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Use of a clinical decision model to support the transition of services for individuals with autism spectrum disorder
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Use of a clinical decision model to support the transition of services for individuals with autism spectrum disorder
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TRANSITION OF SERVICES 1
Use of a Clinical Decision Model to Support the Transition of Services for Individuals with
Autism Spectrum Disorder
Alexandria Emily Leidt
Master of Science (APPLIED BEHAVIOR ANALYSIS)
University of Southern California
August 2019
TRANSITION OF SERVICES 2
Table of Contents
Abstract…………………………………………………………………………………………3
Literature Review………………………………………………...……………………………4
Current Study…………………………………………………………………………….15
Methods.…………………………………………………………………………………………16
Results………………………….……………………………………………………………… .17
Discussion.………………………………………………………………………………………20
Limitations……………………………………………………………………………….21
Future Research…………………………………………………………….……………22
References……………………………………………………………………………………….24
Appendix………………………………………………………………………………………26
Figure 1…………………...……………………………………………………………...26
Figure 2……………………...…………………………………………………………...27
TRANSITION OF SERVICES 3
Abstract
In the field of applied behavior analysis, the goal of autism treatment is to prepare a child,
and their family, for independence. The literature in behavior analysis, specifically the Behavior
Analyst Certification Board Guidelines, indicate that a plan of care including a transition plan is
required when discussing treatment for individuals with Autism Spectrum Disorder (ASD). A
Clinical Decision Support System (CDSS) can be marshaled to support the process of developing
a transition plan. Decision models are tools to guide decision making, they do not supplement
clinical decision making. In essence, they connect the clinician to the existing literature in order
for the clinician to make an informed and evidence-based decision in clinical practice. While our
literature indicates the need for clinical decision support systems, there is no technology-enabled
decision model available to clinicians. The purpose of this study is to demonstrate how a Clinical
Decision Support System can be used to guide clinicians in the development of credible service
transition and fading plans that reconcile with standards of practice and standards of care in the
field of behavior analysis.
TRANSITION OF SERVICES 4
Literature Review
Decision theory involves the identification of a collection of behaviors which allow a
person to consider a decision and examine the outcomes which result from that decision. Two
main types of decision modeling exist within decision theory and contribute to the creation of a
clinical decision support system. Specifically, normative decision modeling focuses on how a
decision should be made based on the rationality of the situation. This form of decision modeling
is informed by the current literature as well as standards of practice, and does not address the
practical factors which may arise in a given professional field. In contrast, descriptive decision
modeling is concerned with the realistic manner in which decisions are actually made. This form
of decision modeling does not consider the rationality of the decision, nor does it require the
referencing of current literature or standard of practice to inform the decisions made. However,
both types of decision theory are necessary to create decision models which are effective at
guiding the decision of professionals (Hansson, 1994).
Derived from decision theory, decision models are tools which guide the behavior of an
individual and assist in the execution of efficient and effective actions in the context of problem
solving. These tools are not meant to supplant independent decision making, rather, they function
as a prompt to teach an individual or group how to approach problems. These models can be
adapted to a variety of environments and have been used across a variety of fields including
physical therapy, speech language pathology, medicine, and economics. However, behavior
analysis is a field which has yet to utilize the full benefits of decision models despite the
demonstrated benefits observed in other fields.
Decision models isolate the most important aspects of a decision and lead the
professional through the different outcomes depending on the unique characteristics of the
TRANSITION OF SERVICES 5
situation. The flexibility of decision models allows application of the models across professional
disciplines. By way of example, physical therapy is a well-established field which uses clinical
decision modeling to guide the progress of the patient and determine what actions should be
taken to maximize patient care and minimize unnecessary cost and treatment. For example,
Watts (1989) identified the key steps in clinical decision making, how to construct the model for
decision making, and provided examples from the field of physical therapy. According to Watts
(1989), the first step involved in any decision-making process is the identification of the problem
or why a decision model is necessary in a particular context. Specifically, in the context of
participants receiving treatment, the treatment setting, as well as the subject of the decision
model are identified as key factors when defining the decision problem (Watts, 1989). The
second step according to Watts (1989) is defining what outcomes constitute success in the
decision model process. As explained by Watts (1989), “we must decide exactly what we hope to
accomplish, what we hope to avoid, and when it will be realistic to judge how successful we
have been”. The third step described in Watts (1989) article is described as the most complex
due to the multitude of actions required and the compilation of the information gathered from the
performed actions into a graphic display known as a decision tree. In order to construct a
decision tree, all options for treatment of an individual must be compiled and considered, as well
as the risks and benefits of each option and the likelihood of success. Once the construction of
the decision tree is complete, the best option must be identified in order to begin treatment or
action towards the final goal of the decision model. Step four, centered on estimating and
analyzing probabilities, evaluates all possible options for future action and determines which
action is likely to yield the most favorable results according to the goal of the decision model. In
addition to determining which action or treatment will be most effective, the costs of the
TRANSITION OF SERVICES 6
different decisions must be considered in order to determine the action which is effective in
action and cost-efficient. Through the combination of steps one through five, the decision model
will provide sufficient information to reach the final step and select a preferred action or strategy.
Physical therapy is one of many disciplines that rely on decision models to guide the actions of
individuals (Watts, 1989).
Similarly, speech-language pathologists incorporate the topic of ending therapeutic
relationships in their own trainings and prepare for the ending of services in the intake process.
In 2010, Quattlebaum and Steppling described the importance of integrating experiences
involving the discharge of patients into the internships of students. As these internships last
between nine and twelve weeks, there is a limited amount of time to provide the student with the
variety of experiences, and the authors note that many switch internship sites before their
patients have reached the point of discharge. However, several key points are addressed as
important factors to consider when training new speech-language pathologists. First, the topic of
caseload management and how new professionals are taught to conduct an intake and manage the
patients they currently oversee. This first step involves considerations centered on direct
services, billing, and collaboration with other professionals working with the patient.
Additionally, the client intake phase is exactly the time to outline the goals of treatment and
prepare for the conclusion of services. In the field of behavior analysis, direct sessions, billing
and collaboration are frequently experienced events which must be attended to by the case
supervisor, especially during the intake process to ensure a smooth transition into services
(Quattlebaum & Steppling, 2010). Within the Behavior Analyst Certification Board’s (BACB)
guidelines there is a requirement to include a service fading plan as part of plan of care. A plan
of care should include a delineation of the conditions under which services will be concluded.
TRANSITION OF SERVICES 7
Second, Quattlebaum and Steppling (2010) identify the provision of services as a
continuum. That is, rather than services being clear in both beginning and end, services often
continue past the time of discharge when the family or patient becomes in charge of their own
rehabilitation. The process of intake into treatment is often the criteria for which the professional
will measure the appropriate time for the individual to be discharged in the future (Quattlebaum
& Steppling, 2010). For most if not all professional therapy, it is the concerns which bring the
client to therapy which should be used as the criteria for discharge at the appropriate time.
Through the use of concrete goals created from the deficits displayed by the client, there is
clarity in the conditions in which the client will be discharged. In behavior analysis, the goals
typically assigned to clients are dynamic due to the broad nature of the domains from which
deficits in autism spectrum disorder originate. Additionally, the continuum of services includes a
parent or caregiver training component. Parent training ideally begins before the discharge of
services is discussed so as to prepare the family for the transition when the time comes; however,
there can be difficulties stemming from the willingness of the parent to participate or follow
through with the interventions when the therapy team is not present.
Third, the topic of funding is often a decisive factor in the continuation of services and
can affect when the discharge of services occurs. The cost of therapy, regardless of form, can be
of concern to insurance companies or the patient’s family (i.e., due to co-pay requirements). The
less time the patient receives formal services, the less the cost; however, if funding sources make
this restriction, it is on the part of the professional to ensure the quality of services is excellent,
regardless of the quantity. The results of a meta-analysis show, “when early discharge was
supported by collaboration of multidisciplinary teams, the hospital stay was shorter, scores on
activities of daily living at home improved and patient satisfaction scores were all greater”
TRANSITION OF SERVICES 8
(Langhorne et al., 2005; as cited in Quattlebaum & Steppling, 2010). Not only is this beneficial
for the patient, but the ability to move individuals through therapy with a high degree of quality
might allow other individuals in need of services access services sooner.
Fourth, effective assessment regarding realistic outcomes of patients must be addressed
throughout the delivery of services. Each individual client possesses unique needs and a past
history of services, or lack thereof, which must be considered in each step of the creation of a
service plan. To disregard any information about a client for the sake of simplicity is a violation
of professional conduct codes across disciplines (Quattlebaum & Steppling 2010). In behavior
analysis, the Behavior Analyst Certification Board outlines the ways in which behavior analysts
must hold themselves to a high standard of ethical conduct which includes the creation of
individualized behavior intervention plans and conduct which serves the best interest of the
client and their community.
Finally, adherence to the codes of conduct drives the ways in which therapy is initiated,
delivered and terminated. In the field of speech-language pathology, there is a focus on providing
a plethora of clinical experiences and course work in order to prepare students for their future
careers. Similarly, the field of behavior analysis requires individuals to pursue a variety of
clinical experiences in direct and indirect work as well as with a variety of populations and
diagnoses. However, both fields identify the imperative nature of the termination of services at
the appropriate time and the education preparing students for the field should include the
practices of service termination as well.
Decision models have also been used in the field of economics to examine the different
outcomes of fading customer relationships. In 2005, Akerlund looked at how customer fading
unfolds in the context of economics and businesses. The disciplines of economics and business
TRANSITION OF SERVICES 9
rely heavily on customer relations and when relationships are to be terminated between a
customer and a business, the decision can manifest in several outcomes. First, the process of
fading a business relationship can result in a “crash landing”. A “crash landing” occurs when
poor interactions or actions on the part of the business drive the customer to dissolve the
relationship. This type of relationship fading is often the most abrupt and stems from
dissatisfaction on the part of the customer due to possibly poor management by the service
provider. Similarly, this form of relationship dissolution is seen in behavior analysis when there
is a failure to deliver on the part of the Applied Behavior Analysis provider due to insurance
limitations. When the parents are approached with news regarding a reduced number of hours
compared to what they were originally told, parents or guardians may react with alarm and
precipitously terminate the relationship. The negativity and frustration associated with the
conclusion of the relationship may be evident in how the parents speak about the company
following the termination of services. Moreover, the family may terminate their relationship
with a company and advise friends and family to refrain from receiving services from the
company in question.
A second means of ending relationships between customers and service providers is
through the “altitude drop”, a smooth and often gradual process of the relationship ending with
little negative affect or hostility involved in the ending of the relationship. In the context of
economics, the fall of the stock market and the withdrawal of customers investing in wealth
management experienced an altitude drop. As the economy worsened, individuals retracted from
investing; however, when the economy improved, customers may have been open once again to
investing. The relationship between customer and the service provider is not damaged from the
relationship termination and no significant affect influences the way the customer now views the
TRANSITION OF SERVICES 10
service provider. In the context of behavior analytic services, the altitude drop can be seen when
insurance or private funding is no longer available to support the provision of services. Although
there may be discontent with the funding source, the severance of the relationship is not due to
the hostility or negligence of either party. If the family is able to find a new funding source or the
service provider begins to accept funding from a new source, the relationship may resume
without a negative affect influencing the relationship.
In certain cases, the relationship between a customer and the service provider terminates
without significant action from either party; this is referred to as the “fizzle-out”. Neither the
service provider nor the customer intends to end the professional relationship, however lack of
communication or initiative taken by either party leads to the dissolving of the relationship. This
happens when there is a lack of communication between the behavior analyst and the parent(s) or
guardian(s). Parents are not typically knowledgeable about the inner workings of behavior
analysis as a therapy for Autism Spectrum Disorder (ASD) and when there is a lack of
communication about progress regarding the child, parents and guardians can feel a sense of
helplessness. Eventually, the family may elect to terminate services since they are not being
educated or included in their child’s treatment.
Finally, the “try-out” involves a temporary relationship between a customer and service
provider due to the uncertainty of the customer. The relationship has the potential to grow and
become a permanent relationship, however the relationship terminates without much turbulence
when commitment, for example through the payment of an annual fee, is not desired by the
customer and they decide to terminate the existing relationship. In the field of behavior analysis,
the “try-out” can be seen when families agree to services at first, but withdraw their child when
commitment present itself such as in cases of parent training. While parents are willing to
TRANSITION OF SERVICES 11
commit to bringing their child to sessions, when training and implementation of programs is
asked of them, this presents as too serious a commitment, much like committing to an annual fee
for a bank or credit card in the field of economics.
With consideration to all the potential ways a relationship can end, the “altitude drop” is
the most preferred as the relationship is maintained with little risk to either party and can be
strengthened if necessary. Implications from this research lend information regarding how to
proceed in professional relationships as well as highlights a need for a fading system which
handles the process with sensitivity to culture and dignity.
Decision models are seen in a variety of disciplines and despite their effectiveness,
decision models are not used extensively in behavior analysis. There are instances of literature
which examines the use of decision trees in behavior analysis, and shows the effectiveness of
decision modeling as an aid to clinical judgement as well as an analysis of how decision
modeling can be used in behavior analysis.
Decision models are not an entirely new technology to the field of psychology and
behavior analysis, as demonstrated over 25 years-ago by Axelrod, Spreat, Berry, and Moyer in
their chapter of Behavior Analysis and Treatment (1993). Decision models have been created to
assist clinicians in selecting and implementing appropriate treatment procedures suited to address
the individual needs of a client. The treatment procedure model is intended to assist the clinician
at the onset of treatment planning, as treatments are likely to evolve or be replaced as the client
moves through behavior therapy. The authors outline the seven components of the decision
model which moves through the necessary components of treatment planning including
identification of deficits, conducting functional and risk-benefit analyses, and selecting the least
restrictive treatment. The model is connected to current literature and emphasizes the connection
TRANSITION OF SERVICES 12
of professional judgement to relevant behavioral interventions in order to best serve the client
(Axelrod, Spreat, Berry, & Moyer, 1993).
Treatment and programming, as with the majority of practices in behavior analysis, are
intended to be individualized to each client and their specific needs, and can benefit greatly from
decision model guidance. Discrete trial training (DTT) is a common structure for conducting
therapy sessions for individuals with ASD. However, the standard ten-trial teaching method may
not be suitable for all individuals. With prevalence in the use of DTT to teach skill acquisition
targets to young children with ASD, it would be fortuitous to ensure the programming being
administered is appropriate for the client in question. In 2005, Ferraioli, Hughes, and Smith
created several decision trees to guide the decision-making process of determining whether
discrete trial training is appropriate for the individual’s learning process. The decision trees
outlined several options for deciding on the course of treatment based on different contexts such
as the failure of programming to generalize, no skill acquisition, or inconsistent progress.
Discrete Trial Training is not appropriate for all clients, and if modifications to the traditional
DTT structure or another programming style, such as natural environment training (NET), are
necessary to improve client performance, the given decision models provide guidance towards
how the programming can be restructured for the client’s benefit (Ferraioli, Hughes, and Smith,
2005).
In addition to programming, decision modeling can be utilized to aid a clinician in
exploring all options for a measurement system for the target behavior. Leblanc, Raetz, Sellers,
and Carr (2016) created a decision model which synthesized the types of data collection in order
to better inform clinical decision making in regards to the measurement of problem behavior.
Behavior analysts rely heavily on systems of data collection in order to inform clinical decisions
TRANSITION OF SERVICES 13
in how to construct programs and best aid our clients in decreasing undesirable behaviors, such
as stereotypy, aggression, or self-injurious behavior. With the plethora of data collection
methods, it is not possible to fully grasp the appropriateness of a measurement system without
referencing literature. LeBlanc, Raetz, Sellers, and Carr (2016) give a clear and informed outline
for the different measurement types as well as rationale and context of use for each measurement
system. This decision model does not decide the course of data collection for the individual, but
rather provides background information for each so that the most pertinent data collection
strategy is used. This is not only important to ensure appropriate data collection occurs, it allows
the individual needs of the client and their behavior to be addressed even if the clinician is not
familiar with the data collection method necessary.
Decision modeling in behavior analysis is not limited to use with individuals diagnosed
with autism spectrum disorder and has been applied to how professionals in the field of behavior
analysis interact with each other and other professionals such as occupational or speech
therapists. In 2015, Brodhead synthesized a decision model to disseminate information regarding
interdisciplinary teams and how to maintain the relationships of members not involved in
behavior analysis while maintaining the ethical considerations of our field. The model
demonstrates a simple way of thinking about how to approach non-behavioral treatments while
maintaining relationships with members of the interdisciplinary team with respect to their diverse
fields. For example, when behavior analysts attend individualized education program (IEP)
meetings for clients, there are typically several professionals each with their own opinions on
how therapy should be conducted. Behavior analysis should not be used in isolation, and usually
requires the input of other professionals in order to produce desired results for the client in
question. However, because decisions are not always unanimous, it is important to identify
TRANSITION OF SERVICES 14
which professional situations are appropriate to insert opinions about our own field which may
oppose the recommendations of another professional. Additionally, the conflict of opinions may
arise in a company setting which includes individuals at various professional levels in a behavior
analytic company.
While the work we do focuses mainly on the well-being of a client with ASD, our clients
are not only the individuals with this diagnosis. Decisions regarding the treatment of clients in
behavior analytic practice are largely under the control of the clinician, however, the parent or
guardian of a client is an equally important factor in clinical treatment. In 2013, Carlon, Carter,
and Stephenson, conducted a review of literature surrounding the factors which influence a
parent or guardian’s decision to seek out specific treatments. In their review, several factors were
identified as potential influencers in regards to the treatment of ASD. First, factors related to
funding and the cost of treatment were found to impact the decision of the parent or guardian. If
the family does not have the insurance coverage or the financial ability to afford behavior
analytic treatment, it is unlikely parents will explore the possibility of behavior analytic
treatment even when it might be the most appropriate treatment for their child’s diagnosis.
Secondly, recommendations from professionals and other trusted individuals was found to be a
key influence in a parent’s decision to seek treatment for their child. This relates closely to other
factors identified such as the needs of the client, time constraints, and the child’s resistance to
specific intervention procedures. Finally, factors regarding the progression of treatment, research
evidence, and the use and compatibility of other interventions were found to impact the decision-
making process (Carlon, Carter, & Stephenson, 2013).
Finally, the assimilation of decision modeling relates to the rapid growth of our field over
time. In 2018, Burning Glass released their analysis of the labor market data for the field of
TRANSITION OF SERVICES 15
behavior analysis and found there has been an 800% increase in the demand for individuals who
hold a Board-Certified Behavior Analyst (BCBA/BCBA-D) certification as well as a 995%
increase in demand for individuals with a BCaBA certification (Burning Glass, 2018). With this
significant increase in demand for certified behavior analysts, it is critical our training and
production of new behavior analysts consider not only behavior analytic research, but the
research and tools utilized by other fields, such as physical therapy, speech language pathology,
and economics.
Current Study
The current study aimed to examine how the use of a decision model impacts the quality
of plans of care including a transition of services plan for individuals with Autism Spectrum
Disorder (ASD). The literature, which dictates the ways in which behavior analytic services
should be faded, primarily stems from the Behavior Analyst Certification Board (BACB)
Guidelines which not only suggests, but requires the creation of a plan of care including a
transition plan for each client. While seen as an effective tool across a multitude of disciplines,
decision modeling is not readily used in behavior analytic services to help clinicians navigate the
best options for their clients. Discharge from behavior analytic services does not indicate the
individual is finished learning, but rather the formal therapy team is no longer necessary to
continue the provision of services or another service provider is now more appropriate. This
study aims to investigate how the use of a clinical decision model can aid clinicians in the
production of plans of care including a transition plan which align with current literature,
standards of practice, and are individualized to meet the needs of the client.
TRANSITION OF SERVICES 16
Methods
Participants, Materials, and Procedures
For this investigation, the participants were four Board Certified Behavior Analysts
(BCBAs) with three or more years of experience as a supervisor in a behavior analytic agency
which provides services to individuals with Autism Spectrum Disorder (ASD). BCBAs who did
not meet these criteria were not included in the investigation. All participants held their
certification for at least four years with two participants holding their credential for five years.
At the onset of the study, the first step was to conduct a root cause analysis, as is
consistent with an organizational behavior management approach. The Performance Diagnostic
Checklist for Human Services (PDC-HS) is an assessment intended to evaluate several areas of
job performance and highlight areas of need at the individual and organizational levels. Areas of
assessment include the training, task clarification, current resources, and performance monitoring
of the organization, all of which are essential when evaluating the reasons why the creation of
plans of care including a transition plan may not occur. The PDC-HS was completed with the
director of the company at which this study was conducted.
The design of the study was a multiple probe design across participants. In baseline,
clinician knowledge was assessed through a series of questions regarding the participants’
knowledge of relevant ethical codes and discharge criteria as stated by the BACB. Additionally,
participants were asked about their previous experience with the initiation of transition of
services and how that was conducted. Following assessment of clinician knowledge, each
clinician was asked to submit three existing transition plans from their caseload with pertinent
identifiers redacted in order to protect client confidentiality. The plans were submitted in an
effort to evaluate the quality of the transition plans.
TRANSITION OF SERVICES 17
All plans and clinician knowledge were evaluated via a rubric created by the principal
investigator with reference to a rubric created by the government with the intent to evaluate
behavior support plans (Wright, Mayer, and Saren, 2006). The rubric consists of four sections
which look at the existence of a plan of care, the quality of the plan, the existing knowledge of
the clinician in terms of ethical codes and discharge criteria, and the clinician’s previous
experience with transition of services. In addition to the scoring guide, the rubric has references
to the Fourth Edition Task List and the Behavior Analyst Certification Board Ethical Guidelines
(See Figure 2). All assessment and analysis of responses was completed via computer and coded
to protect the confidentiality of the participants and their clients. The technology-enabled clinical
decision model served as the intervention and was created by the principal investigator with
reference to current literature, the BACB standards of practice, and the Fourth Edition Task List.
In intervention, each participant was given the decision model after baseline probes were
collected on the transition plans and knowledge surveys sent to the principal investigator. Each
participant was asked to create three new transition plans with the decision model as a guide to
outline current goals, progress and transition of service preparations. Post-intervention, the
clinicians’ knowledge of ethical codes and discharge criteria were re-assessed. Additionally, a
social validity survey consisting of five questions was given to each participant to assess the
goals, procedures, and outcomes of the study.
Results
Although the results from the permanent product plans of care are important, the purpose
of the study beyond the immediate creation of plans of care including a transition plan is the
continued improvement of an organization in areas such as resources to assist BCBAs in task
completion. The results of the PDC-HS showed training and task clarification was in place for
TRANSITION OF SERVICES 18
transition planning, as reported by the director of the company. However, the company did not
currently have resources available to the BCBAs in order to assist in task completion, as the
director cited the internet as the only resource available outside of insurance outlines.
Additionally, it was reported that plans of care are typically not completed during the intake
process as is required by the Behavior Analyst Certification Board. This is often due to other
competing tasks, such as completion of assessments, creation of programming, and
implementation of proposed interventions related to programming. This assessment provided an
indication of the areas of deficit and served as a confirmation of the need for organizational
resources.
In baseline, each participant was asked to cite the relevant ethical codes related to the
transition and discharge of services as well as the criteria for discharge as stated by the Behavior
Analyst Certification Board. Six ethical codes from the Professional and Ethical Compliance
Code for Behavior Analysis were identified by the researcher as relevant to the transition and
discharge of services. The first participant was able to name two relevant ethical codes (33%),
and was unable to name any of the five discharge criteria as stated by the Behavior Analyst
Certification Board. The second participant was also able to name two relevant codes (33%), and
while she was close in naming one of the discharge criteria, she was unable to accurately name
the criteria. The third participant was able to name four relevant codes (66%) and was unable to
name any of the discharge criteria, rather she continued to name ethical codes. Finally, the fourth
participant was able to name three relevant codes (50%), and also provided an approximation of
an answer regarding discharge criteria, however the participant was not accurate in identifying
the criteria.
TRANSITION OF SERVICES 19
Figure 1 depicts the percentage of points received on the rubric in baseline and post-
intervention during the evaluation of the three transition plans the participants were asked to
submit in baseline and post-intervention respectively. The x-axis represents consecutive dates on
which the participants submitted their plans of care. The y-axis represents the percentage of
points acquired during the evaluation of the plans of care via the rubric. Figure 2 displays the
rubric used to evaluate all transition plans and clinician knowledge in the investigation.
The first participant submitted three plans of care and received a score of 50% on her
plan evaluation across the three plans of care she submitted. One plan of care submitted by the
first participant was from an insurance plan and was generic in nature. It included a simple
statement about the need decrease direct service hours as goals are met and the percentage of
parent facilitation of sessions as fading continues. Post-intervention, the reformatted plan
demonstrated the client’s current goals and abilities across multiple domains, included relevant
citations to current literature and a transition plan with rationale as to why the transition plan was
chosen for that client. All the transition plans earned a score of 100% across the three
reformatted plans. The second participant submitted one plan of care, receiving a score of 50%
on the first plan of care and 20% for the plans of care which were not submitted. Post-
intervention, she was able to produce three high quality plans of care, one which improved the
previously submitted plan, and two others for cases which did not currently have a transition plan
in place. She received a score of 100% across all three reformatted plans of care. The third
participant submitted zero plans of care connected to their current caseload, and received a score
of 20% across all plans. Post-intervention, she was able to produce three plans of care for current
cases she manages, all of which were individualized and provided rationale for the selected
transition plan. She received a score of 100% across all reformatted plans of care. The fourth
TRANSITION OF SERVICES 20
participant submitted three plans of care and received a score of 50% across all three plans
submitted in baseline. Post-intervention, she was able to produce three plans of care, all of which
were individualized and provided rationale for the selected transition plan, which earned her a
score of 100% across all three reformatted plans of care. Following the submission of the post-
intervention plans of care, clinician knowledge was assessed again. However, data was not able
to be collected for all participants and was therefore dropped as a post-intervention measure in
the investigation.
Social validity surveys were distributed to all participants, and two participants responded
to the survey. The first participant rated the purpose of the study as acceptable, the intervention
as helpful, and was pleased with the recommendations made by the decision model. She rated the
tool as being neutral in terms of effort and neutral in terms of the likelihood of utilizing the tool
in the future. The second participant rated the study as being neutral in terms of acceptability and
the helpfulness of the tool. She rated the tool as being easy to use, but was dissatisfied with the
recommendations made by the tool and reported it is unlikely she will use the tool in the future.
No comments were included in the social validity surveys, although the principal investigator did
receive anecdotal reports from all participants which indicated general acceptance of the
intervention during monthly check-in meetings. Overall, participants reported being extremely
busy during the course of the study which likely contributed to the lack of responses on the
social validity surveys. Additionally, the novel nature of decision models in the field of behavior
analysis could have contributed to the varied result received from the two participants, and future
investigations could address the acceptability of decision models.
TRANSITION OF SERVICES 21
Discussion
The technology-enabled clinical decision model was successful in assisting clinicians in
the creation of high-quality, individualized transition of services plans for their clients. Decision
models has been shown to be effective in a variety of fields outside of behavior analysis through
their ability to guide difficult and weighted decisions. In behavior analysis as it relates to therapy
for individuals with Autism Spectrum Disorder, our primary goal, as set forth by the BACB
Guidelines, is to allow the client and those who surround them to gain independence. As a field,
we strive to align our decisions and clinical judgements with the current literature, and as
demonstrated by other fields, decision models allow us to be cognizant of the current literature
when making clinical judgements.
Decision models are valuable tools utilized by a variety of professional fields. Despite its
demonstrated effectiveness, applied behavior analysis has yet to utilize the full benefits of
decision models as aids in clinical decision making in regards to clients with ASD. The main
goal in the application of behavior analysis in the treatment of autism is to provide independence
to the client, and this is a key quality of life indicator considered in the course of treatment
planning. Decisions made by supervising clinicians are influential in the trajectory of a client’s
progress and should be connected to the evidence produced by researchers in the field of
behavior analysis as well as related fields such as occupational or speech therapy. Decision
models are not replacements to the expertise of a working clinician, rather they connect the
clinician to the existing evidence-based literature as well as the guiding principles of the field of
behavior analysis when making crucial clinical judgements.
TRANSITION OF SERVICES 22
Limitations
While decision modeling has been shown effective in a variety of environments, there are
limitations involved with the use of decision models. Clinicians are not able to predict the
outcomes for their clients with full confidence as there are a vast number of variables to consider
as the client moves through therapy and after therapy has concluded. Even at the conclusion of
services when the client is ready to transition out of services, there is an amount of uncertainty
since there are multiple stakeholders to consider beyond the benefit of the child and immediate
family. Even with decision models and the best clinical judgement, clinicians can never be
completely confident in fading out services as unplanned difficulties may occur in the future of
the client following the conclusion of services. However, decision modeling helps give the
clinician a good prediction of the outcome when following a certain path of transition of services
and what consequences may come from the transition of services.
Future Research
The social validity surveys demonstrated mixed results in the acceptability, helpfulness, and
likelihood of use for the clinical decision models. The purpose of this study was not to require
the use of a clinical decision model, but to give the option in order to demonstrate the
effectiveness of the model in this specific context. In order to better form the decision model, an
extension to this investigation could include the use of the Delphi Consensus Process as outlined
in Williams and colleagues (2013). Williams and colleagues (2013) investigated the use of this
process in the context of patient decision aids in the healthcare system when more than one
option for treatment is viable. The Delphi method allows field professionals to examine the
decision model in progress and give clinical opinions on the relevant information to be included
in the decision model. Field professionals are also given the opportunity to participate in group
TRANSITION OF SERVICES 23
discussions regarding the appropriateness of certain criteria if a consensus was not immediately
apparent from the two rounds of voting. Future replications of the current investigation could
include a Delphi method component in order to strengthen the validity of the decision model in
terms of the criteria deemed important by clinicians in the field.
This is one of the first decision models created to aid clinicians in the creation of transition
plans and future research can expand on the betterment of the model for future use as the field,
our guidelines, and our clients change in the future. The guidelines of the BACB and existing
literature are constantly evolving with new research produced each year. This decision model
represents the literature which currently exists but can and should be enhanced when new
literature is published. Additionally, the permanent product of the plan of care is subject to
change as stakeholder needs evolve in order to present clear intentions for the course of
treatment. Additionally, future research can look to the important aspects of transition of services
as well as a decision model for how to fade services for a client who has not responded the
behavior analysis therapy as expected.
Decision models have been shown effective in a number of areas; it is important to remember
the role these models serve in clinical judgement. Decision models are not a complete solution to
any issue and will not replace a clinician’s judgement of a situation in the moment. However, the
use of a decision model can be crucial in laying out all possibilities for the outcomes of decisions
made in the clinical setting and allows the clinician’s options to be clearly defined instead of the
clinician relying on previous cases as reference for how to plan for transition of services at the
intake of a client. It is possible a clinician will take on a case in which the individual aspects of
the case have not been experienced by the clinician previously, and with the decision model and
its connections to the existing literature, the clinician can appropriately suggest a transition plan
TRANSITION OF SERVICES 24
which aligns with the specific needs of the client as well as the standards set forth by the
Behavior Analyst Certification Board.
TRANSITION OF SERVICES 25
References
Åkerlund, H. (2005). Fading customer relationships in professional services. Managing
Service Quality: An International Journal, 15(2), 156–171.
Axelrod, S., Spreat, S., Berry, B., & Moyer, L. (1993). A Decision-Making Model for Selecting
the Optimal Treatment Procedure. In Van Houten, R. & Axelrod, S. (Eds.), Behavior
Analysis and Treatment (pp. 183-202). New York: Plenum Press.
Brodhead, M. (2015). Maintaining professional relationships in an interdisciplinary setting:
strategies for navigating nonbehavioral treatment recommendations for individuals with
autism. Behavior Analysis in Practice, 8, 70–78.
Behavior Analyst Certification Board. (2018). US employment demand for behavior analysts:
2010-2017. Littleton, CO: Author.
Carlon, S., Carter, M., & Stephenson, J. (2013). A Review of Declared Factors Identified by
Parents of Children with Autism Spectrum Disorders (ASD) in Making Intervention
Decisions. Research in Autism Spectrum Disorders, 7(2), 369–381.
Ferraioli, S., Hughes, C., & Smith, T. (2005). A Model for Problem Solving in Discrete Trial
Training for Children with Autism. Journal of Early and Intensive Behavior Intervention,
2(4), 224–246.
Hansson, S. O. (1994). What is decision theory?. Decision Theory: A Brief Introduction (pp.6-8).
Stockholm: Royal Institute of Technology.
Joseph-Williams, N., Newcombe, R., Politi, M., Durand, M., Sivell, S., Stacey, D., … Elwyn, G.
(2014). Toward Minimum Standards for Certifying Patient Decision Aids: A Modified
Delphi Consensus Process. Medical Decision Making, 34(6), 699–710.
LeBlanc, L. A., Raetz, P. B., Sellers, T. P., & Carr, J. E. (2016). A Proposed Model for Selecting
TRANSITION OF SERVICES 26
Measurement Procedures for the Assessment and Treatment of Problem Behavior.
Behavior Analysis in Practice, 9(1), 77–83.
Quattlebaum & Steppling (2010) Preparation for ending therapeutic relationships. International
Journal of Speech-Language Pathology, 12(4), 313-316.
Watts, N. (1989). Clinical decision analysis. Physical Therapy, 69(7), 569.
Wright, D. B., Mayer, R. G., & Saren D. (2006). Behavior Intervention Plan Quality Evaluation
Scoring Guide II. Retrieved from http://www.pent.ca.gov/beh/qe/bipscoringrubric.pdf
TRANSITION OF SERVICES 27
Appendix A
Figure 1. Graph of Rubric Scores
TRANSITION OF SERVICES 28
Figure 2. Rubric
Abstract (if available)
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Leidt, Alexandria Emily
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Core Title
Use of a clinical decision model to support the transition of services for individuals with autism spectrum disorder
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College of Letters, Arts and Sciences
Degree
Master of Science
Degree Program
Applied Behavior Analysis
Publication Date
07/29/2019
Defense Date
06/18/2019
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