We appreciate the additional guidance in the practice and development of functional behavior assessments and behavior support plans. While we agree on most parts of the practice guidelines, it appears to be written more through the lens of an in-home ABA perspective versus a consultative model through the waiver. Typically, behavior consultants practice in “messy” environments where the context changes rapidly (ex. Change in staff, supervisors, etc.) and variables contributing to a person’s behavior are unable to be controlled consistently. Direct Care Staff are often tasked with many duties relating to client care and documentation requirements. This competes with their ability to implement behavior support plans and keep up with additional documentation reliably. We respectfully ask that DBHDS view behavior consultation truly through a consultative perspective, as the behaviorist is often faced with challenges and variables within a residential setting that is often outside of their control. We understand that the different ways in which our licensees practice can be confusing, but it is important to not restrict clinical decision making by favoring one setting over another.
On page 3 in the Functional Behavior Assessment section, it states, “A reassessment of the functions of behavior is required when data suggest treatment expectations are not being met or there has been a significant change in status of the individual that is negatively effecting the outcomes.” We recommend the following change: When data suggest treatment expectations are not being met or there has been a significant change in status of the individual that is negatively affecting the outcomes, the provider shall (a) make data-informed changes to the client's treatment plan, (b) reassess the environmental determinants of behavior, or (c) provide a rationale and next steps when neither treatment changes nor reassessment are indicated (e.g., documentation of treatment infidelity and a training plan for implementers).
On page 4 in the Behaviors targeted for decrease and increase sections, while we recognize and appreciate the need for data to drive decision making, we respectfully ask for flexibility in collection methods with respect to how often, who is collecting, and the methods of measurement, based on the clinician’s best judgement and factors in the environment. It is often challenging to have staff reliably collect data on a behavior for decrease 1x per day, much less, a behavior for increase that occurs frequently throughout the day (ex. Asking for assistance, tolerating a denied request, duration of waiting for a reinforcer, etc.). This could be done directly by the behaviorist through collecting probe data, but we don’t believe that it would be particularly useful in a consultative model where this information may be collected a few times month and you are not observing the other 99% of the person’s time. In these common situations, we request that measurement of behaviors of increase include staff and caregiver reports, as this qualitative information is valuable.
Lastly, we request that the word “training record” be excluded as this would be an additional document requested by an auditor. The recommendation for keeping a record of staff who have been trained can be satisfied by requiring that this be included in quarterly report / Person-Centered Review instead of a training record.
In summary, we are in agreement with the majority of the guidelines, but would suggest that DBHDS consult with behaviorists who have extensive experience in providing behavior consultation through the waiver prior to finalizing the guidelines, as the way they are currently drafted is slightly unrealistic in “messy” settings where the behaviorist has little control over the system that they are operating in. While it is important to provide regulations to ensure that providers are being consistent, it is necessary that we take the environment and type of service into consideration.