Effective ABA services do not occur in isolation. We, as behavior analysts, are part of a larger team including those we serve, stakeholders, and other professionals. In fact, our code of ethics outlines that services provided extend to team members such as caregivers (BACB, 2020). While effective ABA services might result in progress on selected goals and objectives, collaborative practices are necessary to achieve best outcomes. We must learn and teach others a specific skillset that produces coordinated or maybe even integrated treatment plans.
Clinicians often extend direct ABA services by collaborating with families through caregiver training (Blackman et al., 2020). Training members of the larger team such as caregivers promotes the continuation of ABA services well beyond direct service sessions. Consistent support across behavior changes agents (parents, caregivers, and clinicians) enhances outcomes for the individuals we serve. Successful collaboration with caregivers requires clinicians to demonstrate a complex repertoire integrating technological skills with soft, interpersonal skills (Melton et al., 2023; Rohrer et al., 2021).
An essential aspect of caregiver training includes utilizing an effective instructional method to teach new skills such as Behavior Skills Training (BST; Dogan et al., 2017; Parsons & Reid, 2012). Behavior skills training is an evidence-based practice, which includes the use of performance-based and competency-based strategies, during which the trainee practices the skill and demonstrates competent or mastery of that skill (e.g., Harper et al, 2023). Therefore, clinicians must be skilled in the technology of training others as behavior change agents utilizing such methods. As an evidence-based practice, BST has been successfully in training caregivers to implement a variety of practices with their children (Schaefer & Andzik, 2021).
Parsons and Reid (2012) describe BST as a multistep process, which includes identification of the skill, a written description, demonstration, practice, and feedback. In the case of the family and caregiver training, the trainer would be a highly skilled clinician and the trainee would be the family member or caregiver. Here is an outline of the steps of BST as it would be implemented with a caregiver:
- The clinician provides the caregiver with the rationale for teaching the specific skill.
- The caregiver is then provided with a definition of the skill and a written description of how to perform the skill.
- The clinician demonstrates the skill, step-by-step as written and provides the caregiver an opportunity to ask questions.
- The caregiver completes the competency check, which means they perform the skill and the clinician provides performance feedback or corrections.
- The caregiver continues practicing the skill with feedback from the clinician until they have learned the skill to mastery.
- The clinician provides ongoing performance feedback on the implementation of the skill within the context of ongoing treatment.
Evidence-based training models such as BST provides clinicians with a foundation to enhance the skills of caregivers as behavior change agents. However, the training model does not end there; we must continue the collaborative relationship between clinician and caregiver by providing ongoing feedback.
An important skill in the training process with caregivers is the ability to deliver performance feedback related to treatment adherence. Daniels and Daniels (2006) describe performance feedback as the sharing of information related to a person’s performance that supports a change in their behaviors and plays a key role in one’s ability to learn. The how and when to deliver feedback has been evaluated extensively over the year (see Balcazar et al., 1985; Alvero, Bucklin, & Austin, 2001; Sleiman et al., 2020). Some common characteristics of effective feedback consistent within the literature include specification of presented information, immediacy of feedback delivery, and individualization of feedback. While it is still unclear which combination of characteristics produce the greatest effects, all authors were consistent in noting the use of performance feedback as a potent and cost-effective tool for clinicians wanting to change behaviors (Daniels & Daniels, 2004; Sleiman et al., 2020). However, no matter the combination used, the effectiveness of feedback can be easily hindered if we don’t take the time to understand how the delivery of feedback can affect the caregiver/clinician relationship.
Effective training and feedback models must extend beyond the technical procedures to create a supportive and responsive relationship with caregivers (Taylor et al., 2019). The need for therapeutic relationships with those we serve is well rooted in our history. Wolf (1978) presented this point in his seminal article: Social Validity: The Case for Subjective Measurement or How Applied Behavior Analysis is Finding Its Heart. Social validity provides a framework for establishing a supportive and therapeutic relationship by asking what caregivers think about proposed goals and procedures, and about the outcomes achieved (Wolf, 1978). What people think about what we do matters. Without caregiver acceptance, no amount of training or feedback will produce the best outcomes for those we serve. Recently the field has shifted focus; again, from technological procedures such as what questions we ask to how we ask those questions in the context of delivering services, including caregiver training. From the goals to the procedures to the outcomes, we must support caregiver training by providing compassion and care every step of the way.
Compassion and Care
Developing and maintaining caregiver relationships requires clinicians to develop skills in the area of compassionate care and interpersonal relationships. Taylor, LeBlanc, and Nosik (2019) describe compassion as “bringing action to the empathic response” (p. 655). Actions on the part of the clinician may be actively listening to concerns, reflecting on the caregiver’s perspective, or allowing themselves to feel what the parent may be feeling. In the context of feedback, clinicians can leave time after the delivery of feedback to hear parent concerns or consider adjusting the treatment plan after reflecting on the caregiver’s perception of the plan’s feasibility.
Let’s look at an example. A clinician trained caregivers on a treatment plan to decrease the sleep onset of a four-year-old. The initial training produced 100% adherence to the treatment plan. During the one-month check-in, the clinician noticed that caregivers were no longer completing the 5-minute checks until the child fell asleep. Following this observation, the clinician simply asked the caregiver, “I noticed that you are no longer completing the 5-minute checks. Could you tell me a little bit about why?” The caregivers thanked the clinician for asking and shared that they were no longer able to because only one caregiver was available during the bedtime routine for all three children in the house. With this feedback, the clinician provided an alternative method to complete the checks via a baby monitor and the treatment plan was a success. In this case, the way in which the clinician provided feedback strengthened the therapeutic relationship and ultimately the outcomes for the child and family.
An equally important area is the development of interpersonal skills. Similar to compassion, interpersonal skills are specifically related to one’s ability to listen and speak, both vocally and non-vocally (Sellers, LeBlanc, & Valentino, 2016). As noted earlier, clinicians should take the time to learn the family’s culture and beliefs, including their communication preferences. For example, some family members may not make eye contact when receiving feedback or shy away from suggesting treatment plan changes even though the plan may not fit within their family’s system. Wright (2019) provides a discussion on the practice of cultural humility, describing the process as a lifelong journey of learning. We, as culturally humble clinicians, must continue to learn and always consider the cultural identifiers of others in the context of the work we do.
One example that always comes to mind is cultural differences around where people sleep. There are many different variations in sleeping arrangements within a family unit. We must educate ourselves on the preferences of the families we serve. Extending on the question posed by Wolf in 1978, we must ask caregivers not about our goals as clinicians, but rather about their goals as an important member of the team. If a caregiver comes to us with a concern about bedtime routines and that family happens to co-sleep as unit, it is not up to us to decide that co-sleeping must end. It is up to us to discuss how we can best support caregivers in producing meaningful change within the preferences of their family unit.
Conclusion: Putting it All Together
Our goal as behavior analysts is to achieve best outcomes by providing high quality, evidence-based services in collaboration with the greater team. To achieve this goal, we must support that team, in particular families and caregivers. One way to provide such support is through caregiver training. Thus, skilled clinicians will be well versed in training methodology, such as BST and performance feedback. However, to provide training and feedback alone will not foster the therapeutic relationship necessary to achieve best outcomes. Clinicians also must be skilled in working collaboratively with caregivers by providing support through training with compassion and care. The integration of technological and interpersonal skills is more than just adding steps to the training checklist. It requires clinicians to create a feedback loop with caregivers through the therapeutic relationship. We must ask for caregiver input each step of the way, hear what caregivers are saying, and incorporate this information into treatment plans. It is through this process that we as clinicians will provide the support needed to achieve best outcomes.
Jennifer Ruane, MS, BCBA, LPC, CDE®, is Director of Professional Development and Clinical Training at Melmark Pennsylvania. Jennifer Flanders, MEd, BCBA, LABA, is Training Coordinator and Jill Harper, PhD, BCBA-D, LABA, CDE®, is Senior Director of Professional Development, Clinical Training, and Research at Melmark New England.
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