Why Ethics
In the early 1970’s in Florida, abuse happened Krazner, L., & Ullman,.L.P. 1965 released a paper on behaviour modification (BM), which promised dramatic changes and BM could be carried out by anyone. All the analyst would need to do, would be to manipulate the consequences and use primary reinforcers contingent on good behaviour. Behaviour was decreased by punishing consequences. The establishment of cause and effect was not considered at this time. The use of food and aversives were given out without any consideration to the individual in question. Lack of guidelines lead to many cases of abuse in the UK and USA such as Winterbourne View & Sunland Miami scandal. This investigation, revealed neglect, abuse and unethical treatment of people from professional psychologists and staff including Dr Todd Risley (well known behaviour analyst). Some of the punishments administered were forced masturbation in front of people, forcing people to have homosexual acts in response to “evidence” of this activity and someone was confined to a bath for 2 whole days Bailey and Burch (2013 Page 5-6). If procedures did not work more severe forms were applied and there was no procedure to get approval for this. It is likely that these cases have been necessary for an unregulated industry to blossom into what would evolve to be what we have today. The “Blue Ribbon Committee” was concerned with respect through appropriate training, understanding, development and conduct with all people behaviour analysts come into contact with as part of their professional obligation to the board of behaviour analysts. The behaviour analyst faces many questions such as wondering what they are doing is right, is it fair and are they qualified to do this, does it harm, am I taking enough data, is my interpretation valid and is the treatment necessary? (adapted from Jon Bailey Ethics for Behaviour Analysts Page 12-13).
Baer Wolf & Risley (1968) suggested that behavioural science should be analytic, technological (can it be repeated easily and is it easy to follow), conceptually systematic (4.01), effective (is the effect significant) and generalisable (must be maintained by the natural environment or should be applied to different environments where relevant and have long lasting effects for the individual). Heward (2005) added that practice also has to be Accountable (2.10) we must use measurement and demonstrate the effectiveness of the intervention to make appropriate changes where necessary, doable for anyone involved, optimistic, and public and behaviour analysts need to be open to scrutiny, nothing is hidden and it is empowering to the individual Heward et al (2005 p. 38). The variables in applied behaviour analysis are scientifically proven to be the most effective in improving target behaviours Terdel, P. (2013) . If there is no ethical code, the entire field of ABA is at risk and it will be more difficult for it to effectively compete with other less systematically applied treatments Brodhead, M. T., & Higbee, T. S. (2012).
Natural Science
Applied behaviour analysis (ABA) is a natural science, this means that the subject matter of our science is behaviour. Behaviour change is the dependant variable of our experiment and our independent variable is the environment. Descartes was the first to identify that the environment plays a large part in determining behaviour and that we have to take into account how the environment shapes the organism after he responds and behaviour is shaped and maintained by consequences (Skinner 1978). This has lead to the Behaviour Analyst Certification Board (BACB) developing and continually updating their professional and ethical code of compliance Here we will give an outline of the moral principles governing the behaviour of behaviour change specialists which will focus on the BACB code and will hereby be referenced according to the code numbers for example 2.0 refers to a behaviour analysts responsibility to clients and 2.01 in accepting clients. The code of ethics is made up of principles which give a behaviour analyst the distinction between right and wrong in their practice based on evidence of best practice and a functional approach which relies on the scientific foundations of prediction, prediction & control (Cooper Heron & Heward Page 23-24). Strategies with specific purposes in mind, which are tailored specifically for each individual and with a specific best outcome are best. These require a systematic (measurement and data collection) technological, pragmatic, deterministic and integrates evidence based practice (EBP) approach. ABA is above all empirical and requires clinical expertise, along with ethical consideration to its clients values and the best possible outcome for the individual Slocum, A.T (1994).
Paul Terdal (2013) summarised the evidence for ABA using evidence from peer reviewed articles, Federal government, agencies of research institutes, clinical practice and medicine, autism research, legal case examples and court of law rulings and finally regulatory agencies which gives a strong argument that applied behaviour analysis is the only proven evidence based technology which, when correctly applied by trained Board Certified Behaviour Analysts (BCBA’s). Skinner reports that (Chapter 12 1974 page 212) “we sometimes say that we acted in a given way because we knew it was right or felt that it was right, but what we feel when we behave morally or ethically depends on the contingencies for our behavior”. Here he is referring to the ethical principles which govern behaviour change procedures by the analysts.
Ethical
One of the reasons problems such as those mentioned in the USA and UK in the 1970’s and 2011 are because people were using subjective measures based on their own thinking or thinking of knowing with regards to their clients. Science shows that these subjective conclusions are prone to human error and more often than not can and do lead to “abuse”. This is not often the intention of the behaviour change implementer, but is likely due to a number of highly important factors. First and foremost a clear chain of communication and open dialogue is essential for the team who are working with the individual. This means that the team should be effectively and positively encouraged to give and discuss the case. Effective training and supervision should be carried out on a regular and ongoing basis. Also, a clear plan which is person centred which addresses the specific needs of the individual will reduce the likelihood of people having their own “behavioural drift” Ethics in behaviour analysis (Bailey, J.; Burch, M. 2013 page 8).
Measurement
Due to the ethical considerations highlighted previously, ABA uses single case research (SCR) design. Taking data before during and after implementation eliminates the types of conclusions which are prone to human error. This approach systematically reports on how effective an intervention is and helps to monitor progress which will be in line with the clients progress objectives. In ABA we use SCR instead of statistical measurement (unless we are using them to compare an individual with himself) because we can compare each individual with himself and this gives us great internal validity. We can demonstrate experimental control and we can see the difference in behaviour compared with how it was before intervention. We can basically see if we are going in the right direction and if what we are doing is working. If it is not, we can reassess and change what is necessary.
The SCR design consists of 3 components these are repeated measures, baseline and treatment phases. The baseline and treatment phases are shown using graphical representation, through collection of data before, during and after each intervention phase.
Scientific exploration of any (behaviour) topic usually starts out with a question (or hypothesis) which is composed of an independent and dependent variable (referred to as the IV and DV respectively). We are manipulating the IV to see what effects this has on the DV. This means we are changing the “environment” which is functionally related to the DV (behaviour) and we identify a functional relationship via functional assessment (3.0). In accordance with current research this is done before any recommendations or program development (3.01). The functional relationship between the behaviour and environment is demonstrated through experimental control (1.01). Once we have identified a client, decided that the target behaviour is significant, determined that we have the skills 2.01 and appropriate consent and we are happy to take on the case we want to conduct repeated measures of the dependant variable (problem behaviour). These repeated measures will take place prior to the intervention at regular time intervals and if it is ethical to collect this baseline data (2.03). In some cases, a management intervention might be necessary particularly in a case where there is harm to the individual or other people. In these instances, instead of gathering these baseline data we would gather as much “indirect” data and information in order to get a baseline from all people involved with the person and all other records and data available would be analysed to get an idea of baseline. This approach is less accurate, but in some cases is the most ethical, low risk option. It might also be necessary to involve 3rd parties for various reasons (2.04), such as, medical assessments (3.02). We are looking at making significant changes as soon as the intervention is applied, because we want the treatment to be effective (Houten et al 1968) and less due to history, maturation effects or some other threat.
Effective
Clients have a right to the most effective treatment (2.09) based on research (Houten et al 1988). The most scientifically supported and effective treatment procedures will meet the short and long term objectives of the individual and his environment. This will also be socially significant and relevant to the society in which he resides. These procedures are validated by evidence and it is the behaviour analysts job to make sure the ends justify the means in terms of service delivery (2.09b) cost-risk benefits, training and side effects (2.09c). Therefore it is important that clients are made aware of the risks and effects of the treatments and how this relates to the program as much as possible (2.09d).
The most pragmatic and parsimonious approach for dealing with an individual’s target behaviour is one that is applied to the context that is relevant to how he or she interacts with his environment and using technological systematic measurement which gives us evidence (actual data along with risk analysis) to weigh up the intervention. The most rigorous approaches are those that control anything that threatens internal validity. This is the main reason that we use SCR and is the most rigorous design to control for these threats. We also continually monitor the design in accordance with the intervention in place to continually measure and track our progress. This means that we make changes as appropriate. If something is not effective in terms of how the behaviour is changing, we can see it and therefore reduce any risks, by changing the strategy. The SCR design focuses solely on the person as his own control (4.03), we are asking if the intervention works for this particular individual. This strong focus comes at a cost to how these particular interventions which are tailored to the individual, can be generalised to other populations or people. This is why it is against the code of ethics for behaviour analysts to use the same cookie cutter (Decker, J. 2012) approach to treatment for each individual- it is said to lack external validity. This problem in part is being addressed by meta-analysis of SCR where the peer reviewed articles have been aggregated (Jenson, Clarke, Kircher & Kristjansson 2007).
SCR design, like any scientific approach has its own ethical obligations. Given that SCR has one participant in its study, we have the ethical issue of consent and we need to make sure we have informed consent of the person we are going to be working with. This consent will occur before any intervention or even an assessment has taken place (3.01a) and behaviour analysts are obligated to take data and graphs using applied conventions so that decisions and recommendations can be made for the development of the program (3.01b). The information needed in consent relates to the confidentiality, procedure, participants, how information is used and this must be in the form of written consent (3.03a and b). The repeated measurements that we acquire in baseline and any withdrawal of treatment test for experimental control (where it is not harmful to do so). In cases where we might take baseline data until it is stable or there is a better picture of how the intervention should be planned it might mean there is a delay in treatment and the intervention is not started until this information is gathered. This is particularly important when conducting a multiple baseline. The implications must be discussed with the individual before gaining consent (3.01a and b, 4.02, 4.05, 4.06). It may not always be possible to predict what will happen in a withdrawal condition or when the treatment is ended, sometimes a condition gets worse. Furthermore, SCR’s may be useful for understanding the process of change and how change occurs with particular clients. SCR avoids much of the uncertainty relating to how effective the intervention is and is the best possible solution for providing evidence/data about how your IV and DV are functionally related to each other and this provides a clear direction for your client to ensure that he is contacting his right to effective treatment through evidence based research and practice.
Assumptions Of Science
Science is defined as a systematic approach, helping to guide us through information, which helps to organise our knowledge of the natural world. Hypotheses are formulated about the phenomena under study and the temporal relationships are measured (between IV and DV). Behaviour is lawful and thus is subject matter of this science. Using description, prediction and control (Cooper, Heron & Heward 2007 page 23-24).
The laws of science are deterministic and the events that relate to our enquiry have attributes from which we can determine systematically. Behaviour has functions for the organism involved and these functional relationships are correlations. It is these “functional relations that are the ultimate product of our scientific investigation between behaviour and its determining variables” Johnston and Pennypacker (1980 p.16). ABA assumes that behaviour is maintained by escape, attention, automatic, tangible and multiple functions (Hanley, G. P.; Iwata, B. A. ; McCord, B. E. 2003).
Objective observation of the phenomena of interest defines the attitude of empiricism. Behaviour analysts work only with validated experimentally approved methodology and research based intervention, these are data driven and monitored closely for effectiveness (4.01). Experimentation to accept or deny the relationship between the IV and DV via functional assessment procedures is vital so that environmental (IV) variables can be manipulated to affect the (DV) problem behaviour (page 23 BACB code). Behaviour analytic implementation procedures need to be visible and accessible so that replications and new discoveries can be made. This fulfills a scientists obligation to the furthering of his science. Clear operational definitions and data collection methods are essential for legal, ethical and funding purposes where appropriate on a case by case basis, particularly relating to research (9.09) to promote accuracy and the use of data (3.0) by other scientists in the field. ABA experimentation works with the tangible product of behaviour. It does not rely on mentalisms or explanatory fiction to make its case. The ruling out of simpler explanations is carried out via scientific methodology and philosophical doubt, before more complex phenomenon are considered (often referred to as the law of parsimony). Qualities such as thoroughness, ethics, honesty, diligence and curiosity guide the success in this science. The data that we obtain at these crucial stages before, during and after will guide us and help us to be optimistic for future applications of applied behavioural science. Making a meaningful difference to people’s lives should be the ultimate (and ethical) goal of our interventions. Baer Wolf & Risley (1968) suggested that behavioural science should be analytic, technological (can it be repeated easily and is it easy to follow), conceptually systematic (4.01), effective (is the effect significant) and generalisable (must be maintained by the natural environment or should be applied to different environments where relevant and have long lasting effects for the individual).
Reducing Punishment
Evidence shows we should use a functional assessment before implementation of a behaviour or treatment plan. If a function based approach to treatment is more effective, it is less likely that restrictive measurements would be employed and it will fulfil the requirement of social validity. The reduced need for punishment (4.08), recommending a reinforcement based procedure rather than punishment (4.08a) and if punishment is necessary there should be reinforcement as well (4.08b) to increase an alternative behaviour. Where punishment is considered reinforcement should always be used unless the behaviour is severe or dangerous and aversives are necessary (4.08c) and that these procedures go alongside increased training (4.08d), supervision and oversight. Behaviour Analysts always use least restrictive procedures that are likely to be effective (4.09) and avoid reinforcement that could be harmful to the health of the individual (4.10).
The data gained before, during and after will guide us by the use of graphs and descriptive ABC (antecedent behaviour and consequence) data which can be further quantified by analysis of times of days, contexts severity and other salient information to build a picture of what part if any of the problem we are looking at what other factors need to be addressed. The data guides us to evaluate the treatment effects before during and after intervention. Striking the balance between prevention, effective, socially significant and scientifically rigorous techniques brings about some very interesting debate from the perspective of ethics. A data and evidence based approach no doubt gives us accountability, robust and replicable results and it also shows us what is and what is not working. It also has implications in how other people can interpret our plan and how we can ensure that it has integrity across the platform in which the plan is rolled out.
Applied
The difference between scientific research methodology in the laboratory and that which is carried out in society is that the nature of applied behaviour analysis is just this, it is applied to the problems we identify which occur in our society and they are deemed to be of the importance of “man” rather than theory (Baer et al 1968). So the applied behaviour analyst has the burden of studying organisms in his environment that are currently afflicted with a socially significant challenge in their behaviour. For applied behaviour analysis there is a much closer relationship between the behaviour and its environment and this is what we study. The behaviour we look at has to be relevant to the organism in question and significant to his environment. This also implies a function based approach rather than a topographical based assumption as to what is causing the behaviour. We want to work with the “do” rather than the “say” (unless the behaviour of what they say is somehow socially important). There is also the risk of human error and by not collecting appropriate or salient data before you begin could have detrimental effects to the individual involved. Such as is the example given in the text Baer et al (1968) of the person who might be targeted on the end result of getting dressed. If he was not dressed, then a penalty would be applied, however nobody took into account who was dressing him and how long he had to do it. “by discovering and analysing the causes we can predict behaviour; to the extent that we can manipulate them, we can control behaviour” Skinner (1938 Page 23). What if he/she did not have the power to not make a choice? what if the methods employed did not give him the choice, even if the choice caused him harm? does he or does he not have the right to make that choice? We need to be highly vigilant that we are not designing intervention strategies which use intentional control. Thus, it is important that we are not using strategies that overly rely on punishment strategies (4.08). To go in and punish a behaviour that we have not taken data on before, during and after and implementation is a direct “misuse of controlling practices and blocks progress towards a more effective technology of behavior” Skinner (26-27 1971). Contingencies should therefore be set up so that better choices for the individual can be made, they must be able to make their choices uncoerced without programmed consequences for their selection.
By conducting a functional behaviour assessment (FBA) Knoster, T.P. (2000) means that there is information present for the multidisciplinary team relating to the reasons (function), when and the conditions (context). We need to take data on the frequency, duration and severity. The functional assessment tells us the context in which “Jasper” (for example) is most likely to hit himself by giving us information about the function of the behaviour. The function based assessment was developed by Iwata and Dozier (2008); Mace (1994) stated the reason that early applications of behaviour analysis failed was due to the fact that underlying functions were not considered.
Dixon, D.R;Vogel, T. & Tarbox, J. (2012) “Appreciating the function of behaviour when planning treatment is now widely regarded as best practice”. Behaviours have different purposes in different contexts for either the same or different individuals Carr, E.G 1977; Smith, Iwata 1997.
When evidence based practice (EBP) is effectively applied by service providers the proven outcomes are increases in communication, social interaction, better life skills and increased intelligent thinking Schoenwald, S.K. ; Hoagwood, K. (2001) . It is common that evidence based practices are unsuccessful in their implementation and some treatments used by providers are lacking in supportive evidence. This is often harmful or even life threatening to people. Without the appropriate data collection methods the implication for only say delivering one intervention without a FBA would not constitute effective treatment. Or, people that are applying methods which are not supported by evidence based practice could lead to dangerous outcomes Schoenwald & Hoagwood (2001). Most mental health justice initiatives have now passed legislation to suggest that only empirically tested treatments should be used for these types of initiatives.
Effective Treatment
The meaningful or socially significant outcomes for the individual undergoing applied behaviour analysis will involve the collaboration of an effective team with clearly identified and measurable goals for evaluating and obtaining data before, during and after implementation which is both direct and indirect. The treatment package will help him participate in community life, help him to develop relationships, make his own choices and develop personal competencies (Meyer & Evans, 1989). The treatment goals will have both long term and short term generalisability and an appropriate cost-risk benefit analysis will be tailored. The support network will be involved in the entire process and can only be achieved by effective training, assessment, collaboration and utilisation of the relevant support system through effective teamwork Kincaid, D. et al (2002).
The program will identify a significant increase in the use of alternative skills. These will function to replace unwanted strategies that might have previously been used by the individual, along with the ability to be able to cope and apply general skills which will appropriately reduce problem behaviour but still allow the individual to meet his environmental needs in a more socially significant way (Knoster, D. et al 2002). Other related assessments for the side effects of these interventions should be health, well-being, less need for medication, less injury and overall satisfaction (Meyer & Evans, 1989). This will ensure that the focus is clear, it will encourage support within the team, and provide a “public” approach.