver!

I hope these tips helped. If one good thing has come out of my kid not sleeping, at least I got a different (maybe even kinder) perspective that will help me better serve my clients!