Precision, Passion, and a Pint with Dr. Kerri Milyko, BCBA-D (Part I)

ABA pn Tap is proud to present Dr, Kerri Mlyko, BCBA-D (Part 1 of 2):

Pull up a chair and pour yourself a cold one! In this episode of ABA on Tap, hosts Mike Rubio and Dan Lowery sit down with the powerhouse of Precision Teaching herself, Dr. Kerri Milyko, BCBA-D, LBA.

Dr. Milyko isn't just an expert in the field; she’s a pioneer in instructional design and evidence-based curriculum development. Known for her "Capital-P" passion for Precision Teaching, Kerri joins the guys to break down how we can move beyond standard "check-the-box" therapy and start driving real, outcomes-based results for neurodiverse learners.

In this "pour," we dive into:

• The Component-Composite Relationship: Why failing to master foundational "element" skills makes higher-level learning nearly impossible—and how to fix it.
• Precision Teaching 101: How Kerri first "caught the bug" at the University of Florida and how she’s using it today to transform clinical practice.
• Modernizing ABA: A look at her work with CentralReach in creating digital, integrated curricula that actually work in the real world.
• Systems & Leadership: How to balance clinical priorities with effective leadership to improve both staff engagement and client outcomes.
• Backyard Tinkering: We get to know the "human" side of the BCBA-D, from her love of sci-fi novels and true crime to the perfect wine and butter pairing.

Whether you’re a seasoned BCBA or an RBT just starting out, this episode delivers high-level science with the laid-back, "straight talk" vibe you love.

Grab a glass, settle in, and always analyze responsibly.

Transcript

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SPEAKER_03 0:01

Welcome to ABA on Tap. A mic review with Dan Lowry. So without further ado, sit back, relax, and always analyze requirements. All right, all right. Welcome back to yet another installment of ABA on tap. I am your ever-grateful co-host, Mike Rubio. To my right, as usual, Mr. Dan Lowry. How are you doing, sir?

SPEAKER_04 0:46

Doing great, doing great. We we got a gold medal in in hockey today. First time in 80, right?

SPEAKER_03 0:52

Is that that's right. The miracle.

SPEAKER_04 0:54

Yeah. Oh, sorry, no spoiler alert.

SPEAKER_03 0:55

Sorry, Carrie, if you uh spoiler on which end you just uh announced our guest. Anyway, we're gonna get right to this. We've got a heavy hitter today. Somebody who's done all sorts of things, you know, whether it's precision teaching and and exploring curriculum and now moving into other aspects of technology and I'm guessing artificial intelligence and systems that assist uh in clinical decision making. So somebody who's uh very interested in the origin story, and then we're gonna have a lot of ground to cover. I don't know that she's playing hockey, but there's certainly snow where she's at today. But uh anyway, without further ado, Dr. Carrie Millico. Dr. Carrie, thank you so much for your time. We really appreciate it. We record on Sundays, and it's we're just ever grateful for for folks like yourself who take a little chunk out of their Sunday knowing that you've got kids, family, sledding, intertubing, snow play to do out there, and and you're choosing to spend a couple of hours with us. So thank you in advance for all your time and all your insight. How are you doing today?

SPEAKER_01 2:06

Oh, Mike Dan, thank you guys so much for having me. This is this is an honor. I'm doing great. Yeah. Surviving a week of my kids being home for snow days. But yeah, no, they're they're older, so they're very independent and they're great. And you know, in you may hear hear them like screaming in the background from video games or something. So we like that.

SPEAKER_03 2:28

We we invite that on ABA on tap again, just a very casual pub style conversation.

SPEAKER_04 2:32

So there's we've had a multiple episode where Mike's daughters visited from different rooms in the house as well. So it all works.

SPEAKER_01 2:39

I wasn't sure if I was supposed to show up with a beer. You know, we Although it is a little early on the website.

SPEAKER_03 2:47

So we've been trying to work that out a little bit. Uh it's it's harder than you think, especially for people in different states. So that's something that that hopefully will be up and coming as we can ask our guests, you know, what's what's your libation? What do you like, whether it's tea or something, and then be able to have something like that delivered so we can share that drink. So maybe we'll just start inviting it. Well, you you're welcome to it. Yeah, we're sorry we couldn't provide, but please feel free, you know, just make sure you pace yourself so that we're yeah.

SPEAKER_01 3:15

All right, I got my hydration here.

SPEAKER_03 3:17

There you go, me too.

SPEAKER_01 3:18

Perry menopausal woman. I gotta, yeah. Hydration number one, fighting the patriarchy number two.

SPEAKER_03 3:25

So I was uh I was drinking my coffee and Dad goes, what is that, bourbon? I'm like, well, that's a little early, but what do you what are you thinking about me these days? Am I slurring already? I don't know.

SPEAKER_04 3:35

You don't have a nice coffee? You got a whole dresser of of coffee stuff in the in the kitchen, right? Oh yeah, a whole uh I don't have a collection of coffee.

SPEAKER_03 3:45

You're right. I've got a collection of bourbon. Good point. Touche, sorry, touche.

SPEAKER_04 3:49

Vintage coffee.

SPEAKER_03 3:50

Yeah, vintage, right, right, aged, barrel, barrel-aged coffee. That's correct. Anyway, Dr. Carey, we we like to start with the origin story. You've done so much, so you're gonna have a lot of ground to cover. Pace yourself here as well. And we'll sort of you know take from that and yeah, get us going. So he'll interject. Uh we will, we will. Dan's very good at that. And then I'll take notes too. Yeah, that's what he says. He's looking at his yeah, TikTok or something. Yeah, that's what he pretends. Uh no, but yeah, we'll we'll be free to interject and and yeah, certainly tell us about everything you've done up until now, and then that'll guide our conversation. So, what's your origin story, Dr. K?

SPEAKER_01 4:27

Um, my origin story way back in the day. I went to undergrad at University of Florida and hopped around different majors, landed on psychology. Really, I took a class with Dr. Hink Penny Packer. And he was like this this class was uh, I think it was just like standard, like ABA, like just general, like a survey class, like ABA. But if you know you guys are familiar, like if you're listeners, I know you all are familiar with Penny Packer, but if your listeners are familiar with him, he was just like one of the truest of our of our early pioneers of the field and looked at any sort of like social scenario and talked about how you can break down this the situation behavior analytically. And so that's how he taught our just general ABA class. It wasn't the white book or anything like that. It was cool, cool.

SPEAKER_05 5:26

It wasn't the Cooper book say what?

SPEAKER_01 5:28

I actually never took a class using the Cooper book. What? Um that's interesting.

SPEAKER_03 5:37

We'll get into that.

SPEAKER_01 5:38

Yeah, but yeah, so I mean, so he talked a lot about his experience. We read some books, like just some readings from this. There's this Skinner book that has different essays. It was called Like Upon for the Reflection. We had Sidman's uh coercion that's fallout, things like this. And so he really created a passion for psychology for me. And then he took other psychology classes, and they were I thought kind of fluffy, and some of them bullshit. So and I and I'm uh we have to come back to those too. And I'm a Matthew girl, and so when he had us charting, I was like, yeah, like data, this makes sense, right? Like this is this is more objective than subjective. And so I also took EAB with Tim Hackenberg, who also is a powerhouse. And and between them, I was like, this is this is where I need to go. But at the same time, I'm thinking, like, I'm not getting my doctorate in behavior analysis. I this just led me to confirm that like psychology, and I was thinking like you get the jobs in clinical psychology. So I went to apply for some grad programs in clinical psychology. And I went to Penny Packer to do a letter of recommendation. And he said That's a nice letter.

SPEAKER_03 7:01

That's a good signature to have on the letters.

SPEAKER_01 7:03

So yeah, I also have a story around that. But yeah, so I um I go to him and he he just looks at me and he goes, Did you learn nothing in my class? And he's just so he's like, he's your most politically incorrect man, you know, like he's gotta figure it out.

SPEAKER_03 7:21

He doesn't care, yeah. He doesn't very little scruples, right? Like I'm gonna tell it straight to you.

SPEAKER_01 7:26

Yeah, and so and that was just like, and here I am. Also back at that time in my life, I was very, you know, people pleasing. And I this is my mentor for all things now. And and I was like, No, you've taught me everything. And you're like, he goes, like, well, then why are you applying to these bullshit clinical programs? He's like, you need to go to a behavior analytic program. And I was like, Oh, I didn't like realize I was just still really naive and lean around all of it, you know. And so we went online and he was he was like going through each one, and at that time there was like, you know, it was Western UNR, I could stay at Florida, LSU was another powerhouse, and but you know what I mean at that time for PhDs, uh, BCBA, like was Kansas in there at that time as well? Uh Kansas, yep. But he yeah, for some reason, I don't know why Kansas Kansas wasn't on his radar. I mean, I he had he had like a whole course and he just will not go here because of this. And or he would go through the faculty and he was like, Okay, like this, nope, because like look what they're doing, and you don't want to do that. You want to, and so he would go through, and so that's how we like created, you know, the the plan for where I was going to apply to grad school. Nice. And so then I go and apply, and I'm I'm interviewing at UNR with Dr. Patrick Gesi, who eventually turned into my advisor. And he he's like, Oh, so I see this letter of recommendation from Hank Pennypacker, and that's pretty. And I'm like, like, yeah, yeah. And he's like, Do you want to know what he said? And I was like, Oh, can I?

SPEAKER_05 9:06

Oh wow.

SPEAKER_01 9:06

And he's like, Well, I'm just gonna read you the first line. And I was like, Okay, and this is gonna date maybe us, because we've I feel like we're the same generation. He's like, uh my maiden name is Kalen, and he goes, I am honored to introduce you to Carrie Kalen, no relation to Kato. And if you guys remember, Kato Kalen was the dude living in OJ's like pool house that whole system where he was murdered and all this stuff. And I was just like, oh my god. Yeah, so that's I have no, I mean, apparently he said good things after that, but I don't know what they were.

SPEAKER_03 9:48

What an opener, what a cool opener. Awesome.

SPEAKER_01 9:53

But so anyway, so I went to grad school at UNR, study precision teaching there, and really UNR gave you a really great breadth of experience. They were very much of that, you know, behavior analysis isn't here just for autism and you need to have a job if like some pill or magic, you know, whatever. Like they always said in interviews, what if a pill was created and it solved all you know issues with uh people with autism?

SPEAKER_04 10:18

Well, RFK was supposed to do that by September, right? Uh oh. Yeah, yeah.

SPEAKER_01 10:23

They're a little uh I think they missed the deadline on that, right?

SPEAKER_04 10:26

Apparently. I was worried we were gonna be out of employment, but it looks like we're okay.

SPEAKER_03 10:31

You went there. All right, you went there. This is I I'm scared about where this might go today.

SPEAKER_01 10:36

This is well, and I couldn't get into ABA because of auto. Like I got in to solve social issues.

SPEAKER_05 10:42

Nice.

SPEAKER_01 10:42

I was actually at the time looking at because what I did, I also was in the Penny Packer's lab and I did precision teaching with teaching all all of his like under like all of his undergrad courses were uh through a precision teaching focus. It was personalized system of instruction, it was we learned with precision teaching, we have these modules. It was uh, you know, like Fred Keller, like all of that stuff showed up in his classes. And so I was one of like the moderators for the class. I worked with a graduate student who is now Claire St. Peter. And so we, well, she was Claire St. Peter back then too, but she's she's the Claire St. Peter now. And so we went through I did precision teaching with college students with with the class and then like helping those who were struggling. I also did research for his breast self-exams and clinical exams. Oh wow, wow. Things like that. So it was actually if I didn't get into here's another story sliding doors moment. It was that if I didn't get into his lab, I was gonna go work at Hooters. So I uh things could have looked a whole lot different if I didn't. Let's just put it that way.

SPEAKER_04 11:55

Okay.

SPEAKER_01 11:56

But anyway, so so I I didn't go for I I actually at that time didn't even know about ABA's, you know, intensive focus with autism. Iwatta was at at Florida, but there there was kind of like two sides of the camp. And I didn't, I didn't live in the Iwata world. I was in Penny Packers world. And so with that, it was new when I went to grad school seeing all these people who were focused on autism intervention. And that was, you know, it wasn't the a motivating factor for me. I just wanted to solve like big issues, um, which that is a big issue for sure, but I was like, hey, y'all are y'all are doing that, and this is where my passion is. So precision teaching led me down through looking at the system of education and how it's not really showing up for our children in the way that we know that it can. And I helped with Nick and Kimberly Barrens and Kendra Newsom to create then was called Center for Advanced Learning Cal, which is now known as Fit Learning. And we were, it was just a really cool time to be a part of it. It was definitely an age of innovation and discovery, which was really cool to be a part of. And with that came a lot of my experience with curriculum generation. I've always been like a systems girl. I see things like in organized buckets wherever I go. Uh, I'm a really great project manager because of some of these executive functioning skills. And so I brought that to curriculum. And I wrote a great deal of the curriculum that I'm sure they've revised since, but that was the origin the starting of learning, along with all those other people that I named, obviously. And then I I wanted to divide, I wanted to have my own business. I come from a small business-owning family and moved back to Florida. My husband, who was also a precision teacher, uh, he worked at Cal with me. We went and moved to Florida and opened up our own precision teaching center. It was running there for a few years until we Florida was not a place for us. I found out that I couldn't, uh, I'm a West Coast girl now. You know, while I grew up on the East Coast, it had a different vibe when I came back. And and so we came back to Reno. We we sold our business in Tampa to who who turned out was my first employee there, and her husband, Robin Elizabeth Hasbrook. And we came out here. I worked for the government, the the state. It was like the Medicaid just started providing services to children with autism. And and and and given like where I worked with at Cal and then our own precision teaching learning center, I like about a quarter of my clients were had an autism diagnosis. And it was mostly coming from like they've already received early intervention training and now they had to get caught up with academic skills.

SPEAKER_05 15:09

Okay.

SPEAKER_01 15:09

But then I had a lot of families who were like, we were not happy with the services, we understand, like we really like your approach, but but my child's not yet ready for a hundred percent academic. And so I started, you know, going into the world of just autism intervention services, but with a precision teaching focus. And so when I came out here to Reno, that's what we started creating. The business of like setting up an after-school academic focused intervention center, learning center, is is tricky just because you you have the majority of your students from three to six, right? And so when you're thinking about a business model, it's you know, you have to be really creative in having contracts with school districts or private schools and homeschool students, things like that. So it's definitely like a hustle. And so I wanted to pivot and be like, okay, well, let's let's see, you know, I spent some time. Well, I have good friends, Mikey and or Michael Fabrizio and Kelly Ferris, who do precision teaching work for early intervention out in Seattle, and just really leaned into them and other people on how to create this here in Reno. And so I was hired by the state, because the state just opened up Medicaid funding for ABA, but the rates were low. So no independent organization was signing on as a Medicaid provider. As such, the state was like, we will hire our own BCBAs. And like they actually did it in, like, I don't know, like not a business person was running that because they just gave us as the BCBAs, we're independent contractors, the the full reimbursement rate. And then we then would pay um our, we would have to hire our our own little, it was like essentially we're building up our own business under kind of the state umbrella. Well, because they didn't know how to manage it well, they after a few years, they're like, Well, our program is going bankrupt. And we're like, yeah, no shit. Like you didn't like carve out any overhead costs, but I mean, like, banks, yeah, because I would we benefited from that. And so they gave us a few months to say, like, you need to, like, we will no longer be employing you as an independent contractor. You need to create your own business. And so I was like, done. I know how to do this, right? Like you essentially created the framework already. We just need to do the paperwork for it. So that led, and it was ironically, at the time, a friend and I, a group of friends and I were, including my husband, were looking at starting up a school out here in Reno. And so we already were, you know, had plans in place. And so we pivoted and opened up this business. And it's called the Learning Consultants in Reno. It is now going on its eighth year and it's expanded and and it's it's doing well. And that's where my husband works, along with my business partners, Jeff and Kelly Gizek and Jen Bono. Megan Zito is also one of the founders. And so we all like went to school together, or they were spouses, and so we opened it up and and it was great. So during there, I was creating curriculum and I was doing online trainings and you know, precision teaching, being the focus, and all this kind of stuff. And my buddies Rick Kupina and Dave Stevens created Chart Lytics. And at that time, we were in conversations about kind of putting my curriculum on chart lytics. Well, little did I know that they were in the conversations with Central Reach. And so they stopped conversation with me, which I didn't know why, and I was a little grumpy about it because I was just waiting to sign the paperwork, but turned out like they had a really great deal, right? And so they sold chart lytics to Central Reach. And then they in between, like they were having some conversations with the then news CEO, Chris Solens. And I then I was like, you know what? They bought a really amazing engine, but they don't have the full car. So many times when I was in precision teaching and trying to like uh like disseminate precision teaching, I felt like I was Billy Graham trying to get everyone to do precision teaching. It was they they wanted to, but they just didn't know how to get it off the ground because no curriculum was really lent itself to doing it and or it's accessible. And what the only curriculum that was accessible was morningside, which was school-based and academic based, right? And so I was like, we need some curriculum for the majority of behavior analytics services that are being funded right now. And so I pitched that to this, you know, Chris Swans, and he was like, hey, I just like I'm like three months in. I have, you know, give me some time to figure out what the landscape is. Conversation then came back a year later and was like, cool, cool, cool. Yeah, I'm I'm in. But we're not gonna, we we want to, we don't want to like partner with you. We want to buy it and we want you to be an employee. And so I was like, I you know, at that time I was like, you know what? Cool. That sounds uh yeah, nice and steady. Yeah, and so I brought two people who uh one was someone like my one of my best friends that I've worked with and helped with curriculum when we were at Cal together, Molly Heligan and then Kristen Smith, who worked with my business partner Jim Bono in Washington, and she's the best instructional designer I've ever seen. And and at that time I thought I was pretty damn good. And it just I was like, okay, just kidding. She's pretty incredible. So the three of us created a pretty kick-ass curriculum that unfortunately is collecting dust, yeah, tear. Just the software needed some enhancements to get it on there, some like technical, because you guys, I don't know if you guys or you said you used Central Reach. I don't know if you remember this one January where it kept on, you know, shutting down and like they had to like close it off and restart it and all that kind of do you guys remember? It was like 20, it was I think it was before was it before that or it was after the pandemic? Oh, it was having some uh production issues. And so and so they had to they had to do some things that was absolutely the right decision to do, which meant that a lot of the enhancements that the the enterprise system needed to have to bring, because it was it it's a beast of a Curriculum as it should be, but the if people were to copy over their learning trees with the whole curriculum, it would shut down for like everyone. And so there was a lot of some technical things that needed to happen in order for that to work. And and it just unfortunately never got prioritized. So then, yeah, so four years later, and we built this pandemic curriculum. Oh man, it was so cool. And we're like, let's release this, let's get this out. And then it was just, you know, I mean, it is what it is. But a lot of cool things that happened during that time, a lot of great learnings, and it was great to have job security in the midst of the pandemic. For sure. And doors were open that never would have been open before. But then, you know, they said your position is no longer gonna be available in in 2025 four. And so I was like, oh, okay, cool.

SPEAKER_03 22:57

So all that stuff could come over now to like telehealth-based services or like VR stuff. I don't know.

SPEAKER_01 23:03

Well, I mean, they own it, yeah, they own it. Right. But yeah, I mean, it's there. I don't know. So many this there's been a lot of turnovers. So I don't think the people who are there know what to do with it, even though that they own it. But yeah, like we we actually wrote it. We wrote it. It was a curriculum, it was oh, that's so pretty. Um, but it was curriculum that it was allowed you to hop across instructional arrangements. I don't know if you see the curriculum now, you see like you open up a book and it's like, well, this is definitely for DTT, or this curriculum is just for precision teaching, or this curriculum is NET. We we created, we we had these old pictures of us at like we rented a house and we just stayed in there for like three days coming up with like, okay, how is this curriculum gonna look? Right. And we took together like content areas and a whole bunch of skills that we knew learners needed to have. And so we had it all on post-its, and there was just like this entire group covered in post-its. You can see the like the picture of Charlie from what's this is always sunny in Philadelphia. Right, with what's yeah, right? That's what I was thinking of. The string, and that's kind of like how we all felt, right? Yep, and so and with each skill, it also had it broken up into steps. And so it's like, we're gonna take this, you start at like zero, right? You start at nothing, like zero percent, zero rate per minute, and we're gonna shape it up within this step of the skill, but there may be like 10 steps in order for you to actually learn the skill to where casual observer could be like, oh yeah, they can do that, right? And then we had, and it was all based on instructional design. We had, you know, critical attributes, we had variable attributes, we had like un we also had what we called uncontrollable attributes, where just like we want these to always be in circulation so that way we don't have like, you know, people are like, oh, I only I only know how to do this in the contents of fill and stimulus control, right? And so it was it was beautifully sophisticated. We had examples and now we had scripts, we had teaching tips for people who are bringing new BCBAs. We wrote it directly to to for RBTs who didn't have any experience to learn. It was like it was it was incredible.

SPEAKER_03 25:24

I love it.

SPEAKER_01 25:25

And and it's yeah, it's sitting somewhere. Can you yeah, isn't it isn't a vault?

SPEAKER_04 25:31

If they're not using it, can you buy it back?

SPEAKER_01 25:34

Uh you know, that's a good question. I don't know if I have the money to do that.

SPEAKER_03 25:39

Uh but um the influence, that's what you but now, but like it was written without AI, you know, it was that's amazing.

SPEAKER_01 25:48

Yeah, and so and we busted that out, we busted that out. It it was it was it it was, yeah, it was a great experience. But now it's because I I still work with Kristen and the way that the world looks, and also like we that was before 2020 when that was written. And look how our field has evolved, right? Curriculum should be an every-evolving thing, it should never be like that's why it gets so grumpy when we're like, we have these books, and I have them on my shelf, that it's like, you know, uh, you know, peak and ables and eight, you know, AFOLs, and also those are assessments, they're they're they're inventories, but you know, they're not curriculum. And as such, you should have a curriculum that is ever evolving because you don't want to be teaching something that was dated 20 years ago, you know, and so now it gives us an opportunity to be like, how you know, how does AI show up in all of this? And where can we like can like can we create a more appropriate criterion reference assessment? Because all those that I just listed are not created for the model in which we are operating under today. We are living in an insurance-funded, medically based ABA service provider, right? And those were all based on education. And you know, we we picked a lane. I wasn't a part of that conversation. I don't know if I would have picked the same lane, but we picked a lane, right? And we chose medical and not education. And as such, we don't have the tools, but yet you're we're using the tools that are really creative for an educational model. And so these assessments lack standardization, or if you do bring in standardization, then there'll be a very long, like the you ran the whole ables, it would take you hours upon hours to do the whole thing, right? Where that's not what Jim says. Jim says, like, hey, pick only the pieces that apply to you, but then that makes it a non-standardized instrument, which makes it hard when you're talking to funders and it's a whole thing.

SPEAKER_03 27:50

So you uh you mentioned something. I'm gonna interject you mentioned something very interesting to me. And there's correlations here, and maybe this is kind of an open-ended question, but the idea that we often so milestones is something that's kind of related to inventories, meaning that people will take the idea of missing skills and then we draw this straight line. So this is missing, and this now becomes a goal. But that's that's a far cry from a curriculum, which is now gonna list so so an inventory is part of a curriculum, an inventory by itself is not a curriculum, if that's maybe a good way to say that.

SPEAKER_01 28:24

Yeah, thank you. Right? Like uh rectangle is a rectangle is a square, no, a square is a rectangle, but a right angle isn't a square.

SPEAKER_03 28:31

Yeah, you go and I and I'm coming from at this from a and I I I really love early intervention. I'm coming at it from sort of our angle where we worked really hard to combine like best practices in early childhood education with the ABA we do for early intervention. So we have a lot of open-ended, child-directed, play-based learning, which I think fits right into what you're saying. We start with this idea, this inventory of stimuli and ideas and things that might hit a certain skill, and then you have a script, and it's great to have that to launch from, and this will maybe launch us into an AI discussion. But then how that comes to life, the dynamics behind that, the interpersonal exchange of you have a clinician who has all these things at their disposal, but they're not just taking those and throwing them in. It's it has to come to life somehow. So the way you described it with the way you guys were were planning these curriculums, there's probably a lot you can share with us regarding specific activity visions or or combinations of stimuli that now hit those milestones toward those inventories, but now again, you've got a curriculum, you've got a a large set of ideas that includes all these things that really good clinicians do really well in bringing to life. So share a little bit with us about that.

SPEAKER_01 29:45

Yeah, you know, it's kind of like if you you think about it like as a ratio, if there's like a line item on on one of those assessments that we're all very familiar with. Yeah, it may take it's likely that it'll take more than just a direct teaching of that in order to to really get the right. You're gonna need you have these prerequisite skills, and then you have comp you have fractions of it. It's like, you know, like different slices, it's it's you know, let me brush off the dust here, but it's it's been a little bit more. Well, I don't know.

SPEAKER_04 30:23

I mean, I feel like when I've been in schools, if the kid's not self-advocating, if they just write a goal, child will self-advocate, then that just solves everything.

SPEAKER_01 30:31

I love that we're getting to this because advocate for all of that.

SPEAKER_04 30:34

Boom.

SPEAKER_01 30:34

No, I this so there is a I don't want to get in trouble, but there is this. My the example that I love is that there is a a like adaptive behavior assessment slash curriculum that came out, and it one of one of the goals was to teach learner how to swim.

SPEAKER_05 30:55

Okay.

SPEAKER_01 30:56

And it is it there's maybe 300 words in the whole program that's written, like like that probably includes the titles. And it essentially was like you go to a body of water, make sure that they're wearing swim clothing, and you say, Okay, time to swim.

SPEAKER_03 31:18

What could go wrong? So that I mean, with that SD, that's right, yeah, immediately, of course. Obviously. Did they list possible consequences on that one, on that contingency?

SPEAKER_01 31:30

Yeah, I mean, it did say like, you know, make sure if you have a floating device, if you need it. It's um so it's when you're thinking about teaching a skill, you need to make sure, like you know, Rick Tabina talks about like the all the precision teachers, Carl Binders. Rick Dabina talks about it as element compound, Carl Binder, component composite skills, right? And so it's a constellation of skills. And so that's why it's really important for you to map out all of the dependencies. And we need to also look at different learning channels. It's like you may you, and this is something I think is is not always strong and it's strong in precision teaching, but it hasn't really come over into traditional ABA, but it's like, what is the sensory modality of input and output? Um, how how are they going to contact the discriminative stimulus? And what is the behavior in which they are to respond? And how strengthening up across multiple learning channels can create for a stronger like retention, maintenance of the skill, and and like really promote generativity.

SPEAKER_05 32:42

Yeah.

SPEAKER_01 32:42

So well, let me just like for a very easy example. And I'm just sometimes examples are easier when we're it's like academic-based. So you are trying to teach someone how to read. You have, I want to teach you how to sound out these words, right? So that's a component of the composite is reading the word, a component of that. Well, if we want to teach you how to read phonetically, because we know just sight word reading isn't the way to go, then you need to know these, these, uh these sounds. But guess what? Also, you need to do you need to be able to hear the sounds that you're saying and blend them together to form the word. So there's an auditory channel in this as well, right? So now I'm going to say the sound of the letter and you're gonna tell me what letter makes that sound. And I want to bring both of those components up to fluency levels so that you are not struggling when you are working on the composite. I'm also gonna teach you how to sound it out and then blend it together. So now I'm gonna combine these learning channels into a multi-learning channel in and of itself. I I have isolated uh programs that are like tool skills of this, that are an isolated learning channel that are that are variable.

SPEAKER_05 34:02

Yeah.

SPEAKER_01 34:02

And then I'm going to take a like an interlinking skill that I'm gonna combine some of these to get you really good. And guess what? I'm gonna get for free. You reading the word. Or if I don't get it for free, your baseline has elevated from let's say 10 words per minute to about 50 words per minute, and our goal is 80 to 100. So the time that I need to have that to be in intervention is just a short window of time. And so it's it's it reduces the time in which, or it actually tries to eliminate, avoid the time in which a learner is frustrated and struggling because you're just going up here. You're saying, Hey, you're going to run a marathon. Guess how you're gonna practice that? By running a marathon, right? And that's not what you need to do, right? And it's all of these little combinations of skills, it's strength training, it's I don't, I don't know, I don't run marathons. Like if someone was she's me with a knife, I'd run, but like us, but but my mother-in-law used to do it all the time. And so it's just like it's leg work, it's strength training, it's breath work, it's it's also obviously like running short distances to get up to that. So it's endurance building, but there's a lot of other things that you need to do in order to be really good so that way when you do run that marathon, you're not gonna be like, this is the worst thing in the world. And we are trying to create conditions for our learners so that way they're not saying this is the worst thing in the world, right? Every everything we were trying to, we we don't want that. That's obviously not not something that we want. So we have to look at, and so when you're looking at the I I know a lot of people who've used the VB map or ABLES as a curriculum, and it's not sequenced in a way. I mean, that it is roughly, but there's so many more skills that need to be broken down into the elements or component skills to teach those higher composite skills that are identified on the assessment.

SPEAKER_04 35:59

I remember when we were uh transitioning to Central Reach and it was like all based around the VB map. So if we did the VB map, then everything fit perfectly. School things there, but we didn't do the VB map, so we had to like backdoor like how we did it. It's just funny because you think about that.

SPEAKER_03 36:17

So what what would you say is and I hope this question like I can make sense of it. It makes sense in my head. In terms of like so recipes is a good analog or a good analogy to use here, right? The idea that to go touch on like the VB map and how nice that would fit systems-wide, and then you might feel very good as a BCBA supervising a younger RBT because now they've got this huge inventory of things they can work on, and you can relate them to all these different stimuli. And then at the end of the day, there's some nuance to how those things are ordered, how they're sequenced. You know, the idea that you've got your again, going back to cooking or baking, the idea that you've got your wet and your dry ingredients, and you can't just throw those things in a bowl. I mean, yes, you might end up.

SPEAKER_01 37:00

Right. You might end up with a big thing.

SPEAKER_03 37:05

So, what's your insight on avoiding that clump, right? I mean, again, this and then this is probably gonna propel us into all sorts of other things because there's there's a beauty to gold banks and templates, and then there's uh sterility sort of uh it can lose its feel. It can miss the mark if it doesn't have and you're referencing a lot of those nuances already in what you've discussed. Like I hopefully that made sense. But what would you say to that?

SPEAKER_01 37:29

Yeah, for sure. Um, okay.

SPEAKER_03 37:32

I there's like 20,000. I know, I'm sorry going on.

SPEAKER_01 37:35

No, it's your fault. I want to make sure sometimes I get a little bit more.

SPEAKER_04 37:40

Do a component analysis of your thoughts. Yeah, yeah, there you go.

SPEAKER_01 37:44

Uh yeah, half away constellation in there, and I I'll try my best not to be rambly.

SPEAKER_03 37:50

Please do be rambly. I think there's a lot of a lot to learn from the rambly.

SPEAKER_01 37:54

I think that there's two, the way that I see it, like what I heard when you were describing it. I think that there's two scenarios. I think that there is a scenario where our recipes are like Tom Caliccio recipes. So I I like to cook. You say recipes. So part of my bookshelf over here. That's all recipe. There you go. Granted, the the the invention of the internet in all of its glory allows me to you know have less cookbooks than I used to. There is a I also have a cookbook that's like a dupe cookbook. It's like you want to learn how to make Auntie Ann's pretzels, you want to do you know, Mrs. Spiel's cookies, right? I got that.

SPEAKER_03 38:42

And there's a certain precision to that that you're trying to achieve as a product, and then there's a process to it. Maybe that helps clarify my question a little bit.

SPEAKER_01 38:49

Okay, yeah. So my my friend reminded me of this one analogy that I used to use all the time. I when I was, I was before I became a cook, I was a baker, you know, in high school.

SPEAKER_03 38:59

A lot of precision there, right?

SPEAKER_01 39:00

A lot of precision there. Yeah, but when you get the and so I was also an I was a nanny and over the summer I would hang out, you know, it was full-time nanny for this one girl. And I was like, we're gonna make chocolate chip cookies. I like I used to, I mean, uh brownies are my thing, but you know, cook chocolate chip cookies, I can do this. And they have the recipe on the back. Great. And and I would follow the recipe, and every time my cookies would come out different. And I was like, what the hell is happening? I'm using the same amount of butter, I'm following the steps, I'm using this, like, you know, you got the, I think from what I remember, there's brown sugar and white sugar, like all of the things I'm doing it, but every time it's it's like flat, where the highest point of the cookie is the chocolate chip, right? Or it was, and I'm baking it at the same time, like all those things. Come to find out, uh, you know, with Instagram, it was the temperature of the butter. The temperature of the butter will indicate how the cookies show up in a different way, right? The back of the bag doesn't tell me that. And so I think that that's where a lot of our clinical experience. And so, but I think that that's like I think that there is a need and a and and a and a re almost a requirement given that where our field is now. I think a lot of our BCBAs are not taught, like they go through a very quick master's program. You know, and and when they get their bib, uh getting your BCBA is essentially the bib to enter the race. You you just started the the marathon, and you still have a long way to go.

SPEAKER_04 40:42

But nobody knows more than a new BCBA though.

SPEAKER_01 40:44

Oh, that is for sure. And you know, I that was absolutely me too. And before kids, I was like, oh man, all the things I told parents to do without understanding the contingencies that was like showing up in their world. Absolutely.

SPEAKER_03 40:58

Then you get the supervisor's job and the salary. Oh, yeah, illness.

SPEAKER_01 41:03

It's ridiculous. But so I so I think that there is absolutely a need for you know the gray-haired BCBAs like us who maybe had a yeah, right, who maybe had a different bit of experience in training to create some of those back of the box recipes, but at the same time, like teach the nuance in which so going back to what I was saying, so Tom Calicchio, you know, is a chef, he was on like he was the the guy on top chef, and his cookbook, while it has recipes, it teaches you about these recipes will only be good based on their ingredients. And so if you're in the winter, look at this, and here's how you change it up. And like he teaches you how to be innovative as a chef without having to rely on either steps one through 12. And in the event I have one thing out of place, I don't know what to do.

SPEAKER_05 42:03

Yeah, right.

SPEAKER_01 42:04

And so having the steps one through 12 is good because that's gonna get us 80% of the way there. Whether it's you have a client who like is you know, their the their profile shows up that like that is a good intervention for them and they're gonna be successful that way, great. Or if you have like there's so many things that can show up, right? The variance in the in the clients, variance in your BTs, variance in the context in which you're teaching. And so there's there's moments in time where that recipe will not be effective. The same thing with a doctor, right? You show up to a doctor and you're like, hey, I got this going on, and they're like, Cool, like, like, you know, with Perimenopausal woman, we're like, hey, guess what? I can't sleep. I, you know, I have rambling thoughts, I, you know, I can't lose weight. And they're like, Yeah, we try and count in calories. Like, yeah, man, you know, right? Like, so so it's like, yeah, you can't.

SPEAKER_04 43:00

My girlfriend's going through the same thing. Yep.

SPEAKER_01 43:02

Yeah, yeah. And so you're like, okay, there is the standard, and you got to make sure that those boxes are checked. But in the event that you're presented with a, you know, something that's a curveball, whether it's the context, the learner, your BTs are brand new, like whatever it is, you need to know how to deal with that curveball. And that's where the sophistication comes in. So we need to create, and no one's getting it out there. Well, little are getting it out there in with respect to, I would say, both their experience in a practical placement and their experience in a university setting, because a lot of it is just like, hey, let's let's just get this going. And there is a demand that needs to be met. So, like, this is not me bad mouthing that, but it there's a demand that needs to be met, and that's how our field is showing up about just mass production.

SPEAKER_05 43:56

Yeah.

SPEAKER_01 43:57

But we need to, we need to. create so with that my approach is how can I create tools and resources that educate without that being a a dependency a requirement at the onset so based on your interaction with the software with this curriculum with this product how you will learn about the behavioral constellation that that how you can create to identify components skill or composites components from composites right how you will know how to pivot because like we've guided you that way because we can't spend any more time and we can't put in any more classes in univers in on in master's program universities right that they're maxed out and they need to get out of there and I I it took me five years to get my master's at you and R. Like let's not let's not do that. I'm not saying that that's the answer right but let's create ways in which people can learn through their experience with proper mentorship but through their interaction of the tools and resources that we who have spent five years for their master's and then another three years for their PhD, right?

SPEAKER_03 45:14

Can then provide them I I love the word constellation and and I think that's a super important one here because everything else then it becomes the straight line and sure that works sometimes but again it you know back to this my whole premise with that question was I think so often in practice it becomes here's this assessment or this you know behavior scale or whatever it is people are using from a standardized medical perspective. Here is the zero on that parent response and now we're gonna draw a straight line right to that deficit. And again there's a lot of logic to that I am not criticizing a very clean linear logic and then there's what you just talked about.

SPEAKER_01 45:54

Yeah which is yeah it's not it's not easy. No but you know what behavior isn't easy like it's you know the armchair psychologist can can like oh I'm a behavior analyst I can analyze your behavior and things like that but but really it it's not easy and it shouldn't be easy. And so when people are out there saying that like I created this goal bank and I'm calling it a curriculum it's doing our field a disservice is doing our new practitioners a disservice and ultimately is doing the clients that we serve a disservice and we need to embrace the complexity but it doesn't have to be hard right it's complex but it doesn't have to be hard and so how can we given the age of technology and AI how can we create a products that you like the iPhone iPhone is sophisticated technology but when my kids were two they knew how to use it without any sort of instruction they knew how to find their favorite app or watch Daniel Tiger on PBS kids right and so how can we create some sort of that simplistic interaction user experience while also gaining skills at the same time and and and not and not dumbing down the sophistication of what needs to be presented to our clients wow man there's so much to to to get into there.

SPEAKER_03 47:19

Mr. Dan I'm I'm monopolizing all the time I know you got some some questions on your list sir.

SPEAKER_04 47:24

So we talked about gold banks and I've kind of have you know both positive and negative and I'm curious your thoughts of it from more of kind of like the you know BSD applied side of things the gold banks can have a lot of value and it seemed like again a lot of the electronic data like again I'll just use Central Reach because that's the one I have the most familiarity with a lot of that I know when we got onboarded with that was like look you can have this gold bank and I think maybe if you upgrade to a better one then you can have like this extensive gold bank which was great because like maybe I don't have a lot of familiarity with toileting and look I got these 45 toileting goals I can look through or whatever. So it allows you knowledge from other people which is great because obviously you can't acquire all of the knowledge yourself. Concurrently in a field that's run a lot by billable standards what seemed to happen a lot was I need to hit my billable standards. So what I'm gonna do is I've got a client and I'm gonna pick this goal this goal this goal this goal this goal and just I kind of cookie cutter my way through it without any individualization of it just so I can get through this report so I can build my six hours to kind of keep it moving. And I know there's a lot of deeper nuances that we can talk about with funding and in some ways I think insurance funding actually kind of likes that because they just kind of want to check boxes it's very clean it's you've got this child that goes to this curriculum that you know it's it's very clean. So I kind of saw positives and negatives from gold banks and I know you're talking more curriculum. I'm talking more gold banks so I want to make sure that that's differentiated there.

SPEAKER_01 48:52

You can create a gold bank from a curriculum but not all gold banks are curriculum.

SPEAKER_04 48:56

Exactly I love it we're back to that analogy kind of kind of your general thoughts there on on gold banks and their usefulness in the field and if if you think they are kind of a net positive or net negative based on the other variables that are in the field as well.

SPEAKER_01 49:11

Sure. I think it's how the clinician shows up in their own values I think again we picked Erlane right and so we're gonna get eight hours of five one you know or you know whatever funding company they're they're gonna limit that and apparently only two hours a day which is so fucking absurd.

SPEAKER_04 49:29

Sorry that's just a battle that I've been fighting forever.

SPEAKER_01 49:32

Agreed I right there with you it's it's absolute bullshit but also that's what happens when we let insurance people decide things for us and we're not the ones like causing a ruckus on the next ABA on tap that's a whole like series like a four part series you just opened up there. That's that's my we're gonna have to open up your calendar Dr. Carrick do it but so we uh so I think that with that uh because you know if if we it's we have businesses to run and and I this is not about me making money or anything like that but if we spend you know 40 hours on every assessment but can only bill eight then and you know you gotta pay your employees is either that that employee is not getting paid or the company has overhead costs and then and then the issue around that it's not about the pro it's about the the company being able to serve clients. Of course right so so it so it is what it is but with that so I think that we need to have again things that are allow our work to be efficient yes and goal banks do so sure absolutely and now the question is is that are you taking that goal bank well well one there's all given what we just said I don't think we need to reiterate is that like okay how was that goal bank created but let's just talk about the use of like hey here's something let's say let's say it's the most magical thing ever and you just apply it you still have to personalize it and so just ensuring that the behavior analyst personalizes it for the client I think it's I think it's absurd that insurance companies are like within the first eight hours of you meeting this client tell me all the things that you're gonna do in the next six months and it's just like oh and how long they're gonna need services for yeah yeah yeah and so you're like so many times the client doesn't show you who they are within the first eight hours right and so often I would create an initial assessment or initial like curriculum from you know the initial assessment and had to completely rework it throughout that first six months. So I think that there's a bit there but it's just like how you can only do what you know and say based on what I know for this client I need to make sure that I personalize this toileting thing or whatever it is. But I think that you know it is our diligence as clinicians to ensure that you know uh we need to maintain regulatory compliance and compliance with our funders and things like that. But we need to do the best for our clients and if that means that you know there needs to be significant adjustments because you now know more because you've been with the client more, then you need to update those things and you know have addendums and requests for more time or less time or whatever it is, right? However it shows up. But I think the use of tools to make the administrative part of it I think I do I think that that is important and necessary. I think it's just we need to ensure the vetting of all of those gold banks that were written were written by someone who should be an expert in structural design and I would say oftentimes they are not.

SPEAKER_04 52:54

Yeah I I I really like that and uh we've you know had some people on talking about AI as well and efficiency is a great thing although that word brings up some PTSD because historically when I've worked for other companies it's always been efficiency and the ability to build more hours. So I feel like if it can be efficiency to allow you to either actually review the data or spend more face-to-face time with the client to see if the data is actually representing because I was an RBT for a long period of time and just because you put a data point doesn't mean it's accurate.

SPEAKER_01 53:24

So like is the efficiency being used for like a clinical reason or is it just being used to now allow somebody to have more inefficient or indirect billing hours I love that I love that you said that because one of my soapboxes right now is that so it's it's naive of us to think that we we can do anything outside of electronic health record right given given all of our our reporting requirements and audits and you know if you want to be accredited with you know ACQ or whoever right you need to live in the digital world. Yep but I would say the majority of our electronic health record companies have prioritized operational efficiency and have not spent adequate time growing the garden of clinical care. So if we look at you know some of these products now there's some that I've seen in presentations and I'm like okay you're showing up but a lot of the clinical care models are still operating under practices that were 20 years ago and there's been a lot of innovation around how we provide care areas of care that we now prioritize which which one of our electronic health records are collecting ascent data?

SPEAKER_05 54:47

Right?

SPEAKER_01 54:47

Like I love it where they are we able to identify the number of ascent withdrawals per program so I can make it a a review of how many like is is it is it like like from from my perspective teaching and when I would when I did paper data I would look at we collected ascent data and it was like is it around a learning channel? Is it around a content area is it around do we have more scent withdrawals around uh programs that are new I can do this level of analysis with paper data. Granted it took me a lot of time and that was back when I could bill for indirect hours but we we don't have any of that now yeah I can even do it I can't we'll look at decisions made which one of our health record EMRs allow us to analyze the number of decisions made per week per case to look at clinician activity. And I'm not only talking about change decisions, I'm also talking about decisions in which you say this is good and I want to stay the course. And so you know there's a lot of and then I can evaluate a client's progress by saying look I on this program all of these change lines were decisions to make harder. Oh but on this program all of these phase change lines were decisions to make easier and as such they require more intervention and so I didn't start them out at the right point or something else is showing up for the client right and so I can talk about I can I can evaluate agility by looking at things this way I also need to have a like a some sort of structure curriculum as well to like look at curricular leaps but there's so many things that and this is stuff this stuff is is in the world of precision teaching has been in existence since I started precision teaching you know 25 years ago that that the electronic health records company just they're like well you know what the fact that you can just you do do a mass trial of 10 responses of this program or you know what the innovative care is allows us to do is that you don't have to do mass trials anymore. You can jump around with trial across programs or something like that. But you may still have to scroll so like the the amount of innovation that the tech that our the companies that we subscribed to that put to operational efficiency which was necessary and needed but not to the detriment of care enhancement. And so as such we are now in a state where funders and you know whether that's given our political climate or that's just because they're like hey time's ticking and and you behavior analysts haven't shown up to talk about outcomes in the way the rest of the medical field has is that we have to defend our care in a way that is that is we've never seen before. And us saying well this one learner no no no they don't give a shit about one learner they want to talk about all of their clients all of their members right and because we we've built systems that allow ABA to grow to expand to meet the demand again necessary but not sufficient that we are now in the state because everyone is on EMRs we don't have the sophistication of of being able to report on outcomes because all of these systems are not they're not looking at anything that we at least in the prestigious teaching world would look at to be able to talk about like meso level data or meta-level data. They're all focusing on micro and a bit of macro but you need the whole system in order to say like find trends and analyses and start clustering and understanding like hey this learner walks in my door and they show up as this profile like it's an educated guess but I'm saying like I've seen a lot of clients like that and with that with this type of curriculum with these types of like these interventions we're able to see these gains in this amount of time and that's what these insurance companies are asking for. You look at a heart doctor and you have you know a man in 65 walk in that's you know 250 pounds who doesn't necessarily extra like that's that's enough muscle right and and maybe he smoked for you know 20 years back in his right and they're like okay given this profile you need to do these things and you can and and now these symptoms will be be reduced by this much.

SPEAKER_00 59:19

Yeah and we can't we're we we're we can't do that in ABA oh no no no no we don't do that in ABA don't even think about it girl please return for a part two of our interview with Dr.

SPEAKER_02 59:32

Carrie Maliko and always analyze responsibly ABA on tap is recorded live and unfiltered and we're done for today you don't have to go home but you can't stay here see you next time