Editor's Note: This text is a transcript of the course, Collaborating With Applied Behavior Analysts: What Every SLP Needs to Know, presented by Kelli Marshall, MS, CCC-SLP.
After this course, participants will be able to:
- Explain the importance of collaboration between SLP and ABA.
- Describe knowledge and skills of applied behavior analysis in order to navigate differences in approaches.
- List 1-2 strategies to improve collaboration and better advocate for client communication needs.
I'm excited and a little nervous about presenting on this topic. I'll explain why, but I spent a lot of time discussing collaboration and working with teams on this very important topic. So, I'm excited to delve into this specific relationship and collaboration between speech-language pathology and applied behavior analysis (ABA).
I wanted to share briefly why this topic hits home for me and my experience with it. I've worked in this field for almost 20 years and spent the majority of my time working with individuals with autism spectrum disorder. Given this, I have had a lot of exposure to BCBAs. In the last 15 years, I've assisted in supporting a research project with one of the universities in Oklahoma at an early childhood program for young children with autism spectrum disorder. In that experience, I have worked with behavior analysts for a good portion of my work week. I currently collaborate with over a dozen BCBAs.
Collaboration is hard. It is hard with entities that might cross over in expertise and abilities and can sometimes be even more complex than those with obvious separations. So, this has proven to be something that I've had to work on my skills in collaboration and effective communication for that purpose.
Another event that has significantly increased the likelihood of collaborating with behavior analysts is that in my state of Oklahoma, about six years ago, we became one of the final states to pass insurance reform. That reform included the coverage of ABA for individuals that met certain criteria, many of those with the diagnosis of autism. That law led to a sweeping change in the type of service providers available to individuals with autism spectrum disorder in our state, and I'm sure that many have experienced that also throughout the nation. We saw a great insurgence of ABA clinics in my state and region.
I'm a consultant, and I spend more of my week at multiple sites than I do at any one particular site. In doing that and working with a lot of different teams, I have to work on what I value in my area of expertise and others' areas of expertise, and do it with effective communication and collaboration.
Before we move on, I want to share that I am a bit nervous about this topic because I follow a lot of the chat surrounding speech-language pathology and ABA. I am aware that this is a controversial topic and talked about that with the developers of this particular training when we were in the beginning stages. So, I am truly aware of that, which is why I think it is an important topic to discuss.
I don't want to sway anyone's opinion one way or the other with the information that I present. I just hope that we can keep an open mind and be objective about the information when we're faced with possible collaboration with behavior analysts or any other discipline that is in our school, agency, hospital, or clinic.
Why Collaborate with ABAs?
Let's think about why we should be collaborating with ABA. We could probably insert any other profession into that question too. But knowing that ABA is a hard one for us, what are the reasons for collaborating aside from "...because we have to work with them."
Interprofessional education and practice suggest that collaboration is possibly the most effective way to improve student and client achievement. Working with others towards a common goal is important to later outcomes and progress. If you're having a hard time referring back to this information and saying, "Okay, these are the reasons I have to do this. These are the reasons I have to keep moving forward in this collaborative relationship," IDEA also requires collaboration in the provision of special education services. Our ASHA scope of practice states that as our global society becomes more connected, integrated, and interdependent, SLPs have access to a variety of resources, information and technology, diverse perspectives, and influences. This increased national and international interchange of professional knowledge, information, education, and communication sciences and disorders is a means to strengthen research, collaboration and improve services.
So, within our scope of practice, we have a responsibility to educate other stakeholders about our science and what we know and open our minds to what they might have to contribute as well. We can partner with other professions and organizations and share responsibilities to achieve functional outcomes. We might consult with other professionals to meet the needs of individuals with communication and swallowing disorders. We might serve as case managers in some respect, service delivery coordinators, and members of those collaborative teams. Our scope of practice includes this piece in our responsibilities. Also, within our Code of Ethics, Principle 1-B states that individuals shall use every resource, including referral and or interprofessional collaboration, when appropriate to ensure that quality service is provided. The phrase "when appropriate" is subjective, and I have some considerations for that later in the course.
Principle 4-A in our Code of Ethics also states that individuals shall work collaboratively when appropriate with members of one's own profession and or members of other professions to deliver the highest quality of care. I have one team I've been working with recently, and the struggle is between the one provider within the behavior analyst area of expertise and the speech-language pathologist. It is tough for this entity, as ABA has been an added discipline. So we've been working hard on how we do this because it impacts patient care. How do we collaborate with each other, when do we collaborate, and why do we collaborate? We need to return to these principles because we know that is what's best for our patients at the end of the day.
Interprofessional Collaborative Practice (IPP)
There was a big push for interprofessional practice (IPP) by ASHA in 2020. As you can imagine, it got somewhat derailed in its focus because of the pandemic. But, it stated that our disciplines should include four IPE/IPP principles:
- Interprofessional communication
- Teams and teamwork
This means that within values and ethics, we're working to maintain a climate of mutual respect and shared values. We're coming to the table with whatever our school, agency, or place of work finds as our purpose and how we can get everyone to share those values while providing quality care.
The next principle is knowing our roles and responsibilities. What can we bring to the table with this specific profession of ABA? We know our own roles and the roles of everyone else. We have to open our minds and maybe read some scopes of practice to learn more about other disciplines that we're working with. Again, this is needed so that we can assess and address the needs of our students and patients, and promote and advance any population that we're working with.
The third principle is interprofessional communication which suggests that we will communicate directly with our patients, students, families, the community and other professionals. We are being responsive to various things such as conflict or progress or strategies that are working for the student or family. We are doing this in a responsible manner that supports a collaborative approach to promote health, prevent further difficulties and treat the underlying disorders that our patients are dealing with.
The final principle is teams and teamwork. We are using our identified values to effectively act as a team to plan, deliver, and evaluate a person with a family-centered approach.
In my experience of working with different organizations on improving collaboration, many of us have this misconception that because we have many different providers within our agency that we are multidisciplinary or transdisciplinary. You might be multidisciplinary because you have multiple disciplines in your facility, but transdisciplinary means operating across those boundaries. Collaboration is a bit different. It's looking at how we are effectively communicating with each other to get these great outcomes. Being under one roof does not mean we're a collaborative practice. Collaboration requires vulnerability and great communication skills, which we should be good at because that's our discipline. Collaboration requires the ability to encounter and engage in meaningful conflict resolution or meaningful disagreement.
What are the benefits of IPP? The literature suggests that we have better outcomes and better client satisfaction when all professionals contribute to these different goals. This is especially true when incorporating families. As a parent of a child with a disability, when I get conflicting information from providers or know they're not communicating with each other, it negatively impacts my daughter's outcomes. I can say that based on the literature as well as personal experience; this is incredibly true. And I don't need any more confusion as the parent of a child with a disability; it's already hard enough. When other people communicate effectively and know how to make that magic work, it helps my child and me as well.
We also see improved client and patient safety. When we're sharing information across disciplines, it ensures that our clients and patients will have improved safety.
IPP is an evidence-based practice. It's hard to find anything that says doing it on your own is better. Collaboration has greater evidence to support it. This is especially important when working with individuals with lifelong or chronic conditions. Those with lifelong developmental disabilities would be included in this population because working with a team will be a part of life. When team members disagree and won't come to the table for effective communication and resolution, it will negatively impact those outcomes. Knowing that this is going to be a part of an individual's life when they do have a lifelong or chronic condition, it is essential that we work across those lines.
Collaboration is also a more cost-effective practice. When we support each other's goals and communicate what is important with the family at the helm, we see better and quicker progress is made with better overall outcomes. This also feeds into those new payment and service delivery models like the PDPM, where we have to show that we're making progress and that clients and families are deciding what is important in their care. If this is a service that they've decided is important to the care of their child or their family member, then that is an area of respect that we must give.
Knowing the Disciplines
Let's dig into knowing the disciplines. We need to know what each person is doing so that we can share what we do with behavior analysts and see what we can gain from them. Behavior analysts often have the credentials BCBA, BCABA, or RBT. A BCBA is a master's level, and a BCABA is a bachelor's level. RBT is similar to an SLPA level in our profession. However, RBT is a certification rather than an associate's degree, for example.
We all know that SLPs are master's level. We have SLPAs (assistants), and in audiology, there are AUDs who are doctorate level and audiology assistants that are also involved in communication.
What are the challenges? Collaboration, as I said earlier, can be hard no matter what other entity you are working with. Trying to treat our clients on our own will not be the best for our clients. Collaboration is hard, but it's worth it. This includes collaborating with other SLPs or other professionals.
What are some of the broad challenges that we're going to face in collaboration? Again, these might be issues you face with ABA professionals, as well as other disciplines. I often hear that there is a negative impact on our service delivery. We provide direct service, and this is going to impact productivity. But that is not supported by the data and literature. We do get better outcomes. We're able to serve more people and we have quicker progress. So that's getting people in and out of our services quicker.
The actual service delivery model is another challenge. For those in the schools, this might be a big factor with traditional pullout model. There is new evidence to support a more collaborative place within the schools, and that pullout model with predictable schedules doesn't easily support collaboration. So, we might need to look more into episodic care, that's usually the term used in healthcare. In education, you'll hear the term block scheduling for delivering intervention. Those are great options to overcome that service delivery hurdle.
The three-to-one model of service delivery has also been proven to be very effective in the school setting. There is a lot of support for that model in the literature, and anecdotally, many organizations that I work with select a three-to-one service delivery model, which is basically spending three weeks doing more traditional service delivery and one week focusing on collaboration, team education, classroom observation, etc. It does require writing up the IEP minutes a little bit differently, but it can be done, and it's well supported.
Time constraints are always a barrier when you're making changes. Initially, anytime we make a change, that requires some additional time in the beginning. But the literature supports that this will be better overall; therefore, it's worth the time. You may be spending that time being frustrated, maybe venting to colleagues about those frustrations, seeing that the progress is not what you want to see, or hearing other people have disagreements about this teamwork that's happening. That's actually time being spent on thinking about collaboration, it's just not the right kind of time.
Next is resistance. Anytime we try to make a change, there will be resistance because we prefer for things to go the way they've always gone. When I hear colleagues say, "But we have always done it this way," that tells me a lot about where they are in the change process. That is a signal that I'm battling with things like role release, or letting some control go, which is hard to do.
Finally, there is the challenge of lack of support. If your employers or administration doesn't support this change, that can be incredibly frustrating too.
Again, I know that these challenges exist. Hopefully, some of the information I share will help you navigate some of these challenges as you move along.
Specific Challenges: SLPs and ABAs
What are the specific challenges for SLPs and ABAs? There are differences in training and education, our approaches and techniques, and some crossover in scopes of practice. You can find controversy about any number of interventions. So, we want to make sure that we know the facts, know what does and does not work for our clients, and what the family wants in those instances.
History Influencing Practice
As speech-language pathologists, we are heavily influenced by the work of Brown as well as Blanton, Swift, Gifford, and Van Riper. These are all pillars within the history of our science. As a profession, we've had a century to grow and change with the evidence, whereas the field of applied behavior analysis has had half that time. That alone tells us that they're at a different phase in this science, and they're going to change. I've seen changes within the last 15 years of working with this profession. Of course, it's very dependent on what agency you're working with and what provider you're working with as well. But behavior analysis is heavily impacted by the works of Skinner, Lovaas, and Koegel. I'm not going to spend time talking about that input, but if you're interested in pursuing more about the history that influences these practices, you can look to those individuals' work. So, we are coming from a different direction. We're seeing things through a different lens on how humans operate and develop, specifically regarding communication. Behavior is communication, and communication is one of our human behaviors. So, understanding Skinner's work on behavior and how that has changed over time is important to know and consider when working with individuals.
Differences in Approach
Let's move on to the differences in our approach. We are very much told within our literature, and for a long time now, that our approach should be a client and family-centered approach. That is who directs the care; that is who will be involved throughout our client or student's lifetime. What they find important might differ from what we find important, but that is their choice. We should give autonomy to the client and their family to decide what services they wish to access. Therefore, it's important that we present objective, unbiased information to families when they approach us about looking at another service provider.
When we look at behavior analysts or those in the applied behavior analysis field, we see more of an expert model mindset. This model existed within our discipline for the last two decades, and some still live there. What I was taught in school almost 20 years ago was very much the expert model, "I'm the expert. I know what's best. I will prescribe what is good for the client based on the information I collect." However, that approach does not have much evidence to support it. While we might know a lot about communication, deficits and strengths, assessments, and the data we gather, the family will always know their child best. Individuals will always know themselves best and know what's important to them. So it's important that we have shifted from an expert mindset to a client/family-centered mindset. With an expert approach being employed in behavior analysis, that can be difficult. Sharing literature about family-centered practice is imperative because this is one of the most well-established practices within the evidence, for both education and healthcare.
We also have to look at the differences in approach for fragmented care versus multidisciplinary care. This has also been called "siloed care," where speech handles communication, PT handles gross motor, OT handles fine motor, ABA handles behavior, etc. But, we have never seen a human being isolate those skills. And since we do not isolate those skills, it's important that we know how to support them and not sabotage them when we're working with the individual. So, that fragmented care at one time was used in our discipline, and I still see it happening. However, the literature supports multidisciplinary/collaborative approaches, where we are working together and communicating about what works best for that patient. We are working in a consistent manner to support the client or student.
There is a bit more fragmented care with ABA, but, again, we are at that initial phase of having a lot of ABA clinics around. They don't have a lot of different providers in those clinics, so it doesn't allow the opportunity to collaborate. I am seeing some shifts in those clinics starting to include other providers, which at least allows for the opportunity. When we don't have the opportunity, it will be a barrier. It's going to be a challenge. When we can model positive collaboration and support other professions with the literature to support that, that's how we start to move forward in these practices.
Strengths of SLPs
One strength of SLPs that is important for ABAs to know about SLPs is that we have a good understanding of typical development. A lot of times, we see ABAs following a very rigid protocol. For example, with autism, if a child has a splintered profile of skills, ABA providers often target skills that are beyond the typical range of development and may not be focusing on those skills that the child needs to catch up on. So, our knowledge of typical development will be important, especially regarding communication development (e.g., the development of speech sounds, and how we develop language). A big concept that I've been talking to many BCBAs about lately is the difference between core versus fringe vocabulary. That is not something that they have a lot of understanding of, in my experience. My experience is not everyone's, but sharing that knowledge makes change happen.
Another strength of SLPs is with differential diagnosis. Since many insurers only cover a subset of individuals with certain specific diagnoses, the experience of behavior analysts is often skewed to those populations. We want to provide them with an understanding that these challenges or difficulties can be present in other disability populations as well. This is also important for medical diagnoses and medical conditions. Many BCAs don't have a background in the comorbidities of seizures, swallowing issues, feeding issues, and stability in physical gross motor movement. Therefore, we want to share that information with them.
Naturalistic teaching is another SLP strength. We know how to generalize skills to a more natural environment, instead of that rigid direct one-on-one. Also, we use a strength-based approach. We have transitioned from a deficit-focused model to a strength-based model, making sure we know the client/family-centered approach. Additionally, SLPs focus on functional skill development rather than a scope and sequence that are predetermined by some protocol.
Challenges of SLPs
A challenge that I often see with SLPs is understanding that behavior is communication. Thankfully, this is changing a lot, and there are direct statements made by ASHA that behaviors serve a communicative purpose more often than not. When we see challenging behaviors, we should be looking for what could potentially be the communicative purpose associated with them.
Data collection is also a challenge for SLPs. This goes back to well-written goals, knowing how to break down skills, knowing how to collect data based on the goals that we write, and how to interpret that data. Our goals should be specific, measurable, attainable, relevant, and timely (i.e., SMART goals).
Another challenge is role release. If we have been in that fragmented "siloed" system where speech belongs to speech, OT belongs to OT, etc, then we need to learn that it's okay for others to have our knowledge. We need to be willing to share it, and be willing to teach other adults how to do it. Teaching a child how to do a specific skill is one thing, but teaching another adult how to do that specific and individualized approach is more difficult for us. It is a skilled service that we're providing, but when we share our knowledge with another professional, that also helps the child to get practice opportunities outside of those sessions that we're in. More practice opportunities equal greater progress, equals better functional outcomes.
Strengths of BAs
I know it might be hard to think of the strengths of BAs, but let's be objective. Behavior analysts use task analysis to break down skills, functional behavior analysis, functional communication training, data collection and progress monitoring. Task analysis is what feeds into well-written goals. If your goals are not written well, then you're going to have a hard time showing progress.
I worked as a reviewer for an insurance company for several years, and I have also read numerous articles from ASHA and outside of ASHA that note that SLPs have difficulty writing attainable goals. We write, "Johnny will increase age-appropriate vocabulary to 80% accuracy with prompts and cues as needed." I don't have a clue what I'm measuring with that goal because if Johnny is over a year old, then he's going to have a whole lot of words. What words am I measuring as far as age appropriateness? What prompts, what cues, and how often? I don't want to make Johnny prompt dependent. So, a well-written goal is critical for monitoring progress. If you are billing insurance companies, and also in education, we need to show progress. If we don't have a well-written goal, we don't have great progress.
Task analysis helps with forward chaining and backward chaining. We're going to look at the skill a child is using, and see how many steps they can do independently before they need help. Or, we can help them with the skill and use backward chaining by reducing the number of prompts to get them closer to independence. The key is knowing exactly what skill we want to develop and listing the steps it takes to achieve it. We observe the student doing the task and note the level of independence versus the level where prompts are needed and what types of prompts are needed. We write our goal based on that. That is a totally different training. Again, this is an area that behavior analysts have a lot of experience.
Functional Behavior Analysis is determining the function of a behavior through assessment and analysis. The idea is to identify a specific behavior they want to look for. They will observe the student or individual and gather data on that, looking at the Analyze, Behavior and Consequence (ABC). So, what happens right before the behavior (Antecedent), what is that behavior that we're observing (Behavior), and what happens right after (Consequence)? This purpose is to develop a hypothesis about the behavior so that we know what replacement skills to teach the individual so that they're not going through this challenging behavior. We can teach them a more appropriate, meaningful skill to achieve the same consequence.
Functional Communication Training also looks for a specific behavior and tries to determine the function of that behavior. It is determining why the behavior is happening based on our observations and discussions with other team members, the family, and professionals so that we know what specific communication replacement might be needed. For instance, Tessa hits her peer on the playground and smiles when the peer chases her. A lot of people will see that as a challenging behavior. I often hear, "She/he is a hitter." Well, Tessa might not have the skills to know how to initiate the routine of playing chase with her peer. So, what can we do? We could teach Tessa a functional, meaningful, and appropriate way to engage with her peers because not many situations in life will allow you to hit someone to get their attention.
This is where we make that differentiation between conditioning a person with a disability to do some socially appropriate norm, or teaching a skill that the person needs to learn to be a part of the community. That's the question I ask myself oftentimes with social skills. Is this a skill that will be meaningful for this student so that they can be a part of activities that they enjoy and need to be a part of? Can they go to doctor visits, grocery stores, restaurants, and movie theaters, and would that behavior be acceptable in those locations? Could they potentially be turned into law enforcement for some of these behaviors, which definitely happens.
I use the example of "Zach yelling and being removed from the room." We have to ask ourselves if he is yelling because he wants to get out of the classroom. If so, we need to teach him a way to ask to stop the task/activity and to leave the room because asking is much better for everyone involved than yelling and likely being removed from the room.
Data collection and progress monitoring overlap with task analysis and requires that we are very specific with our goals. I've had a lot of help from behavior analysts on how to break that skill down.
Dynamic assessment is often used with bilingual and multilingual populations, but it's also a great tool when working with individuals with chronic, lifelong medical, or developmental conditions. When we write goals that are specific, and we know exactly what the skill is that we're going to observe and collect data on, then we know that goal is attainable. Here is an example. If a student gets a standard score of 50 on a standardized assessment, saying he/she will achieve 90% abilities in receptive and expressive language is probably not attainable. We need to scale that back to what is attainable because we want to be able to show progress and change over time. I review a lot of IEPs and often see goals stating 10% or 30% accuracy in a quarter of the school year. That goal is not attainable. We need to change the goals so that the student can exhibit the small steps in progress.
Goals must be relevant to the situation, the individual, and the family. They also need to be timely, meaning they need to have an end so that we know they're going to accomplish the goal within a certain timeframe or across a certain number of sessions. We need to know the cueing level and the specific types of prompts because that helps to decrease the likelihood of prompt dependence. We want to increase independence and decrease prompt dependency. We want students to eventually do these things on their own. If you do a quick online search for 'prompt hierarchy' that will provide the various levels so you can decide when to level up or level down and to be very specific in the type of prompting you're going to be collecting data on. Again, we must ensure that our data truly shows what skill the student is increasing or maintaining (or not gaining).
Graphing is another area that I've learned a lot about from behavior analysts. This is the idea of graphing independent versus prompted responses, and certain graphs mean certain things. For example, a graph that shows slow, steady progress is exactly what we want to see. When we see a graph with data hovering around the 10-30% range, then we've made a goal that's not attainable. After you graph a certain number of sessions, you can start to see if this intervention is working.
Graphing is more objective than subjective. We need to say they're making progress based on the objective data that we've collected. We want an objective, descriptive way to describe how a student or individual responds to our interventions. As SLPs, we are being pushed to show progress objectively. So we need to know how to collect that data and how to show that to other systems so that we can continue to get the funding we need to do the jobs that we love.
Challenges of Behavior Analysts
BAs have a really wide scope of practice. Many providers tell me that if they allow BAs to reach into what they own, they're reaching into "my area." So, I encourage you to look at the scope of practice for BCBAs, BCABAs, or RBTs. The scope will be broader at the national level and more focused as we reach the state and local levels. Reaching across boundaries happens in many professions. I've seen it with music therapy, recreational therapy, etc., and these are all great therapies we can use to support the individuals we see. When collaboration occurs in positive ways, both entities can use their robust knowledge to achieve greater success and better outcomes.
Behavior analysts are also known for using a rigid approach, particularly those who use a specific intervention type of applied behavior analysis that uses discrete trials, etc. Whereas SLPs typically use a drill approach or mass trial because with discrete trials, the person gets a set number of chances or opportunities with a skill. For example, if we're working on following simple directions with a client; a discreet trial would have the instructor give an instruction of, "touch your nose," using a prompt or cue to achieve errorless learning (i.e., making sure they get it right instead of practicing it wrong). When the child or individual gets that right then they're reinforced with something. When they respond incorrectly, there's a method of error correction that occurs, which is essentially repeating the instruction prompting to get the answer right and allowing the student to access reinforcement of that. Then, there's a pause between the trials. Typically there are only five opportunities per type of trial. For example, there would be five following directions, five receptive identification, and five fine motor. So, it is a "burst" instead of doing mass trials of 15-20 opportunities. However, you still get 15-20 responses because you cycle through them multiple times instead of going to that point of exhaustion. That is a quick description of the discrete trial approach and how it impacts rigidity within the field.
Lastly, there is an emphasis on instructional control versus shared control. We have all seen good and bad professionals in any career field, but some are still working on robotic compliance control versus shared control. Sometimes I have control and sometimes you have control. That is how our world works. I am not always in control, nor is the other individual. To be a part of many different community settings, learning to share control is an important skill. Again, it's not about controlling the individual all the time. It's more so about shared control.
Strategies for Collaboration
How do we collaborate? First, you have to be willing to have the conversation. It starts with a conversation and that's what I see as the biggest hurdle, especially after two years of a pandemic where we haven't been around each other much. Writer of "Atomic Habits," James Clear has one of the best quotes about having tough conversations, "Are you willing to be uncomfortable for five minutes?" Think about it. Exercising is easier once you've started the workout. Likewise, conversation is easier once you're already talking. Once you get that ball rolling, it's easier when you're in the middle of it. Many rewards in life will allude you if you're not willing to be a little uncomfortable at first.
Some strategies include asking open-ended questions. For example, don't ask, "Did you want AAC, or did you recommend communication?" That's a yes/no question. Instead, say, "Tell me what you're thinking about Johnny's communication. What ideas do you have about it?" Make it an open-ended question and give people the opportunity to talk.
When the person answers you, listen reflectively. Repeat what you hear to the person to ensure you heard it right. Don't listen to give an answer or to give a solution. Listen to listen, listen to understand.
Another strategy for collaboration is to ask for permission, "Hey, could we talk about Johnny's communication program? I think we might be coming to a difficult situation or a difficult decision."
Finally, find a conflict resolution plan that works for your agency or organization. There are many different plans available. It's important to make one that works for everyone. When we have a good plan for conflict resolution, it allows us to have a description of the problem, what our intentions are, what goals were discussed, and what are all of the possible solutions. We discuss why one solution might be better than another and why some might not even be possible. Then we decide which plan we will implement. Keep in mind, that this does require some flexibility, and although that's hard, it's worth it for our clients.
I recently worked with a BCBA who was upset after a lot of conflict and collaboration one day. She said, "Kelli, when can I stop being flexible?" I think we all have those times when we ask when we can stop bending to someone else. When can I stop having to go to that middle ground? I told her, "I hate to tell you this, but it's not like you do this once or twice, and then you get to go back to how you always did it." Collaboration is constantly engaging in communication, talking to each other, and educating each other.
Advocating while Collaborating
Advocacy is important in our field. We know how to advocate for what we know. We, as SLPs, are highly trained professionals in communication, and we should feel confident in those skills. We want to inform behavior analysts of our skill level because, again, they may have never worked with an SLP.
Advocate by modeling flexibility and collaboration. Share with BAs those areas we know so well - typical development, differential diagnosis, naturalistic teaching, strength-based approach, client, family-centered, functional skill development, etc. Promote that client, family-centered practice, knowing that every goal and plan of care should reflect what is important to the family. Those might be different than what you know, and what you think. But if the family unit has chosen for their child to receive this service, we must give our best effort to collaborate.
Families deserve autonomy. They deserve to select their own care. Within a family-centered practice, there are four pillars: respect and dignity, information sharing, participation, and collaboration. We need to listen to others and collaborate with others to make that positive change occur for our clients.
Questions and Answers
How do we show this sort of collaboration in the language of the IEPs?
I know a lot of the providers that I work with are changing that. Instead of saying that you're going to do therapy twice a week, in individual or group session, for X minutes, they're changing it to a certain number of minutes for the year. Then they're indicating a number of minutes that are direct and a number of minutes that are indirect for the year. That way, you can work in a little more flexibility for the purpose of collaboration. You might be able to find more on it if you look up block scheduling or the three-to-one model.
How is collaboration reflected in our strategies?
Remembering within the IEP, we're going to make goals that are individual to the student, and then we as providers will see how to support those goals. So that goes back to that siloed care or fragmented care in that "I make speech goals and OT makes OT goals." What we need to do is say, "This is what Johnny needs to succeed in school. These are the skills he needs. How can speech support that? How can OT, PT, or ABA support that student-centered goal?
Our school district is adding BCBAs starting next year, there'll be one per elementary school. How does our SLP team advocate for clear roles and responsibilities and start strong with collaboration?
There are going to be growing pains because you're adding new people who know a little bit about your role. Sometimes that can leave you feeling uncomfortable. So I would strongly recommend, before your school year starts having a meeting to discuss each others' skill sets. Also, devise a plan for when you disagree on how to intervene. How are you going to discuss those?
I have had some less than positive interactions with some ABA professionals who don't seem to be so open minded and don't wanna listen to the SLP recommendations. Any suggestions there for getting that process going?
First off, I have been there, and am currently fostering some collaboration. The best thing is to get uncomfortable with things coming to the table. I believe I was reading an article the other day saying that 86% of professionals haven't had any kind of direct coaching on conflict resolution. I thought, "This is why nobody wants to go to the table. Nobody feels comfortable there, and nobody knows what they're supposed to do." But, it's a necessary evil to have those uncomfortable conversations. What has worked for me most of the time is to rely on the data and on the evidence of the science. If you can find articles, or research that backs the disagreement, that's going to be the best. For instance, core versus fringe vocabulary with AAC. Many students were learning scripted language, which we know as SLPs is so limiting. We want our students to have robust systems and to get them to change from, "I want M & M, I want drink, I see book." That's so limiting. To help ABAs to understand, I provided some research articles. Then we came to the table and shared what we learned from that. They just need to know the background, and if we're willing to share it, it goes a long way.
Has there been any recent change in the field of ABA to reflect neurodiversity-affirming therapy?
The push is definitely there. I see it happening. I see it happening more in collaborative teams than in isolated settings. I am a big believer in neurodiversity, as a mom of two children that are very neurodiverse, I believe that's exactly how we need to practice. But I think that - to play devil's advocate - there are many voices that we're hearing from in the communities that are really resisting and angry about ABA. But those are individuals who actually have voices, and some individuals are nonverbal and require 100% adult support. They don't have a voice. So that is something we have to consider when we're looking at the population that is upset.
I had a parent who was talking to me about this topic and she is an advocate. She said that she doesn't even know what her son's favorite color is. So she went to an autism advocate, and said, "How do I foster this? How do I understand this anger towards ABA when how he's responded and been able to do with our family and in the community is because of the skills he's learned there? How do I process that? The person responded with, "We'll just ask him what is favorite color is." What that tells us is that the community doesn't really know sometimes the spectrum that exists. Her son can't just tell her what his favorite color is because he does not have that skill. We need to consider that there are individuals who have gained a lot of meaningful skills and have been able to participate in life, family, and the community because they were taught in a very systematic routine-based way. SLPs do that too. We have students and clients who we need to teach in a more direct systematic approach. So, we do need to think about that, but I do see movement. It just depends on what agency or what outlet you're hooked into. But there is a push for more family-centered care and more collaboration.
Asha Leader (2015). U.S. Education Department Says ABA Is Not the Only ASD Treatment
ASHA (n.d.). Applied Behavior Analysis and Communication Services
ASHA (n.d). Code of Ethics
ASHA (n.d). Scope of Practice in Speech-Language Pathology
Bondy, A., & Frost, L. (2001). The Picture Exchange Communication System. Behavior Modification, 25, 725-744.
Duchan, J. F. (2002). What Do You Know About Your Profession’s History? And Why Is It Important? The ASHA Leader, 7(23), 4-29.
Franzone, E. (2009). Overview of functional communication training (FCT). Madison, WI: National Professional Development Center on Autism Spectrum Disorders, Waisman Center, University of Wisconsin.
Marks, A.K. (2018). Interprofessionalism on the Augmentative and Alternative Communication Team: Mending the Divide. Perspectives of the ASHA Special Interest Groups, 3(12), 70-79.
Mitchell, M. P., Ehren, B. J., & Towson, J. A. (2020). Collaboration in Schools: Let's Define It. Perspectives of the ASHA Special Interest Groups, 5(3), 732-751.
Nunez, L. (2015). Achieving quality and improved outcomes through interprofessional collaboration. American Speech-Language-Hearing Association.
Pfeiffer, D. L., Pavelko, S. L., Hahs-Vaughn, D. L., & Dudding, C. C. (2019). A national survey of speech-language pathologists' engagement in interprofessional collaborative practice in schools: Identifying predictive factors and barriers to implementation. Language, Speech, and Hearing Services in Schools, 50(4), 639-655.
Marshall, K. (2022). Collaborating With Applied Behavior Analysts: What Every SLP Needs to Know. SpeechPathology.com. Article 20531. Available at www.speechpathology.com