"Sometimes it's that simple." Is your child's plan being done the way it was written?

A free article for families, derived from Special Learning's course "Ensuring Treatment Integrity," presented by Christine Austin and Erin Lombard.

Your child has a behavior plan. It was explained to you, and maybe you signed it. But weeks later, the behavior isn't coming down, and you're starting to wonder. Is the plan wrong? Or is it just not being done?

This session was recorded for the people who supervise the staff working with children. Its presenters ran clinical operations and consulting at a center-based autism program. But the question underneath it is the one families ask all the time, and rarely out loud.

Two questions come first

The session starts with a blunt rule. Before anyone decides a plan isn't working, they have to ask two questions: "are the data accurate and are the staff implementing the behavioral interventions the way that they have been trained."

Until those two are answered, the presenters say, nothing else matters. "It doesn't matter about the other questions ... until you've ruled out these two things first."

Why? Because every decision in a plan is made from the numbers. "If the data is inaccurate then it's just misinformation."

When the numbers jump around

One presenter describes what she does when a child's graph looks wild, with numbers all over the place. She doesn't change the plan. "The very first thing I do is I go in and I check for interobserver agreement." In plain words, she checks whether the person writing things down is counting what she trained them to count.

That's a fair question for a parent too. If the numbers you're shown swing wildly from week to week, ask who is collecting them, and whether anyone has checked.

How behavior gets counted

The session explains the main ways behavior is measured, and the reasoning is easy to follow:

• Counting, for behavior with a clear start and stop, like getting out of a chair.
• Timing, for behavior that lasts. A tantrum might last "5 minutes" on Monday and "2 hours" on Tuesday. Counting it once each day would tell you nothing.
• How long it takes to start, after being asked. The presenters describe a young man who took "45 minutes to get out of bed." Over time, with "very very gentle prompts" and changes to the room, it came down to "within 1 minute." Physical help was never an option, because "if we tried to assist physically he would just become aggressive."

The method also has to be one a person can actually manage. One child hurt himself "200 times a day" in a three-hour morning. Nobody could have written that down with a pencil and kept him safe too, so staff used counters. In one family's home, where there was no counter, a presenter used "masking tape on my thigh."

And a number always needs its time frame. "150 times within 3 hours" is not the same as 150 times in a day. When you're shown a number, it's fair to ask: over how long?

What a good definition looks like

A good plan doesn't just say "aggression" or "elopement." It says exactly what counts, and lists the ways it usually looks, so two people watching the same moment would write down the same thing.

The session has a small story about why. A child finished a task, got a small reward, sat for a bit, and wandered away from the table. Staff were about to record it as running away. The presenter saw it differently: "he was just bored ... He didn't really know what was coming up next ... That's not elopement."

A loose definition fills the data with noise, and then nobody can trust the numbers.

Two people, same moment

The idea the presenters call "the heart of ensuring treatment integrity" is simple. Two people watch the same child at the same time, each writes down what they see, and then they compare. If the records match, you can trust the definition and the data. If they don't, you've found the problem early.

They start this from a new staff member's first days, because "it's much easier to help somebody in the beginning than it is to go back and change some bad habits."

A beautiful plan does nothing on its own

The session quotes a definition of treatment integrity as "the consistent and accurate implementation" of a plan "as it was designed." And then it says something families may find reassuring to hear from professionals: "we can create the most beautiful great design ... but it won't change behavior if it's not being implemented as it was designed."

When a plan looks like it's failing, the presenters' first move is the simplest explanation. Go and watch. "Is it simply just not being implemented as designed ... Sometimes it's that simple."

How staff learn to do it

The second half of the session is about training, and it's honest about what doesn't work on its own. A manual on its own isn't enough. Showing someone once isn't enough. Standing next to them and correcting them on the spot "can be really overwhelming." In the presenters' words, "something alone is likely not to be effective ... it's when you have that whole package."

The package is written guidance, a demonstration, practice with feedback, and then someone watching and checking over time. They teach new staff the same patient way they teach children: "Don't expect them to just know everything."

Three details from this part are worth knowing as a parent:

• The plan travels with your child. "That behavior plan should go around with the child so the staff know exactly what to do when something happens."
• The supervisor does it first. The presenters say to "implement the plan first and have the staff overlap you," because "if you're willing to do it then your staff's willing to do it."
• Someone keeps checking. Staff are held to 80% accuracy, with "one formal evaluation a quarter" and a supervisor who will "get in there once a week and observe." Feedback is specific, with "about three times the amount of praise to one corrective feedback."

The people who know your child best

The session doesn't pretend the work is easy. It names staff turnover, injuries, plans that get harder before they get better, and children who grow bigger than the adults around them.

And it ends with advice meant for staff that fits parents just as well: "ask for their opinions ... Whether you're working with staff or parents they're the experts ... They're the one who knows the child the best."

Questions to take to the meeting

• Who collects the data on my child's plan, and how are they trained?
• Has anyone checked the data by having two people watch at the same time?
• What exactly counts as the behavior? Can I see the written definition?
• When you show me a number, over what time period is it?
• How do you check the plan is being done as written, and how often?
• Does the plan go with my child to every setting, and does everyone working with them have it?

If you are reading this outside the United States

The session was recorded in the United States. Where you live, the professionals, their titles and the rules they follow may be different.

What transfers is the question. A plan is only as good as the way it's carried out. Whatever the service is called where you live, it's fair to ask how anyone knows the plan is being done as written, and how anyone knows the numbers are right.

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This article is drawn from a recorded Special Learning course. It is general information for families, not clinical advice, and not a treatment recommendation for any individual. It does not describe the rules of any particular school district or country.

Special Learning is a BACB Authorized Continuing Education (ACE) Provider (OP-14-2437). Authorization as an ACE Provider does not imply endorsement or approval of the ACE event content by the BACB.