Deochand et al. (2020) Toward the Development of a Functional Analysis Risk Assessment Decision Tool PDF

Behavior Analysis in Practice (2020) 13:978–990 https://doi.org/10.1007/s40617-020-00433-y DISCUSSION AND REVIEW PAPER Toward the Development of a Functional Analysis Risk Assessment Decision Tool Neil Deochand 1 & Rebecca R. Eldridge 2 & Stephanie M. Peterson 2 Published online: 20 July 2020...

Behavior Analysis in Practice (2020) 13:978–990 https://doi.org/10.1007/s40617-020-00433-y DISCUSSION AND REVIEW PAPER Toward the Development of a Functional Analysis Risk Assessment Decision Tool Neil Deochand 1 & Rebecca R. Eldridge 2 & Stephanie M. Peterson 2 Published online: 20 July 2020 # Association for Behavior Analysis International 2020, corrected publication 2020 Abstract Risk-benefit analyses are essential in the decision-making process when selecting the most effective and least restrictive assess- ment and treatment options for our clients. Clinical expertise, informed by the client’s preferences and the research literature, is needed in order to weigh the potential detrimental effects of a procedure against its expected benefits. Unfortunately, safety recommendations pertaining to functional analyses (FAs) are scattered or not consistently reported in the literature, which could lead some practitioners to misjudge the risks of FA. We surveyed behavior analysts to determine their perceived need for a risk assessment tool to evaluate risks prior to conducting an FA. In a sample of 664 Board Certified Behavior Analysts (BCBAs) and doctoral-level Board Certified Behavior Analysts (BCBA-Ds), 96.2% reported that a tool that evaluated the risks of proceeding with an FA would be useful for the professional practice of applied behavior analysis. We then developed an interactive tool to assess risk, which provides suggestions to mitigate the risks of an FA and validity recommendations. Subsequently, an expert panel of 10 BCBA-Ds reviewed the tool. Experts suggested that it was best suited as an instructional resource for those learning about the FA process and as a supporting resource for early practitioners’ clinical decision making. Keywords Clinical decision making. Ethical practice. Functional analysis. Risk assessment. Safety precautions Demand continues to grow for Board Certified Behavior to support the professional practice of behavior analysis. Analysts (BCBAs) and their expertise (Behavior Analyst Determining the needs of behavior analysts requires intermit- Certification Board [BACB], 2018; Deochand & Fuqua, tently conducting job analyses and expert panel reviews 2016). This demand has created a “supply” issue, in that there (Shook, Johnston, & Mellichamp, 2004), in addition to exam- is a shortage of BCBAs. The BACB reports that a vast major- ining ongoing challenges encountered by those in the field. ity of individuals certified as behavior analysts have been Two surveys published in the Journal of Applied Behavior certified for 5 years or less (BACB, n.d.). This heightened Analysis presented cause for concern, because a majority of demand, coupled with the junior status of many practicing certified behavior analysts (BCBAs, as well as Board behavior analysts, creates a need for tools that will continue Certified Assistant Behavior Analysts [BCaBAs] and doctoral-level BCBAs [BCBA-Ds]) reported they were facing barriers to conducting functional analyses (FAs) in practice, This article was updated to correct the spelling of Rebecca R. Eldridge’s despite endorsing FAs as the most informative tool in the name in the author listing. functional behavior assessment arsenal (Oliver, Pratt, & Electronic supplementary material The online version of this article Normand, 2015; Roscoe, Phillips, Kelly, Farber, & Dube, (https://doi.org/10.1007/s40617-020-00433-y) contains supplementary 2015). Oliver et al. (2015) reported that 62.6% of certified material, which is available to authorized users. behavior analysts surveyed (N = 682) indicated never or al- * Neil Deochand most never using an FA. Similarly, Roscoe et al. (2015) re- [email protected] ported that 61.9% of certified behavior analysts surveyed (N = 205) had entire client caseloads where none or almost none 1 had received an FA to inform treatment. The participants in Behavior Analysis Program, School of Human Services, University of Cincinnati, 450H Teachers-Dyer Complex, 2610 McMicken Cir., the Oliver et al. (2015) survey reported insufficient time Cincinnati, OH 45221, USA (57.4%), lack of space/materials (51.8%), lack of trained sup- 2 Department of Psychology, Western Michigan University, port staff (26.7%), and lack of administrative policies (24.9%) Kalamazoo, MI, USA as the primary barriers to implementing FAs in practice. Behav Analysis Practice (2020) 13:978–990 979 Roscoe et al. (2015) reported four primary barriers: lack of train staff, minimize the time required to conduct their space (57.6%), lack of trained support staff (55.6%), lack of assessment, or embed their assessment into the client’s support or acceptance of the procedure (46.3%), and insuffi- ongoing routine (and, hence, natural environment) to ame- cient time or client availability (42.4%). A majority of partic- liorate the need for a separate space for the FA. ipants indicated having prerequisite assessment training expe- For the FA to gain social acceptance, it must be used in rience. For example, only 12% of the sample reported lacking practice when it is the best suited assessment procedure. “how-to” functional behavior assessment knowledge in the Administrative support for conducting FAs might increase Oliver et al. (2015) sample, and 82.4% indicated serving as if administrators had more knowledge of the risks and the primary therapist or data collector in an FA in the Roscoe benefits of the procedure. Recently, Wiskirchen, et al. (2015) sample. These data seem to suggest that practi- Deochand, and Peterson (2017) concluded that safety rec- tioners have been trained in FA technologies but are not ommendations for FAs were not easily accessible to behav- implementing these technologies due to either resource issues ior analysts, which may make it difficult for behavior ana- or a lack of administrative support. lysts to effectively judge whether it is safe to conduct an FA FAs allow practitioners to better identify functionally or even what factors they should consider in making this matched treatments for problem behavior that do not rely judgment. Researchers have found that safety recommen- as heavily on aversive stimuli to achieve beneficial treat- dations are often not consistently reported (Weeden, ment outcomes (Neef & Iwata, 1994; Pelios, Morren, Mahoney, & Poling, 2010) or they are scattered in the be- Tesch, & Axelrod, 1999). There is a continual growth of havioral literature across numerous journals and books functional analysis technology (Schlichenmeyer, Roscoe, (Wiskirchen et al., 2017). Wiskirchen et al. (2017) advocat- Rooker, Wheeler, & Dube, 2013). It is essential that prac- ed for a formalized risk assessment prior to conducting an titioners keep abreast of these changes in technology over FA and suggested four domains (clinical experience, be- time to ensure FAs are appropriately used in practice. FAs havior intensity, support staff, and environmental setting) can be conducted in a variety of environments in abridged that could be included in such a risk assessment. This “call or adjusted forms, such as the single-function, latency to action” is timely given that clinical decision making sur- (Call, Pabico, & Lomas, 2009; Thomason-Sassi, Iwata, rounding FA safety precautions appears not to be transpar- Neidert, & Roscoe, 2011), brief (Northup et al., 1991; ent to those in and outside the field. Wallace & Iwata, 1999), and trial-based (Bloom, Iwata, In recent years, Behavior Analysis in Practice has pub- Fritz, Roscoe, & Carreau, 2011) FAs, as well as FAs using lished decision trees to help guide behavior analysts, cov- synthesized conditions (Hanley, Jin, Vanselow, & ering topics ranging from selecting measurement systems Hanratty, 2014). Some of these developments may help (LeBlanc, Raetz, Sellers, & Carr, 2016) and treatments for ameliorate concerns practitioners identify about using escape-maintained behavior (Geiger, Carr, & LeBlanc, FAs in practice. For example, some practitioners reported 2010), to considering the ethical implications of interdisci- barriers to adequate time and space to conduct FAs or a plinary partnerships (Newhouse-Oisten, Peck, Conway, & lack of trained staff. However, this is not consistent with Frieder, 2017). Such tools offer guidance and resources to the literature. Training staff to implement an FA should not support the growing number of behavior analysts in the be an issue if teachers with no behavior-analytic experi- field. A similar tool for evaluating the risk of FA and for ence can be trained with minimal performance feedback pointing practitioners to helpful literature for decreasing (Rispoli et al., 2015). If individuals like direct-care staff risk could be helpful to the field. However, prior to devel- (Lambert, Bloom, Kunnavatana, Collins, & Clay, 2013), oping the FA risk assessment tool, we first surveyed educators (Rispoli et al., 2015; Wallace, Doney, Mintz- BCBAs to ascertain if they reported a need for such a tool. Resudek, & Tarbox, 2004), and residential caregivers Based on those results, we developed a beta version of a (Phillips & Mudford, 2008), all with various backgrounds comprehensive risk assessment tool for evaluating risk pri- and education levels, can be trained to conduct FAs, then or to conducting an FA. The tool suggested strategies for training support staff familiar with applied behavior ameliorating risks, provided references to peer-reviewed analysis should not be a barrier for using FAs in our literature on how to implement such risk-reduction strate- growing field. Iwata and Dozier (2008) noted that the use gies, and provided considerations to increase the validity of of FAs can actually reduce the time it takes to receive FAs in practice. Ten BCBA-Ds with several years of expe- effective treatment, as selecting an FA like the brief FA, rience conducting FAs and who had contributed to the latency-based FA, or trial-based FA can limit the amount knowledge base on this topic reviewed the tool. Their feed- of time individuals with problem behavior spend in assess- back was used to develop a refined version of the tool. In ment. It appears that practitioners are either not knowl- this article, we describe the outcomes of the survey, de- edgeable about these developments or not “connecting scribe the process for evaluation of the tool, and provide the dots” to see that there are strategies they can use to 980 Behav Analysis Practice (2020) 13:978–990 the most recent version of the risk assessment tool for prac- in the first round. The survey was not searchable through titioner use. search engine queries, so only those with an invite from the BACB® e-mail could participate. Additionally, to prevent multiple user responses generated from the same IP address, Method prevent “ballot box stuffing” was selected in the Qualtrics™ options. Survey data were separated by participants who com- Phase 1: Needs Assessment pleted the first half of the survey and participants who com- pleted the entire survey (defined as having no more than two We surveyed behavior analysts to assess their professional unanswered responses). opinion of the need for a formalized FA risk assessment tool. We also collected participants’ demographic data, as well as Survey Results and Discussion data on their experience conducting FAs. Practitioner Demographics Participants’ mean age was Participants A survey (described later) was distributed 39.2 years (range 24–78 years). Table 1 depicts participant through the BACB’s mass e-mail service to BCBAs and demographic characteristics such as gender, certification type, BCBA-Ds. At the time the survey was disseminated, there age ranges, and years of experience in the field. There was a were 2,088 BCBA-D and 23,582 BCBA certificants world- higher proportion of female participants, which comprised wide. The survey was sent out to all of these individuals. Of 81.2% (n = 539) of the sample. Of those, 450 identified as those behavior analysts who received the survey invitation, BCBAs, and 89 identified as BCBA-Ds. Male participants 708 started the survey, 664 completed the first half of the represented 18.7% (n = 124) of the sample, with 84 identify- survey containing yes/no and demographic questions, and ing as BCBAs and 40 as BCBA-Ds. One participant did not 596 (84% completed upon initiating the survey) completed identify with the binary gender options. A large portion (31%) the entire survey, including the Likert scale responses. Our belonged to the 30- to 35-year-old age range. Approximately, sample was composed of 534 BCBAs (2.26% response rate) 75% of the participants had fewer than 15 years of experience and 130 BCBA-Ds (6.2% response rate). working in the field, which reflects the recent exponential growth of newly certified behavior analysts. Materials A 33-item response survey with an estimated 15- to 20-min time commitment was constructed by the authors using Qualtrics™ to assess the need for an FA risk assessment Table 1 Participant tool (see the survey in Supplemental Materials). Demographic demographic data (N = Characteristic N Percentage data were collected pertaining to certification level, age, gen- 664) der, and years of experience in the field. Thematically, ques- Gender tions were related to experience with FAs, the perceived va- Female 539 81.17 lidity and utility of the FA, and barriers to and risks of the Male 124 18.67 procedure. There were 11 yes/no questions followed by 15 Other 1 0.15 Likert questions. A 5-point Likert scale (strongly agree, Certification agree, neutral, disagree, strongly disagree) drop-down menu BCBA 534 80.42 was used to evaluate participant agreement or disagreement BCBA-D 130 19.58 with statements regarding FA use in practice. The final two Age range yes/no questions allowed participants to type more detailed 24–29 100 15.13 responses regarding how they currently evaluate risk prior to 30–35 207 31.32 conducting an FA, and whether they believe colleagues do not 36–40 131 19.82 conduct FAs even when it would be the best assessment 41–45 70 10.59 option. 46–50 53 8.02 >50 100 15.13 Procedure After accessing the survey using the e-mail link, Years of experience in the field participants could save and complete the survey online at any 0–5 175 26.36 time, but after 3 months of inactivity, responses thus far in the 6–10 195 29.37 survey were recorded (allowing data collection on partially 11–15 126 18.98 completed surveys). Two months after the initial e-mail invi- 16–20 76 11.45 tation, a second e-mail was sent so that anyone who had not 21–25 40 6.02 participated in the survey could do so. This also served as a >25 52 7.83 prompt to those who had started but not completed the survey Behav Analysis Practice (2020) 13:978–990 981 Table 2 Participants’ responses to questions regarding FA Questions Yes No experience N (%) N (%) N = 664 Have you analyzed data from an FA? 631 (95.0) 33 (5.0) Have you implemented treatment based on the results of an FA? 610 (91.9) 54 (8.1) Have you assisted with or observed an FA? 602 (90.7) 62 (9.3) Have you designed an FA? 543 (81.8) 121 (28.2) Have you supervised an FA? 461 (69.4) 203 (30.6) Were there times you were unsure whether it was appropriate to 519 (78.2) 145 (21.8) conduct an FA? If you were to conduct an FA, would you be concerned about the 534 (80.4) 130 (19.6) validity of the results? Have you heard of the term “risk assessment” in relation to 550 (82.8) 114 (17.2) conducting an FA? Do you believe there is a need for a risk assessment tool that 629 (94.7) 35 (5.3) determines the risk of conducting an FA and offers ways to reduce risk posed in an FA? Would a tool that helps evaluate when it would be safe to 639 (96.2) 25 (3.8) conduct an FA be useful for the field of applied behavior analysis? Would you be more likely to conduct an FA if a tool existed that 546 (82.2) 118 (17.8) helped offer safety precautions, validity recommendations, and other considerations? N = 598 Have you used a formalized (standard decision-making tool) 35 (5.8) 563 (94.2) risk assessment before conducting an FA? Do you believe some behavior analysts do not conduct an FA 559 (93.5) 39 (6.5)v when it is actually the best option to guide treatment? Practitioners’ FA Use and Perceptions of Risk As depicted in than agreement would shift the bar to the right and away from Table 2, 95% of participants indicated that they had analyzed the statement on the left, and vice versa). Roughly 596 partic- FA data, 91.9% had implemented treatment informed by FA ipants of the original 664 completed the entire survey includ- results, 90.7% had assisted or observed an FA, 81.8% had ing the Likert questions. Participants could leave two re- designed an FA, and 69.4% had supervised an FA. In spite sponses unfilled and still meet inclusion criteria. Statements of this exposure, 78.2% of participants reported instances in Figure 1 are organized by the total responses for each state- when they were unsure whether it was appropriate to conduct ment, as some participants did not provide an endorsement to an FA. Similarly, 80.4% of the participants reported that if the provided 5-point Likert scale by leaving an unfilled they conducted an FA, they would be concerned regarding response. the validity of the results. A clear majority (96.2%) of partic- Most participants (99.2%) agreed or strongly agreed that ipants expressed a desire for a risk assessment tool that con- the FA helps guide future treatment when other methods have solidates safety precautions for an FA. Of the sample, 94.7% failed. Also, a majority of the sample (78.4%) agreed or expressed a need for a tool that determined risk and offered strongly agreed that FAs are the gold standard functional as- steps to mitigate this risk prior to FA implementation. sessment. Interestingly, 88.4% of participants disagreed or Interestingly, 82.2% reported that they would be more willing strongly disagreed with the statement “I do not generally con- to conduct an FA if a tool existed that offered safety precau- duct FAs because when I do the results are usually wrong.” tions, validity recommendations, and other considerations. Most (90.8%) disagreed or strongly disagreed that an FA Roughly 66 participants did not complete the second half of could only be used with individuals with developmental dis- the survey containing the Likert and final two yes/no ques- abilities, and 88.3% disagreed that FAs could not be used with tions, and their data are presented separately in Table 2. behaviors that were multiply controlled. Just under 73% Data for Likert scale responses are presented using a di- disagreed or strongly disagreed that FAs were more of a re- verging stacked bar chart (see Figure 1). This chart is optimal search tool than something to be used in practice. In summary, for quick visual analysis of Likert data. The proportion of there seemed to be strong agreement that FAs are robust and participant agreement with any given question shifts the posi- should be relied upon when needed to inform treatment. tioning of the bar chart (i.e., proportionally more disagreement 982 Behav Analysis Practice (2020) 13:978–990 Percentage of agreement or disagreement regarding FA related statements Statement I do not generally conduct FAs because when I do the 9.2% 43.6% 44.8% results are usually wrong. 0.7% 1.3% Some behavior analysts avoid conducting an FA 45.2% 15.9% 31.9% 6.4% because it is labor intensive. 0.3% There is no standard way to assess risk to the client 14.0% 47.3% 16.4% 18.9% when conducting an FA. 3.0% n = 596 As the field of ABA grows there is more of a need to 42.5% 46.3% 8.7% create tools that guide clinical decision-making. 0.3% 2.0% Practitioners in applied behavior analysis need more 13.0% 36.0% 48.0% decision-making tools for effective clinical practice. 0.3% 2.5% There is no tool to help me decide which type of FA to conduct. 19.1% 50.8% 15.9% 12.7% 1.3% Some behavior analysts avoid conducting an FA because they do not have the necessary prerequisite skills. 45.7% 41.5% 9.9% 0.3% 2.5% When I evaluate whether to conduct an FA I usually determine the risks and benefits before starting the FA. 50.2% 37.1% 10.2% 0.3% 2.0% FAs are more of a research tool than to be used in 4.3% 13.5% 9.2% 46.8% 25.9% practice. FAs are the gold standard in functional behavior 44.3% 34.1% 13.4% 7.2% assessments. 0.8% n = 597 If previous treatment attempts have failed, FAs can help 54.7% 41.8% 3.3% guide future treatment. 0.0% 0.2% Many of my colleagues in ABA have not conducted 46.8% 29.9% 11.0% 10.2% FAs. 2.0% FAs cannot be used if the behavior is maintained by 7.5% 46.5% 41.8% multiple functions e.g. attention + tangible. 1.5% 2.7% FAs are only useful with individuals with developmental 5.7% 43.0% 47.8% disabilities. 1.8% 1.7% Functional Analyses (FAs) are inherently risky. 5.5% 36.0% 25.1% 28.1% 5.4% n = 598 Strongly Agree Agree Neutral Disagree Strongly Disagree Fig. 1 Percentage agreement/disagreement regarding ABA-related statements A smaller majority (61.3% of participants) either agreed or at the conclusion of the survey, which allowed participants to strongly agreed with the statement that there is no standard provide textual information if they wanted to offer additional way to assess the risk to the client when conducting an FA. context surrounding their responses. In the first question, There was strong agreement (88% of participants agreed or about 94.2% of participants reported never using a formalized strongly agreed) that there is a need for more tools that guide process to determine risk before conducting an FA. The re- clinical decision making as the field grows, and 84% of par- sponses to the second question indicated that roughly 93.5% ticipants supported the need for more decision-making tools of the sample believed some behavior analysts do not conduct for effective clinical practice. Although a majority of the sam- FAs even when they may be the best option to guide ple (87.3%) agreed or strongly agreed that they engage in a treatment. risk-benefit analysis prior to an FA, most (approximately These data suggest there is a need for a structured support 70%) agreed or strongly agreed that there is no tool to help tool to help evaluate the risks of conducting an FA. They also decide which type of FA should be conducted. Opinions were support the potential utility of including with the tool recom- divided regarding FAs being inherently risky, as 41.5% of mendations to improve the validity of the FA procedure by participants agreed or strongly agreed with this statement, designing FAs to meet the diverse needs of the clients for and 33.5% strongly disagreed or disagreed. In summary, there whom an FA is warranted, as well as cater to the settings seemed to be general agreement that a decision-making tool and contexts in which FAs are conducted. In order of priority that helped evaluate the risk of FA procedures would be based on the perceived needs of the sample, our tool should (a) useful. provide the various safety precautions for implementing an Interestingly, 76.7% of participants agreed or strongly FA found in the literature, (b), offer a way to assess the risk agreed that many of their peers have not conducted FAs. of implementing an FA, (c) provide options to reduce risk, and Just over 77% either agreed or strongly agreed that some be- (d) offer considerations regarding how to conduct a valid FA. havior analysts avoid conducting FAs because they are labor intensive, but 87.2% of participants indicated that the reason was due to a lack of prerequisite skills to implement FAs. Only 598 participants completed both close-ended questions Behav Analysis Practice (2020) 13:978–990 983 Phase 2: Tool Development the client or others at risk, appropriateness of the setting, clini- cian expertise, sufficiently trained personnel, buy-in from In order to develop the tool, we examined a large number of stakeholders, and other liabilities to the analyst. These sugges- seminal articles and books referencing applications of and tions correspond with Wiskirchen et al.’s (2017) four consideration for the FA. We relied on our original domains—clinical experience, behavioral intensity, FA envi- (Wiskirchen et al., 2017) review of the literature and reviewed ronment, and support staff (see Figure 2)—which served as our any new articles that had come out since then. The resources primary categories of risk for the tool. We attempted to quan- we used are listed in Table 3. We manually searched the tify these four domains as objectively as possible. Within each journals and examined cross-citations within a reference. We of these four domains, we created six levels from which the selected references that pertained to safety recommendations practitioner could select. Six levels were selected as they con- for FAs, alternative experimental procedures rather than an veniently helped categorize meaningful contextual differences FA that could be used to minimize risk, and validity issues that could impact risk. We used an aesthetic graduated blue-to- that can arise when implementing FAs, as well as how these red color scale to denote low risk (blue) to high risk (red). For could be resolved. Earlier references were selected in favor of the clinical experience domain, we initially envisioned using a direct or systematic replications that did not provide further set number of FAs completed, but heuristically, behavior ana- insight into variables that could influence safety. A complete lysts might more easily remember the number of years they list of the 83 references we used for this project can be found have been conducting FAs. Thus, we used time-based criteria in the references tab of the tool in the Supplemental Materials. for experience. The levels for experience ranged from 5 or Bailey and Burch (2016) discuss components of a risk- more years of experience conducting FAs with different inten- benefit analysis and identify the following as considerations sities and topographies to no experience conducting FAs. For for risk as it relates to problem behavior: behavior that places FA environment, conceivably the safest environment in which Table 3 List of sources for the references used in the tool in References alphabetical order Journals Advances in Learning and Behavioral Disabilities 1 Analysis and Intervention in Developmental Disabilities 1 Behavior Analysis in Practice 4 Behavior Analysis: Research and Practice 1 Behavior Modification 3 Behavioral Intervention: Principles, Models, and Practices 1 Behavioral Interventions 3 Cognitive and Behavioral Practice 1 Education and Training in Developmental Disabilities 2 Education and Treatment of Children 4 European Journal of Behavior Analysis 1 Journal of Applied Behavior Analysis 42 Journal of Autism and Developmental Disorders 1 Journal of Behavioral Education 1 Journal of Developmental and Physical Disabilities 2 Journal of Early and Intensive Behavioral Intervention 1 Journal of Positive Behavior Interventions 1 Journal of the Association for Persons With Severe Handicaps 1 Pediatric Clinics of North America 1 Research in Developmental Disabilities 3 The Behavior Analyst 1 Book/BACB BACB Professional and Ethical Compliance Code for Behavior Analysts / 3 Fourth and Fifth Edition Task Lists (BACB, 2012, 2017) Matson, J. L. (Ed.). (2012). Functional assessment for challenging 4 chapters behaviors. New York, NY: Springer. 984 Behav Analysis Practice (2020) 13:978–990 Fig. 2 Microsoft screen depicting a low risk scenario to conduct an FA could contain padded walls, affixed furniture, are challenging to block regardless of whether the topography and protective equipment. The least safe environment for an is self-injurious behavior, aggression, pica, elopement, or in- FA is one that has sharp, breakable glass objects; moveable appropriate sexual behavior. and destructible furniture and materials; and small, ingestible Next, we attempted to develop a way for these six domains choking hazards. For supporting personnel to assist with the to be evaluated in an interactive fashion. Specifically, it was FA, the ideal situation would be to have a medical doctor our opinion that risk could not be determined by simply con- provide written documentation that states that momentary in- sidering these four domains in a linear fashion. Rather, risk creases in problem behavior due to FA procedures pose little to was either heightened or lessened based on how the four do- no risk to the participant, as well as to have medical staff mains interacted with each other. For example, the risk of available to monitor the client during the FA and two to three conducting an FA with a very intense, self-injurious behavior well-trained support staff available during the FA. The least (e.g., severe head-banging) might be lowered by conducting ideal situation might be to have no additional staff to assist with the evaluation in the safest environment with highly experi- the FA and no medical oversight. For behavioral intensity, the enced behavior analysts, medical oversight, and trained staff target behaviors that produce the least risk of physical harm to to assist in the evaluation. Conversely, risk is increased when the client or others are those behaviors that are low in intensity attempting to conduct an analysis of severe self-injury with and rate, have not caused tissue/environmental damage in the poorly trained staff and a BCBA with limited experience. We past, and are unlikely to do so during an FA (e.g., off-task needed a mechanism to allow for these kinds of interactions. behavior, mild disruption, screaming). In each domain, there We determined this could be accomplished through Microsoft are instructions to assist the user in selecting the appropriate Excel®. This software allows for the use and integration of level of risk for his or her context. For example, the user is Visual Basic coding, as well as macros to create dynamic tasked with considering the ease of blocking the target behav- interactive programs. We programmed the domains to be dy- ior when evaluating behavior intensity. Target behaviors with namically interactive, whereby a higher risk in the experience the most risk of causing physical harm to the client or others domain or in the behavioral intensity domain inflates the over- are those that are high in intensity and rate, have previously all risk to a greater extent than the other domains. This effect is caused injury to self or others, and are severe; therefore, these magnified further if there is a higher risk in both of those Behav Analysis Practice (2020) 13:978–990 985 categories, or if three or all four domains are selected as higher Overall risk can range from slight, moderate, substantial, to risk ratings. This was accomplished by using different formula high risk (see Figure 3). algorithms for each risk rating. We created three versions of The third tab, “Risk Assessment,” contains suggestions for the tool to operate on Microsoft, Macintosh, and Android lowering risk specific to given concerns selected by the user, operating systems and, therefore, to avoid compatibility is- as well as a published reference the user can refer to for more sues. Using Excel® makes the tool accessible to most people, information. If any of the user’s clicks on the risk buttons on because many applied behavior analysts often use Excel for the second tab (Risk Evaluation) result in higher risk (i.e., creating single-subject graphs (Deochand, Costello, & Fuqua, within the 4–6 range for a given domain), matching sugges- 2015). Thus, most people should not require any additional tions for lowering risk and references in the third tab turn red software to operate the risk analysis tool. to highlight for the user what the suggestions for lowering risk When the user opens the tool, he or she will see multiple are. The fourth and fifth tabs, “Validity” and tabs at the bottom of the Excel® sheet. The first tab, “About “Considerations,” offer tips to the user for maintaining high the Tool,” contains basic instructions for how to operate the levels of validity in the assessment. We used “if-then” scenar- tool. There is also an option to use an interactive help menu ios to help guide the user in selecting appropriate consider- using a macro shortcut, which will help answer additional ations for the client. For example, after a high-risk scenario is questions a user may have regarding the tool. The second detected, the tool might recommend selecting reinforcing pre- tab, “Risk Evaluation,” contains the interactive tool consisting cursor behavior in an FA (Lalli, Mace, Wohn, & Livezey, of the four domains and six buttons for each domain to repre- 1995); using a structural analysis (Stichter & Conroy, 2005), sent the levels of risk within each domain. The user can click modified choice assessment (Berg et al., 2007), or reinforcer on one button within each domain to represent the current or punisher assessments; or complimenting a descriptive as- situation with his or her client. The buttons range in color from sessment with a contingency space analysis (Martens, blue (lower risk) to red (greater risk). At the same time, a DiGennaro, Reed, Szczech, & Rosenthal, 2008). “slider” below the domains incorporates the clicks from all Additionally, in the Validity and Considerations tabs are ta- these buttons to suggest the overall risk of the situation. bles and figures from articles that offer guidance regarding Fig. 3 Macintosh screen depicting a substantial-risk scenario 986 Behav Analysis Practice (2020) 13:978–990 contextual variables for structural analyses (Stichter & domains and asked them to rate the appropriateness of the Conroy, 2005), idiosyncratic variables that impact FA out- overall risk rating the tool produced for each specific scenario comes (Schlichenmeyer et al., 2013), or side effects of medi- combination. Most of these combinations constituted more cations (Valdovinos & Kennedy, 2004). The measurement “middle-of-the-road” risk, as we assumed there would be decision tree by LeBlanc et al. (2016) was also offered if the higher agreement with recommendations at the extreme ends user was unsure how best to track the target behavior. Our of the continuum. The “grayer” areas seemed to be those objective was to offer the supporting pieces that were request- where the most feedback was warranted. We used a 3-point ed by the participants from the survey in the risk assessment Likert scale that included It’s just right, Needs to be lower risk, tool. It is not possible to extract all suggestions from the tool and Needs to be higher risk. If the expert selected anything and present them within this article, but the reader is encour- other than It’s just right, we asked the expert to comment on aged to download and interact with the tool as an educational why/how the risk should be different. Finally, for each of the resource. It is available in the Supplemental Materials site for 12 combinations, we also asked the experts to rate the recom- the journal. mendations for reducing risk with a 5-point Likert scale that included not helpful, a little helpful, somewhat helpful, Phase 3: Expert Review and Revision helpful, and very helpful. Following that question, the experts could type any additional comments for that scenario After we created the tool, we requested feedback from experts combination. in conducting FAs to determine whether they considered (a) After the initial assigned combinations, experts were asked the selected domains appropriate for assessing risk, (b) each to interact with the tool, choosing any combinations for the domain to have produced an appropriate overall risk level, (c) two domains clinical expertise and behavior intensity, while the suggestions for lowering risk and literature base appropri- support staff and environment were fixed at the highest risk ate, and (d) the suggestions for maintaining the validity of the setting. We chose these two domains in particular to get expert FA appropriate. feedback on, as these were the most commonly listed barriers to implementing FAs in the previously published survey re- Expert Reviewers Experts were selected based on their notori- search (Oliver et al., 2015). For these combinations, we asked ety in the field for publishing peer-reviewed research on FAs, the experts to rate the appropriateness of the level of risk operating a behavior-analytic research/training laboratory, or identified, and if they would change it, to provide a rationale. engaging in the clinical practice of FAs at state-of-the-art in- Finally, experts selected additional combinations they wanted tensive treatment centers. We sent an initial request to com- to try out, and again we only asked them to rate the appropri- plete a review of the tool to 58 experts. We received 10 full ateness of the risk, and if they would change it, to provide a responses and 2 partial responses to our request. Experiential rationale. demographic data were collected on each of the experts. Four Finally, we asked open-ended questions about the four do- of the participants had more than 15 years of experience mains, if there were any risk factors they felt we missed, if the conducting FAs, three had 11 to 15 years of experience level of detail in the Risk Reduction tab was sufficient to carry conducting FAs, two had 6 to 10 years of experience out the suggested change, if the level of detail in the Risk conducting FAs, and one had 1 to 5 years of experience Reduction tab and Considerations tab was appropriate, how conducting FAs. Similarly, four had more than 15 years of accessible the tool was, whether the weighting we used for our experience training others to conduct FAs, three had 6 to risk scales was appropriate, if the tool was useful, and for 10 years of experiencing training others, and three had 1 to whom the tool would be useful. 5 years of experience training others. After we received feed- We then took the ratings and commentary provided by the back from these experts and revised the tool, we sent the tool experts and analyzed what, if any, changes should be made to to these same 10 experts for a second round of review. the tool. For most of the scenarios, at least 8 of 10 experts scored the risk rating as It’s just right. If more than one expert Guided Review Process and Results We used a survey to re- provided feedback that something needed to be changed, the ceive guided input from the experts, as this helped ensure our authors discussed the expert’s rationale, compared it to the experts responded to similar stimuli from the tool and there- feedback given by the other experts, examined the literature, fore guide the content of their responses. The survey was and made a determination whether to change the tool and, if so, created in Qualtrics. A link to the Qualtrics survey and a copy how. Examples of changes made included the following. of the three versions of the tool in Excel were provided to the Originally, we had four overall risk ratings that included “min- experts. The survey began by first orienting reviewers to the imal,” “some,” “moderate,” and “high.” Many of the reviewers tool to ensure they could effectively use it and could locate all felt that “minimal” risk was too narrow and that there is always of the features that we had built. Then, we provided them with risk with an FA. This produced interesting and spirited discus- 12 specific scenario combinations of risk within the four sion among the authors. Eventually, we decided to change the Behav Analysis Practice (2020) 13:978–990 987 lowest risk category to “slight” risk. Another common piece of decisions in an interactive decision-making process. In such feedback was that some of our combinations resulted in ratings cases, domains of consideration may interact with one another that were not high enough or ratings that were too high. In these in unique ways. For instance, our four domains all potentially cases, we adjusted the formulas in the tool to produce higher or impact risk in an FA (clinical experience, behavior intensity, lower ratings, whichever was appropriate given the experts’ support staff, and environmental setting) but likely do so in an feedback. Further, a few reviewers requested that we add addi- interactive fashion. High risk in one domain might interact tional considerations to the Risk Reduction tab for reducing with low or moderate risk in another domain to create unique risk. We responded to these by adding in the requested consid- risk situations. In this case, the four domains, each with six erations. After we discussed and resolved all issues, we sent the categories in the continuum, would lead to 1,296 different modified tool and a second survey to the experts who had possible combinations of risk factors. Unfortunately, a deci- completed the first survey, asking that they review our changes sion tree would not be a feasible format to display these op- and make further commentary. tions, nor could it easily be presented on a journal page. Thus, The second survey focused only on the changes we made we created this interactive tool so that all 1,296 possible com- to the tool to address the experts’ concerns. We made two binations could be taken into account in an efficient and useful substantial changes to our tool—specifically changing the for- manner. mulas to produce higher levels of risk and changing our word- Code 4.05 of the BACB® Professional and Ethical ing for the lowest level of risk on the slider representing over- Compliance Code for Behavior Analysts specifies, “to the all risk. We specifically asked reviewers to attend to these extent possible, a risk-benefit analysis should be conducted changes and provide feedback on them. We provided them on the procedures to be implemented to reach the objective” with some risk factor combinations that had produced sugges- (BACB, 2014). Evaluating whether assessments or treatments tions in our first round of reviews, and asked them to evaluate could adversely impact a client can be done at any point whether the overall level of risk was now appropriate or inap- throughout the therapeutic relationship and should conclude propriate, or whether they were neutral about the change. with a course of action where the benefits outweigh the risks There was also an open-ended commentary box for them to (BACB, 2014, p. 24). Unfortunately, the language surround- provide comments. We also requested feedback on the up- ing how to conduct a risk-benefit analysis or what form a risk- dated wording of each risk rating to “some,” “moderate,” benefit analysis should take is rather vague in our literature. “high,” and “very high” risk (previously “minimal,” “some,” Each assessment or treatment procedure can produce different “moderate,” and “high” risk). We asked for feedback using probabilities of success, different amounts of time to take ef- the same 3-point Likert scale and commentary box. However, fect, different levels of restrictiveness, and different impacts to take into account all the respective Likert and qualitative on quality of life, which make the selection process for assess- text data on the topic, we again revised the wording to ments and treatments a delicate tightrope on which to balance “slight,” “moderate,” “substantial,” and “high” risk. (Axelrod, Spreat, Berry, & Moyer, 1993). Code 3.01(a) spec- After the second round of expert reviews, we made a few ifies that functional assessments are prerequisites to behavior additional minor changes using the same rules from before— change programs and the type of assessment depends upon the that two or more reviewers had to agree on a change in order to needs of our clients, as well as their “consent, environmental prompt a revision. The tool presented here is the culmination parameters, and other contextual variables” (BACB, 2014). of our review of the literature on risk assessments in FAs, Because the functional assessment process is one of the largest methods of reducing risk in FAs, tool creation, two rounds differentiating factors of behavior-analytic practice from other of expert review, and final modifications. This tool (located psychological professions, it is essential that the safest and in the Supplemental Materials) is provided to assist practi- most efficacious assessment be selected for our clients’ needs. tioners in assessing risk and determining how risk can be Thirty-five of 598 participants reported using a formal pro- reduced and to offer references to published research to pro- cess to assess risk, but when asked to type additional informa- vide practitioners with more information. tion, only 19 responded. Those who responded referenced using a standard assessment in their facility, the chapter on risk-benefit analysis in Bailey and Burch (2016), or the article General Discussion “Functional Assessment of Problem Behavior: Dispelling Myths, Overcoming Implementation Obstacles, and There is an ethical need for tools that offer guidance and Developing New Lore” by Hanley (2012). It is unknown what resources to support the growing number of behavior analysts the remaining 579 participants use (if anything) to evaluate in the field (Geiger et al., 2010; LeBlanc et al., 2016; risk when implementing an FA. The majority of our survey Newhouse-Oisten et al., 2017). However, sometimes deci- sample endorsed FAs as powerful assessment tools capable of sions are complex, requiring multiple considerations— being used to evaluate cases where behavior is maintained by especially when one decision impacts the context of all other combined functions (Hanley et al., 2014). However, two prior 988 Behav Analysis Practice (2020) 13:978–990 surveys indicate that practicing behavior analysts appear to be further insight as to whether this variable potentially influ- avoiding the use of FAs. Bailey and Burch (2016) discuss the enced responding. Although data were gathered on years of dearth of literature and decision-making frameworks for risk- experience in the field, it would have been beneficial to divide benefit analyses, and note only one attempt to build a mathe- that question into two separate questions: one to ascertain a matical model for weighting risk for treatment selection. We participant’s years of experience post-BACB® certification, speculated that the absence of a clear way to evaluate risk and and another related to working within clinical or special edu- direction on how to lower risk might be contributing, at least cation settings. in part, to the lack of FA use in the field. Our systematic efforts There are notable considerations that should be taken into to consolidate the research and expert recommendations are an account when using the tool. One of the experts evaluating our attempt to offer some guidance surrounding the risk analysis tool rightly noted that not all years of experience are equal. For process prior to conducting FAs. A formalized risk assessment example, even with 2 years of FA exposure, the skill set of a might help bridge the research-to-practice gap that currently postdoctoral fellow with extensive experience conducting exists, at least when disseminating known research recom- FAs with the most severe behaviors under the mentorship of mendations. If clinicians are unwilling to use the FA in prac- leading experts in the field is very different from a master’s- tice because they are unsure whether it is safe to do so or level practitioner working with only a few children who dis- because their administrators are unsure of the potential risks, play mild problem behaviors. As a result, the level of risk for then such a tool may aid in the continued ethical professional conducting an FA for each of these practitioners may be very practice of applied behavior analysis. different. Our tool does not account for this difference in train- ing. We tried to make this apparent in our tool by offering Limitations instructions to the user to account for this (e.g., “Note FA experience in the buttons below do not take into account in- It is important to emphasize that the effectiveness of this tool tensive experience with the procedure e.g. postdoctoral train- in guiding clinical decision making about whether or not—or ing, or an increased # FAs conducted within a time period. how—to proceed with an FA remains to be validated. Our Thinking about these factors, which of the below best captures attempt to create a tool to formalize the risk assessment pro- your experience?”). This is a clear example where clinical cess is a worthwhile goal; however, we must make clear a very judgment must be used when completing and interpreting important caveat: No published tool is a replacement for on- the ratings on the tool. Regardless, behavior analysts have a going clinical decision making. Clinicians must take into ac- duty to promote an ethical culture. Offering this tool as an count a myriad of idiosyncratic variables that play into deci- educational resource is our attempt to provide some guidance sions for specific clients at specific points in time and in their until further empirical support is generated for its application specific context. into behavior-analytic practice. Furthermore, surveys provide at best descriptive snapshots of reported participant responses. Despite a majority of partic- ipants reporting the FA to be the most informative assessment Future Directions for problem behavior, similar to data collected from other surveys (Oliver et al., 2015; Roscoe et al., 2015), there is no There is no guarantee that simply providing a tool to practic- guarantee that the data collected directly relate to the actual ing behavior analysts will result in reducing the risks associ- reasons why the FA may be underemployed in practice. For ated with conducting an FA. Therefore, our next step is to example, the participants reported concerns regarding the va- evaluate whether practitioners’ use of the tool effectively im- lidity of the FA, but then they also endorsed the sentiment that pacts clinical decision making. Our expert panel anticipated the FA does not usually “get it wrong.” This seems incongru- the tool in its current stage may help safeguard the ethical ous and is a bit confusing. practice of FAs for new practitioners or those in training. It Previous surveys gathered additional data on the settings in is our hope that this tool will help narrow the research-to- which certified behavior analysts were practicing (Oliver practice gap and offer a structure for considering variables that et al., 2015; Roscoe et al., 2015). Gathering pertinent infor- may potentially contribute to risk in an FA. We do not pro- mation regarding where participants deliver the majority of mote the use of FAs in all circumstances and contexts. In fact, their services could have informed our discussion regarding there may be some cases where an FA is just not safe to resources and agency buy-in. There can also be cultural bar- conduct. We attempted to offer alternative forms of analyses riers to the effective dissemination of evidenced-based prac- (e.g., concurrent operants assessments, structural analysis) tices derived from applied behavior analysis (Keenan et al., when the risk is just too great to make an FA appropriate or 2015). Therefore, as the survey was disseminated to BCBAs feasible, given the circumstances. It is our hope that this auto- and BCBA-Ds all around the world, including demographic mated, interactive tool will offer insights and feedback to data regarding geographic location could have afforded us practitioners across several domains and that it captures at Behav Analysis Practice (2020) 13:978–990 989 least some of the complexity represented in the clinical Behavior Analyst Certification Board. (2012). Task list (4th ed.). Littleton, CO: Author. Retrieved from http://www.bacb.com/ decision-making process. index.php?page=100165 During the peer-review process, we received additional Behavior Analyst Certification Board. (2014). Professional and ethical feedback on our tool and incorporated those suggestions into compliance code for behavior analysts. Retrieved July 27, 2016, the tool to enhance the final version. The most current three from http://bacb.com/wp-content/uploads/2015/08/150824- compliance-code-english.pdf Excel versions created for phones and tablets, and Macintosh Behavior Analyst Certification Board. (2017). BCBA/BCaBA task list and Windows systems, can be downloaded as Supplemental (5th ed.). Littleton, CO: Author. Retrieved from https://www.bacb. Materials, but we hope that future versions of the tool (which com/bcba-bcaba-task-list-5th-ed/ we hope to continuously update) will be converted to web- Behavior Analyst Certification Board. (2018). US employment demand for behavior analysts: 2010–2017. Littleton, CO: Author Retrieved based platforms to make them even more user-friendly and from https://www.bacb.com/wp-content/uploads/Burning_Glass_ accessible. The tablet or phone version will operate with 20180614.pdf. iPhones or iPads and Android tablets or phones that have the Behavior Analyst Certification Board. (n.d.). BACB certificant data. Google Sheets application installed, whereas the other ver- Retrieved from https://www.bacb.com/BACB-certificant-data Berg, W. K., Wacker, D. P., Cigrand, K., Merkle, S., Wade, J., Henry, K., sions require access to Microsoft Excel™. The current and & Wang, Y. C. (2007). Comparing functional analysis and paired- future online formats should allow for ongoing developments choice assessment results in classroom settings. Journal of Applied in research to be appended to updated versions. In addition, a Behavior Analysis, 40, 545–552. https://doi.org/10.1901/jaba.2007. web-based platform may allow us to gather crowdsourced 40-545. recommendations from behavior analysts so that new releases Bloom, S. E., Iwata, B. A., Fritz, J. N., Roscoe, E. M., & Carreau, A. B. (2011). Classroom application of a trial-based functional analysis. better meet the ongoing needs of those in the field. Behavior Journal of Applied Behavior Analysis, 44, 19–31. https://doi.org/10. analysts have an ethical responsibility to proactively build 1901/jaba.2011.44-19. frameworks that support the professional practice of behavior Call, N. A., Pabico, R. S., & Lomas, J. E. (2009). Use of latency to analysis, and we hope sharing our preliminary work on this problem behavior to evaluate demands for inclusion in functional analyses. Journal of Applied Behavior Analysis, 42, 723–728. topic meets this objective. We hope this tool serves as an https://doi.org/10.1901/jaba.2009.42-723. educational resource that supports the professional practice Deochand, N., Costello, M. S., & Fuqua, R. W. (2015). Phase-change of applied behavior analysis. lines, scale breaks, and trend lines using Excel 2013. Journal of We strongly encourage the readers to download the tool in Applied Behavior Analysis, 48, 478–493. https://doi.org/10.1002/ jaba.198. the Supplemental Materials and contact the authors with feed- Deochand, N., & Fuqua, R. W. (2016). BACB certification trends: State back so we can ensure that we refine this resource for all those of the states (1999 to 2014). Behavior Analysis in Practice, 9, 243– in our growing community. 252. https://doi.org/10.1007/s40617-016-0118-z. Geiger, K. B., Carr, J. E., & LeBlanc, L. A. (2010). Function-based Author Note We would like to express our sincere gratitude for the time treatments for escape-maintained problem behavior: A treatment- and feedback of the 10 expert reviewers who reviewed beta versions of selection model for practicing behavior analysts. Behavior our risk assessment tool. Analysis in Practice, 3, 22–32. https://doi.org/10.1007/ BF03391755. Hanley, G. P. (2012). Functional assessment of problem behavior: Funding No sources of funding were utilized to present this information. Dispelling myths, overcoming implementation obstacles, and devel- oping new lore. Behavior Analysis in Practice, 5, 54–72. https://doi. Compliance with Ethical Standards org/10.1007/BF03391818. Hanley, G. P., Jin, C. S., Vanselow, N. R., & Hanratty, L. A. (2014). Conflict of Interest The authors know of no conflicts of interest that Producing meaningful improvements in problem behavior of chil- would present any financial or nonfinancial gain as a result of the poten- dren with autism via synthesized analyses and treatments. Journal of tial publication of this manuscript. Applied Behavior Analysis, 47, 16–36. https://doi.org/10.1002/jaba. 106. Iwata, B. A., & Dozier, C. L. (2008). Clinical application of functional Ethical Approval All research was conducted in compliance with ethical analysis methodology. 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