Transcript Conducting a Risk-benefit Analysis

CONDUCTING
A RISK-BENEFIT ANALYSIS
Lauren A. Goodwyn
Ethics for Behavior Analysts
Caldwell College
Overview
 Headlines
 Guidelines
 Where’s... the research?
 Why…do a risk-benefit analysis?
 What…is risk?
 How…to perform risk-benefit analysis?
 In practice …
 Benefits for BCBA and field
How to Prevent Such Headlines …
 BACB Task-List 3rd Edition, 1-6
 “initiate, continue, modify or discontinue behavior
analysis services only when the risk-benefit ratio of
doing so is lower than the risk-benefit ratio for taking
alternative actions”
 BACB Task-List 4th Edition
 Nothing specifically stated about risk-benefit analysis
Guidelines for Responsible
Conduct
 (3.05a)
 “The behavior analyst describes, in writing, the
objectives of the behavior change program to the
client or client-surrogate before attempting to
implement the program. And to the extent possible, a
risk-benefit analysis should be conducted on the
procedures to be implemented to reach the objective”
Where’s …the research
 Behavior Analysis and Treatment ed. By Van
Houten & Axelrod (1993)
 Chapter 8 “A Decision-Making Model for Selecting
Optimal Treatment Procedure”
Where’s …the research
 To predict risk v. benefit of behavioral program
must consult experiences of practicing behavior
analysis because evidence in literature is lacking
 Clues about risk factors in articles in which measures
were taken to ensure treatment procedure was followed
to a T
 Research often implemented by trained / experienced
master’s-PhD level therapists
 Highly controlled lab settings doesn’t generalize well to
discover risks that may be uncovered in natural setting
Old school vs New School
Spreat (1982)
Bailey & Burch (2011)
Why …risk-benefit analysis
 Goal is not to frighten but to enlighten
 Presenting information in this manner requires that
you have an upfront & honest discussion w/ client so
that no one is surprised if unexpected side effects
emerge
 Need to clarify for practitioners that some procedures
can increase probability of unintended behaviors
 Can anyone think of some unintended behaviors that could
result from a procedure?
What …is risk
 “exposure to injury, loss, or danger”
 “possibility of experiencing an outcome that is different
from what is expected”
 “Uncertainty arising from possible occurrence of given
events; insured or property to which an insurance policy
relates”
“we need to think of ourselves in part as risk
analysts who determine the factors that can
cause ‘volatility’ in our treatment process”
Related Topic:
Therapeutic Dose
 When taking a drug
 Death / toxicity vs effectiveness
 When implementing a procedure
 Risk of failure / harm vs benefit of success
How …to conduct risk-benefit analysis
 Should conduct risk-benefit analysis for each
behavioral procedure suggested for
implementation
 Generally can use worksheets
 Should research each procedure and prepare
worksheet ensuring that the summary is balanced
and objective
8 General Risk Factors
Nature of behavior
• More severe or intense problem behavior, greater
risk of failure
Sufficient Personnel
• Rely on mediators in natural environment to play
significant role in treatment
Well trained mediator
• Sufficient # of staff does not guarantee success
Appropriate setting
• BACB Guideline (3.01, 3.02, 3.08)
Experienced BCBA
• Operating outside of one’s competence can cause
risk to proper implementation and safety of client
Risk to others
• Settings can present possible safety risks to nearby
clients and staff when implemented
Buy-in
Personal Liability
• Others should agree w/ program and ensure it is
implemented correctly
• Competence of BCBA to handle the case and
mitigate problem situations
5 Benefits of Treatment
Client Direct
• Terms of change of rates of behavior & time frame
for success of each target behavior
Indirect to Setting
• Change of atmosphere in classroom / home should
be considered
Mediators /
Caregivers
• If successful, can produce sense of confidence &
pride in accomplishments
Peers in Setting
• Peers / siblings may benefit from more attention
from teachers / parents
Liability in Setting
is Decreased
• Clients who cease engaging in dangerous behaviors
leads to less stress for administration & fewer calls
for attorneys
The SITUATION …
Joanna, a BCBA, is asked to consult for a third grade classroom. Mrs. Hobbs has
complained about one of her students, Jared, continuously getting out of his seat,
talking to his classmates while doing work, and constantly raising his hand to
make disruptive comments. This results in Jared’s poor performance in school,
classmates being distracted from their work, and teacher attention and time spent
trying to get Jared back on task. Mrs. Hobbs has been teaching for several years
but has never implemented a behavioral procedure before but is eager for any help
in the classroom. After conducting a functional assessment and several
observations it is found that Jared likely engages in this behavior in order to
escape from or delay work. Joanna suggests implementing a NCR escape
procedure in which Jared can have access to 2 minutes of a leisure activity at his
desk (i.e. playing on his iPod) every 5 minutes during independent work time.
Let’s Practice …
Risk-Benefit Worksheet
ABA Procedure: Noncontingent Reinforcement
Special methods: positive reinforcement (i.e. access to tangibles, attention, etc);
negative reinforcement (i.e. escape from work); automatic reinforcement (i.e.
object manipulation)
RISK
NOTES
May reduce motivation to
engage in adaptive behavior
Chance pairings with problem
behavior could strengthen that
behavior
NCR escape can disrupt
instructional process
BENEFITS
Ease of application
Helps create positive learning
environment
Package treatment w/
extinction procedure may
reduce extinction burst
Chance pairing with
appropriate behavior could
strengthen that behavior
Summary Risks vs Benefits:
NOTES
Let’s Practice …
General Risk Factors
Instructions: After completing a Risk-Benefit Worksheet for each proposed
procedure fill out this form and review w/ the relevant parties
RISK FACTORS
1. Nature of the behavior to be
treated – is it SIB or dangerous
to others?
2. Are there sufficient
personnel or mediators to
administer the treatment?
3. Are they skilled and able to
administer it correctly?
4. Is the setting appropriate for
the treatment? Safe, well-lit,
clean, temperature-controlled?
5. Is the BA experienced in the
treatment of this type of case?
6. Is there any risk to others in
the setting?
7. Is there buy-in from the key
people associated with this
case?
8. Is there any liability to the
BA?
Summary of General Risks:
NOTES
Let’s Practice…
Benefits of Behavioral Treatment
Instructions: After completing a Risk-Benefit Worksheet for each
proposed procedure fill out this form and review w/ the relevant parties
BENEFITS
1. Client behavior is
greatly improved, comes
into contact w/ many new
reinforcers and more
choices
2. Client environment is
greatly improved because
of change in behavior –
less stress for caregiver,
peers
3. Caregivers feel more incharge, improved morale,
eagerness to move
forward with client
4. Peers in setting may
change their behavior
toward the client,
providing more
opportunities for social
reinforcers
5. Liability to the setting is
greatly reduced
Summary of Benefits:
NOTES
Risk-Benefit Analysis in Practice
 Intake  FA  review literature for appropriate
treatment
 Meeting held w/ consumer
 Give & take; if there are questions about certain side effects
or possible unpredictable behavioral effects, this should be
noted & revisions made
 If consumer isn’t comfortable with a procedure, may need
to withdraw 1 method for another
 Important to have meeting before implementation
 At conclusion, all parties should reach consensus on course
of action
 Sign & file paperwork, treatment can begin
3 Additional Benefits
for the BCBA and the Field
 If BCBA can make significant improvements in target
behaviors, improve quality of life for client & others it
will increase confidence in ability to take on similar
cases
 Positive effects improves morale & encourages future
participation in profession
 Reduction of liability to designer of
behavior plan
 Possible contribution to body of
knowledge of ABA & good public
relation for the field
References
 Bailey, J. S., & Burch, M. R. (2011). Ethics for
behavior analysts (2nd Expanded Edition).
Routledge.
 Cooper, J., Heron, T., & Heward, W. (2007). Applied
Behavior Analysis. New Jersey: Pearson Education.
 http://uwf.edu/rconstand/FIN3403web/T4RiskReturn/T4-riskreturnP02.htm
 http://www.irmi.com/online/insuranceglossary/terms/r/risk.aspx