Cultural Responsiveness in Applied Behavior Analysis (PDF)

Journal of Applied Behavior Analysis 2022, 9999, 1–24 NUMBER 9999 () Cultural responsiveness in applied behavior analysis: Research and practice...

Journal of Cultural responsiveness Research Department The new Ethics Code for Behavior to culturally responsive service turally responsive evidence-based researchers and practitioners Hence, the purpose of this of ABA related to culturally recommendations, b) to examine ment align with aspects of ior assessment and treatment analytic practices. The content Jimenez-Gomez (2022). Key words: cultural awareness, culture, diversity, ethics Cultural variables impact access to healthcare services (Nelson, 2002), timing of diagnosis of autism spectrum disorder (Constantino et al., 2020), and misclassiﬁcation of diagno- ses (Coker et al., 2016; Constantino We have no conﬂict of interest to report. Given the topic, the authors consider it important to reveal some of the cultural identities spective, while acknowledging many other cultural variables also have impacted their CJG (she/her) was born and raised in Venezuela, is a speaker of English as a second language, in the United States, and has been in the analysis for 20 years. LB (she/her) is a nonreligious White female and was born and raised in the northeast and southeast United States. We thank Dr. Tyra Sellers, the Associate JABA, and the anonymous reviewers for their tremen- dously helpful comments on an earlier version of this manuscript. Address correspondence to: Corina Jimenez-Gom Auburn University, Department of Psychological Sciences, 226 Thach Hall, Auburn, AL 36849-5214. Email: [email protected] or Lauren Beaulieu, New- share cultural variables deﬁne as conforming MA 02460. class="__cf_email__" data-cfemail="fe9c9b9f8b92979b8b92be909b898a9190d095cfccd0939fd08b8d">[email protected] behaviors (Skinner, 1953). The learning histories of members of the community shape what are of Behavior (SEAB). 1 and Lauren Beaulieu Beaulieu and Jimenez-Gomez (2022) for a thorough discussion on the dimensions of cul- tural competence to gain a foundation on this topic with an emphasis on self-assessment—a fundamental step to providing culturally respon- sive services. We have chosen to use the term culturally responsive, which is aligned with the terminology used in the new Ethics Code (BACB, 2020). However, we use the three dimen- sions of cultural competence—awareness, knowl- edge, and skills (Sue et al., 1982; Sue et al., 1999; Sue et al., 2019)—to frame our discussion of culturally responsive behavior analytic services (see Table 2). Cultural responsiveness and ABA overlap in several ways. Cultural responsiveness avoids gross generalizations (e.g., stereotypes) and stresses the importance of focusing on the individual and the distinct intersecting cultural variables impacting the individual’s behavior. This term also high- lights the importance of identifying aspects of the environment (i.e., cultural variables) that impact behavior and effective care. Further, cultural responsiveness embodies relationship building and working collaboratively with clients to achieve effective and meaningful outcomes. Involving clients and stakeholders is explicitly stated in the Ethics Code for Behavior Analysts (code 2.09; BACB, 2020). An important consid- eration for researchers and practitioners is that culturally responsive services implies that behav- ior analysts do not treat all participants and cli- ents identically because the cultural dynamics they bring to the health care encounter differ (Kodjo, 2009). In addition, since cultural inﬂu- ences encompass a host of “invisible” variables (e.g., religion, sexual orientation), including ones that can shift throughout the life cycle (e.g., socioeconomic status/position [SES/SEP], geographic location, gender identity), it is impor- tant to see culturally responsive care as a continu- ous approach to be used with all research participants and clientele, not just those whose physical appearance differs from the researcher or practitioner or at one point in time. Responsive Research and Practice 3 Deﬁnition Citation process in which one works to develop the ability to Sue and Torino (2005, p. 8) or create conditions that maximize the optimal of client and client systems. Multicultural counseling is aspirational and consists of counselors acquiring knowledge, and skills needed to function effectively in a democratic society (ability to communicate, interact, and intervene on behalf of clients from diverse and on organizational/societal level, advocating to develop new theories, practices, policies, and structures that are more responsive to all groups.” is a life-long process that requires continual self- Tervalon & Murray-Garcia, 1998 to produce a dynamic partnership that reduces power between clinician and client and requires respect for superiority toward another’s cultural background cultural characteristics, experiences, and perspectives of Gay (2002, p. 106) diverse students as conduits for teaching them more (2022) assessment and treatment and provide practice recommendations, b) to examine the extent to which current practices in behavior assessment and treatment align with aspects of culturally responsive practices, and c) to inspire research in the areas of behavior assessment and treat- ment to identify best practices with regard to culturally responsive behavior analytic services. This paper highlights important works within and outside the ﬁeld of ABA but it is not a comprehensive review paper. The research ideas in this paper are not exhaustive and the authors recognize that their own cultural variables impacted their selection of speciﬁc research questions. We encourage others to identify fur- ther possibilities of research. Additionally, we acknowledge and encourage others to recognize that training in this area is a life-long commitment. How- s, Culturally Responsive Assessment In accordance with the ethical code enacted by the Behavior Analyst Certiﬁcation Board® (BACB®), behavior analysts should strive to con- duct culturally responsive behavior assessments Jimenez-Gomez and Lauren Beaulieu Analytic Services culture; discriminate and tact cultural variables that impact behavior differences; use a posture of cultural humility with individuals from cultural than own biased behaviors and their impact on services, including both clients and the supervision scope of competence regarding cultural diversity and access additional support or provide treatment of minoritized groups with respect to sociopolitical systems in the country/ knowledge about the cultural group with which one works tact barriers that prevent people from minoritized groups use of behavioral services contraindicated treatments due to cultural variables and conduct risk assessments related to ethical dilemmas and decision-making vary across cultures tact the role of cultural variables in the supervision and training of trainees in deﬁning targets, preferences for treatments, and treatment effects across cultures with clients and caregivers and prevent and disrupt biases to feedback on mistakes one emits related to cultural differences with oneself when confronted with challenges during the life-long learning process emission of mistakes regarding cultural differences cues and communicate effectively with all forms of verbal behavior (vocal and gesture) responsive interventions to clients as needed of rapport building behaviors based on cultural variables and actively listen to caregiver concerns caregivers on treatment goals and treatment selection treatment components if using potentially contraindicated treatments and comprehensive monitoring plan model and understand the context related to cultural variables when making ethical feedback from others to improve future performance assessments throughout the assessment and treatment process (2022). Previous Research There are a few examples of studies focusing on behavior assessments that speciﬁcally incor- porate cultural variables. For instance, Rispoli et al. (2011) demonstrated how linguistic variables can be considered during functional analysis (FA) implementation. The authors evaluated the effects of language used for implementation of FA conditions on the levels of problem behavior emitted by a participant from a Spanish-speaking family. They observed increases in problem behavior when the FA was Responsive Research and Practice 5 necessitates behavior analysts to consider the cultural variables the client brings to the encounter. Failure to routinely consider idiosyncratic vari- ables within FAs may explain why Hagopian et al. (2013) found that out of 176 FAs based on the Iwata et al. (1982/1994) model, only 47% resulted in identifying the function of problem behavior. For the remaining 53% of FAs included in this analysis, modiﬁcations or other forms of assessment were needed; however, it is not clear the degree to which cultural variables impacted lack of differentiation. It is also critical to note that because Jessel et al. (2020) found 51% of publi- shed FAs were standardized, the rest (49%) were not standardized and included modiﬁcations to the FAs, but it is unclear whether the modiﬁca- tions considered cultural variables. Further, as Rispoli et al. (2011) and Tsami et al. (2019) dem- onstrated, the standard FA can be adapted to incorporate cultural variables by considering lin- guistic background and modifying conditions to incorporate variables related to the client’s culture (e.g., modifying conditions to include culture- speciﬁc demands and attention). Although not explicitly described as culturally responsive in the research literature, Hanley et al. (2014) describe a functional analysis model that includes both an interview with caregivers (i.e., fostering the collaborative approach) that explicitly captures the lived environmental condi- tions related to the problem behavior, and the direct observation of the client. Because this approach involves designing conditions based on the inter- view, which captures the lived environment, it might facilitate identifying cultural variables that impact the client’s behavior (i.e., identifying culture-speciﬁc demands and attention). This method has been replicated and extended in numerous studies (e.g., Beaulieu et al., 2018; Jessel et al., 2016; Rose & Beaulieu, 2019; Slaton et al., 2017), but research is needed to speciﬁcally assess the impact of culture on FA outcomes and treatment effects. In addition to considering cultural variables in FAs, Dennison et al. (2019) suggest Jimenez-Gomez and Lauren Beaulieu approach is vital to behavior assessment as it can help practitioners uncover important cultural and environmental variables relevant when evaluating clients’ behaviors. We were unable to identify any behavioral research with respect to methods to improve cultural humility. However, in nursing, Schuessler et al. (2012) evaluated the use of reﬂec- tive journaling during a four-semester experiential learning experience on cultural humility with nursing students. The authors observed changes in the journal entries across semesters that reﬂected an improved understanding of the impacts of culture and biases on health care. In addition, the authors observed changes in the stu- dents’ journal entries as they related to their own biases with their patients. In other words, students were able to reﬂect on biases they originally held with patients and how they shifted over time. Juarez et al. (2006) evaluated the effects of a 1-year diversity course on medical school resi- dents’ behaviors related to cultural humility with simulated patients during mock exams. A strength of this study was that researchers examined behav- ior changes with simulated patients during mock exams as opposed to solely relying on self-report. The authors observed improvements in collabora- tive behavior during the mock exams. For instance, participants sought the perspective of the patient and involved them in decision-making. Research in this area within behavior analysis could inform the impact that particular interventions have on promoting cultural humility and a collaborative approach to service delivery (e.g., collaboratively selecting targets with caregivers, caregivers info- rming the assessment process). Next, we consider the three dimensions of cultural competence proposed by Sue and col- leagues (Sue et al., 1982; 1999; 2019) to frame our discussion of cultural responsiveness in we capitalize behavior assessment. after thor- of using lowercase Awareness our society (see With respect to behavior assessment, the awareness dimension relates directly to being Responsive Research and Practice 7 help the practitioner/researcher consider the impacts of culture on behavior. Fong et al. (2016) assert that considering the impact of culture is necessary for becoming a culturally competent behavior analyst. For example, a more culturally aware practitioner may pause to consider all relevant variables when they walk into a house that they label “chaotic” (e.g., children loudly running around) or observe a parent assisting a child in skills the behavior analyst thinks children should do independently (e.g., a caregiver hand-feeding a 5-year-old child). This practitioner may recog- nize that their interpretation of “chaos” or “order” and what a child should be able to do independently at a given age is based on their cultural background. Hence, this practitioner may be more likely to listen to the goals described by the caregivers rather than identify- ing goals based solely on their observation of the client’s home life. In this way, collecting demographic data can function as an anteced- ent tactic to facilitate the practitioner’s cultural awareness. Second, gathering demographic data can help the practitioner assess whether they are qualiﬁed to provide services to the client. Fong (2020) provides a decision tree for practi- tioners to determine whether they are qualiﬁed to deliver behavioral services when the cultures of the client and practitioner do not match. The decision tree proposes questions that require the practitioner to reﬂect on the client’s culture, their own culture, the practitioner’s training and experience working with individ- uals with the particular cultural background of the client, potential biases that may impede ser- vices, and barriers to services related to culture. Given the emphasis the Ethics Code (BACB, 2020) places on practicing within the practi- tioner’s area of competence, Fong’s decision tree is a ready-to-use tool to evaluate compe- tence in the area of culture; however, it should be noted that research on the utility of this tool is still needed. and Lauren Beaulieu punishment, etc.) are reported; these data could be aggregated to assess patterns. Although behavior-analytic research with such a monitoring system is yet to exist, these systems are being used in education to assess and address dis- proportionality in discipline delivered in schools (Green et al., 2015; McIntosh et al., 2014). McIntosh et al. (2014) describe how school teams implementing school-wide positive behavior inter- ventions and supports can use demographic and discipline data to identify and address dis- proportionality. They recommend that schools collect discipline data on ofﬁce referrals and school suspensions. Behavior analysts could adapt this approach to behavior-analytic procedures (e.g., speciﬁc types of punishment procedures such as time-out or the use of restraint). Types of Demographic Data. Despite a consensus across ﬁelds that demographic informa- tion should be collected, the speciﬁc data deemed most helpful differ across ﬁelds. Furthermore, the speciﬁc types of demographic information that are most likely to enhance behavior-analytic services are unknown. To better understand current prac- tice in collecting demographic information, we reviewed the areas of health care, education, and psychology. In health care, collecting demo- graphics is critical to better understand health dis- parities. A review of literature and the minimum standards set forth by the US Department of Health and Human Services identiﬁed the follow- ing demographic variables: primary language, race, ethnicity, gender identity, sex at birth, sexual ori- entation, age, disability status, and religion (Cahill et al., 2014; Cahill et al., 2016; Lee-Poy et al., 2016; U.S. Department of Health and Human Services [HHS], 2011). It is rec- ommended that questions about ethnicity are asked prior to race and the minimum categories for ethnicity to include Hispanic, Latino, and Not Hispanic or Latino (US Department of HHS, 2011). The minimum categories for race include American Indian, Alaska Native, Asian, Black, African American, Native Hawaiian, Other Paciﬁc Islander, and White (US Department of Responsive Research and Practice 9 the individual to specify if none of the options pro- vided are suitable. In terms of evaluating social class, Hughes et al. suggest the use of a subjective social status (SSS) measure instead of the more tra- ditional SES; whereas others have suggested the use of socioeconomic position (SEP) measures to assess this variable (e.g., Galobardes et al., 2006). Impor- tantly, given that terminology used to describe cul- tural variables is constantly evolving, researchers and clinicians should regularly check the language used in their demographic surveys to ensure it aligns with current norms and the terminology used by members of diverse communities. Overall, there is some overlap in demographic variables deemed important across ﬁelds reviewed (i.e., primary language, race, ethnicity, sex at birth, and disability status). However, the lack of clear consensus on which demographic informa- tion to collect and how knowledge about each demographic variable could be useful for research and clinical purposes highlights a need for evidence-based recommendations for researchers and practitioners in behavior analysis. Considerations When Collecting Demo- graphic Data. Table 3 lists several important considerations when collecting demographic information during intakes. Another important consideration when collecting demographic data is that not all individuals will be comfort- able reporting various types of demographics (e.g., nationality, SES/SEP, gender identity). For instance, for families for whom immigra- tion status may be a concern, asking for demo- graphic information may not be appropriate and could hinder the client–practitioner or participant–researcher relationship. Providing a form, rather than vocally requesting the infor- mation, allows a person to skip questions. Engaging in culturally responsive care includes recognizing cultural differences with respect to sharing personal information. In addition, even if an individual skips all demographic questions, behavior analysts can incorporate the key fea- tures of cultural responsiveness outlined in Figure 1 to enhance their services. Perhaps Jimenez-Gomez and Lauren Beaulieu Table 3 Considerations for Collecting Demographic Information Area Example Explain purpose and “This information is collected to privacy policy ensure our services are aligned with your family’s values. The information is conﬁdential, will be stored in … and only members of your child’s clinical team will have access to it.” Use paper or electronic Instead of interviewing the form individual, providing a form allows for privacy and time to determine which information they choose to share Ensure data collection is Present information in Braille for ADA-compliant visually impaired clients Ensure data collection is Note whether demographic survey offered in various is available in other languages or languages or translation translation services are available is available Use inclusive language Instead of using the terms “mother” and “father” when asking about a child’s parents, use the word “caregiver” to recognize the variety of existing family dynamics Offer multi-select boxes Under the race and ethnicity section, allow individuals to select as many options as they deem appropriate Allow individuals to self- Under gender identity and race, describe provide individuals an option to specify their answer if the ones listed are not adequate Allow for questions to be Provide a “prefer not to answer” skipped option Regularly review Ensure terms used align with terminology used current norms and the terminology used by members of diverse communities directly corresponds with the BACB Ethics Code for Behavior Analysts (2.09 Involving Cli- ents and Stakeholders and 2.14 Selecting, Designing, and Implementing Behavior-Change Interventions; BACB, 2020). When selecting goals, it is critical that behavior analysts are aware of relevant cultural variables and how they impact values and goal selection on the behavior analysts’ part (e.g., cultural practices regarding meals or toileting). Similarly, when designing a measurement system and operationally deﬁning behaviors, the behavior analyst should aim to capture the relevant aspects of the behavior to Responsive Research and Practice 11 in Applied Behavior Analysis (ABA) service implementation, engaging community members and stakeholders in research; Hacker, 2013) is integral to identifying culturally responsive environments to acquire individualized knowl- edge about the cultural practices to which they subscribe. Culturally Responsive Descriptive Assessments When assessing behavioral contingencies, cultural variables provide important clues about likely histories of reinforcement and punish- ment, and these histories can alter the effective- ness of speciﬁc reinforcers and punishers. For example, Black, Indigenous, and people of color (BIPOC) living in the U.S. are likely to experience microaggressions daily (Sue et al., 2007). This history of microaggressions related to race can impact the types and sources of atten- tion that may or may not be reinforcing to an individual’s behavior. That is, the same type of attention that may function as a reinforcer for someone from one racial background may func- tion as a punisher for someone from a different racial background because of their differential history of reinforcement and punishment. For example, a White employee telling another White colleague they are very articulate may function as a positive reinforcer for the White colleague’s behavior; whereas a White employee telling a BIPOC colleague they are very articulate and Lauren Beaulieu Research could evaluate best methods to assist practitioners consulting in schools and residen- tial facilities. For example, a practitioner consult- ing in a school for a BIPOC client could collect class-wide data while the practitioner observes their assigned student to obtain a class-wide benchmark of the target behavior. If the practi- tioner observes that several students are engaging in similar levels of the disruptive behavior, a class-wide intervention may be a more appropri- ate intervention. Class-wide programs are a less restrictive intervention type compared to small group and individual, so this process is in line with the least restrictive alternative outlined in the Ethics Code for Behavior Analysts (BACB, 2020). Collecting class-wide data will not deﬁni- tively indicate whether a client experienced dis- criminatory treatment but doing so can help the practitioner advocate for that child. If the child was singled out, whether intentionally or unintentionally, these data can help educate the team and school administrators with the aim of protecting the child. For behaviors for which the goal is to decrease or shape the topography, not eliminate the behavior (e.g., requesting attention from teacher, call outs), the practitioner could use the class-wide data to set goals for the client and self-monitor their own behavior to ascertain they are not applying more stringent rules for the BIPOC student compared to the other students. For example, the practitioner or researcher can ask themselves and assess whether the BIPOC student is being held to a zero-callout standard while other White students are permitted to call- out at a low level. As with the other suggestions for culturally responsive care provided in this paper, this application would require empirical evaluation to ascertain its utility. Skills There is some overlap among the awareness, knowledge, and skills dimensions. The previ- ously discussed rapport-building and communi- cating with clients and caregivers with a Responsive Research and Practice 13 exhaustive list, but rather as an initial list that we hope will prompt future research and further additions to the list. Culturally Responsive Treatment Previous Research There is limited behavioral research speciﬁ- cally addressing cultural variables in behavior treatments. In one such study, Lang et al. (2011) observed increases in challenging behavior and decreases in correct responding when instruc- tion was delivered in the participant’s second language (English), but researchers observed the opposite when instruction was delivered in the participant’s ﬁrst language (Spanish). This ﬁnding demonstrates the impact of one cultural variable on treatment outcomes. In another study, Jimenez-Gomez et al. (2022) taught lis- tener skills to three boys with autism whose primary language in the home was Spanish. The researchers arranged learning trials to deliver the initial instruction in English while delivering instructive feedback in Spanish, all- owing researchers to promote learning of skills that would be socially signiﬁcant in the clinical (English) and home (Spanish) environments. Dennison et al. (2019) describe several con- siderations for practitioners who work with cul- turally and linguistically diverse families. The recommendations include using a posture of cultural humility, encouraging the use of inter- preters at the ﬁrst point of contact with the family when their language differs from the practitioner’s, conducting a cultural analysis that systematically identiﬁes the impact of cul- tural variables on behavior, and avoiding gross generalizations of a culture to a particular client (see also Wang et al., 2019 for recommenda- tions for linguistic diversity). Sivaraman & Fahmie (2020a) conducted a systematic review of cultural adaptions of ABA-based telehealth services. All nine studies included involved pro- viding telehealth services in countries outside of the United States. The primary adaptions of Jimenez-Gomez and Lauren Beaulieu and/or gender identity), and parent selection of goals. However, there were additional adaptions in some studies such as rapport-building ses- sions, changes in service delivery time due to time zone differences and school day, and culture-relevant tasks. Sivaraman & Fahmie (2020b) is another collecting, reviewing, notable example of how behavior analysts can of Fong (2020) decision make cultural adaptions to treatments. The competence to authors evaluated the effectiveness of a parent- training program at a clinic in India and pro- a posture of cultural vided a multitude of cultural adaptions. Some across time of these adaptions included: matching the eth- methods related to nicity between trainer and participants, translat- ing materials to the language the participants spoke, the trainer speaking in the primary lan- follow-up questions guage of the participants, employing video models matched in ethnicity, role-playing cul- ers/researchers gathered from a turally relevant scenarios (e.g., speciﬁc tasks given to children were relevant to the region), cultural variables on using speciﬁc terminology relevant to the region, matching data collection to culture- assessments to speciﬁc behavior/tasks, among others. Tsami collecting group data et al. (2019) included similar cultural adaptions minoritized groups in best methods to address such as matching language with participants, use of reinforcers relevant to the culture, and for teaching others to parent selection of targets. cultural humility rapport building Despite the studies described, ABA lacks enhance collaboration sufﬁcient research to identify best practices for cultural adaptions and culturally responsive behavior analytic service delivery. This when selecting goals section is not intended to be a comprehensive review of cultural adaptions. Rather, the pur- (e.g., descriptive analyses) and the pose is to highlight some of the culturally responsive work that is being conducted in respond effectively to ABA. In the next section, we review how cur- related to cultural during rapport building) rent ABA practices align with culturally responsive services and discuss how these prac- tices can be implemented to support a more culturally responsive practice by incorporating the various tenets of cultural responsiveness (e.g., collaboration). Lastly, we review some areas of needed research to identify best prac- tices for culturally responsive behavior analytic treatment. Responsive Research and Practice 15 Ferguson et al. (2019) found that only 6% of studies from 1999-2016 in JABA used interven- tion choice as a measure of social validity. The study by Padilla Dalmau et al. (2011) is a notable example of incorporating choice related to cultural variables by assessing preference of language implementation during the reinforce- ment period of an FCT intervention with two participants whose caregivers spoke both English and Spanish in the home. Both treatments—the treatment with the reinforcement period in English and the treatment with reinforcement period in Spanish—produced similar reductions in destructive behavior, and the participants did not demonstrate preference for a particular lan- guage during reinforcement. However, it should be noted that a considerable limitation of the study was failing to evaluate whether the partici- pants discriminated between the languages. Nonetheless, this study provides an example of offering treatment choices related to cultural var- iables that future research could expand upon. It may be possible to increase the effective- ness and acceptability of interventions by giving clients choices of evidence-based treatments. By giving clients a choice between a few evidence- based treatments, practitioner biases are removed from the selection and social validity may be improved (Hanley, 2010; Schwartz & Baer, 1991). Offering choices can be conducted in various manners, such as via discussion with the caregiver or through concurrent chains arrangement (Hanley, 2010; Hanley et al., 2005; Potter et al., 2013). Although we are advocating for behavior analysts to become facilitators of behavioral services by using a more collaborative approach, more research is needed to identify the most effective methods for providing evidence-based choices to clients and caregivers in various settings (e.g., public schools vs. homes). A related topic needing more research within our ﬁeld, but which is beyond the scope of this paper, is consent and assent to participate in research and behavioral interventions (e.g., Morris et al., 2021). Jimenez-Gomez and Lauren Beaulieu should provide caregivers information on the most effective treatment options, and they are required to provide evidence-based treatment. However, the caregiver has the right to choose treatments and may decide to continue with an unproven treatment. Such cases may be an oppor- tunity to foster a collaborative relationship with the client and caregivers by using behavioral meth- odology to evaluate such treatments using single- subject design if the treatment coincides with the behavioral services (e.g., gluten free diet, running sessions after hyperbaric oxygen therapy). Lerman et al. (2008) provide several considerations for behavior analysts who evaluate unproven thera- pies. The authors provide an example using a mul- tiple baseline design to examine the effects of hyperbaric oxygen therapy on problem behavior, communication, and task engagement exhibited by three children diagnosed with autism spectrum disorder. The authors observed no improvement in problem behavior and task engagement for any participant and idiosyncratic differences in com- munication with one participant. Although evalu- ating unproven therapies may assist clients and caregivers to make more informed decisions about which treatments they would like to experience, we could not ﬁnd research evaluating whether this approach impacts the likelihood a caregiver will select a proven therapy after observing little or no results with the unproven therapy or a therapy with no empirical evidence. caregivers Treatment Integrity Treatment integrity, sometimes referred to as procedural integrity, is the extent to which a per- son implements the treatment with accuracy (Wilder et al., 2006). Assessing treatment integ- rity aligns well with culturally responsive services as it enables the behavior analyst to determine whether the treatment is being implemented as prescribed. Often, behavior analysts interpret low treatment integrity as a problem of insufﬁcient or inadequate training, which can be remedied by additional coaching. However, it is also possible low treatment integrity reﬂects the treatment was Responsive Research and Practice 17 barriers that prevent members of minoritized groups from accessing speciﬁc services. For exam- ple, Black and Latino children are less likely to take medication for treatment of ADHD (Coker et al., 2016), which Moody (2016) reports could be due to various concerns related to the mistrust of institutions, cultural misconceptions, and the fear of medication leading to drug abuse. Learn- ing about the varied perspectives of others may lead to a more compassionate approach to service delivery. and if so, caregivers Skills The components of the skills dimension that relate to behavior treatment include producing a variety of verbal responses as a result of differ- ences in client concerns and differences in treatment effects, responding to cultural cues and communicating effectively using all forms of verbal behavior (vocal and gestural), design- ing treatments with cultural adaptions, and exe- cuting intervention skills on behalf of clients as needed. See Table 2 for an in-depth list of skills. Functional Communication Training Functional communication training (FCT; Durand & Carr, 1991) is one example of a treat- ment component that is not typically described as culturally responsive but might incorporate cul- tural variables. FCT aligns well with culturally responsive services as it requires the behavior ana- lyst to teach the client communication skills rele- vant to the client’s challenging behavior. In this way, culture-speciﬁc reinforcers might be cap- tured and utilized in functional communication. Banerjee et al. (2022) adapted FCT implemented with two bilingual learners with disabilities to incorporate linguistic variables. Speciﬁcally, Ban- erjee et al. demonstrated that, when the trained functional communicative response was placed on extinction, the response in the alternative lan- guage did not emerge unless directly taught. This ﬁnding is important for learners in bilingual or Jimenez-Gomez and Lauren Beaulieu the Dimensions of Cultural Responsiveness Research Questions of utilizing social validity assessments for all interventions – before, during, and after – on clinical outcomes, treatment integrity, and maintenance of clinical gains treatment integrity relates to low acceptability due to cultural variables and methods to that are not culturally appropriate providing clients choices of evidence-based treatments impacts effectiveness and interventions to request assent for evidence-based treatments while also assessing impacts of assent on with children (e.g., implications of children assenting on meeting skill acquisition goals) for obtaining assent and consent with clients of various abilities and cultural comparing effectiveness and social validity of different manners of presenting information for providing evidence-based choices to clients of various abilities and cultural for discussing ineffective or unproven treatments and negotiating evidence-based choice after an unproven therapy is evaluated and demonstrated not effect to conduct risk assessments if using potentially contraindicated treatments for making cultural adaptations to treatments of programming for generalization while considering cultural variables and assessing clinical outcomes for providing intervention choice to clients and caregivers and its impact on clinical to which behavior analytic interventions already capture cultural variables (e.g., FCT, by collecting and reporting cultural variables in behavior analytic research for discussing ineffective treatments with caregivers lead to best clinical outcomes to shift preference toward evidence-based treatments to enhance client and caregiver collaboration throughout the treatment process to respond effectively to mistakes one emits related to cultural differences and we encourage readers to expand this list. model discussed previously (Hanley et al., 2014) is followed by a corresponding skill-based treatment that is informed by an interview with the caregiver and the FA results. This interview provides robust information regarding important contexts that occasion the targets, which are then incorporated into the treatment process. It is likely many practi- tioners use procedures that incorporate caregiver input in the design and implementation of behav- ior treatments; however, it is not clear to which degree cultural variables are explicitly incorporated. It is also unclear whether caregiver input impacts goals and interventions selected and whether this would ultimately result in positive clinical Responsive Research and Practice 19 describe any speciﬁc considerations and modiﬁca- tions made based on a client’s culture in their methods (e.g., variation of behavior, stimuli used, instructions delivered, situations targeted, lan- guage spoken), which can allow practitioners to have evidence-based guidance on designing cul- turally responsive treatments. We urge researchers to also include relevant, detailed demographic information of research participants that can help provide guidance to practitioners and better assess generality of ﬁndings. Pro- rs context, Summary Applied behavior analysts work with diverse populations and there is a growing need for behavior analysts to provide culturally respon- sive services. In this paper, we described current practices within and outside of ABA related to culturally responsive behavioral assessment and treatment with the aim of inspiring further research and showcasing how some behavior analytic tools and processes can be used in a more culturally responsive manner. Given the urgent need to provide culturally responsive behavioral services, it may be tempting to sim- ply adopt recommendations and strategies from education, nursing, and psychology into behav- ior analytic practice. Whereas that may be a place to begin, it is important for practitioners to consider whether existing practices are com- patible with behavior science and can be readily incorporated by practitioners. Although we sug- gest more research is needed to identify best practices with respect to culturally responsive behavior analytic services, we describe speciﬁc ways behavior analysts can begin to provide more culturally responsive services with their clients and participants (e.g., collecting relevant demographic information, considering linguis- tics needs of clients, using descriptive assess- ments to collect information related to culture). We encourage behavior analysts to adopt some of the key features of cultural responsiveness, Jimenez-Gomez and Lauren Beaulieu Banerjee, I., Lambert, J. M., Copeland, B. A., Paranczak, J. L., Bailey, K. M., & Standish, C. M. (2021). 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Behavior Analysis in Practice, 12(3), 557-575. https://doi.org/10.1007/s40617-018-00313-6 Beaulieu, L., & Jimenez-Gomez, C. (2022). Cultural respon- siveness in applied behavior analysis: Self-assessment. Journal of Applied Behavior Analysis, 55(2), 337-356. https://doi-org.spot.lib.auburn.edu/10.1002/jaba.907 Beaulieu, L., Van Nostrand, M. E., Williams, A. L., & Herscovitch, B. (2018). Incorporating interview- informed functional analyses into practice. Behavior Analysis in Practice, 11(4), 385-389. https://doi.org/ 10.1007/s40617-018-0247-7 Behavior Analyst Certiﬁcation Board (2020). Ethics code for behavior analysts. Author. behavior Betancourt, J. R. (2006). Cultural competence and medi- cal education: Many names, many perspectives, one goal. Academic Medicine, 81(6), 499-501. https://doi. org/10.1097/01.ACM.0000225211.77088.cb Brach, C., & Fraser, I. (2002). Reducing disparities through culturally competent health care: An analysis of the business case. Quality management in health care, 10(4), 15-28. https://doi.org/10.1097/ 00019514-200210040-00005 Brodhead, M. T., Duran, L., & Bloom, S. E. (2014). Cultural and linguistic diversity in recent verbal behavior research on individuals with disabilities: A review and implications for research and practice. The Analysis of Verbal Behavior, 30(1), 75-86. https://doi. org/10.1007/s40616-014-0009-8 Cahill, S. R., Baker, K., Deutsch, M. B., Keatley, J., & If reliance on epi- Makadon, H. J. (2016). Inclusion of sexual orienta- tion and gender identity in stage 3 meaningful use of Applied Behavior guidelines: A huge step forward for LGBT health. LGBT Health, 3(2), 100-102. https://doi.org/10. 1089/lgbt.2015.0136 Cahill, S., Singal, R., Grasso, C., King, D., Mayer, K., Baker, K., & Makadon, H. (2014). Do ask, do tell: High levels of acceptability by patients of routine col- lection of sexual orientation and gender identity data Responsive Research and Practice 21 Fong, E. H., Ficklin, S., & Lee, Y. H. (2017). Increasing cultural understanding and diversity in applied behav- ior analysis. Behavior Analysis: Research and Practice, 17 (2 ), 103 -113. https://doi.org/10.1037/bar0000076 Fong, E. H., & Tanaka, S. (2013). Multicultural alliance of behavior analysis standards for cultural competence in behavior analysis. International Journal of Behavior Consultation and Therapy, 8, 17 -19. https://doi.org/ 10.1037/h0100970 Galobardes, B., Shaw, M., Lawlor, D. A., Lynch, J. W., & Davey Smith, G.

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