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“Lost in Translation”

Mark is a four-year-old boy receiving intensive (i.e., 3 meal treatment sessions a day, 5

days a week) applied behavior analysis (ABA) therapy for concerns related to his feeding

behavior. The meals are conducted by a behavioral psychology team and include a Board

Certified Behavior Analyst (BCBA) and two Registered Behavior Technicians (RBTs) for the

meals. An interdisciplinary team also consults on the case and provides treatment. The

interdisciplinary team includes a medical doctor, nurse practitioner, speech-language pathologist,

occupational therapist, social worker and nutritionist. Specifically, the speech-language

pathologist and the occupational therapist see Mark twice a week for thirty minutes to make

progress toward treatment goals that include safely chewing and swallowing foods.

Mark and his mother, Mindy, take two buses and commute about 90 minutes to get to the

program every morning by 8:30 am. Mark is observed outside of session often eloping (i.e.,

running away from) his mother and being noncompliant to her instructions. Mark uses simple

sentences (in English and Portuguese) to communicate and otherwise presents as a typically

developing four-year-old. Mindy speaks Portuguese and does not communicate at all in English.

Translators are provided for all treatment sessions, although one of the three assigned translators

may attend the session and advance notice is not provided about which translator will be

attending.

It is the fifth week of an eight-week admission to make progress toward treatment goals

identified in the second week of treatment in a collaboration amongst the interdisciplinary

treatment team and Mindy. The first treatment goal, increasing acceptance of foods and amount

of food consumed, has been met and Mark consumes at or above 95% of all the food presented

to him during meals. The second treatment goal, chewing of table texture (i.e., foods that require

chewing before becoming masticated enough to swallow – foods typical four-year-olds eat) has

not been met and progress has been inconsistent at best.

The behavioral psychology treatment team started introducing bites (about the size of a

pea) of food that are easily chewed (e.g., banana, peach) into meals to begin assessment and

treatment. Mark consumed all the bites, but it was difficult to tell if he was using his molars to

chew the bites, if he was mashing the bites with his tongue, or if he was swallowing the bites

whole without much chewing. Meanwhile, the speech-language pathologist (Kristen) and the

occupational therapist (Trevor) were attempting to increase chewing by using sequential oral

sensory (SOS) therapy and using quarter-sized bites of crispy foods (e.g., toast). When instructed

to chew (starting in the fifth week) Mark sometimes spit the bites out or appeared to hold them in

his mouth until his saliva broke them down. Trevor would repeatedly say, “Chew!” to Mark, but

seemed to not have any other plan to increase Mark’s chewing. The behavioral psychology

treatment team’s treatment protocol included praise for consuming all 5 bites in 5 minutes and

praise when Mark opened his mouth to show that he had swallowed each individual bite (i.e.,

mouth clean). Bites were presented one-at-a-time and two different foods were presented each

meal. No escape extinction was used, so bites Mark did not pick up remained on the table in

front of him.

Also, during the fifth week, Mindy begins expressing (through the translator) to the RBTs

that she is not satisfied with the progress made with Mark’s chewing. The RBTs state that they

are happy to communicate her concerns to the BCBA who will talk with Mindy at their first

possible opportunity. Mindy states that she does not serve Mark many of the foods provided in

any of the sessions (e.g., the fruit, toast, etc.) and that she’d prefer he practice chewing foods that

she would like him to eat at home or at preschool. These foods include hot dogs, hamburgers,

pizza with multiple toppings, raw vegetables, and protein bars. Mindy also tells the RBTs that

she has no idea why any of the foods are selected for any of the meals, including the foods

selected earlier in treatment to increase Mark’s consumption and acceptance of foods.

The BCBA and Trevor meet with Mindy later that day. They bring the treatment plan and

discuss it with Mindy. Mindy acknowledges that the treatment plan calls for chewing of softer

and crispier foods first, but that she is nervous because the end date for the admission is

approaching in a little over three weeks. Mindy relates that she is afraid that Mark will only eat

foods that she doesn’t eat and that she will have to make one meal for Mark and one meal for

herself. The BCBA and Trevor affirm that they want Mark to safely chew and consume the foods

Mindy wants and say that they will start introducing bites of hot dog in meals to assess Mark’s

chewing.

Further, the BCBA and Trevor discuss with Mindy that she will be trained on conducting

the meals herself in the last two weeks. They elaborate that if Mark is not chewing the foods

Mindy wants at the end of treatment that she will have the capability of continuing the treatment

herself after the admission is over. Mindy nods and agrees to proceed as planned, but the BCBA

is not entirely convinced she has bought in to the plan. Indeed, the very next day Mindy tells one

of the RBTs (through the translator) that Mark had bites of bacon, sausage, and biscuits for

breakfast and that he, “Chewed because I told him to.” None of the three foods had been targeted

in treatment by the behavioral psychology team or Trevor nor identified as target foods in the

treatment plan.

Paper: You are the BCBA and must proceed with the rest (3 weeks) of the admission. Your

primary treatment goals are to increase Mark’s chewing and swallowing of foods and to train

Mindy to implement that same protocol on her own.

“Enthusiasm for Escape Extinction”

Dylan is a nine-year-old boy receiving applied behavior (ABA) therapy for aggressive

and disruptive behavior for three-hour sessions four days a week (Monday through Thursday)

from 9 am to 12 pm. The case is overseen by Andy, one of three BCBAs at the clinic where

Dylan is receiving therapy. Dylan otherwise attends school at a local elementary school (Burch

Elementary) and is in a classroom with other children that exhibit disruptive and aggressive

behaviors. The classroom has been observed to not have many rules and the school personnel in

the classroom mostly interact with the most compliant students in the classroom. During an

initial assessment in clinic, Dylan complied with 0% of instructions, engaged in aggression at a

rate of 5.3 per minute during performance demands (academic work) and verbally threated the

BCBA (Andy) doing the assessment (“I’m going to cut you; you’re going to bleed”).

Dylan is one of Andy’s first cases after being hired at the clinic. Andy has received

considerable training in ABA both in graduate school and in a variety of practicum settings.

Andy has had his BCBA credential for 1.5 years but has previously still had his work supervised

by a more experienced behavior analyst. At the current clinic, Andy does not receive supervision

for his case’s, but sometimes consults with the clinic director, Kathleen, who is a much more

experienced BCBA (15+ years’ experience). Kathleen reports to the Director of Clinical Training

for the hospital that is providing the space for the clinic, but the Director of Clinical Training has

never visited the clinic. You are the third BCBA in the clinic with Andy and Kathleen. You’ve

been there for 2 years and are also not supervised by Kathleen. You are also never present in the

clinic when Dylan’s sessions are conducted because your clients only come in the after-school

hours.

Upon arriving at the clinic one day Andy spontaneously relates to you that Dylan is,

“Quite a handful.” Andy states that they are doing escape extinction of problem behavior

(aggression and disruptive behavior) and reinforcement for completion of academic work. Andy

tells you that Dylan does not seem to like escape extinction and has been saying and doing more

provocative things in session. Andy elaborates that Dylan called him a, “stupid asshole,” and

said, “you need to wash your asshole ‘cause it’s stupid.” Andy laughs and smiles and says, “It

was really funny, I had a hard time not reacting.” You ask if Andy thinks things are going well,

and Andy says, “Oh yeah, Kathleen and I have it under control, nothing to worry about!”

The next week you arrive at the clinic and walk into an office in the middle of Kathleen

and Andy discussing Dylan’s treatment. Kathleen says, “You would not believe what he’s been

doing! He’s been spitting in our faces, so we have been wearing smocks and plastic face

shields.” She indicates that using the equipment did not stop Dylan from spitting and that he now

puts his hands down his pants and says, “Let me out of here or I have something worse for you!”

Kathleen and Andy laugh throughout the entire exchange and as you leave Andy cheerfully says,

“I guess we’ll find out what new stuff he has in store for us tomorrow!”

Later that day Mary, a Registered Behavior Technician (RBT) at the clinic, looks

exhausted and you ask her how she is doing. Mary says that she works with Dylan every day.

Mary elaborates that while Andy will come in and out of the room, and sometimes another RBT

will be there to help, that Mary covers 100% of Dylan’s time in clinic. She says that she doesn’t

agree with the treatment that Andy is telling her to do and that she thinks it is making the

problem worse. Mary stated that she once asked about another treatment, but Andy immediately

said that they need to keep doing the treatment. You ask Mary if there is a protocol and she

reports that there isn’t one. Mary states, “I do what Andy tells me and if Andy isn’t there, I do

what Kathleen tells me.” Mary then sighs and says, “He’s begun putting his finger in his butt and

smearing feces on the walls and the table and chasing us around the room with it. Andy just says

to block it as best I can.” Mary responds to your question about addressing the working

conditions with Andy and Kathleen by saying she has but was told that this was something they

dealt with while they were learning, so Mary should to. Before leaving for the day Mary is seen

filling out the data sheet for her session with Dylan that occurred four hours earlier that morning.

Mary is a graduate student in an ABA program that Andy and Kathleen teach in. She

freely admits she is afraid of receiving bad grades and potentially being removed from the

program is she speaks up. Mary states, “I only have one more semester to make it through, then

I’m done so I’m just going to grin and bear it.” You ask Mary if she wants your assistance with

what she is dealing with and she says that she thinks that being seen talking to you could get her

in trouble.

The treatment room Dylan is seen in has no observation room or other recording for you

to observe the treatment and his behavior. You smell Lysol® in the air whenever you pass the

treatment room in the afternoon, but you cannot directly observe the result of the therapy in the

room. Dylan’s mother, Beverly, is a single parent with four other children at home. Beverly has

stated that she trusts Andy and Kathleen completely. Lastly, Kathleen has made multiple

comments recently that she is looking forward to securing a contract with Burch Elementary to

work with more of the clients from the classroom in the clinic.

Paper: You, as the BCBA, need to come up with plans to address the ethical issues using the

information above.