Escape Extinction, Evidence Based Practice & Autism Ethics with Dr. Megan Miller

Dr. Megan Miller is a Board Certified Behavior Analyst who is an expert on behavioral procedures in kids with autism. In today’s podcast, we discussed why we should carefully comply with consistent ethical standards in a clinical practice, how the definition of escape extinction can change, and why we should rely on evidence-based practice.

Ethical Practices

Reviewing the ethics code regularly is important to make sure you aren’t violating it yourself. Over time, it’s normal that our behavior could begin to shift into questionable behavior because humans aren’t inherently ethical. We should be training and teaching our staff about it regularly so that they can keep this standard in the front of their minds. With new clients, we need to open the conversation about patient care with them so that there’s no confusion when you can’t accept their gift or their friend invitation on Facebook.

Evidence-Based Practices

As professionals, Dr. Miller says, we should rely on evidence-based practices by using the three-pronged approach for delivering interventions. 1: look at the relevant research that exists. 2: look at the clinical expertise that a practitioner has. 3: find out what the clients’ needs and values are, especially mental health. By using these three approaches together, she feels that she is better equipped to treat the patient.

In this podcast, we discuss evidence-based medicine along with our experience with escape extinction and how that definition has changed. We both share some personal experiences – based on patient outcomes – that have shaped our approach to this theory. Dr. Miller’s The Do Better Movement podcast addresses some alternatives to escape extinction when you might need to use it, and some of its limitations.

If you enjoyed this podcast, then check out my podcast on social media ethics and applied behavior.

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Mary Barbera: Welcome back to another episode of the Turn Autism Around podcast. I’m your host, Dr. Mary Barbera and I have been in the autism world for two decades. First as an overwhelmed and confused parent and then as a behavior analyst and author. So, today I am going to share a very lengthy excerpt from a ethical interview I did with Dr. Megan Miller. It was a awhile back. It was in early 2018 but we have cut it down and I think we pulled out some of the key points of that interview where Dr. Miller talked about the ethical implications and the problems with using escape extinction. And she also talked about her do better movement, which she started way back in 2018. Dr. Miller is also featured in podcast number seven with some more of her ideas, but I think you’ll enjoy this ethical interview with Dr. Mason. Welcome to the Turn Autism Around podcasts for both parents and professionals in the autism world who want to turn things around, be less stressed and lead happier lives. And now your host, autism mom, behavior analyst and bestselling author, Dr. Mary Barbera.

Mary Barbera: So, welcome Megan.

Dr. Megan Miller: Hi. Thanks for having me.

Mary Barbera: Yeah, thanks for being here. So, before we get started with really the meat of the presentation, can you tell us how how you got involved with the ethics field?

Dr. Megan Miller: Sure. So, I was really fortunate when I went to Florida State, I was voluntold basically that I would be helping a second year graduate student with a video series that he was doing. And so, within my first week of starting the graduate program, I was at home making ethics videos with this graduate student and Dr. Bailey. And that he, you know, has a lot of students that he encounters at Florida State. So, that kind of made me a quick, Oh, I know who you are because we’ve spent, you know, several hours together making these videos. And of course, while we were at Florida State, I greatly valued the training. We received an ethics and I maintained a professional relationship with Dr. Bailey after graduating. So, I’ve presented on several ethics panels with him, worked on a few projects he was involved in. And then throughout my career I just find like-minded behavior analysts are present at conferences with about ethics and we’ve presented on things from you know, general ethical issues that you can encounter problem solving and then all the way to like running a business.

Dr. Megan Miller: So, really anything within the realm of ethics. And one of the things that really struck me after I left Florida State, I did a presentation for the Cleveland. There’s a conference in Cleveland that’s an autism conference and I was shocked that there, first of all, only like 10 people came to my presentation. This was back in 2009. And none of them at that time had read Dr. Bailey’s book or received any like really intensive training on ethics. So, that just kind of furthered my resolve on, Oh, this is something we need to make sure that we’re training people on and talking to people about. It’s been a huge focus in the work I do as a behavior analyst, whether I’m working independently with just, you know, the various projects that I do or when we’re training our employees with navigation in Virginia Beach.

Dr. Megan Miller: So, it’s just kind of one of those things that has always been important to me and I’ve been fortunate to have some good mentorship over time relating to it. One thing that’s really important about the traditional escape extinction discussion that we have is what I’m focusing on and I think most of us when we talk about this is for things like discrete trial training programs and skill acquisition. When you have children engaging  in problem behavior around like teaching them their daily living skills or you know, matching things or whatever skill acquisition type things and you have problem behavior occurring around that. That’s what this discussion applies to. If you’re working in like an Institute where you’re the residential placement for some really severe challenging behavior where there is a three on one involved and there’s, you know, really dangerous things that are happening, that’s not what I’m talking about.

Dr. Megan Miller: I don’t aim to have any sort of expertise in addressing that. Now again, still same things apply. We shouldn’t just be like forcing people to do stuff and we should use least restrictive procedures, but there are going to be situations where I like a cost benefit analysis and for the safety of everyone in sort of intensive emergency crisis management type things are in place. So, I don’t want people to like listen to this discussion and think, Oh we could not, we don’t ever have to touch our clients again. Those safety plans are training me on our crap. Like that’s not what I’m saying. So they said, I’m talking more about these, you know, real skill acquisition related things, not just the broad over arching challenging behavior as a whole. Does that make sense?

Mary Barbera: Yeah. So you’re, you’re when you’re talking about alternatives to escape extinction, you’re talking about the kids who can get through a lot of the day without any problem potentially, but have some bursts when you’re focusing on, you know, intensive teaching or you’re focusing on, you know, having them go to the bathroom or wash their hands. So, either a daily living skill or an acquisition skill that they are resistant and that could involve just pulling away from you and that sort of thing. Or it can involve them escalating but don’t to pretend to give advice on, you know, really critical situations where there’s dangerous behaviors and you have crisis plans in place that you can’t throw out the bath water before you have new water. So, it might have to be, even in the, in the first situation, it definitely is going to have to be a gradual shift to stop using escape extinction. Maybe you use it sometimes with some clients and you try to move your whole organization to trying to use it less or use it just in those crisis situations.

Dr. Megan Miller: Yeah, so, and I and I always make the disclaimer traditional escape extinction because if you have a client that’s engaging in problem behavior maintained by escape, at some level, extinction is going to be involved just not the procedures that you’re typically trained to implement. You’re going to have a much more comprehensive plan, hopefully.

Mary Barbera: Right. And, and I also say like in terms of restraint, you know, if it’s a, if it’s an emergency situation of a kid is going to, you know, throw a chair through the window or, or you know, they’re escaping into the street or out of the house or whatever. I mean, it’s fine to protect the child or protect the others around him. So yeah, I think that is a good distinction before we really get into some alternatives because in those very severe cases, you may not be able to jump right into the alternatives. Great. So, when you talked about Dr. Bailey’s book, can you give us the title and when it was published, if you know that I’ll stop you.

Dr. Megan Miller: Well, it’s on. It’s there’s multiple editions of it. So, I think when I read it back in 2007, that was maybe the first edition. But it’s just ethics for behavior analyst and it goes through the code and gives different it’ll explain the code and then give some different scenarios that you have to kind of work through and decide how you would respond. So, when I was at FSU, the class was set up where we would go through these scenarios and then our homework assignments were to write out, you know, using the code to justify how we would respond to those different situations. And then we would have a discussion about kind of weighing things. You know, people might have, generally speaking, people would have certain aspects of the code that everyone would agree this applies and this is how you would respond. But then there were always different aspects where it was like, Oh, is this, does that actually apply here? Is that what that really means? And how do we weigh these things and ultimately decide how we’re going to respond. So, that was really helpful to have that practice, you know, throughout the course. And then we kind of would carry that over throughout our training at FSU I think, I can’t remember if it’s the third or fourth edition that they’re on right now though.

Mary Barbera: Yeah, I have it here on my bookshelf. I didn’t want to reach for it. And I also didn’t want to just be talking about Dr. Bailey’s book without mentioning.

Dr. Megan Miller: Yeah. And there’s multiple hooks. So yeah,

Mary Barbera: In case you know, people wanted to reference that. Okay. So in general, what three or five things do you think behavior analysts should know about ethics?

Dr. Megan Miller: So, the first one that I think is important is to make sure you’re reviewing the code regularly and reflecting on your own behavior to make sure you aren’t unintentionally violating anything. So, I’m highly committed to engaging in ethical behavior and that’s a huge focus of the work I do. But even with that, every single time I like look through the code either to help someone find an answer or just to look through it myself, it’s like, Oh yeah, I forgot about, you know, I need to make sure I’m really attending to that when I do whatever. So, there’s things that as we practice, we start to kind of drift a little because of the contingencies operating on us. So, it’s important to kind of check in and have that reflection occasionally to make sure that, and then sometimes it can go the other way where I think, Oh, the code absolutely says this and I shouldn’t behave in this way because of what the code says.

Dr. Megan Miller: So, there was an example on Facebook just recently where there was like a debate about whether or not you can use clients and pictures and videos. And there were certain people that were adamant that no, you absolutely can’t. And then there were certain people that said yes, you can. And when somebody finally posted what the code actually said, it says with consent, you can. So, it’s things like that where, you know, just to make sure you’re really clear on on how to behave in a, if you’re trying as you should be to behave according to the code. And one of the the very first things that I also make sure to do and I think, you know, we’re all required to do as behavior analysts when meeting with a new client is make them aware of our ethical code and that this is what we’re operating under and that this is what we have to adhere to and here are  the steps you can follow if you believe that I’m violating this code or that one of the people that I have working with you is violating this code.

Dr. Megan Miller: And this is important to point out so that they, you know, you can have that open dialogue because you wouldn’t want a client to think you’re violating something and get really upset about it and maybe like report that and never have that discussion with you. So, having like a clear, you know, I’m human and these are, this is what I abide by and I do my best to do that. But occasionally something may come up that we need to discuss and just lay that out on the front end. But it’s also a good time to point out particular aspects of the code that are a little bit different so that everybody can be on the same page, like pointing out, you know, the requirements for the multiple relationships and what that means. Social media, I can’t be Facebook friends with you. And of course the, the hot gift giving one that I know already came up with one of your other interviews, but just kind of talking about some of those types of things so that you’ve laid all that out on the front end.

Dr. Megan Miller: And it’s discussed preventatively because it’s going to come up anyway, but if you’ve discussed it on the front end, you can kind of refer back to that and like this is what I follow relating to these policy or this code. The third one is for us to hold each other accountable. So, doing so in a professional and supportive way. I know, Mary, that you gave an example where somebody was like, mean to you about something you had posted based on being a nurse. And it’s like, that’s not really the best way to go about those types of things. So, no pointing fingers or acting better than someone else. But just bringing up our professional discussion about, you know, Hey I, I was wondering how the code might apply for the to this, you know, let’s have a discussion about that and you’re going to get a lot further.

Dr. Megan Miller: Obviously if you do it that way, as opposed to saying the code says you can’t do that. And kind of like pointing your finger at somebody. And then the last one is that we need to make sure that we’re learning about ethics as a whole so that we can better supervise our staff or fieldwork supervisees or our own beings in developing just ethical behavior  because people don’t just behave ethically. It’s not like an innate thing that we all just do. It’s shaped and it’s under the same contingencies as everything else. So reading, research and looking at the field of ethics can really help in terms of when we’re in a situation where we need to make an ethical decision, we can have a better idea for that. And one resource that we’ve been using in our workshops lately is called giving voice to values. And it’s by some, there’s some researchers that have looked at ethics as like a six pillar system.

Dr. Megan Miller: And if you can train people on these six pillars, they’re more likely to engage in ethical behavior. And when you look at the six pillars, they line up very nicely with our ethical code. So, it’s very much in line with the type of work that we do as behavior analysts. And it’s really nice because they have free videos on YouTube. So, if you just search giving voice to values on YouTube, you can watch the videos and get an explanation of what it is and then maybe incorporate that when you’re trying to train others on ethical decision making.

Mary Barbera: That’s great. I haven’t heard of that resource.

Dr. Megan Miller: Yeah, Tim Courtney from Little Star was the one that wrote that to me, so  it’s been really helpful.

Mary Barbera: Okay, great. So a few months ago I heard you on Matt Cicoria’s podcast, which is behavioral observations. You’ve been on there a few times and, but a few months ago you were talking about evidence based treatment and what you said really resonated with me because I think in general people are, when they think of evidence-based, they think of like a research article. And you have a very different opinion about what evidence based is. So I was wondering if you could elaborate a little bit on your thoughts on that.

Dr. Megan Miller: Sure. So, I follow the medical model of evidence based practice, which I think at this point, especially if you’re working with autism, we’re kind of, we’re in the medical situation now, we’re billing insurance, we’re considered a medically necessary treatment. Maybe if you’re using behavior analysis in different populations, that wouldn’t be the case. But  for autism at least you’re, you’re, we’re in the medical field. So, it’s a three pronged problem solving approach to delivering interventions or determining what treatments you’re going to use and the prongs are looking at the research that exists the clinical expertise that you have and then the client’s needs and values. So, there is already in the, I mean I never would have come up with this if it weren’t for publications that already exist in our field where there are some behavior analysts already advocating that for years now that behavior analysis adopts this model as well.

Dr. Megan Miller: Right now we don’t have a clear definition in our field. There’s not an agreed upon when somebody says evidence based practice, if you were to pull 10 different behavior analysts, you’d probably look for, right? And you’d probably get nine out of 10 would say it’s the research, but that doesn’t necessarily mean they’re right. But there is no consensus on what that even means. But Dr. Muchinsky and Dr. Slocum are two of the people that have been publishing on this and advocating that we adopt this model for our field as well. And basically what typically I see happen for behavior analysts is they’re trained on just that one prong, the research. And then what we when you look at the literature on evidence based practice at the medical model and like the decision making process that looking at just the research is what we would call empirically supported treatments.

Dr. Megan Miller: So, we definitely want to use empirically supported treatments as often as we can, but there’s not going to be a research study published on every single thing you do or need to do with a client. And that’s where we need to make sure that we’re, we’re doing using the all three prongs. And when we look at what’s in the literature related to the intervention, which in a lot of cases when we do that for a lot of the work we’re doing, especially with autism, there’s going to be research on broad behavior analytic principles such as reinforcement or shaping. And that there’s guidelines there for that effectiveness of like those procedures as a whole. But there’s not going to be a research study on every single different application imaginable for those types of things. So, we need to look at the research that’s out there on those like broader procedures  and then determine if that’s something that we can apply in the situation that we’re in based on our expertise and the needs of the client.

Dr. Megan Miller: And the amount of behavior analysts who are missing out on providing effective services to their clients because there are certain resources or techniques that are not yet established in the literature is quite sad. We have an ethical responsibility to our clients to provide them with the most effective services possible. And there was a quote on Facebook, I can’t remember if you posted it or somebody else, but it said something along the lines of today’s proven theory was yesterday’s untested idea. So, the fact that a lot of the things that people say even now are evidence based, which I would say are empirically supported, like functional analysis. When Dr. Awada first started publishing on that, before he could even publish those studies, he had to be doing those things and collecting data on it. What if we held him to, Oh, you can’t do that because there’s no research on it.

Dr. Megan Miller: You know, so the idea that we can’t do something just because there’s not a research article on it, it’s pretty silly. And again, like I said, it doesn’t mean every imaginable, I didn’t say this yet, but it doesn’t mean every imaginable thing out there should be used. So, like if you hear about, you know, some something like the whole giving kids with autism bleach, that doesn’t mean you should be like, well there’s no studies on it, but I’m going to go ahead and try that anyway. That’s not what I’m saying. But you should use the three prong problem solving model and critically analyze how different resources and research can apply to your client. And it’s not just behavior analytic research, like whatever topic you’re trying to address, you should be looking at all research that could be related to that and all experiences and resources as well. And as long as you’re collecting data and measuring progress and troubleshooting, then you’ll be a more effective provider. And I know we’re going to talk about this later, but this is such an important topic to me that there’s a whole entire month devoted to it and our do better movements that we’re doing for this year. So, I’m hoping to help get more behavior analysts really understanding that it’s not just what’s in the research.

Mary Barbera: Yes. I, I love everything you just said and I didn’t post that quote but I, I agree with you on that. Okay. So, let’s talk before we talk about your do it better movement. Let’s talk about one of the procedures that is evidence-based that is used frequently, daily and by most behavior analysts is traditional escape extinction. And I know you also have some strong views on this. So first, can we talk about what is traditional escape extinction? Just to make sure we’re all on the same page.

Dr. Megan Miller: So, traditional escape big things. And when I talk about it at least is referring to the standard procedures that you’ll find either in research  literature or the training provided to individuals who deliver like one-to- one services or might be working in like special education classrooms  overseen by a behavior analyst. And it’s especially prevalent within skill acquisition programs. This typically involves physically prompting a response and forcing the person to respond even if they’re resisting. So, if you present a demand like touch red and the person’s like just sits there and you go to prompt them, they like pull their arm back like, no, you’re not going to make me do this. You overpower them and like make them respond. And then sometimes the physical force isn’t used. Instead, you’re just repeating an instruction on a time based schedule. So maybe every 10 seconds, maybe every minute. And then sometimes the two are combined where you’re physically trying to force the person to respond while repeating the instructions. So, that’s when I say traditional escape extinction, what I’m picturing and talking about.

Mary Barbera: So, that nagging procedure where you just keep the demand on even  though the kids on the floor or whatever.

Dr. Megan Miller: Yeah. The person could be having an all out meltdown, screaming, crying, throwing stuff. And every minute you’re like sit down and then a minute goes by and sit down.

Mary Barbera: And then also when you’re talking about physically overpowering or physically prompting and when I was with the Pennsylvania verbal behavior project, which is now the patent autism initiative, we did a lot of talking about restraints and what is a restraint. We did a lot of training on  restraints and in my trainings when I was giving trainings and what were, we were talking about what we training others is that if you go to prompt a student and they pull back equal but opposite pressure, that’s actually a restraint and is not appropriate to use in public schools. And I’m not sure about private schools and how, you know, but it is, it’s not just a, is this ethical or not? It’s actually a legal consideration. And do you have similar views on this would be a restraint?

Dr. Megan Miller: Yeah. So, that was actually something that came up when I was in grad school because I remember this was before I started diving into the alternatives when we had a client that we were, you know, prompting or whatever and we were had to use escape extinction. When we wrote the behavior plan, It said something along the lines of like physically assisting them in completing the demand and are in Florida. We had like it’s some of the clients were Medicaid where they have a local review committee and they have to review the plan. And our professor at the time who was like overseeing that kind of stuff, made a comment that in the state of Florida for anyone receiving those Medicaid services, anything, any touching that occurred for longer than five seconds was considered a restraint. So, it didn’t even matter what direction you were going in.

Dr. Megan Miller: If you were touching someone for longer than five seconds, it was a restraint and it wasn’t illegal, but you had to get special approvals to be able to do that. And the local review committee was very strict about approving that obviously. So, there’s definitely that as well. As far as I know, because I don’t use restraint, I don’t use these procedures like the traditional procedures. But as far as I know, each state obviously has their own laws and it can differ depending on the setting. So, the public school versus a private school versus home and the funding, Medicaid versus insurance and that kind of things like Tri-Care also has that you can’t use your strength but they haven’t necessarily defined what that means. So there are, you know, beyond what we’re going to talk about today. I haven’t even really gotten into that a whole lot in my presentations, but everyone who is choosing to use these traditional procedures should definitely also be looking at the laws in the state and the funding source  guidelines and make sure that they’re not violating anything there as well.

Mary Barbera: Yeah, and I, I think, you know, these traditional escape extinctions and especially when it’s a full out you know problem behavior, tantrum, meltdown, whatever you want to call it, that it’s a lot of time. I remember other behavior analysts would say like, I just got into like a 45 minute escape extinction procedure. You know, in a school it’s like, you know, it’s a waste of time. Like, you know, that you’re trying to train the teacher to do an escape extinction for 45 minutes. What is she supposed to be doing? What is this kids mostly be doing and the other students in the classroom. And I would just be like, I would not get into those situations. I would get out of them as quickly as possible. I mean, I, you know, I have seen and experienced a lot of that, but in my experience as a new behavior analyst in early two thousands, I quickly realized that there were better procedures and we needed to not, I think in some ways it gives ABA a bad, a bad rap, you know, it’s just not very you know, if there’s visitors in the building, the principal coming by, I mean that it looks abusive.

Mary Barbera: Yeah. And, and I know, I remember saying, which is still true. I’m going to knock on wood, even though that’s not behavioral, but I’ve never been bitten by a client. And when I said that, you know, in 2008 or 10 or something, I remember a behavior analyst that I work with, she was like, well that’s because you’re, you know, you know, you’re just so wimpy. Or she didn’t say that, but she was just like really like, like, it’s almost like a Rite of passage. Like people told me my getting bitten stuff, it’s like this isn’t cool. Like there are better ways. And this is actually one of the reasons I wanted to do this ethical series and one of the reasons I wanted you on as a guest, because I do think that you not only are talking about the problem with it talking, you know, which we’re going to get into a little bit more talking about the alternatives to it. But you’re actually, you know, coming up with presentations and, and showing people really how there can be a better way for this. So, what are the ethical considerations related to this related to the code? If you can bring that into it.

Dr. Megan Miller: Sure. I had a few points that I also put down relating to like evidence based practices piece of it. Do you want me to talk about that first or the ethical?

Mary Barbera: Whatever makes sense for you.

Dr. Megan Miller: Okay. I’ll do the evidence based practices. There’s actually – it wasn’t something I had thought about until we decided we were going to do this. So I’m, I’m kind of excited to get that, those points out there. So and so when I first started discussing this topic about 10 years ago, I probably would have agreed with the statement that traditional escape extinction is well established. But the more I talk about it, the more I asked is it really well established? And the reason for that is well I have a few of them. One being the research that’s published on these traditional procedures is often conducted in a very structured laboratory setting with trained individuals implementing the procedures.

Dr. Megan Miller: I haven’t done a recent lit review on this, but we all know, like if you think  back to any article you’ve read on traditional escape on escape extinction, it’s done in like, you know, one of the things like Kennedy Krieger like USF or one of those like really nice places that deals with problem behavior. So, we all know the issues we face. So, when we try to train in a natural environment at a school like you were just talking about or with parents out at the grocery store maybe. So you know, so is it generalizable to that extent that these procedures that are working and like a structured laboratory setting are going to apply in these naturalistic settings with untrained individuals? I don’t think we actually do have enough research to say, yes it does. And enough of us as practitioner, no, no it doesn’t.

Dr. Megan Miller: And then of course the research also highlights that there are side effects similar to punishment such as increased aggression when you’re using traditional procedures. So where way at all in 2003 Lurman and a lot at 95 Piatsa at all and 96 and Sigman all the way back in 89 they documented these side effects. But most behavior analysts, they don’t plan for those side effects when they’re implementing traditional escape  extinction. Nor do they explain to the families or the individuals that they’re working with who would have to implement these procedures of that. And they don’t get approval ahead of time. So, when they work with a family, they’re not saying like, Oh, by the way, X, Y and Z could happen when we do this procedure is that still okay? And getting consent for it, they usually just come in and say, Hey, to stop the challenging behavior, we’re going to follow through with the demand and this is what we’re doing.

Dr. Megan Miller: And it’s that, that’s the end of the conversation. So the other piece of it is, it depends on what we mean by us at what costs, what impact is using traditional escape extinction having on the human beings that we’re putting under escape extinction. And like you said, the image for our field that it can, that it can cause when we’re physically forcing people to do things over touching red, really? I don’t know about that. So so of course that, you know, okay, maybe people might argue with me that it’s well established, but at what cost and what do we mean by effective? I think we could all say the need for extinction, the idea of removing a reinforcer, maintaining a challenging behavior is well established. That’s not up for debate, but we need a ton more research to identify what those procedures should consist of in the natural environment and how best to ensure that access to the maintaining reinforcer isn’t occurring. So, for all of those reasons, I probably would say it’s especially it’s an important, it’s not counterproductive. Like it’s really important for us to critically analyze whether or not it’s even established. But if you’re using evidence based practice and problem solving and you add in our ethical considerations, it becomes pretty clear that we should not be using these traditional procedures at all. So, I don’t know if you want to, if you have any comments on that before I talk about the ethical piece, but I really don’t.

Mary Barbera: I, we do actually have a, a comment from a behavior analyst that’s on live with us now and she said, Cynthia said, that’s so funny. Early in my special ed ABA career, it was like a badge of honor or something to have scars from aggressive students and clients. Five years into my career I was more proud of my ability to not get injured in that way by my students  and clients. And you know, we both obviously agree with that statement. And so what are we to do, you know, what’s a parent to do if a behavior analyst or RBT is being trained or you know, new new BC or students are being trained on these procedures and are, I mean it’s like required that they do it. I remember one of Lucas’s therapists, she went up to an approved pro, I think it was a, a residential placement. She got an offer to go up there. They would pay housing or whatever. And she, you know, she thought she was taking a job with the little kids with autism and she got up there and she was put with these highly aggressive teens and she literally had bite marks and she ended up quitting. I mean like this isn’t like 4. Years ago, this is like five years ago, 10 years, you know, like this is still happening in our field and I, I guess I’m just wondering what we should do about it.

Dr. Megan Miller: Yeah. So the first thing I would say is we definitely need to be looking at the ethical side of it. So I do have a webinar that we’ll talk about at the end that kind of goes over all of this and a lot more detail. But here are some of the like main ethical issues that come up. And I think it’s important for obviously behavior analysts to be aware of those, but also anyone who has a child with a disability, it would be helpful to understand these considerations as well so that you can have a discussion with your behavior analyst if, if this is happening in your life and kind of try to work through, you know, these are my concerns and you should have these concerns too if you’re a behavior analyst. So the first one it’s often implemented without even conducting a functional assessment.

Dr. Megan Miller: It’s like as soon as a person engages in some sort of challenging behavior and response to a demand being presented, it must be for escape so we’re just going to apply escape extinction. And what’s interesting is or not interesting, but just kind of like as an aside, I wanted to point out that I’m a colleague of mine, Carrie Wozniak and I are hoping to start presenting in 2018 at some conferences about everything I’m kind of talking about here applying to extinction in general. So isn’t that just unique to escape extinction, like extinction procedures overall are kind of applied poorly at this point in time without, you know, especially  consideration with the functional assessment but also looking at like the fidelity and being able to train people to do it properly. So, maybe we can talk about that at some point in the future. Just extinction ethically. But what the escape extinction specifically from an ethical standpoint, it can often turn into a battle which could be related. Then you get those increased aggression, the child or individual that you’re working with as well as the person implementing the procedure could get injured, which is what you were just talking about. Those bite marks are injuries and that’s traumatic for a lot of people. So you’re pushing good people potentially out of the field and they may have,

Mary Barbera: So far as a nurse, I mean a human bite is actually pretty significant. Like you should the ER, you should have antibiotics, you know, if the person has hepatitis B or AIDS or anything like that. Like when I said I never got bitten by a client. I have gotten bitten by both my boys when they were very young. And like biting in general is such a bad behavior. It’ll get you thrown out of every place possible. You know, regular daycares and preschools and regular schools and mainstream sites. But I’m totally wigged out by biting and I think people shouldn’t be like, Oh, you’ve never gotten bitten. Like you’re a wimp. It’s like they should be saying you’ve never gotten bitten? What are you doing?

Dr. Megan Miller: Yeah, exactly. So, that’s obviously one of the issues. Another issue is like forcing compliance isn’t always a good thing. So, what kind of learner does that create? Someone who just passively responds to demands but isn’t really in it or eagerly motivated to learn. If you think about things that you were forced to learn, you don’t remember those things. You don’t actively seek out continuing your education related to that stuff and get going even beyond that. Worse, someone who blindly follows every command presented to them is at risk of saying yes to inappropriate things. So, like if Lucas had been taught anything an adult tells you to do, you must do it. What could people do to him? Like that’s a lot of advantage that could taken out of him, whether it’s from like a sexual standpoint or financially, like any type of thing that we would see as you know, dangerous for our clients could happen because we’ve  developed this repertoire of you must do what I say, so don’t even bother fighting me on it.

Dr. Megan Miller: You have to do it. And then treatment integrity, it’s really hard to train other people to implement the traditional procedures. So, this can often shape worst behavior. So, if I’m trying to teach you to do traditional escape extinction procedures and eventually you give up and give in all of the fight that happened or all of the challenging behavior that happened before that is now, that’s going to be their go-to. As soon as they don’t want to do something, they’re just going to go straight to what, what stopped it the last time. And that’s obviously an issue. So, for each of those issues that can happen with escape extinction, our ethical code, you really wouldn’t even have to discuss it, right? Like I just talking about those things right there. Even if our code didn’t exist, all of those should be sufficient reason for people to say, yeah, I don’t think we should be doing this, but we also have our ethical code.

Dr. Megan Miller: So, we have aspects of the code, I’m not going to go into detail right now on that piece of it, but just so that people know I’m not pulling this out of nowhere. I’m the primary one that applies when looking at escape extinction and using traditional procedures would be 4.09 which is that as behavior analysts, we use least restrictive procedures as our go-to. But like we talked about, it’s appalling. The number of people who are subjected to traditional procedures without having least restrictive procedures tried first. It is most behavior analysts go to to implement traditional procedures without ever even trying some of these alternatives. Or even just basic reinforcement like modifying the demand. Like there’s so many things that could be tried first before jumping to physical force or even just like the pace prompting.

Mary Barbera: Let me just jump in here and in addition to a possible FBA or FAA and those are tough within school settings as well. But what I usually say or see if I see a big power struggle, escape extinction, a situation going on, I just shake my head and go like, what does his VB map look like? Like where is the assessment of the milestones of the barriers of the transition assessment. Because you know, no child of any age should be  that distraught over, you know, some situation. If they’re, if they’re flopping for recess, do they want to be in, do they want to be out? Where’s the reinforcement? You know, there’s so much more to look at than just jumping in to trying to solve that immediate behavior. And I think lack of assessment I would say would be number one.

Dr. Megan Miller: Yeah. So, that’s actually the next one. So, 3.0 behavior analytic  assessment, both for the FAA or FBA, the function and skill deficits or you know, environmental factors. Like all of those types of things that generally aren’t assessed or like we don’t problem solve or troubleshoot any of that. It’s just, Oh, they’re trying to escape. Here we go.

Mary Barbera: Or they could have also a new medical problem, which, which, you know, Oh, the doctors ruled it out. I can tell you that the doctors cannot rule it out with a child who is not speaking or even like Lucas who can speak and say head hurts, but he can’t tell you like the head my head, you know, it’s, it’s right over here. It’s tingling.

Dr. Megan Miller: Yeah.

Mary Barbera: You, he can’t describe things and a lot of his behavior problems, actually 99% of them over the years have been related to medical issues. So, just to jump in there.

Dr. Megan Miller: Yup, exactly. But regardless of my soapbox about all of this, I think we need to make sure that families and consumers are comfortable having conversations with their BCBs about anything that may be happening that they’re not comfortable with, whether it’s traditional escape extinction or something else. Because our clients have a right to consent to the treatment that we’re receiving and as a behavior analyst, there have definitely been times where even though I do my best to collaborate and work with a family, I don’t know what I don’t know. So, if you don’t bring those concerns to me I won’t know that we need to discuss it and modify things. And of course there are behavior analysts out there who are like my way or the highway and that’s a lot more difficult to deal with. But having a professional conversation with the behavior analyst or the team about your concerns, if the BCBA or anyone  on the team refuses to have that discussion or is completely unprofessional about it, it’s time to find a new behavior analyst.

Dr. Megan Miller: It’s not beneficial for anyone to try to go through a situation where you can’t work as a team about these things. Especially something as important as traditional escape extinction where there’s all these ethical, legal and just, you know, things to consider. If the people that are working with your child aren’t willing to discuss it, then it’s time to figure out a new team. And if that’s not possible, I am available. I know Mary’s available. There are people out there who are willing to help families navigate, you know, kind of working through that situation. And of course Mary, your course has been so helpful for families that you know, are stuck where they are with the team that they have because there are no other options, but now they can get online access, you know, to some valuable information. I’m relating to that. So, that would be my recommendation for parents and caregivers. It’s not super helpful, I don’t think. But the main thing being advocates for your child and their needs.

Mary Barbera: Well, and I think just the knowledge that just because it’s a prestigious school or organization and these are bad people. Like I mean there, there could be many people here who are using traditional escape extinction for a variety of reasons. And we’re not saying like you’re bad people and we’re going to just, you know, we’re just saying, Hey, there’s alternatives to this. There’s pairing to banding and kind of clearing the slate and assessing and assessing, not just maybe the traditional way, but using a newer assessment like the VB map or the peak assessment, which I know you’re familiar with. And to look at not just the problem behaviors but the skills and to really focus on keeping the child busy, keeping the child happy, keeping the child engaged in preferred functional tests. And then that way the you know, the problem of behaviors could melt away.

Mary Barbera: I often ask, you know, when a kid is having problem behaviors or not acquiring skills, but mostly for problem behaviors. It’s like what does this kid do all weekend? You know, trying to get into like what does he do? Is he, is he on the TV? Is he on the iPad? Is he, is he climbing on things? Does he, is he eloping from the house. You know, these are real issues of  getting back again to, this isn’t just the child for six hours a day. This is the child now, the child in the future, the family values, the cultural sensitivities, all that stuff. Yep. So, what if you are a new BCBA and you’ve got a job and or your or your season BCBA or RBT working in an institution where you’re being pressured to use escape extinction. That’s part of the protocol with the Lucas’ former therapists who got bite marks in that, you know, she had to quit. I mean there was just no other way out. What can they do?

Dr. Megan Miller: So, I forgot to mention this for the parents piece too, but for everyone, the seven steps of earning instructional control is a nicely laid out. It’s all things you could find individually in our literature, but it’s just a nice seven step follow this and there’s tons of resources. I know you, you share that in your course, Mary.

Mary Barbera: And that is the seven steps to instructional control. It was first an article by Robert Tram and now is a book by Barbara Tram and Megan Miller. Is that correct?

Dr. Megan Miller: Yes. And he talks about it in his, his other book, motivation and reinforcement. But and we both, Robert and I both have YouTube videos kind of demonstrating his or better. His are like full on presentations and whatnot, mine are just some short like demonstrations, but so definitely make sure you get familiar with that. And that’s one of the big alternatives that when we’re saying there are alternatives, the seven steps is like the most effective one I found. And for anyone that’s in the field working as a professional, I would be more than happy to at least share my PowerPoint with you to help you kind of see some information. So again, if you want that, you feel free to touch base with me. The basically discussing

Dr. Megan Miller: And all just to jump in there too. So we, we use the seven steps. I mean pretty much I’m very much in alignment with Megan and we’d been in alignment for years, but we use the seven steps and one of one of the most powerful steps I think, well there’s a bunch of them are powerful. I don’t know all seven off the top of my head, but one of them that I think  we get into trouble with that if we do this step, we can turn things around pretty readily, is to sanitize the environment. Especially in home situations. So when, when so that’s one of the seven steps. So, we get rid of like all the fun stuff and everything and then have the fun stuff, have control of that at the work area. So, that’s one consideration. But I also, and I’m not sure if this is an official seven step, but like a heavy focus on assessment, making sure you are starting right where the child is at and you are, you are even going below that.

Dr. Megan Miller: You know, I recommend like potato head and the shoe box and flashcards and people like my kids three, they’re, you know, they have a hundred words. So, I really need to get out potato head. Yes. Get out potato head. It’s not, you know, even for a 10 year old who’s not talking, yes you need to get potato head out because we can teach the child to man for ears and, and so people are like, well that’s not functional playing with potato head but you know, calm down. You know, the child is not vocal, he’s 13 but his language age is a one-year-old. Like we need to scale back. And not be so much like this isn’t age appropriate, this isn’t functional. It’s like we need to use procedures that use pairing and mandate and good assessment and sanitizing the environment. Having the child want to run to us, not escape from us. Having yourself paired so well that you can, you can really gauge the situation. And then once you have the child, you know, really happy and paired unwell, then you start systematically increasing the demands. All my video blogs, I do a video blog almost every week. All my video blogs are on subjects that are related to, you know, basically good procedures that don’t involve all out meltdowns in the escape extinction and getting,

Dr. Megan Miller: Yeah. So, what I would also recommend for people that are  professionally in this situation is just have a discussion with whoever is telling you to do that and bring up the ethical concerns that we’ve talked about here and and discuss that, you know, least restrictive most humane procedures should be used. And if they refuse to do that and they don’t have like a rationale or data driven discussion about it with you, I would get a different job. What we do is in high demand, so it should be relatively easy to find a different place to work for. You can  also join the Do Better Movement, which we’re going to talk about in a little bit and encourage the powers that be to join it as well because then hopefully everyone will be part of this discussion we’re having about how to do better and this, these topics are going to be coming up throughout the year. So then

Mary Barbera: Why don’t we talk about the, Do Better Movement. And I think this  would be a good time.

Mary Barbera: So, what is it? What, what made you think of it?

Dr. Megan Miller: So basically it’s, I was going, I have tons of training topics and webinars that I just have this list. Some of them I’ve already created the PowerPoints for that I’ve been saying for years. Oh, I need to like get that down and make it a webinar, but I’ve never done it. So, I was seeing repeated themes coming up on Facebook and with my supervisees. And I decided, you know what, the only way I can insert that this happens is if I do something public and say, this is what we’re doing. So rather than just do it, you know, kind of on my own, I thought there’s a ton of people out there that really are motivated by this as well and would want to learn about these things. So, let’s build a community of individuals who want to do better as behavior analysts. I have content that I’ve scheduled to release based on a monthly theme and community members are encouraged to share what they’re doing and come up with their own ideas so they can participate in what I’m doing, but they can also share, you know, whatever things they’re doing.

Mary Barbera: I want to thank Megan, thank you so much for coming and being with us today and sharing all your wisdom mostly about evidence based practice and andd escape extinction. And hopefully we will have sunny weather in San Diego in May. But thank you very much.

Dr. Megan Miller: Thanks for having me.

Mary Barbera: I hope you enjoyed that episode with Dr. Megan Miller talking about the ethical considerations, especially when using escape extinction and some of the nontraditional approaches. You can use some alternatives to  escape extinction. If you would like to learn more about my approach, you can attend a free workshop at forward slash workshop and I hope to see you right here next week.

Thanks for listening to the Turn Autism Around podcast with Dr. Mary Barbera. For more information, visit

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