Positive Approaches Journal, Volume 8, Issue 1

Knoster | 27-34

In 2008, Nancy Weis and I published an article in the Journal of Positive Behavior Interventions entitled “It May be Non-aversive but is it a Positive Approach?”¹ In that article, we provided a series of questions to consider when providing individual-intensive behavioral assessment and subsequent interventions and supports. Many of those questions continue to be germane today. However, the questions we posed at that time should be further informed today through the integration of the increasing body of knowledge that continues to emerge concerning social-emotional-behavioral wellness and trauma informed approaches. To this end, the following questions are intended to provide important ethical considerations for those of us involved in various forms of behavior change endeavors.

Has the Person Experienced Adverse Childhood Experiences and Trauma?

A growing body of literature highlights the negative impact that adverse experiences early in life can have on physical, social, emotional and behavioral wellbeing long-term^2,3,4,5,6. Adverse Childhood Experiences (ACEs) have been associated with poor health outcomes and lowered quality of life. In this same vein, trauma has as well been linked to undesired outcomes. Chronic exposure to trauma (such as repeated exposure to abuse) can lead to toxic stress that can profoundly alter growth and healthy development. The seminal ACEs Study⁷ identified three types of ACEs with these three ACEs further broken down as follows:

More recent examples of ACEs have been expanded to include Foster Care Placement, Exposure to Harassment & Bullying, Death of Parent/Caregiver, Forced Separation from Caregiver, Life Threatening Illness, Experiencing Violence, and Exposure to Discrimination. It is important to consider screening for ACEs and exposure to trauma in light of the impact that these factors have on healthy growth and development. To this end, alignment (if not integration) of behavioral technologies with evidence-based approaches that support what is increasingly being referred to as trauma informed practice is highly encouraged.

To What Degree Does the Person Have Opportunities to Make Meaningful Choices
Throughout the Ebb and Flow of a Typical Day?

Many ethical issues related to behavior change programs revolve around issues of self-determination and locus of control. There can be an inherent imbalance of power whenever one person who has greater authority endeavors to alter the behavior of another person with less autonomy. The natural inclination of many caregivers and service providers when working with a person with behavioral challenges is to limit choice opportunities in the individual’s daily routine. As alluring as this can be in the short term, it can create longitudinal challenges when we consider that the best way to teach someone to make “good” choices requires naturally occurring opportunities to learn to make meaningful choices. This is not to suggest that structuring choice opportunities when teaching decision-making skills is ineffective or near sighted. Rather, the focus should be on how to structure such instructional situations in a manner that does not inadvertently limit choice opportunities to trivial matters as opposed to more personally meaningful age appropriate opportunities (e.g., choosing to complete as task or go to “time out” vs. providing opportunities in task sequences to allow the person…based on how resilient s/he is feeling that day…to exert influence over what they do first and what they do last – presuming of course that the tasks to be completed has some degree of value/importance from that person’s perspective).

How Do We Minimize the Likelihood of Future Problem Behavior?

Exclusive application of short-term consequence procedures, or the delivery of reactive consequences following problem behavior, unfortunately continue to be a primary emphasis in many behavior-change endeavors today. To be clear, consequence strategies certainly have a place in behavior change programs…but just one place in a multi-component approach that places greatest emphasis on prevention through proactive environmental changes in tandem with teaching an array of alternative skills (replacement behavior, general skills and self-regulatory/coping skills). Understanding the function of the person’s behavior, through functional behavior assessment culminating in the development of hypothesis statements from which to design a Positive Behavior Support Plan, best positions caregivers and service providers to emphasize prevention through environmental changes in tandem with promotion of prosocial skills thus reducing over reliance on reactive consequence in response to undesired behavior. Consideration of the personal history (or narrative) of the person should be incorporated within the assessment process to increase sensitivity to trauma that may have been previously experienced. This should also facilitate alignment or integration of multi-disciplinary approaches in a person-centered manner.

How Will Our Actions Impact Personal Wellness and Quality of Life of This Person, His/Her Family and Friends,
and Others Who Directly Interact with this Individual on a Regular Basis?

One significant shortcoming of traditional behavior management approaches that primarily emphasize reduction in problem behavior is that they can come at a cost to personal relationships and impede the person of concern from realizing a sense of belonging inclusive of feeling valued by others. Certainly, reduction of problem behavior is one desired outcome through the application of Positive Behavior Support. However, reductions in problem behavior actually become a constructive byproduct of adjusting environmental factors that trigger problem behavior in concert with teaching an array of more habilitative alternative skills (or behaviors). In this sense, the primary focus of Positive Behavior Support is on understanding the person’s behavior in context of that person’s personal history and his or her goals and aspirations for the future. Asking questions such as the following can help to gain perspective and insight that is valuable:

True application of Positive Behavior Support is more than the linear application of scientifically validated behavioral technologies. Rather, it is the application of those technologies in a manner that reflects personal understanding, empathy and focus on the longer term. In essence, Positive Behavior Support is about supporting individuals on their personal journey towards social, emotional and behavioral wellness.

How Will We Measure Progress in Terms of Both 1: Fidelity of Implementation (Treatment Integrity)
and 2: Impact of Interventions?

There are two primary facets of meaningful assessment related to implementation of Positive Behavior Support. The first is that of ensuring the integrity of implementation of the designed multi-component behavior support plan. This requires stakeholders…those that will be directly impacted through implementation of the support plan… to self-monitor their implementation of 1) short-term prevention through environmental changes; 2) delivery of proactive instruction in a) the replacement behavior, b) general skills and c) self-regulatory or coping skills; 3) consequence strategies (both reinforcement of desired behavior and redirection of undesired behavior), and 4) long term prevention through strategies to a) increase meaningful choice opportunities, b) maintain and generalize learned alternative skills, c) address chronic health concerns (as relevant), and d) enhance personal connections and relationships with others based on common interests. The degree to which meaningful gains can be realized are, in large part, dependent on the integrity of implementation of the agreed upon strategies across these four component parts of the multi-component support plan.

The second facet of meaningful assessment associated with the delivery of Positive Behavior Support emphasizes impact in terms of socially valid outcomes. Measuring progress and outcomes in this regard focusses on 1) reductions in problem behavior, 2) increases in use of alternative skills and 3) improvement in quality of life. Each of these three domains of impact should be viewed as inextricably connected to best ensure that progress and outcomes realized are truly meaningful as well as sustainable.

In summary, the design and delivery of Positive Behavior Support requires applying scientifically supported behavioral technology in a manner that is firmly grounded in person-centered approaches that take in to account both the person of concern’s personal history…his or her life narrative…as well as his or her goals or aspirations for the future. Certainly, this differs in terms of age appropriateness when providing Positive Behavior Support (e.g., with a six-year-old child as compared to a sixteen or sixty-year-old individual). However, at the core, the basic tenants highlighted through these guiding questions best position us to ensure that the ends of behavior change and the means (our application of behavioral support strategies) are mutually justifiable