Association for Behavior Analysis International

The Association for Behavior Analysis International® (ABAI) is a nonprofit membership organization with the mission to contribute to the well-being of society by developing, enhancing, and supporting the growth and vitality of the science of behavior analysis through research, education, and practice.


50th Annual Convention; Philadelphia, PA; 2024

Event Details

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Symposium #504
CE Offered: BACB
Caregiver Treatment Adherence: Highlighting Current Practices, Acknowledging Limitations, and Recognizing a Need for More Research
Monday, May 27, 2024
3:00 PM–4:50 PM
Convention Center, 100 Level, 103 A
Area: DDA/AUT; Domain: Applied Research
Chair: Omar Elwasli (Eastern Michigan University)
Discussant: Claire C. St. Peter (West Virginia University)
CE Instructor: Omar Elwasli, M.A.
Abstract: Outcomes of behavior change interventions in the natural environments where they are intended to have life-changing impacts are often suboptimal. The most common approach to building the capacity of incumbents in those environments has been behavioral skills training, and the most common measure used to reflect the development of sufficient capacity for implementation has been treatment integrity. Treatment integrity involves the implementation of a protocol as it is designed, and in behavior analytic research and practice, is typically indexed through direct observation. This is also the typical default when behavior analysts evaluate generalization across settings or circumstances, and maintenance across time. Alternatively, treatment adherence involves implementation without oversight and has received limited attention in behavior analytic literature. Evidence to date suggests adherence to behavior analytic interventions, when measured, is less robust than observed integrity (e.g., Moore et al., 2011), corresponding with decades of adherence research in allied health professions. The papers in this symposium bring awareness to adherence and our field’s related research and practice limitations, through a variety of perspectives. In so doing, we provide a foundation and invitation for behavior analysts to address, and advance the conversation about, adherence through their own work.
Instruction Level: Basic
Keyword(s): Caregiver, treatment adherence, treatment nonadherence
Target Audience: intermediate
Learning Objectives: (1) Audience members will be able to define caregiver treatment adherence and nonadherence. (2) Audience members will be able to identify the variables that may serve as barriers to caregiver treatment adherence. (3) Audience members will be able to describe strategies for addressing barriers to caregiver treatment adherence and improving durable treatment outcomes.
Treatment Adherence in Behavior Analysis Literature Before and After Allen & Warzak: A Rapid Review
YUANZHEN WU (University of Minnesota), Katie Brown (Utah State University), Alyssa Hurd (Utah State University), Timothy R. Moore (University of Minnesota Medical School)
Abstract: The publication of Allen & Warzak (2000) invited behavior analysts to consider the distinction between treatment integrity and adherence (ie, implementation without direct observation in non-clinical settings), while providing a formulation of the shortcomings of existing frameworks for understanding and improving adherence in medicine and behavioral health. In particular, these frameworks failed to consider the environmental circumstances and contingencies behavior analysts know to be central features to a model of behavior change. As we approach 25 years since the publication of Allen & Warzak, the current research review provides an opportunity for reflection on the impact of the paper as well as considerations for continuing to advance the importance of adherence in our research and practice. This rapid review included current behavior analytic journals with publication dating back to at least 1980, allowing for comparisons between papers published prior and subsequent to Allen & Warzak. Data extraction, following full text review and the initial screening of 421 de-duplicated papers, will enable analysis and discussion of publication trends overall, conceptual vs treatment papers, measurement trends, systematic support for & barriers to adherence, and related factors clinicians and researchers should consider in contemporary behavior analysis to more deeply root our powerful technology where it matters most.

Factors Associated With Readmission to Intensive Outpatient Services for the Assessment and Treatment of Severe Problem Behavior: A Retrospective Controlled Consecutive Case Series

SAMANTHA JO NERCESIAN (Utah State Univeristy), Katie Brown (Utah State University), Alyssa Hurd (Utah State University), Lauren Laymen (University of Nebraska Medical Center Munroe-Meyer Institute )

Factors Associated with Readmission to Intensive Outpatient Services for the Assessment and Treatment of Severe Problem Behavior: A Retrospective Controlled Consecutive Case Series. Treatment maintenance of interventions that reduce severe problem behavior is largely unknown outside clinic settings. Several variables may impact the re-emergence of problem behavior following successful reductions during treatment, or post-treatment relapse. To date, variables that contribute to post-treatment relapse have largely not been empirically examined and warrant exploration. By identifying variables that contribute to post-treatment relapse, clinicians may be able to identify patients and families at an elevated risk and implement more comprehensive support. The purpose of this study was to conduct a retrospective consecutive controlled cases series to determine the prevalence of post-treatment relapse following intensive outpatient services for severe problem behavior. For cases re-admitted to intensive outpatient services, we conducted an exploratory analysis of variables that may have mediated a lack of treatment maintenance. We discuss implications for practice and future research based on these findings.


From Integrity to Adherence: A Continuum of Measurement Strategies for Tracking Caregiver Implementation of Behavior Plans

MARY KATHERINE GERRARD (Johns Hopkins School of Medicine/ Kennedy Krieger Institute), Craig Strohmeier (Kennedy Krieger Institute)

When working with caregivers of children with problem behavior, treatment integrity refers to the extent they implement behavioral treatment plan procedures as intended under the direct observation of clinicians (e.g., during appointments). Treatment adherence refers to the extent that caregivers follow treatment recommendations, over time, and in the absence of direct observation. Procedures to measure treatment integrity are well established and reported frequently in the behavior analytic literature. Conversely, minimal guidance exists for the measurement of adherence, despite growing evidence of the gap between observed integrity and adherence in natural environments. This presentation describes two methods for measuring adherence when working with caregivers during the outpatient treatment of problem behavior. One method involves a contingency space analysis of caregiver behavior using data extracted from video, recorded in the absence of the behavioral treatment team. The other method involves a semi-structured narrative recording system to help parents record their own responses to problem behavior and alternative behavior in relevant contexts. The presentation includes example data from the two methods, and a discussion around certain caregiver behaviors that do not typically represent omission or commission errors but may compromise the effectiveness of behavior plans.

Initial Evaluation of the Reliability and Validity of an Assessment-Based Approach to Identifying and Addressing Barriers to Caregiver Treatment Adherence
OMAR ELWASLI (Eastern Michigan University), Eleah Sunde (Eastern Michigan University), Adam M. Briggs (Eastern Michigan University)
Abstract: Although technology exists to effectively train caregivers to implement behavioral interventions, little is known about the barriers impacting caregiver treatment adherence. The purpose of the current study was to understand the conditions under which caregivers are likely to adhere to interventions, identify the variables leading to non-adherence, and evaluate the effects of an intervention to support caregiver adherence. We evaluated the effectiveness of a standard treatment protocol at improving a caregiver’s behavior- management implementation (Study 1) and assessed the validity of the Performance Diagnostic Checklist–Parent (PDC-P) by comparing the effects of an PDC-P indicated intervention to a non-indicated intervention (Study 2). In Study 1, results indicated that a standard training protocol provided sufficient support for most caregivers across all phases. In Study 2, the indicated intervention resulted in improved caregiver performance and provided preliminary evidence for the PDC-P’s ability to rule out ineffective interventions and rule in effective ones. We will discuss clinical implications and directions for future research.



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