Skills Based Treatment: A Wholistic Approach for Severe Behaviour

Written by: Bimisayo Adeyi

Edited by: Rayah Realista M. ADS, BCBA, RBA (Ont), IBA, CBSS?

“Why can’t she just do it?”? “I’m not even asking that much!”? “I can’t get my child to do anything!”?

These frustrations are familiar to anyone who’s been responsible for a child. By nature, children, ?may struggle with cooperation at various stages of their development. One of the key aspects of caregiving is teaching children how to cooperate with the various adult-led routines and instructions placed on them throughout the day.?

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Cooperation can be particularly challenging for neurodivergent children for the same reasons as neurotypical children, but the emotional responses associated with following adult-led activities can be exacerbated by difficulties in communication. Of course, the level of difficulty will vary from child to child and moment to moment. In the Applied Behaviour Analysis field, Behaviour Analysts often work with children who respond to even the mildest requests or instructions with intense and sometimes dangerous behaviors. Traditionally, Applied Behavior Analysis (ABA) has used principles of reinforcement and the process of extinction to encourage more appropriate responses and teach new skills. ?This typically involves:?

1. Identifying the function of the interfering behavior that is preventing the child from engaging in the instructions or activities that are asked of them (i.e. why the child is acting out),? ?
2. Teaching the child to engage in a more appropriate behavior that achieves the same function, and?
3. Withholding reinforcement for the interfering behavior.?

While this approach can reduce interfering behaviors that children use to indicate unmet physical or emotional needs and promote functional alternatives, it may come with significant costs, especially when working with children who engage in high-risk behaviors. The potential consequences can be serious; for instance, children may harm themselves or others, property damage can accumulate, and caregivers may experience burnout. In many cases, children grow up ?before these behaviors can be meaningfully addressed, thus leading to increased levels of risk for children, caregivers, and support workers, ?because it is not just one skill that needs to be taught, but a range of skills that support communication, cooperation, and willingness to learn new things. When behavioural interventions are rigid and rely solely on single-function treatment approaches, we lose the ability to address the nuanced interactions that occur between the child, the caregivers, and environmental variables that contribute to the likelihood of high-risk behavioural responses. A treatment approach that provides a framework for a wholistic understanding of the child, the family, and the specific reasons why interfering behaviour occurs is necessary to empower the child’s village of support throughout their lifespan.?

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What is Skills-Based Treatment??

Skills-Based Treatment (SBT), also known as My Way Protocols or Hanley Protocols, is a comprehensive intervention approach that focuses on working with the child to build cooperation skills, while prioritizing safety. Rather than simply reducing challenging behaviors, SBT teaches the underlying skills needed for child assent, or cooperation. These skills are broken down into manageable components, taught systematically, practiced frequently, and generalized across all of the contexts or environments where the child usually needed more support in?

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Before exploring the specific skills involved, let's look at the guiding principles behind the process:?

1. Synthesized Contingencies?

In SBT, we focus on understanding all the reasons behind a child’s behavior, rather than just isolating one specific function (e.g., seeking attention, avoiding a task, sensory seeking, or gaining access to preferred items or activities). Dr. Hanley sums it up well: “Children engage in challenging behavior to avoid things they dislike, to get things they like, with people they like, and some other stuff.”?

? |In SBT, we work with two conditions:?

• Everything is freely available and nothing is hard, within reasonable and safe limits?

• Relinquish the fun and do the work.?

? ? To start, we conduct a practical functional assessment to answer three key questions:?

1. Can we create conditions where all possible reinforcers are available, so the child has no reason to engage in unsafe behaviors??
2. Can we create a set of conditions which will reliably evoke the early warning signs of the unsafe behaviour? To prioritize safety, we don’t want to evoke the full behaviour, but can we get some early warning signs??
3. Once we place demands or give instructions and get those early warning signs, can we easily and return the child back into the state when they were happy and had no reason to engage in challenging behaviour??

2. Start with Joy?

Before teaching, we ensure the child is happy and engaged. Consider these two scenarios:?

• Scenario 1: You’ve had a great day—slept well, had no delays, everything went smoothly at work, and you’re in a positive mood. But then, you find out someone ate your lunch.?

• Scenario 2: You’ve had a stressful day—no sleep, delays on the way to work, and a wasted meeting. You’re feeling stressed and behind schedule. Then, you find out someone ate your lunch.?

Which scenario is more likely to trigger an emotional response??

Children are similar. When they are happy, relaxed, and engaged in preferred activities, it takes more to trigger unsafe behaviors. We use the term HRE (happy, relaxed, engaged) to describe this state, and we find that teaching is most effective when children are in this mindset.?

3. Predictable and Slow Transitions?

Transitioning from fun to work is never easy. So, we give plenty of cues before making a transition and allow time for the child to process and respond to each cue or demand. The goal is to gradually increase the demand, giving the child time to adjust, mildly protest if needed, and gently build tolerance towards doing the difficult tasks they weren’t able to do or avoidant of doing in the first place. This slow approach helps us avoid emotional outbursts that could hinder the learning process.?

4. Unpredictable Reinforcement?

When placing instructions to complete adult-led tasks, we avoid giving specific information about the task or how much of it will be required. The goal is to build generalized cooperation skills, rather than cooperation specific to a certain task or duration. As the process unfolds, children may be expected to complete the full task or simply express their reluctance. This unpredictability keeps the child engaged, as they remain hopeful that their next response could meet the expectation and end the task.?

By incorporating these principles, we see significant progress in children's ability to cooperate across a variety of tasks and contexts.?

Earlier, we discussed breaking down cooperation into its various component steps. When a child is engaged with a preferred item or activity and is expected to cooperate with a task, here are the steps involved:?

1. Communication?

The first step is to empower the child to use their words. Often, simply expressing their desires or needs can be enough to prevent the child from engaging in an undesired or unsafe behaviour. Throughout this process, it’s important to reward their communication at least some of the time. If we don’t reward initial requests to continue the fun, children may feel less motivated to communicate their needs in the future, if their efforts aren’t acknowledged.?

2. Toleration?

While we want to respect their communication, we can’t always give in when they ask for “more time” or say, “I don’t want to”. The next skill we practice is tolerating “no.” Before pushing the demand further, we give the child a chance to show us that they can accept our refusal. The goal is for the child to respond to denial in a way that signifies, “I heard you, and I can handle that response.”?

3. Relinquishing?

As much as possible, we want to give children the opportunity to relinquish their preferred items themselves. While it may be quicker to take the item from them, allowing them to put it down serves two purposes:?

1. They practice relinquishing.?
2. They do it at their own pace.?

If they need a few extra seconds to prepare themselves to relinquish the item, offering that extra time is often more effective than rushing them, which could lead to emotional outbursts that make it harder to teach.?

4. Transitioning?

Once the child has put away their preferred items, we want them to move to the area where the task is required. They may still need gentle guidance, such as a hand to hold or a light touch on their back. The key is to offer support rather than forcing, pushing, or pulling the child.?

5. Enduring?

At this stage, the child not only has to leave the fun activity but must also learn to cooperate with a less enjoyable task. We start with brief, manageable bursts of work across different kinds of work, gradually increasing the duration and difficulty of the tasks as the child’s cooperation improves.?

6. Persisting?

Once we see consistent cooperation across different tasks and activities, we encourage persistence, even when things don’t go as planned. It’s one thing for children to complete a task, but can they remain calm and problem-solve when faced with unexpected challenges? Some of these challenges may include the task difficulty increasing, having to transition to work faster, less warning signs that a preferred activity is ending soon, or completing work with more independence. This phase of learning is unique and individualized for the student because the specific things that make adult-led activities or tasks difficult can be very unique to the individual child.?

7. Generalization?

This is the most important step, as it makes the entire process meaningful. It's not enough for children to cooperate in specific contexts or with their favorite people. We need to introduce new tasks, environments, and instructors to ensure they can generalize their cooperation skills. If the child had not been able to access and be successful in a group learning environment or other community settings, g, we also begin reintegrating the child into these environments, while supporting caregivers, teachers, and other supports to work together with the child to build a positive rapport that creates the foundation for lifelong learning to occur?

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Conclusion?

It’s important to note that not every child needs this level of systematic training to develop their cooperation skills. However, for those who do, Autism In Mind is equipped to provide this level of support. Our team is trained to help individuals at various stages, from those who experience severe reactions to minor environmental changes, to children who are ready to complete daily learning and self-care routines with the appropriate level of support.?

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