Scenario

Dilemma: Supervisee slaps a child in the school setting.

Response

• Mandatory reporters- DCS
• Reach out to the BACB 
• Reach out to the state psych board 
• Look at supervision contract and what the criteria to terminate it is 
• Learning point- make sure you are writing your contracts accordingly to cover certain situations that require immediate action 
• How would we know if someone has a previous incident against them? – probably not known until it’s been substantiated by the BACB 
• Need support of other BCBA’s

Scenario

You receive an ABA referral from a pediatrician for a 3-year-old client; you call the parent listed and gather insurance details and enough background information to see if the client’s behaviors are within the scope of the practice. The client is severely impacted and engaging in high rates of SIB; your colleague that specializes in SIB has an opening on his caseload. When the team proceeds to obtain prior authorization from the client’s primary insurance, pre-auth is denied as there is no IQ score listed on the developmental pediatrician’s evaluation. Additionally, there is not a standard assessment included on the developmental pediatrician’s evaluation; an additional reason for the denial. The ABA team for the insurance company acknowledges the autism diagnosis on the report but state they cannot process the pre-authorization with the missing components. You explain the situation to the parent; he attempts to schedule another appointment with the pediatrician, but the next available appointment is in 9 weeks. The parent is extremely worried that the child might cause serious selfharm in the interim and is desperate for help. Does our code guide us in how to approach this situation? What are the ethical considerations? 

Response

• 2.01 accepting clients- business decision pro-bono work
• Disseminating information to diagnosing physicians 
• Setting up contract to provide consultation in the interim

Scenario

You have been working with a family for 18 months. The father is consistent with parent training attendance, actively engages in sessions and follows through with protocol implementation. The client recently experienced an increase in aggression; the team has developed a modified protocol and you are prepared to share it at the next parent training session. At the parent training session, Dad mentions that he is trying CBD oil (with THC) with the child in hopes to reduce aggression – he read about this on an online forum. When you ask if this is under medical orders or supervision, he mentions that the child’s pediatrician was indifferent to the decision but did not medically endorse the use of CBD & THC for the young child. When you ask how the parent is obtaining the substance, he makes a general statement regarding one of the locations that you may purchase such items with his medical card. You are concerned but not sure how to navigate the situation. How might you handle this?

Response

• Behavior analyst required to follow the law 
• Mandated reporter 
• 1.01 Reliance on Scientific knowledge 
• 2.09 Treatment/Intervention Efficacy 
• 4.01 Conceptual Consistency 
• 6.01 Affirming Principles 
• Need a script for child under 18 
• Difference between CBD and THC; CBD not illegal 
• Asking for clarification on prescribing Physician for any and all medications 
• Direct to medical provider for spike in behavior if team is controlling other environmental variables

Scenario

You keep in touch with a good friend from High School and you know that their young child is showing signs and symptoms of Autism. They end up getting a diagnosis and reach out to you asking for some tips. You give them some tips on increasing communication, following through with demands, and capturing motivation. The information is well received, but they’re now asking you more questions, about behaviors, and school support, and whether you think their child will ever be able to have a conversation with them. You want to help, but also know they need more intensive support and are starting to feel uncomfortable. From an ethics perspective, what next steps are there?

Response

• 1.05(a) define the relationship/role 
• 1.06 multiple relationships 
• Create and distribute list of referrals of agencies 
• In a specific/unique situation, contact the BACB for guidance on how to proceed

Scenario

You are starting to build your online presence, and network with other professionals via Facebook and Instagram. You are judicious in checking your security settings, and only add people that you know are in the field. That being said, you do not have a personal connection with all of your online “friends.” One day, on Instagram, you see an online friend post a picture, with a “friend” (online only) holding a bottle of alcohol and stating that it was a gift from a client. Do you seek clarification because it appears to be a violation of multiple relationships? Should you ask if it is an ABA client, or otherwise? Should you just mind your own business?

Response

• Confirmation that it is a behavior analyst and seek for clarification on if the gift was from an ABA client 
• Send message for clarification sooner than later and take a screen shot of the initial post for evidence to support the claim 
• Message should state how the photo was interpreted and that it may be interpreted by other professionals in the same way 
• 7.02- reporting guidelines; 1.06 not receiving gifts; 10.02 timely responding 30 days of the date 
• Second component- is this a reportable offense, first approach the person, then employer/supervisor, then BACB (and AzBoPE is appropriate) if the matter meets reporting requirements

Scenario

I understand that your organization is the Arizona chapter of the Association for Behavioral Analysis International. I also understand that there are no laws or regulations for ABA in Arizona. However, there are professional and ethical standards from your organization and ABAI, and as a parent of an autistic child, I have some questions that deal with professional and ethical standards. My daughter attends an establishment that offers speech and occupational therapy. I have come to learn that this establishment is utilizing ABA practices (compliance training) on clients. The speech and occupational therapists are using these practices on children, even though they do not identify as ABA therapists or have the training to consider themselves ABA therapists. A couple of questions: What is your stance on using ABA practices by people not fully trained in ABA? Should people using ABA methods (like compliance training) be under the supervision of a BCBA? Are there any professional or ethical standards with regard to informed consent and ABA? I.e. should people using ABA practices inform parents they are using these practices and gain consent from parents before these methods are used? If you have answers to any or all of these questions (from the standpoint of professional or ethical standards), I’d appreciate it.

Response

• OT and speech are not bound by our compliance code 
• Related service providers working closely with BCBAs may use similar strategies however they are bound by their own codes 
• Not enough information provided to give appropriate recommendation 
• • Is there dissatisfaction with the services? 
  • Did the provider say they use ABA? 
  • What procedures are being used? 
• In no way can we speak on behavior of a non-behavior analytic provider, could provide some codes to answer the questions however needs to be handled very delicately 
• Go to the designated licensing board or supervisor of the provider; recommend ABA services with BCBA if the mom is not satisfied with what the provider is doing and is interested in ABA services

Scenario

A BCBA is working with a medically fragile teenager, significantly impacted in several domains (communication – very little functional language, daily living, social skills etc.). The client suffers from a rare heart condition requiring an AED (on her person – in backpack) at all times. The family recently learned of the only potential surgery that could save her life (implant of internal defib). However, the setting on the implant cannot be set for her specific needs so it will “fire” a shock, at random times, to ensure appropriate electrical functioning. The medical provider requested the BCBA implement a protocol to prevent and treat trauma associated with the unpredictability of the electrical shock. The BCBA has experience with PTSD clients but is unsure of all the components involved in this scenario. The medical provider shared that there is no way to measure the intensity of the shock, as that is relative to the patient (this client does not have enough functional language to share such information). Parents are unsettled regarding the procedure but feel it is the only way to ensure her safety, longterm. Parents are requesting a coordinated plan of care prior to surgery. What are the next steps for this BCBA?

Response

• Ensure experience and competency with PTSD and trauma, if not, seek out additional resources and supports 
• Reviewing what is in our scope of practice; risk benefit analysis for getting the surgery vs. keeping defib on her person at all times 
• Discuss with doctor as well as previous patients if available to talk about the effects and intensity of the shock 
• Refer to counselor or psychologist for family care and ongoing needs that the client would need to build a collaborative team 
• BCBA, continuing to build communication, Likert scale for communicating pain etc. 
• Taking a supportive approach to parent training after the surgery and keeping in mind the fragile state of the family to slowly integrate protocol training into sessions

Scenario

I am a BCBA working in a school setting. My boss has created a hostile work environment (i.e. threatening job security, public humiliation, gaslighting, intentional sabotaging and retaliation). Due to stress, I have found that my quality of work is decreasing and impacting my ability to provide effective services to my students (ethical code 2.09). However, if I leave my job, my students will lose their BCBA (the school will not hire another) and they will not receive the behavioral services they need. I want to act in the best interest of my students (ethical code 2.15) and not leave them without a BCBA. However, working in a hostile work environment has impacted my ability to be an effective BCBA. I filed a complaint with HR regarding my boss’s behavior. An attorney was brought in and began an investigation. The results of the investigation stated that my boss had not done anything illegal and there would be no action taken against him.

Response

• Our responsibility is to transition clients following ethical guidelines, but it is not up to the employee to stay in order for the school to staff/fill the position 
• Send letter of recommendation to school administration for student’s receiving services to providing supporting documentation showing the need for continued service/dosage 
• Due diligence to have conversations with boss etc. first then moving to HR to attempt to resolve conflict 
• Meet with families during IEP possibly bring up outside services the family could pursue and provide a referral list or resources for additional support if they choose

Scenario

is a mid-level therapist, currently in supervision with an agency in which utilizes ABA for children with Autism. Frank has been working with a family for the last 12 months, with two children recommended 40 hours a week of early intervention. There has been little to no data, hampering adherence to service requirements. The parents have a difficult time with transitions, developing relationships and managing the schedule of two child on the spectrum with higher level(s) of medical attention. Frank has had numerous conversations with the parent and the supervising BCBA regarding the concern of not being able to work the program with fidelity due to parent inconsistencies.  The input Frank has received from the BCBA is that unless the parent is wanting to terminate or transition services, it is unlikely to occur prior to end of contract due to funding source regulations. Without a collaborative change, the barrier remains between the client and provision of intended services. Parents are reluctant to make a change, risking loss of the one person who is consistent in their schedule, Frank. The agency and Frank remain in contract with the family at this point. What should Frank consider ethically in his next steps with the family?

Response

• 4.07 environmental conditions that interfere with implementation 
• Ethical obligations to make decisions based on data 
• Establish re-evaluation of medical necessity, clinical team continues responsibility and funding source is required to provide the service if the team deems the treatment medically necessary 
• Work with funding source as soon as there is a pattern noticed that may inhibit effective treatment 
• Termination criteria/discharge criteria- outline parent participation etc. 
• Establish effective parent training and response effort for parent participation 
• Initiation of services ensure informed consent and outlining discharge criteria for services, what does the service look like to ensure all team members understand expectations 3.05

Scenario

I have been working with a child that is diagnosed with ASD. She engages in severe self-injurious behavior (head banging). She has been hospitalized 2 times for cuts to her forehead and concussions. Behaviors have decreased at school after staff training from our team but stay consistent in the home. The family is struggling with staying in close proximity to her, being proactive and implementing strategies when staff is not around. Their insurance company is suggesting a helmet to keep her safe, but the parents don’t want their child to walk around with a helmet on all the time even if it means keeping her safe when staff is not around. I am not sure what approach to take with this family since behaviors are still very high and dangerous when staff is not around. To keep the child safe, a helmet is the next best choice…thoughts? 

Response

• Review record of parent training and approach to parent training 
• Increased frequency of parent training, assess where the function lies with the parent not implementing with procedural fidelity 
• Reassess to ensure proper function is identified in the home setting 
• Ethical obligation to communicate with family that adaptive equipment could increase behaviors and should be handled carefully with risk/benefit assessment and appropriate protocols in place 
• 2.09 right to effective treatment