Month: March 2018

Is the intelligence barrier real for occupation training?

/ Chris Sawyer, M.Ed.,BCBA / Leave a comment

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This post is more speculative, and an exploration into current research, than a tried and true ABA topic I usually expound on. I saw something that struck me this morning on Twitter. The claim that an individual with an IQ less than 80 could not be trained to functionally work in society. I know for a fact this is not the case, because I’ve seen and worked on it, but I wanted to get my sources down to confront this Tweet.

It was harder than I expected.

I wanted a single consensus of an answer, but unfortunately could not find one. I think I know why, and the answer does not specifically have to do with the IQ scores of the participants, it has to do with how that training is done in relation to the population. We’ll touch on the details of that below.

I have personally worked on hundreds of Applied Behavior Analytic cases, with a broad range of ages, abilities, intelligence, and skills. I have seen more success than I have plateaus. I’ve seen employment aids and training work. The challenge of the process is certainly true, but I dislike the idea of firm impossibilities. This may influence how I first took affront to that Tweet. The research is vast, but the narrative I’ve come to understand does not simply allow an IQ score to determine a cut off for functionality in the workplace. Not exactly. Let’s look at the research I was familiar with:

 

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Rusch & Hughes (1989) in the Journal of Applied Behavior Analysis-  “An Overview of Supported Employment”. They used the common term “Supported Employment” for individuals with disabilities and were focused mainly on those individuals sustaining paid work. The paid work part was fairly important to them, and I’d argue that maintaining paid employment is a reasonable counter to the claim that training is ineffective with the target populations. This study did explore the “place and train” model, which later studies found to be less than optimal, but the findings here did find a measure of success. Some individuals did benefit from these methods. That’s the important finding. They were able to sustain paid work in society. Their terminology for intelligence scoring is a little outdated in this study. We use the term Intellectual Disability these days. They used the terms “mentally retarded”- “mildly”, “moderately”, and “profoundly” specifically. Looking up the diagnostic criterion used at the time, we can see that Rusch and Hughes had the following distribution:

Out of 1,411 individuals with disabilities sustaining paid employment, 8% of these individuals fell within the “mentally retarded” category with IQ scores below 70.

  • 10% of these individuals fell within IQ score ranges of 20-25 (“profoundly mentally retarded”)
  • 45% of these individuals fell within IQ score ranges of 35-55 (“moderately mentally retarded”)
  • 38% of these individuals fell within IQ score ranges of 50-70 (“mildly mentally retarded”)
  • <8% of these individuals fell within IQ score ranges of 70-80 (“borderline mentally retarded”)

So, even with outdated “place and train” models, this study does give us some information on some level of effectiveness that supported training can meet the criterion and disprove the Tweet, and this was as of 1989 referencing successes from decades prior. There are a place for individuals with a vast range of intelligence scores in society. Problem solved, right?

Wait just a minute. There are some challenges in the training process that can not be overlooked. Challenges that might just hint at why people believe that supported training does not work. We see in Rusch and Hughes the successes of certain methods for a small amount of the population. Since then, we’ve seen some longitudinal studies that have raised more questions than they’ve given us answers, and raised more challenges than we thought were there.

 

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Conroy & Spreat (2015)- Journal of Policy and Practice in Intellectual Disabilities

Conroy and Spreat titled their study a “Longitudinal Investigation of Vocational Engagement”, and were interested in how individuals with intellectual disabilities remained employed during a 15 year period from 1999-2004.

An important point I want to bring up first is the concept of Self-Determination, which is the point which all people have to make choices about their lives. An individual, no matter their situation, can make choices about their own lives freely. That includes employment. So when we speak about supported employment, this is due to the individual wanting to work, and maintaining that employment freely.

What Conroy and Spreat were studying were vocational attendance, and quality-of-life data. They found a similar trend in individuals receiving both residential supports and day-to-day supports:

“The overall amount of vocational, prevocational, and nonvocational activities changed sharply during the 15‐year period. Vocational and prevocational activity declined, while nonvocational engagement more than doubled, both in numbers of people and hours. During the same time period, the number of employed individuals consistently declined, as did the total number of hours worked.”- (Conroy and Spreat, 2015)

So we see a trend here where worked hours decrease over time, and nonvocational engagement increased with the studied population. Why could that be? According to Conroy and Spreat, it was due to “segregated forms of vocational activity”. These individuals were not in society working side by side as we saw in the older “train and place” method with Rusch and Hughes, they were doing workshops and prevocational activities separately. Those factors, according to Conroy and Spreat, seemed to have a large effect on the downturn of worked hours.

Again, I see a theme here. The individuals themselves had no innate limitation to working those hours, but the vocational training and workshops appeared to play a role in either the disinterest in maintaining employment, or maybe it was not a good fit for those individuals for that particular skill. That system of separating out workshops and prevocational skills from inclusion with the broader population just did not seem to be effective. So, what is an alternative?

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Lattimore & Parsons (2006)- Journal of Applied Behavior Analysis article titled “Enhancing Job-Site Training of Supported Workers With Autism: Reemphasis on Simulation” was a great find. It had everything I was looking for. I wanted to seek out a (evidence based) reasonable solution that had individuals in the work place (job-site), engaging with the broader population, and had a degree of success. But, they came up with a challenge (and solution to) I had not seen before: Job-Site training alone is sometimes insufficient for quick skill acquisition. Simulation (prevocational training, like what we see used in Conroy and Spreat) added in to the job-site supports seemed to be the key to speeding that acquisition up.

“Job-site training occurred in a small publishing company during the regular work routine, and simulation training occurred in an adult education site for people with severe disabilities. Two pairs of workers received training on two job skills; one skill was trained at the job site and the other was trained using job-site plus simulation training. Results indicated that for 3 of the 4 comparisons, job-site plus simulation training resulted in a higher level of skill or more rapid skill acquisition than did job-site-only training. Results suggested that job-site training, the assumed best practice for teaching vocational skills, is likely to be more effective if supplemented with simulation training”- (Lattimore and Parsons, 2006)

In this study, adults with severe disabilities (the DSM-V IQ score for this population is 25-40) were tested in conditions where on-site community employment training and support were given. Interestingly, both were effective, but skill acquisition was much faster when simulation (off site training) was provided as well. This combination was a fascinating read for me, because it tied some of the factors that the previous two studies saw as challenges.

There is a mountain of research out there, and this just scratched the surface, but this exploration did seem to reinforce my original anecdotal belief that an IQ score alone is an insufficient barrier, and shows an ignorance to the power of effective training and applied behavioral therapy. This is a complex problem, and one I might not have been able to boil down into a single tweet, but one I am happy to see researchers coming up with solutions to every day.

 

Thoughts? Comments? Leave them below.

 

Sources:

Lattimore, L. P., Parsons, M. B., Reid, D. H., & Ahearn, W. (2006). Enhancing Job-Site Training of Supported Workers With Autism: A Reemphasis on Simulation. Journal of Applied Behavior Analysis, 39(1), 91-102.

Rusch, F. R., & Hughes, C. (1989). Overview of supported employment. Journal of Applied Behavior Analysis, 22(4), 351-363. doi:10.1901/jaba.1989.22-351

Spreat, S., & Conroy, J. W. (2015). Longitudinal Investigation of Vocational Engagement. Journal of Policy and Practice in Intellectual Disabilities, 12(4), 266-271. doi:10.1111/jppi.12136

 

Image Credits: http://www.pexels.com, http://www.pixabay.com

Behavioral Therapy (ABA): Beyond Ethical

/ Chris Sawyer, M.Ed.,BCBA / Leave a comment

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This is an opinion piece which was inspired by a few sources recently, which I believe although anecdotal, has some insight from 10+ years of doing therapy, both behavior analytic and counseling. I was reading an article that came up online, one of those anti-ABA groups that search the internet selectively, for studies that support their views on this specific type of therapy. This article in specific was called “Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis”, and it seemed independently researched and not peer reviewed, whose findings were based off of subjective surveys, with questions worded negatively suggesting inherent bias. I am not here to review it. Suffice to say, I found it unconvincing, but it did raise questions. What if there were practitioners out there that were causing harm? Subscribing to a set of ethics is not too difficult, but if you don’t know why, you might lose sight of the principle of it being there; to do the right thing.

In Applied Behavior Analysis, there are rigorous codes of ethics. Codes that have to be studied and make up a large portion of the board examination, and beyond that, ever re-certification cycle requires hours of continuing education on the topic. However, I find, that it’s still hypothetically possible to meet all of that ethical rigor, and still fall short of doing a proper job of maintaining a positive and supportive relationship with clients. Nothing inherently dangerous, or harmful, per say, but still leave a neutral or negative view of the experience down the line. I don’t think any practitioner, BCBA or not, would want something like that if they could help it.

A famous humanist psychologist named Carl Rogers came up with one of the best precepts for therapy I’ve ever heard of. He called it ; Unconditional positive regard. It is exactly as it sounds; acceptance and respect from the clinician towards the client, no matter what. It doesn’t have to be continuous genuine joy, or merriment for every second of each session, but it does require the clinician to have one thing if they want to keep this therapeutic relationship going, and expect it to work well; positive regard for that individual no matter what happens in that session. Mainly, because all therapy, even ABA, is a relationship. It requires two people, or even more, and those interactions are in a sense what we model for our clients. It’s important that they know that they are respected, and the door will be open every time for them, unconditionally, and it has to be genuine.

There are situations that can cause some friction in any therapeutic relationship. Every single therapeutic field has it. With ABA it takes on a more difficult form, I think, especially when some of our clients do not have language, or any interest in forming a rapport, or even interest in any other person at all, therapist included. Sometimes clients can get aggressive; both verbally and physically, and sometimes therapists take on both kinds of scars. It’s not easy work. Sometimes that unconditional positive regard takes some effort. Behaviorally, you could call that all of the operants in your “positive regard” repertoire. Maybe it’s how you look at the client, or how you speak, or the tone you use, or even the direction of how you present your session. If it’s not aiming for the betterment of your client, then that’s the wrong direction.

Another concept from Carl Rogers is, the client has to want to change, or engage in therapy for it to work. B.F Skinner also talks about this type of engagement in his book “Science and Human Behavior”, but from a behavioral standpoint it all comes down to the same thing: positive reinforcement. There has to be something there that the client wants, for this change to take place. Don’t punish when you can teach instead. With non-verbal clients, sometimes they might not know why they are there, or understand what exactly is going on; we can’t say. It’s unspoken, and we can’t guess at it, but what we can do is make sure that their process is one that leads them towards that independent and socially significant lifestyle without harm, interpersonal or otherwise. Behavior change is hard. The targets we introduce, even if we aim them for exactly their level of proficiency, will challenge our clients, and we can not underestimate the effort in that challenge. We have to use positive reinforcement that works, and is strong enough to make the client “happy” to keep trying. That is ethical, but more than that, is the right thing to do. In ABA we are taught to avoid “default technologies”; unnecessary punitive procedures of disciplining, or appeals to authority. I can not imagine a condition where we would need to make a target where a client does something solely “because __ says so”. Would we accept that kind of contingency without questioning it? Of course not. As practitioners, we have to look beyond the short term and away from the older forms of discipline to help individuals go as far as they can in their lives. Long term strategies kept in mind while working on the short term, and while all that is going on… unconditional positive regard, positive reinforcement, respect for our clients and respect for what we are doing.

I believe this form of therapy is a force of good, and progress, in this world. It is evidence based, and supported tirelessly by decades of researchers, for the purpose of getting it right. When we use a therapeutic technique, we back it up. Every time. And always for the betterment of the client. That’s the point of removing the guesswork and ambiguity of the techniques; so we can shape it to work for that individual. We make it applied. Practitioners are trained endlessly on single subject designs for the purpose of avoiding the rut of comparing one person to another statistically. That puts the blinders on. The individual client comes to us for their progress, not in regard to their cohort. From that perspective, every individual does deserve that level of respect and regard for their future, and their life. As a practitioner, that’s a large responsibility, and it takes going beyond just ethics. It’s not just following a guideline. It takes doing the right thing, and knowing why.

Sources:

COOPER, JOHN O.. HERON, TIMOTHY E.. HEWARD, WILLIAM L. (2018). APPLIED BEHAVIOR ANALYSIS. S.l.: PEARSON

Rogers, Carl (1995). A Way of Being. Houghton Mifflin; 1 edition (1980)

Skinner, B. F. (1953). Science And Human Behavior. Riverside: Free Press.

Image Credits:

Clark Tibbs- unsplash.com