Collaborative Treatment, Part II

Mike and Dan discussed collaboration with SLP and OT. Now they explore current and prospective efforts with psychiatric care, use of medication from said psychiatric care, as well as future efforts in primary medical care, an 'off-label' use of ABA, per the current treatment model. ABA provision and related data could easily provide a wealth of information to treatment with medication, addressing side-effect management and possible enhancement of treatment effects, given fidelity to both medication and ABA treatments. So, take  your recommended dose of ABA on Tap in this ameliorating episode, preferably with a full glass of water, or any other reasonable libation. And always analyze responsibly.

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Transcript

SPEAKER_00: 0:00

Hey Mike, how do you feel about today? Feeling pretty good about it?

SPEAKER_02: 0:04

I think today's a great day, Dan.

SPEAKER_00: 0:06

I couldn't agree more. Like you say, any day that you wake up and your name's not in the obituary, you're off to a good start. Speaking of which, today's also a great day to start your own podcast. Whether you're looking for a new marketing channel, you have a message you want to share with the world, or just think it'd be fun to have your own talk show, like we did. Podcasting is an easy, inexpensive, and fun way to expand your reach online. Maybe learn something. Now, Buzzsprout is hands down the easiest and best way to launch, promote, and track your podcast. It's what we use. Your show can be online and listed at all of the major places podcasts can be found, like Apple Podcasts, Spotify, Google Podcasts, et cetera, within minutes of you finishing your recording. You know, podcasting isn't hard when you have the right partners. And the team at Buzzsprout is passionate with helping you succeed. Join over 100,000 people just like us sharing their message, already using Buzzsprout as the conduit to get their message across the world.

SPEAKER_02: 1:08

We use Buzzsprout and we love it. Buzzsprout will give you a great looking podcast website, audio players that you can drop into other websites, detailed analytics to see how people are listening, tools to promote your episodes, and much, much more. So here's what you'll do if you want to start your podcast today. Follow the link in the show notes. This lets Buzzsprout know we sent you. It gets you a$20 Amazon gift card if you sign up for a paid plan, and it helps support our show. So make it a great day today. Get on to Buzzsprout and start your podcast. Inform the world. And of course, always analyze responsibly.

SPEAKER_00: 1:46

Cheers. Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_02: 2:43

All right, all right, all right. Welcome yet again to another installation of ABA on Tap. I am your co-host, Mike Rubio, along with my gracious co-host and good friend, Daniel Lowry. Dan, how are you doing today?

SPEAKER_00: 2:56

Pretty good. I think I successfully made it through 2021.

SPEAKER_02: 3:00

Almost there. Don't count your blessings too soon here. We're almost there. We've got at least two episodes of The Tap to get through. No, I think we're almost there. Very excited to be wrapping up a second season of ABA on Tap. So thank you, sir.

SPEAKER_00: 3:17

Absolutely, no sophomore slump here.

SPEAKER_02: 3:20

And thank you all out there for continuing to listen and give us feedback here and there as you're listening, asking questions, giving us some good pointers. Today, we've got a continuation episode on collaborative treatment. On our first installment, we focused primarily on our current, prospective, more desired collaboration with speech-language pathologists and occupational therapists. And today, we will be focusing that effort toward collaboration collaborating with I guess more of the medical side, psychiatric treatment, medication, and so forth.

SPEAKER_00: 3:53

And I'm really excited for this because I think historically as ABA and for individuals on the spectrum has been more of the educational model. So we've primarily worked with schools and occupational therapists and speech pathologists. And not to say we don't, which we still do. As it gets more and more into the medical model, I think we're going to be working more and more with the psychiatric staff that we'll continue to talk about. So I'm really excited to talk about this prospect as it looks like that's what ABA is going to be moving towards in the future.

SPEAKER_02: 4:22

Yes, and if we have a chance, a little teaser here, we might talk a little bit about behavioral pediatrics. I think we mentioned it in the last episode, something that we're very excited about currently. Certainly not a new idea, but something that hasn't really taken hold like a lot of us wish it would have at this point in time. So without further ado, let's jump into our current topic here. In looking at our prior episode and looking at models of collaboration, I want to start with a few bullet points from the Association for Science in Autism Treatment, And they're speaking specifically about ABA and SLP, or speech-language pathology collaboration. But they outline some very important points here that I think apply across the board. And these are things that maybe we're trying to do already or doing to some extent, but could certainly find more room for collaborative effort, concurrent effort within. So the first bullet point they lend here is that the assessment data of one provider can better inform the implementation efforts of the other provider. We exchange a lot of collateral information here from provider to provider currently, maybe it could be better than just exploring those reports, but actually working together to provide common procedures, things like that. Again, we'll explore these topics a little further in the episode.

SPEAKER_00: 5:45

Absolutely. And also understanding what the assessment results provide and the terminology and lingo within there. I know things aren't necessarily congruent between different services and modalities.

SPEAKER_02: 5:56

Periodic co-treatment and or direct observation of each other's work or sessions that the client is doing with another professional. I think that's, again, something that we try to do, often done primarily when there's some sort of problematic behavior. So I know that as the behavior people, we are often pigeonholed, quite mistakenly, to just Behavior that is maladaptive or undesired so we often get invited to hey Will you come see the speech therapy session or the occupational therapy session because they're not attending or their behavior is bad So please come to your work knowing that through this podcast and not just these episodes. We're exploring how Talking is also behavior and obviously moving and coordinating whether in gross or fine motor is also behavior So we need to explore more of that common ground there.

UNKNOWN: 6:48

I

SPEAKER_00: 6:48

I agree. And like you said, collaboration in a supportive format, I think is huge historically. And I can speak for myself as well. You know, us in the ABA field sometimes tend to poo-poo other modalities and say, oh, that kid doesn't need medication. We can do whatever. Or, oh, that kid doesn't need occupational therapy. We can deal with it. But then when you actually go watch an occupational therapist work, while they might approach it from a different modality, man, some of the stuff they do is just super fun. And I always walk away amazed. even if it's not necessarily from my area of expertise or how I would approach it. If nothing else, it just gives a different tool in the tool belt. So when you're running short on suggestions in a particular time, you can use that. So I think that supportive collaboration and going to collaborate with whatever that entity is and not going in to say, oh, this is what you're doing wrong, but, oh, this is what I can learn from whatever that modality is, is just going to make that individual's progress that much better.

SPEAKER_02: 7:45

Well, perfect segue into the third point. One provider can focus on the systematic assessment and promotion of carryover or generalization of the acquisition efforts of the other provider. Again, a lot more of that could happen where maybe we're out in the community and taking certain activity out to the playground. Well, some of the movements... that the occupational therapist is talking about would be very, very well suited for that particular environment, and now not in isolation or in treatment, but in a social setting. So I think that's something that could be explored much, much more, and today we'll focus those efforts again toward psychiatry and medication. And then lastly, for these bullet points offered here by the Association for Science in Autism Treatment, they give an example of how this can play out with behavior analysts and speech-language pathologists collaborating and saying that a behavior analyst could implement a functional communication training intervention for a nonverbal student relying on the speech-language pathologist's expertise with AAC. And I really like that point, because I know that currently one really fun and effective and easy thing that I'm doing with one of my clients is just an AAC exploration, meaning a simple match and receptive ID and telling him a word or showing him a picture and having him explore the dynamic screens on his AAC device, which happens to be an iPad, and find and match up with that particular icon. Again, really just an effort for that client to tour their device so they learn more of where these particular words and icons sit and hopefully increase the fluidity of their communication. So how would we apply this current model or this current effort that's outlined here for speech-language pathologists? I think we can easily transfer that application over to occupational therapy. And now moving to our current topic, psychiatric treatment, medication treatment. Dan, where do you see the current state of our collaboration with our psychiatric partners, knowing that a lot of our clients are taking medications for off-label use, meaning that I think to date, and somebody out there can correct me, there is not one approved medication specifically for autism, right? I'll let you launch there, sir.

SPEAKER_00: 10:00

Yeah, yeah, I agree. And I think it just, you know... Barkins, that there's a lot of untapped need there on both sides. I don't think it's been a collaboration that's really been explored. As I mentioned earlier, as ABA traditionally, until recently, has not necessarily been looked so much under the medical model. So, yeah, and I'll pass it back to you, Mike, because I think you've got a really good anecdote, and then we can move into further discussion about it. But I think you would probably say... Don't let me put words in your mouth, but I think you would probably say that 15 years ago, you were probably a lot more anti-meds than you are now. So can you talk a little bit about why that is? And then I think that'll be a really nice segue into our collaboration.

SPEAKER_02: 10:47

That's a really good point. I think that you're correct. I've come around quite a bit in my career in trying to understand collaboration, especially when it comes to medication. And I will end an anecdote, a story that my father used to tell me and has told me many, many times throughout my lifetime, in trying to, I guess, help me examine the world and its circumstances with a cleaner lens and not make any erroneous attributions or try to really look at the full picture and arrive at the simplest answer, if you will. But... not just the simplest answer, the simplest answer that actually applies. Someone

SPEAKER_00: 11:24

called that parsimony,

SPEAKER_02: 11:25

right? Yeah, that's what we're after right there, right? So again, I think I've mentioned my story here about Maybe I did last time about the efforts with undergoing an effort to teach a child the word apple, and you're bringing apples, and you're snacking on apples, and you're reading books about apples, and the very hungry caterpillar is eating this many apples, and then the child goes to the doctor, and they get their medication prescription, and they take that first pill, and the next day they say apple, and the parents are like, wow, is it that great? Is that apple? And you're excited about all your efforts because you know that you've been working on apple, and they go, man, it's a good thing that the psychiatrist gave us that attention medication. And you're like, wow, okay. And again, a lot of that's a little bit of personal, maybe it's ego. Again, back to the idea of not being collaborative but wanting to be the front runner on the team. But I'll go back to the little anecdote that my father used to share with me. And he's got a scientist in his lab coat and he's sitting in his lab and he's got a frog. And he's going to do a study on the frog, puts the frog on the table and he slams the table and the frog jumps off. Three meters. Goes over to his central reach tablet. He puts in his little three meter mark, keeps his data point. Beautiful, right? And then kind of a cruel anecdote here, so a little parable here, so please don't take it too literally. Scientist proceeds to chop one of the frog's legs off, puts it back on the table, slams on the table. Frog jumps two meters, goes back to central reach, puts in his little two meter data point. Proceeds to do this several times until the frog has no limbs left, Puts it back on the table. Slams on the table. The frog doesn't do anything. Slams on the table again several more times. The frog doesn't do anything. So he goes back to his central reach data and he puts in zero meters and he's trying to figure out and make a conclusion with his data here. What does this mean? And it dawns on him. Frog with no legs goes deaf. And I think that's part of the problem with what we do a lot of times with medication and or our own treatments, trying to really take the limelight to be the ones that are at the forefront of the client or the child's progress, where we got to take a step back and realize that there's an SLP active, there's an OT active, there's some meds active. We cannot extricate, not mathematically or otherwise, the effects of those particular treatments on any of the success that we feel is may be attributed to our particular intervention. So it's a real lesson in checking one's ego. It's a real lesson in collaboration. But it's also a real lesson in science and trying to navigate the multivariate circumstance that exists for a lot of these clients, knowing that most of their parents are really just looking for the silver bullet, right? So all of us are looking for the one thing that worked, but with so many things active, how do you figure that out?

SPEAKER_00: 14:16

Yeah, yeah, that's a... Great anecdote, Mike. I appreciate the deaf frog. Circling back to your original question, I think there's two approaches that we can take in this podcast or two perspectives that we can have. How can us collaborating with psychiatric staff help psychiatric staff? And how can us collaborating with psychiatric staff help our services? And a little bit of foreshadowing that in the near future, we will be doing a podcast with a distinguished colleague, a psychiatrist He used to be a medical director of a large hospital organization out here. We'll be getting a lot more input from him, so the specific questions will be better for that podcast. But let's start with what we can do for the psychiatric staff, because I feel like it's always best to say, how can we help? So you brought up a really interesting point, Mike, that most, at least a lot of the behavioral medications given by psychiatric staff are used off-label. In fact, most, if not all, for the autism demographic and the behaviors are used off-label. So it still seems, you know, it's still kind of like a research phase of medication. And if we use this medication, what are the behavioral symptoms that we see? And what are the things we see increase and decrease? And I'm sure there's, you know, a lot of studies done on that, but they're still trying to figure it out. And what would be better than the amount of data that we can provide in an ABA setting onto what The actual behavioral ramifications are of these medications. Because oftentimes these psychiatric staff only have these clients, you know, 10, 15, 20 minutes, maybe an hour visit every couple of weeks. But that's not necessarily relevant or representative of what their life is like. who has that data while we do as ABA therapists. We often have daily data or data close enough to daily data and a lot of it that can be used comparatively and show the potential effectiveness assuming that enough controls are held steady throughout the other extraneous variables of the effectiveness of that medication. I think that's something that we could really bring to the table for our psychiatric staff and really give them some more power and more validity in the autism demographic as we look for drugs that may or may not be clinically proven to show increase or decrease ASD-like symptoms.

SPEAKER_02: 16:44

I like everything you're saying. So how, the real big question that emerges, how do we make that collaboration more active? And I think that a lot of it starts with the notion, again, back to the same idea of ego, Many psychiatrists is going to value and prize the effects of the medication that they might be providing. And we don't blame them for that, just like we might then value and prize the effects of the intervention that we do. We're talking about bringing those together so we can see how those two things might enhance the outcomes for the client if we took into account each other's variables. So let's start with something like side effects. It would be the general premise of any medication that you take that because of the actual treatment effect of the medication, anyone is going to tolerate and sustain any number of side effects that may come from it. But when you consider those side effects, then we get a lot of parents talking about, well, we did a little washout this weekend because we don't like when this or that happens or they're chewing on their shirt. That can happen with stimulants. What about things like weight gain? Right. These are all behavioral pieces that I think are begging for collaboration. They're begging for us specifically to be able to go in there and say, now the psychiatrist, Dr. So-and-so said that this is going to increase their appetite. So you might expect some conflicting situations over snacking at night. You might want to start not keeping this, that, or the other available, or keeping more of that available in an effort to satiate this new increased appetite. I can go on and on and on, but I think that that's one general area where very easily we could offer a great deal of value to our psychiatric partners in, from a health education perspective, also the consumer, and letting them know, expect this side effect, undesired effect of the medication. And then better yet, in order for it to work as promised, do this in response to the side effect as you tolerate and get to that treatment level, whether it's a couple weeks for certain antidepressants or whatnot. You have to upgrade the neurotransmitter levels by taking this medication. And if the consumer isn't taking it on a day-to-day basis, then that psychiatric experiment is now confounded. Now that data is... botched, we don't know what's working. If it's not working, we certainly know that the active chemical isn't being ingested. So that's just one way in the data that you talk about. We could certainly, in being there two, three times a week with these clients, ask our psychiatric partners, what data would you want to know about? And let us capture that for you, put it into our little database, and there we go. So largely untapped, as you say, that particular area there.

SPEAKER_00: 19:36

Yeah, I think that's a lot of nice foreshadowing into your behavioral pediatrics piece that we'll talk about either this podcast or the following one, talking about also how we can assist with them in the routine of the medication administration. That's another important thing, right? So like you said, there might be a fade out over the weekend or the parent forgot or whatever, and now all of a sudden the medication experiment for that single subject study is now confounded. So you're definitely going to have some issues there. I I think the biggest questions are kind of twofold. You asked why this collaboration doesn't exist. One of them is obviously going to be funding. A lot of times it comes down to that and how is that going to be funded. Fortunately, we are the only one that I know of. I'm sure that there's plenty of other ones that exist, but we're the only one. ABA company, I know that's part of a larger psychiatric medical group, so it just kind of fell into our hands, this collaboration. But I imagine it would be difficult for different entities of different medical groups and things like that to collaborate. And then number two, you go back to what you said earlier, the assessment results. I remember when we were showing some of our psychiatric staff the large data books back when we had paper data books, and they just looked confounded. I'd give them a data book. I'm sure they could figure it out, but they wouldn't necessarily know what that means and what they need to look for. And just like if they give me a psychiatric test, I wouldn't necessarily know what to look for. So making sure that we can speak the same language and also making sure that there's some sort of fiscal or logistical incentive To create this collaboration. That being stated, if we can do that, like you said, I think the door opens up significantly. I think we can enhance the power that the psychiatrists have when they're divvying out their medication and really show whether things are effective or not. And also, but that's just a little side note. I've seen this happen a lot in my experience, so I'm sure it's representative of a larger issue or a larger demographic that parents will try medication, kind of like your Apple example, but then they'll do a bunch of other stuff on the side. They'll try a different ABA intervention. They'll start ignoring their kid when they're doing attention-seeking behaviors or they'll start changing their diet or they'll change a whole bunch of stuff. And then they'll say, well, oh, the medication doesn't work, or the medication does work. Always comes down to the medication just completely trivializing everything else that's being done. And in fact, a lot of times parents don't even give a representative statement You know, testament of what's going on, because potentially, again, in my experience, maybe they're over attributing their child's behavior in the situation and under attributing the surrounding environment. So it's funny, you know, a lot of speaking from personal experience, a lot of times we'll work with a client who's really good in every other environment except for the home environment. And what do they do? Well, they have to go see a psychiatrist and get medication because the kid's disruptive at home, but they're really good at every other environment. And then they go through all these sorts of medications, like you said, that have different side effects to work on the home environment. Yet the kid's been good at every other environment other than the home environment. So the question here being that collaboration could solve. that hopefully we could work with the psychiatrists is, is medication even needed? Because from a psychiatrist only getting it from one perspective, I would say, of course the medication's needed because the parents are just talking about how disruptive the kid is everywhere. But the kid's actually not that disruptive everywhere. They're not getting an objective measurement.

SPEAKER_02: 23:21

You just made me think of something that I hope is as humorous to everybody else as it is to me in my head right now. But one of the problems I have, and again, everything that you were speaking made me conjure up this thought, I think one of the problems that we all have, or one of the concerns that we all have with, say, the idea of kids being over-medicated, that we aren't able to articulate for ourselves, is we're often medicating kids not based on a problem they perceive, but it's a problem that we perceive for the child, right? So it's like if you had a cold, and instead of saying, hey, Dan, you should take this cold remedy to make you feel better, I was saying, damn, Dan, take this DayQuil because I'm sick and tired of your coughing and sniffling, man.

SPEAKER_00: 24:05

That's such a great analogy.

SPEAKER_02: 24:07

And I think that that's part of the problem here is that we know that in our better moral selves, but it doesn't make it any easier for a parent who's out at the park or who's getting calls from the school every day about their child's behavior. And in that respect, maybe we'll do a separate episode on this, but in that respect, then we also have another set of professionals who are saying, hey... We're hands off. We're just the school. You deal with your kids' behavior, right? And then we're somewhere in that mix trying to figure that out.

SPEAKER_00: 24:34

And then in your example, too, the day cool might cause sleep loss or weight gain or something like that as well. And that always

SPEAKER_02: 24:41

helps socially, right? With your health and all the other variables that might come in that make it more difficult now. And again, even the conflict in just saying, hi, I've got an increased appetite. Well, now I see you gaining weight. Now I'm trying to restrict you from eating this, that, or the other, even though we have it in the house and before it was okay. So It changes so many rules based on some adults' inability to tolerate and regulate a child's behavior. And again, I don't say that critically. I'm a father myself and have been in many situations where my child is doing something that I know is bothering somebody else. And there's a lot of pressure that you feel in that moment. There's a heightened state of arousal, a fight or flight, if you will, because You hear your child's distress, you see other people's distress, and you're stuck in the middle often, unable to quell it fast enough for either your child or anybody else who's being critical of your child. Oh, wait, and now somebody's being critical of your child. Of course, that doesn't have an effect on any parent in that moment, right? So it's like this avalanche of a whole surge of emotions and concerns and very, very... strong instincts to protect your child, to quell their distress, and then on top of that now you've got social pressures on top, right? So I can completely understand why we're trying to solve the problem this way, but Now, to my long-winded point here, in starting with the original premise that I'm doing this because I can't tolerate your symptoms...

SPEAKER_00: 26:15

Are you taking medication for me or

SPEAKER_02: 26:17

you? Now the parents don't necessarily always understand, nor do we, quite frankly, which is something that I think is a health education effort that we're undergoing with this notion of behavioral pediatrics, is understanding better what these chemicals are supposed to do. And I'll give you a quick example here, and then I'll turn it over to you. When we're talking about medication for hyperactivity and talking about stimulants to, and again, I'm not a doctor, but I do understand a little bit of this, to somehow stimulate the brainstem and more self-regulation efforts. That's great. That's a great theory if that's in fact what's happening. And we do have some of that data from what those stimulants do to anybody who takes them in terms of increasing their attention or the acuity of their attention to singular things. So this is whether you've got ADHD or not. But then you might also find a client or a child that has ADHD who's being given guanfacine. What's guanfacine?

SPEAKER_00: 27:20

I'm guessing a stimulant?

SPEAKER_02: 27:21

It's not a stimulant. It's actually a beta blocker.

SPEAKER_00: 27:27

Okay.

SPEAKER_02: 27:27

Used to bring your blood pressure down. Because if you bring your blood pressure down, then what happens to your activity level?

SPEAKER_00: 27:33

Probably decreases a little bit.

SPEAKER_02: 27:35

So we're no longer talking about a child having a medical issue with blood pressure or some understimulation of their brainstem and their self-regulatory areas. We're completely admitting we're just trying to slow this kid down. They do too much, right? So again, it's not the child having trouble with their level of activity. It's their surroundings. But then we might come in and still try to manipulate some of those variables from the child's perspective. But fortunately, we're also looking at the environment. So we stand a chance of collaborating here and making some of these misconceptions go away. I know I laid out a lot there. I'll turn it over to you and see what you're thinking.

SPEAKER_00: 28:14

Yeah, that brings to the second part. So we talked a little bit about what we can do for psychiatrists. Talked a little bit about what they can do for us. So in ABA, we need to establish a situation or an environment for an individual to access reinforcement. And then when they access that reinforcement, the behavior that happened before it will increase. Hopefully that's an appropriate replacement behavior, and then the replacement behavior will take over the maladaptive behavior. But if we can't establish a situation for that replacement behavior to occur, our hands are a little bit tied. And that's where medication might actually be useful for what we do to create a state where that individual is able to access reinforcement. Because if they're running all over the place or not able to sit down or do anything, we might need to... We might need to get them in a state where they can access the reinforcement. Now, the key thing here, at least in my opinion, and I look forward to speaking with other individuals on the mental health side of things, is that these should only be used in a fairly short-term solution so that they can access the natural reinforcement and then fade this medical barrier intervention into more natural environmental interventions where they can learn to regulate their own environment to give them the reinforcement that they need. But that's definitely what I've seen with some clients that I've worked with that just are all over the place and may need some level of or may benefit from some level of medical intervention to help them succeed.

SPEAKER_02: 29:55

That's a great point in the sense that they have to be accessible to their environment. So that's a great...

SPEAKER_00: 30:01

That's a better way to word

SPEAKER_02: 30:02

it. Well, no, and again, you're complimenting my point perfectly because at the end of the day, whether it's me or the child that can't regulate hyperactivity, you also need that educator, that speech-language pathologist, that behavior analyst to be able to access that child enough to implement a certain intervention. And again, that raises all sorts of questions. The first thing that I think of is that attribution error again. So always going back and forth between what was it that caused the change, knowing that we really can't extricate anything, right? So more of the health education and understanding, us getting a better understanding of, and the parents too, what is this medication supposed to do? What is it for? Number one, how is this off-label use going to potentially benefit the child? What are the potential side effects so that behaviorally we start managing those or preparing for those? And then what are the expected treatment effects of this medication so that when we see those, we can also start counting them and then give a little call over to the psychiatrist and say, hey, guess what? We've got the treatment outcomes now. Now what you want to see is happening Do you want to adjust your dose? Or how does that work? Do you bring it down now? Do you sustain it for how many weeks? So that we know on our data and our efforts how long we have to sustain that effect. It's not just the medication. It's something we're doing. It's not just what we're doing. It's also the medication helping the child become more accessible. And you're absolutely right. At that point, start the fading efforts, if you will, or start reducing the dosage. Currently, what happens is either the medication is not working or the ABA is not working, but somewhere in there, neither dosage of either treatment is fading or being pulled back for many, many years. So we're talking about really enhancing the speed of intervention effects, hopefully positive effects, if we can undergo this effort to collaborate fully. Now, what do you think is our first effort? What's our first step here in trying to open this up? How do we make ourselves... more valuable, more attractive, what would be the first step, do you think, behaviorally in having our psychiatric partners say, we do want you to take that data. We want this type of data. What are you thinking about that?

SPEAKER_00: 32:30

So I think about that, that you bring up a really good point earlier, that most often when the parents, at least in our experience, when the parents are requesting meds for their kids, It's because the environment can't handle the kid. The parent can't handle their kid's assault or impulsivity or whatever they want to call it. The environment can't handle it. It's not necessarily a kid issue. It is to an extent, but it's more of the environment can't handle it. Like you say, most of the time when kids are crying and stuff like that, the kid's not the one with the problem. We're the one with the problem, right? It's bothering us. Now, you know, that's a little more than half true, right? Like, obviously, the kid isn't enjoying it, but we're the ones that have the biggest issue with that. And I think that's where our biggest help with the psychiatry field can come in, is that if you give a medication to a drug addict and put them in a similar environment that they seek out drugs, they're probably just going to seek out those same drugs because they have the same environments around them. With our kids, if you give them medication and put them in the same environment that's enabling certain behaviors or making certain behaviors pay off in other behaviors, that medication's going to have a really low likelihood of being successful. Short of, like you said, giving them maybe a blood pressure medicine or something to literally get them to physically calm down or be sedated. Other than that, the behavioral stuff, the impulsivity and things like that, if... If every time the kid asks for a cookie, I give them a cookie and then I claim that that kid's impulsive, you can give them all the medication they want. Unless I stop giving them a cookie every single time they ask for a cookie. We're kind of handcuffing the psychiatrist, to be fair, and that's almost not fair to them. And then the parents go into the psychiatrist saying the medication doesn't work and then ragging on the psychiatrist to everyone saying that the psychiatrist doesn't prescribe them the right medication. Or it wasn't really a medication issue. The psychiatrist did the best they could with the information they were given, and then their hands were basically tied from the get-go. That's what I think our best benefit to this psychiatry staff. I think we could really make them... Show in a good light and say, you give them their medication, but also include these things in the home. This environment, medication plus environment is probably going to equal success. I think that's what we could do that would be the most successful.

SPEAKER_02: 34:49

So this is a perfect segue into the notion of what we're grabbing onto today. with regards to a definition of behavioral pediatrics. And a little shout-out and recognition to our colleague, Patrick Freiman, who I think has brought the current definition here, the more modern-day definition. from something back in the 80s.

SPEAKER_00: 35:16

Everything's a perfect segue to behavioral pediatrics, right? Right now,

SPEAKER_02: 35:20

everything is. You could have talked about

SPEAKER_00: 35:22

rising... I think the Packers are beating the Ravens right now. That reminds me. The

SPEAKER_02: 35:27

Packers and the Ravens. Behavioral pediatrics. But what you're talking about would require us to posit ourselves in a situation where... Bear with me, if you will, here. I'm a psychiatrist, and I'm sitting in my office doing a consultation with a mom who's at her wit's end. And this child is aggressing and throwing objects at her and calling her all sorts of names. And this psychiatrist says, wow, that's a heightened level of aggression. Your child has autism. I'm going to prescribe this medication. Now, along with this medication is going to come your stop on the way out here, to see these gentlemen here, these folks, not just gentlemen, these gentle people here, in the behavioral pediatric office, and they're gonna talk to you about how to administer the medication, so the behavior you need to follow to ensure that this chemical, endogenous chemical, exogenous chemical, comes into your child's body, and then what to expect after that, and we need you to follow the things they tell you to do. So that's a pretty tall order, for us to gain that level of, I guess, influence, if you will, at this point, it means that, I'm not sure, do we have to make our behavioral treatments that much more in the spotlight or seemingly more effective? I'm not sure how we motivate those particular medical professionals right now to, as you're saying, to understand that we could enhance the outcomes of what they're trying to do. I don't think we've done a very good job at all of trying to impress them quite yet. I think you're right. We're in direct competition. But to your point, that's what we need to do is posit ourselves in a place where psychiatrists like pediatrician in the future is saying, this is the medical reason. Now, as far as your behavior, mom and dad, and your child's behavior... those people over there are going to tell you how to act.

SPEAKER_00: 37:26

Yeah, it's kind of like you. I know you just tore your Achilles, right? They do the surgery, but if you don't do anything after that, you're not going to be in that much better shape. They partnered with a physical therapist who found out that, yeah, the surgery helps, but in addition to the surgery, we need these sort of environmental modifications or we need this sort of behavioral things to be done consistently to really accentuate the value of the surgery. That's what physical therapy is doing currently for you as I look at your swollen Achilles. And that's kind of what we are, right?

SPEAKER_02: 37:56

To your point there, that's perfect. A little personal disclosure here. I've been a great patient with the exception of two slight behaviors. I don't elevate or ice enough. And that's why my swelling isn't as good as it could be or as reduced as it could be. So to your point, it could be Something as small as the time of day that's going to affect the perception of the effectiveness of the child's hyperkinetic activity or lack thereof that's going to lead some teacher or some parent to say that medication did or didn't work as we somewhere fit in that mix trying to do all sorts of behavioral interventions and trying to get the kid to self-regulate and breathe and count to 10 and tear this or that that's acceptable to tear. All sorts of things to try and get them to calm down or soothe a little bit. But at the end of the day, hey, something as simple as not icing or elevating your foot or skipping a dose or whatever it is that parents do is going to change the perception of the effectiveness of that medication, knowing that we're not starting with anything quantifiable other than qualitative perspectives on whether or not certain behavior is tolerable. Absolutely. That's a mouthful. I'm sorry. So, yeah, I think you make a really good point. Absolutely. To continue on with this conversation, how do we make ourselves or posit ourselves in a position to say we can help your medication efforts work better?

SPEAKER_00: 39:28

So it's kind of like this, Mike. I know you're big on the contingent imitation and language mapping, right? So let's say, hypothetically, we have a one, two-year-old client, three-year-old client. It's really not reciprocating much of the environment. So, you know, the parents trying to do all sorts of stuff, talk and present all sorts of stimuli and arrange the environment. The kids just not seeming to be receptive. The parents doing all sorts of stuff and the kids just not seeming to be receptive. So the parents just frustrated and they come to us and they're like, no, I do all this stuff and I just cannot seem to engage my kid or get any sort of response. What? Would your recommendation in that situation be to stop presenting the stimuli because you're not getting any input back?

SPEAKER_02: 40:11

No, I'd heighten the effort. You'd heighten it, right? Make it louder, make it stronger, make it more salient.

SPEAKER_00: 40:16

Absolutely. And so often the parents eventually get frustrated, and I can't blame them, they stop the stimuli. They stopped the environmental part. So then when the neurology, because the neurology is behind. So then when the neurology actually comes online or is susceptible or the client child is ready, ready to take the stimuli and reciprocate them, they're not getting that stimuli anymore in the environment because the parents got frustrated and stopped. Understandable, right? The reciprocal interaction, the parents stopped. So when the neurology comes online, now they're not getting the environmental stimulus. So the behavior doesn't happen. Same thing with the medication. If the neurology comes online with the medication, if they're not getting the environmental stimuli, the environment's not maintaining the behavior, the behavior's not going to maintain, even if the neurology's ready for it, because the environment's not ready for it. So I think that's, you asked me how we get a seat. I think that's how we get a seat. And it only helps out the individuals, you know, the doctors and the psychiatrists that they're working with. It makes their medications more powerful. It makes their success rate go up. It makes their whole modality that much more impacted.

SPEAKER_02: 41:22

That's a really, really excellent point you're making there in terms of how to heighten our collaboration. We need to really become purveyors of effectiveness, if you will, right? So it's almost like what you're saying is It's on us to go to the psychiatrist and say, hey, tell us more about this. We've got consent from the parent. Tell us more about this. Hey, speech therapist, what interventions are you doing? What are your goals? And what would you like us to do during our sessions? Hey, occupational therapist, what's the deal? Tell us what to do. Maybe we're a little too proud for that sometimes. And moreover, We've got our huge laundry list from most traditional approaches of all these things that we're already planning on doing. Oftentimes, even before assessing the client fully, we've already got our template data books and programs. I know something that we work very hard at moving away from is sort of waiting to meet the client. But we're often way ahead of that game where maybe we can make our lives easier and say, before we build anything, let's see what everybody else needs this kid to do and help them do that.

SPEAKER_00: 42:31

It could be. It could also be that I think ABA both fortunately and unfortunately got in some ways kind of the golden spoon of autism treatment through evidence-based methodologies and things like that. So we've never really had to sell ourselves as a product. You know, a treatment plan. Now, certain companies sell themselves compared to other companies. So if you're getting ABA, go to company X instead of company Y. But it's never really like, hey, we need to sell this ABA because that's always been the gold standard. But maybe that's what we need to do. We need to look at how we sell this methodology to these other entities and go to doctors and say, hey, you want to see a 30% increase in your success rate? Let us help you with that. Or occupational therapists, you want your kids to actually pay attention a little bit more while they're learning their motor skill? let us help you with that. Or if you want to help, you know where to reach us. We're not going to teach the motor skills. You're the experts in that. We're not going to force ourselves on you. But I think that might be where it comes from. It's almost like going into an ABA sales pitch and selling ourselves to these different individuals so that we can make their lives a little bit easier. If nothing else, even if they totally disagree with the methodologies that we're doing, at least we get the data. We have the the data to show what's going on, whatever OT regimen, if they want to have that, we can take data on that. And we're going to see, almost guaranteed, we're going to see these clients more than a speech pathologist, a doctor, an occupational therapist, whatever. We're going to see it more often. So we can provide that, if nothing else.

SPEAKER_02: 44:06

I agree. I agree 100%. We have to make ourselves available. And it's funny, back to your description, again, I think most doctors see us as the gold standard for autism treatment, for example, but they don't necessarily regard us that way at the medical table. That's what this whole conversation has been about. So I agree with what we're saying here. We have to make ourselves purveyors, servants, if you will, of this multidisciplinary team and say, you've got a whole bunch of actions you need this client to be undertaking. We're the ones that can help motivate those actions. not just in conversation in your office during consultation, but in the actual environment in which you want the medication to be administered. Just like we want certain things to happen that are supposed to hopefully be enhanced or facilitated by your medication. If a child's hyperactive and we need them to sit a little longer for certain activity, then yeah, there's a lot of collaboration there that we could be taking advantage of with regard to the client outcomes. But Though the research says we're the gold standard, we certainly like to tout ourselves with that. The medical establishment might see that in terms of a referral or a prescription of service. I would say that a lot of our partners may not regard us that way at the current moment, but what you're speaking about will get us to that level. In terms of now recognizing, I'm not an articulation expert. By any means, I'm not a linguist. I understand some of those things with my developmental background. I understand a lot more than maybe your average behavior analyst because I've got that background, but I don't know what a speech-language pathologist does. They do. And if they're the ones that have that constant expertise and I can make the child and the parent do those things more fluidly and consistently, then, yeah, now we're bringing something much bigger to the table and we're not just the bad behavior people anymore.

SPEAKER_00: 46:03

The bad behavior. Right?

SPEAKER_02: 46:04

Because that's usually what we get tired of. Oh, no, no. The speech therapist does the talking. Right? Because vocalizing and moving your lips and coordinating all those things, that's not behavior at all. Well, of course it is. Of course it is. But it's not our bread and butter. It's not our constant expertise. And that much we will admit. As much as we can talk about verbal and vocal behavior and we're very good at what we do, we are not experts. speech language pathologists, right? And they're not us. And I think as long as we can continue to embrace that fact and work with each other more collaboratively, that's gonna serve the client better, it's gonna serve our professional education efforts much better. Going back to the medication, again, not knowing what half of these things do, We've been talking about off-label applications. A lot of our listeners may not even know what that necessarily means.

SPEAKER_00: 46:54

Viagra is quite a good example

SPEAKER_02: 46:56

of that. We want to talk about that really quickly just in case our listeners don't have a clear indication of what off-label

SPEAKER_00: 47:02

use of medications is. I believe Viagra was a blood pressure medication. Yes, sir. It was something that was developed and effective for blood pressure medication. But there just happened to be a really interesting side effect. that came about with Viagra that all of a sudden became so powerful that the side effect or the other thing that it did superseded the fact that it helped with blood pressure. So then all of a sudden it was prescribed for something it wasn't even clinically, I guess, developed to do. So yeah, off-label. Another example is many of the clients that we work with and individuals with mental health issues Issues are prescribed antipsychotics when they're not psychotic because some of the behavioral effects that they see kind of transgress that psychotic realm and help individuals that are not psychotic. So off-label medication being used for something that is shown to be effective for, but it's not clinically proven to be. or was not necessarily developed for.

SPEAKER_02: 48:10

And of course, the side effect that Dan is referring to with Viagra is it makes you more attractive to your partner. Yes. Correct? Absolutely. Just to make sure that I listened. We also talked about guanfacine again, a beta blocker or a blood pressure reduction medication, which is currently seeing a lot of off-label use, often along with stimulant use. So you bring your kid up, and then you bring them down a little later to make sure that they're okay. And again... Not understanding fully the medication parameters or mechanisms behind that, that would be a little concerning, especially not knowing that information, or better yet, knowing behaviorally how to fit into the model to make that particular application of the medication more successful. Back to your point. So we've had a very lengthy, very convoluted, very complex conversation today. A lot of things that we want to understand more about as we collaborate prospectively with our psychiatric partners. Real quick segue, because it's always a good segue, to talking about behavioral pediatrics, again, now not from an autism or a medication perspective, but looking at it from more a developmental psychopathology model, meaning that you and I have traipsed into the discussion today about, say, what's normal behavior for a three-year-old that might tantrum a lot, and whether or not their parent can tolerate that level of tantrum or not, and then maybe you add a little bit of a language delay, and now we might have a diagnostic situation. But there are a lot of children that grow up in this world and in this country who might seem overly picky with their eating, who might have trouble going to sleep, who might have some toilet refusal. Kids who will never be diagnosed with these problems later on, but might be spared some challenges along with their parents in dealing with these things. And something that I think we need to collaborate more with as behavior analysts is primary care, primary medical care. So really briefly, again, the idea being that a lot of kids nail bite, a lot of kids have issues. Bedwetting is a big example that Dr. Pat Freiman outlines in a very, very good 2010 publication called Come On In, The Water Is Fine, achieving mainstream relevance through integration with primary medical care. And he's, of course, referring to ABA relevance in primary medical care. And I think it's an area of collaboration that more of us behavior analysts need to be looking at toward our professional development, and toward understanding more about the clients we currently serve from a continuum, or sort of a spectrum, if you will, or continuum of development, knowing that a lot of the challenges that our clients might face on a day-to-day basis, we also face. It just may not be muddled along with a whole bunch of other traits or features of a diagnosis that also further complicate their lives. So just another collaboration, I think, that really enhances our relevance, enhances... what we can give to the world out there in terms of helping people modulate, regulate, acquire new behavior to better interact with their surroundings and circumstances.

SPEAKER_00: 51:28

Very exciting, getting ABA out of the ASD realm. I know there's a lot of research and studies on ABA with schizophrenia, ABA and PTSD, ABA and all sorts of just different demographics. And the prospect of us getting a seat next to the pediatrician for individuals without ASD and just like we talked about enhancing the effectiveness of their medications or their procedures which are clinically sound and medically validated is just it's something I really look forward to and it'll be really cool to hitch my trailer to your wagon on this behavioral pediatrics and see if that's something we can lead into the future and you know I want you to attach your name too.

SPEAKER_02: 52:10

I appreciate that. I want to give a really quick and early shout out to Dr. Pat Fryman again, who... Not only was I inspired by his particular publication, but decided to reach out just to see if he had any words of wisdom, and he very graciously responded. I'm pretty sure he's a busy guy, so I really appreciate the quick encouragement and the quick guidance that he lent there. I do really take his paper very seriously in terms of a call to action to make this much more relevant to bring. I love the way he talks about just our particular profession and what we could bring to the world in terms of changing behavior and all the positive effects It's super, super inspiring. I'm sure a lot of people outside of the field might find it a little bit cheeky or cheesy, but I really appreciate the way he posits our relevance in the world, given that, like he likes to say, we've only really been utilized to address a population at the far left tail of the normal distribution.

SPEAKER_00: 53:12

Sure.

SPEAKER_02: 53:12

There's a whole other... normal distribution in right-hand side where we haven't necessarily been seen as relevant yet.

SPEAKER_00: 53:20

We're going to start using some ABA off-label.

SPEAKER_02: 53:23

ABA off-label. I think that's a perfect place to stop. Mr. Lowry, always a pleasure.

SPEAKER_00: 53:33

Always a pleasure. Look forward to one more podcast coming out this year. Just doing a recap of all of our podcasts and just some highlights and some things now that we've had time to let marinate our 12-ish podcasts of the year. So that should be coming out before the end of the year, right around the turn of the year. And a big 2022 planned. We've got a lot of cool guests coming on. We've talked about the psychiatrist, but just a lot of guests. And we encourage anyone to write us on the comments and we will open up our floor whether you agree or disagree. We will provide you the forum for discussion. And yeah, on to a successful 2022.

SPEAKER_02: 54:12

Can't stress that enough. If you're out there, you've got a unique idea. You're a practitioner in the field. You like the way you do something. You see that other people don't do it that way. We're really looking for anything to highlight in terms of new directions, new ideas. We've gone through a wonderful transformation over the past two years professionally in trying to explore new directions and really add to the existing ABA mold really expand the ideas make things much more naturalistic make it easier for us to capture data while focusing on teaching procedures much more closely so please anything you've got out there that you find exciting hit us up send us a message give us a call and we'll find a way to get the information out there maybe even have you come on the show and talk We will sign off for now. Happy holidays, everybody. Happy New Year, in case we don't see you until a little bit after the New Year.

SPEAKER_00: 55:05

And always during the holidays, what's the most important thing, Mike?

SPEAKER_02: 55:09

Well, you've got to say cheers, but after that...

SPEAKER_00: 55:12

Always analyze responsibly.

SPEAKER_02: 55:15

Good seeing you, brother.

SPEAKER_00: 55:16

Cheers.

SPEAKER_02: 55:19

ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.