Direct assessment of quality of care in secure residential treatment facilities for criminal offenders with intellectual disabilities

Direct assessment was used to evaluate quality of care in 2 secure residential treatment facilities for criminal offenders with intellectual disabilities. This population and type of setting have not been previously studied in this context. Observations were conducted of environmental condition, resident condition, resident activity, and staff member activity at various times of day over a period of 3 weeks in Facility 1 and 2 days in Facility 2. An additional analysis was conducted to determine the optimal number of observations needed to obtain a representative sample. Results indicated high levels of quality in terms of environmental condition and resident condition in both facilities. Data on resident and staff activities were more variable but generally consistent with previous research. Implications for the optimal number of observations are discussed, as well as limitations and future directions for research.     

The Evidence-Based Practice of Applied Behavior Analysis

Evidence-based practice (EBP) is a model of professional decision-making in which practitioners integrate the best available evidence with client values/context and clinical expertise in order to provide services for their clients. This framework provides behavior analysts with a structure for pervasive use of the best available evidence in the complex settings in which they work. This structure recognizes the need for clear and explicit understanding of the strength of evidence supporting intervention options, the important contextual factors including client values that contribute to decision making, and the key role of clinical expertise in the conceptualization, intervention, and evaluation of cases. Opening the discussion of EBP in this journal, Smith (The Behavior Analyst, 36, 7–33, 2013) raised several key issues related to EBP and applied behavior analysis (ABA). The purpose of this paper is to respond to Smith’s arguments and extend the discussion of the relevant issues. Although we support many of Smith’s (The Behavior Analyst, 36, 7–33, 2013) points, we contend that Smith’s definition of EBP is significantly narrower than definitions that are used in professions with long histories of EBP and that this narrowness conflicts with the principles that drive applied behavior analytic practice. We offer a definition and framework for EBP that aligns with the foundations of ABA and is consistent with well-established definitions of EBP in medicine, psychology, and other professions. In addition to supporting the systematic use of research evidence in behavior analytic decision making, this definition can promote clear communication about treatment decisions across disciplines and with important outside institutions such as insurance companies and granting agencies.     

Bidirectional Effects of Parenting Quality and Child Externalizing Behavior in Predominantly Single Parent, Under-Resourced African American Families

This study investigates the bidirectional perspective of parent–child effects by examining the extent to which parenting quality predicted child externalizing behavior and vice versa. Data was collected over four time points from primary caregivers and early school age children in low-income, primarily single parent homes (N = 249, mean age of children at Time 1 = 6.41 years). Parenting quality was operationalized as primary caregiver perceptions of positive parenting, effectiveness of parenting discipline, parenting efficacy and satisfaction. Child externalizing behavior data was captured via an assessment of the frequency of externalizing behavior as reported by caregivers. We hypothesized that parenting quality and child externalizing behavior would remain stable over time and that a bidirectional relationship would be present. Data was analyzed using structural equation modeling and results indicated that child externalizing behavior predicted subsequent parenting quality, and parenting quality predicted subsequent child externalizing. Specifically, our research team found that the influence of child externalizing behavior on parenting quality decreased with time, while the influence of parenting quality on child externalizing behavior increased with time. Overall results reveal the complex transactional influences of child externalizing behavior and parenting quality in our sample. Findings support the notion that parenting quality and child externalizing behavior are interactive processes which might best be handled by continual assessment and which may be potentially strong targets for interventions.     

Therapeutic Assessment in Psychological Triage Using the PAI

This case illustrates the utility of incorporating therapeutic assessment in a triage context that typically involves a focus on gathering information. A man referred to our clinic by a local mental health center was seen by our assessment team for a triage that includes the administration of a single psychological test, the Personality Assessment Inventory (PAI). Although this triage must rapidly gather information to determine client suitability and treatment assignment, we still attempt to work with clients to collaboratively develop goals for this assessment that include addressing questions that are central concerns for the clients. In this case, the test results suggested a severe disorder that accounted for many phenomena that he had been experiencing but had apparently been reluctant to share. The information gathered led to a referral to a different treatment program that could provide pharmacological and more intensive forms of treatment. However, the collaborative bond formed between the assessor and the client during this triage was sufficiently strong that it was our assessor to whom the client turned in a subsequent crisis precipitated by a symptomatic exacerbation. This case illustrates complementary information gathering and therapeutic goals of assessment even in the context of a brief assessment.     

Psychosoma in crisis: an autoethnographic study of medically unexplained symptoms and their diverse contexts

In this study, we examine autoethnographic data from three critical incidents as experienced by the first author demonstrating the importance of context in understanding medically unexplained symptoms, their incidence and underlying patterns. We make the case for ethnographies as a crucial research strand in discerning the finer aspects of the patient or client experience; aspects that might be missed where people are directed along protocolised pathways of care. The article describes care as fragmented and depersonalising, leading to disembodied exchanges, as reflected in other autoethnographic studies, particularly those that highlight the complex relationship and controversies surrounding diagnostic uncertainty. We observe that psychological therapists, given the quality of the therapeutic relationship and sustained attention to the person’s experience, are well placed to assist in the necessary processes of re-contextualisation and re-embodiment.     

A descriptive analysis of client outcomes associated with staff interventions in developmental disabilities

Although a large body of research supports the use of behavioral staff management interventions in developmental disabilities, the nature of client outcomes associated with such interventions has not been systematically assessed. We reviewed 59 staff management studies published over 20 years (1971–1990) in order to determine the generality or scope of the research (i. e., range of settings, types and levels of clients' disabilities, clients' ages), the frequency of inclusion of client outcome measures, the types of measures and levels of analysis selected (i. e., individual groups, combination), and the effects of the interventions on client behavior. Results indicated that: (a) over two-third of the studies were conducted in institutional settings; (b) more than one-half involved clients with profound to severe mental retardation; (c) clients of various ages were served; (d) assessment of client outcomes increased progressively over the period; (e) engagement and skill acquisition were the most frequently used measures; (f) group data were presented twice as frequently as either individual or a combination of group and individual data; and (g) staff interventions were associated with either positive or mixed client outcomes in 80% or more of the cases, although maladaptive behavior went unchanged in one-fifth of the studies in which they were reported. Based on these findings, suggestions are made for how researchers might extend the generality of staff management research, improve client outcome assessment practices, and produce even more consistently positive results.     

Influence of Coaching on Integrity Test Performance and Unlikely Virtues Scale Scores

Little is known about how assessment center exercises might be designed to better elicit job-relevant behavior. This study uses trait activation theory as a theoretical lens for increasing the number of behaviors that can be observed in assessment centers. Two standardized exercise stimuli (specific exercise instructions and role-player prompts) are proposed, and their effects on the observability of candidate behavior are examined. Results showed a significant effect of role-player prompts in increasing both the general number of behavioral observations and the number of behavioral observations related to three out of four dimensions. Specific exercise instructions did not have effects on observability. Implications for trait activation theory and assessment center practice are discussed.     

Direct assessment of quality of care in a geriatric nursing home

Direct observation was used to examine multiple aspects of care provided in a proprietary nursing home. The samples were taken at random intervals, 7 days per week for 5 weeks, across several categories of environmental and resident conditions as well as staff and resident activity. Results showed a high degee of compliance with predefined standards (based on current federal regulations) for environmental and resident conditions. Overall distributions of resident and staff activity showed results similar to those found in previous studies, with residents spending most of their time engaged in nonsocial activity and staff spending the majority of their time engaged in nonresident work. When data were analyzed across areas of the facility, times of day, and weekdays versus weekends, some differences were noted. Weekend versus weekday comparisons showed higher resident:staff ratios on weekends and more resident inactivity, but no significant differences in environmental or resident conditions. In addition, more frequent resident care, resident interaction, and resident activity were observed in Medicare units than in non-Medicare units. Results are discussed in terms of federal requirements for monitoring the quality of care in nursing homes and the potential use of time sampling expressly for this purpose.     

Some actions for behavior analyst licensing bodies to consider in response to the COVID‐19 pandemic

The COVID‐19 global pandemic has had a significant impact on the practice of applied behavior analysis (ABA). Practitioners and caregivers have had to adapt quickly as physical distancing, stay‐at‐home orders, and shelter‐in‐place directives have become commonplace. As the field copes with the changes produced by the COVID‐19 outbreak, many behavior analytic practitioners are seeking guidance from regulatory bodies to ensure they are practicing legally and ethically. This article outlines some actions that the regulatory bodies that manage state behavior analyst licensure programs may consider to assist ABA practitioners and consumers during this unprecedented time. Additionally, suggestions are offered as to how state licensing bodies might prepare to support the practice of licensees during future events that present challenges similar to the current pandemic.     

Impressions of psychotherapists' offices

For counseling settings, research suggests that softness, personalization, and order might affect the experience and the perceived expertness, trustworthiness, and social attractiveness of the therapist. This article discusses exploratory studies on college students' perception of the counseling office environment and whether the likely client experience was associated with the softness/personalization and order of the office. As stimuli, the studies used 30 color photographs of psychotherapists' offices viewed from the client's perspective. After obtaining ratings of the characteristics of each office, we obtained ratings from different groups of students of the quality of care and comfort expected in each office (Study 1) and how qualified, bold, and friendly the therapist in the office would be (Study 2). Additional studies examined the likelihood of choosing a therapist based on the office, and the first thought or feeling that came to mind about the office, the therapist, and the patient experience. There were strong correlations in response between groups (by whether they had experienced therapy; their level in school; their gender; and their major, location, and school size). The quality of care, comfort, therapist boldness, qualifications of the therapist, and the likelihood that one would choose a therapist based on the office improved with increases in the office's softness/personalization and order. Friendliness improved with increases in softness/personalization. The office choices, open-ended responses, and reported reasons for the ratings confirmed the importance of softness (comfort) and order. Research should test longer term exposure and behavior.     

Establishing verbal repertoires in children with autism using function-based video modeling

Previous research suggests that language-training procedures for children with autism might be enhanced following an assessment of conditions that evoke emerging verbal behavior. The present investigation examined a methodology to teach recognizable mands based on environmental variables known to evoke participants' idiosyncratic communicative responses in the natural environment. An alternating treatments design was used during Experiment 1 to identify the variables that were functionally related to gestures emitted by 4 children with autism. Results showed that gestures functioned as requests for attention for 1 participant and as requests for assistance to obtain a preferred item or event for 3 participants. Video modeling was used during Experiment 2 to compare mand acquisition when video sequences were either related or unrelated to the results of the functional analysis. An alternating treatments within multiple probe design showed that participants repeatedly acquired mands during the function-based condition but not during the nonfunction-based condition. In addition, generalization of the response was observed during the former but not the latter condition.     

The use of structured multi-domain job analysis for the construction of assessment center methods and procedures

This article addresses the defensibility of the assessment center based on a content oriented validation strategy. One reason for the confusion in this area is the fact that there are no agreed upon methods for constructing the assessment procedures. Therefore, the purpose of this article is to describe how structured multi-domain job analysis information can be used to develop an assessment center which is well grounded with regard to content validity.     

Culture-sensitive functional analytic psychotherapy

Functional analytic psychotherapy (FAP) is defined as behavior-analytically conceptualized talk therapy. In contrast to the technique-oriented educational format of cognitive behavior therapy and the use of structural mediational models, FAP depends on the functional analysis of the moment-to-moment stream of interactions between client and therapist. This distinctive feature makes FAP particularly sensitive to the challenges posed by cultural differences between client and therapist. Core elements of FAP philosophy are invoked to argue that this vulnerability paradoxically implies an increased ability to capture and use relevant issues in the therapy process with culturally different clients. This argument focuses FAP's preference for concrete behavior over theoretical modeling, its emphasis on functional principles rather than topographically defined techniques, and its inclusion of the therapist's behavior in the assessment of clients' clinically relevant behavior. Suggestions are given concerning how academic and practical training and personal experience may be used to foster sound multicultural practice.     

Familiar/interactive raters are not always best: The influence of sampling schedules and class of behavior

Retrospective rating scales are widely used for formal assessment of typical performance. Raters who are the most familiar/interactive with ratees are routinely recommended to maximize the quality of ratings. This caveat to use the most familiar/interactive raters fails to distinguish sampling parameters of the observations on which ratings are based that may be important to assessing different classes of behavior. We hypothesized that systematic observational schedules would be of greater importance to ratings of public events than familiarity/interaction, per se, while the caveat would hold for ratings of private events. We used the Psychotic Inpatient Profile (PIP), which provides separate factor scores for ratings of public and private events, to examine these hypotheses in a quasi-experimental study with adult inpatients of mental hospitals. A large multiinstitutional data set provided retrospective PIP ratings by two types of raters. The most familiar/interactive local clinical staff for each client completed the PIP after observing on an ad lib schedule, along with ongoing job duties. Unfamiliar, noninteractive raters completed the PIP for each client after observing on a systematic time-sampling schedule for purposes of coding an entirely different instrument. Data were selected so that each of 189 clients received PIP scores from four raters, reflecting functioning during the same time period based on day-shift observations by one rater of each type and evening-shift observations by one rater of each type. Analyses of variance, consistency/discriminability of ratings, and prediction of social-action outcomes all supported the hypotheses. We discuss alternative strategies that are better for assessing typical performance in most circumstances. We also provide recommendations for improving the adequacy of observations for those circumstances in which the standardized retrospective rating scale could be a cost-effective assessment strategy.This study was the basis of a master's thesis at the University of Houston by the senior author under the direction of the junior authors. Richard M. Rozelle served on the examination committee. This study was partially supported by grants to Gordon L. Paul from the National Institute of Mental Health, Public Health Service (MH-15353; MH-25464); the Illinois Department of Mental Health and Developmental Disabilities; the Joyce Foundation; the MacArthur Foundation; the Owsley Foundation; the Cullen Foundation; and the Center for Public Policy of the University of Houston.     

The behavioral treatment of neurodermatitis through habit-reversal

Azrin and Nunn's habit-reversal technique (1973, 1977) was used to treat four clients with neurodermatitis. Following a single treatment session, scratching associated with this skin condition was markedly reduced for three clients, whereas this reduction occurred for the fourth client 4 days following treatment. Results at 6-month follow-ups showed that scratching was eliminated for the client with the mildest case, whereas this behavior remained at low levels for the other three clients.     

Persuasion criteria in research and practice: Gathering more meaningful psychotherapy data

Psychotherapy research should ultimately benefit the psychotherapy client. Unfortunately, traditional psychotherapy research continues to have little influence on practicing clinicians and, therefore, does not benefit psychotherapy clients. As behavior analysts begin to show interest in this area of research, they may be in a position to improve its quality. We argue that traditional psychotherapy researchers have become prematurely wedded to a methodology that does not address the concerns of clinical audiences. Furthermore, we make a case for defining and evaluating psychotherapy data in terms of its capacity to influence both researchers and clinicians. We also suggest several alternative methods for gathering psychotherapy data based on the case formulation approach. We argue that this approach may be one of the most promising methods for gathering useful psychotherapy data.     

Clinical applications of analogue behavioral observation: dimensions of psychometric evaluation

Clinical assessment applications of analogue behavioral observation are discussed in the context of psychometric principles. Analogue behavioral observation involves the measurement of a client's overt behavior in a contrived situation that is analogous to situations that the client is likely to encounter in his or her natural environment. The goal of analogue behavioral observation is to derive valid estimates of the client's behavior in a current or future natural environment. Analogue behavioral observation instruments are often developed with insufficient attention to their psychometric properties, particularly content validity. Psychometric evaluative dimensions vary in their importance, as a function of the goals of the assessment. Although analogue behavioral observation instruments can be sensitive to change, their validity can erode over time and is affected by numerous sources of variance. Analogue behavioral observation assessment may be especially useful in detecting important functional relations in clinical assessment.     

The Use of Role‐Player Prompts in Assessment Center Exercises

So far, a substantial amount of assessment center (AC) studies have aimed to improve the quality of the AC method by focusing on the assessors. However, systematic studies about the role‐player in AC exercises are nonexistent. This is surprising as the role‐player might serve as a key figure for consistently evoking job‐relevant behavior across candidates. Therefore, this study focused on the ‘role’ of role‐players in ACs. We examined the effects of instructing role‐players to use prompts among 233 candidates. Results suggest that role‐players are able to use prompts and that their negative impact on candidates' reactions is negligible. In addition, some AC dimensions (problem solving and interpersonal sensitivity) were better measured when role‐players used prompts. No effects on interrater reliability were found.     

Client perspectives on counselling: Before,during and after

This four‐year study investigated the under‐researched area of first‐time users’ perceptions of counselling and how these evolved over time. Research participants were drawn from six settings within university counselling services, the voluntary sector and primary care. Using an interpretive hermeneutic framework based on thematic analysis, 30 interviews were carried out. Results revealed that before counselling, participants were uncertain about the nature of counselling and what to expect, described stigma associated with peer influence and varying levels of confusion about specialist language. During counselling, participants experienced some level of positive change. At the same time, divergences of counsellor and client perception highlighted theoretical issues concerning counsellor approach and the exploration of emotions. Post‐counselling interviews revealed further positive change, and practical issues with implications for counsellor training and practice in terms of client assessment, preparation for counselling and the influence of cultural assumptions on theory and practice.