The ABCs of Caregiver Attendance Behavior

By Daniel B. Sundberg, PhD

bSci21 Contributing Writer

Most people with experience providing clinical ABA services to children with developmental disabilities would agree that caregivers play a critical role in the overall success in the treatment plan.  However, caregivers, like most everyone, are extremely busy people with multiple responsibilities throughout any given day which often results in underused billable hours.  It would benefit the BCBA and staff to apply a simple Antecedent-Behavior-Consequence (ABC) analysis to these situations to see things from the caregiver’s perspective, and understand how to better support attendance behaviors.

Attendance is behavior, and like most other behaviors, we can place it along a continuum of frequency from 0% to 100% attendance.  Lesser frequencies can be attributed to things like cancelling sessions, showing up late, or ending early, for a variety of reasons.

And for these classes of behavior, there are a great many antecedent events that happen before a caregiver can engage in attendance behavior. Below is a short list of some potential antecedents. No doubt, if you live and work in this world every day you’ll see many things to be added, but this list can get us started.

Some of these antecedents may lead to higher rates of attendance than others. Notice how many factors may be competing for attention and energy, and how many may be outside a caregiver’s control? And of course, antecedents aren’t the only thing that influences behavior. Consequences for these behaviors will have a tremendous impact. Below is an example of some consequences you might find in place.

And when we look at these consequences, it is necessary to also look at the impact of these consequences. One useful model for this is the E-TIP analysis (Bracksick, 2010) (similar to Aubrey Daniels PIC/NIC model). This model asks 4 important questions about a given consequence 1) does it encourage or discourage behavior? 2) how timely is it? 3) how important is it to the performer? 4) how probable is it? Those consequences that are Timely, Important and Probable are most likely to encourage or discourage behavior. These simple questions give very important insight into our original question of what influences attendance.

Keep in mind – this is from the perspective of the caregiver! You may look at that list and think “wait, it’s really important that staff get paid, and we are able to bill for services!” but is it important to the caregiver? Caregivers are hard-working and very busy – we can’t expect the needs of the agency to be their top priority.

What can we glean from this analysis? Well, there often aren’t many natural Immediate, Important, and Certain consequences to support good attendance behavior, and there are quite a few that support bad attendance behavior. In fact, the consequences are the exact opposite of what you want!

So, what’s a behavior analyst to do?

In simple terms – provide lots of immediate important reinforcers, with some regularity, for the desired behavior! Clinical ABA service providers are often competing with other contingencies that can easily influence a caregiver’s behavior, so effective counter-contingencies must be designed.

And as behavior analysts we have no excuse to indulge in performer blaming by saying “they should just care!” Probably most families care quite a lot, but they are also juggling so many things that ABA services may sometimes take a back seat. Providers engineer many aspects of the environment in which services are received, whether intentional or not. Perhaps caregivers could “care more”, but hoping won’t help, supporting caregivers with the intentional use of behavior analysis will.

And there is a strong business case for taking these actions too. For example, one clinical ABA service provider decided to implement a simple weekly feedback card that fed into a monthly raffle. The raffle was based on a preference assessment done with caregivers, and they could win some pretty high value items. At a cost of about $550 per month to the company, there was an increase in attendance, and timeliness that amounted to over $5,000 in increased billing per month, well surpassing a “10x” Return on Investment.

Here are some quick tips to rebalancing consequences to encourage attendance (disclaimer – these are just suggestions, what works in one situation may not work in another)

• Clear expectations about what good attendance looks like, and why it matters
• Clear description of the available consequences for attendance (positive and negative)
• Give caregivers frequent (e.g. weekly or monthly) feedback on attendance
• Identify valuable reinforcers for good attendance behavior (that is within compliance with any funding source requirements). For example, respite care, gift cards, a “reward box”, charitable giving, thank you cards from staff, events
• Create a system of reinforcement for families with good attendance behavior such as a raffle, token economy, spot recognition, report card system
• Monitor performance and be prepared to switch up consequences

These solutions may not totally fix the issue, as there are factors outside of everyone’s control, but it is possible to make a dent. And making that dent is certainly worth it, because that means providing more critical services, building a better relationship with the family and funding source, and creating a more sustainable business.

Let us know your experiences with encouraging attendance in the comments below and be sure to subscribe to bSci21 via email to receive the latest articles directly to your inbox!

References:

Bracksick, L. (2010). Unlock behavior, unleash profits (2nd ed.). New York: McGraw-Hill Companies.

Daniel B. Sundberg, PhD, is a behavior analyst dedicated to creating meaningful change for individuals and organizations using the science of human behavior. Dan has worked in a variety of organizations, including non-profits. Additionally, Dan spent two years as a university lecturer, teaching undergraduate students how to improve the workplace with behavior analysis

Dan earned his B.A. in Psychology at the University of California at Berkeley, M.S. in Organizational Behavior Management from Florida Institute of Technology, and Ph. D. in Industrial/ Organizational Behavior Management from Western Michigan University. During this time, some of the best thinkers in behavior analysis and OBM mentored Dr. Sundberg as an academician and business professional.

Dan is currently Regional Manager of Consulting Services at ABA Technologies, where he helps to develop and deliver OBM consulting services. Dan is also a guest reviewer for the Journal of Organizational Behavior Management, and in his spare time he creates behavior-based products that allow people to manage their time and accomplish their goals. He also has a special interest in building effective work practices and cultures for start-up companies, and increasing the positive effects of organizations working towards an environmentally sustainable future.  You can contact him at [email protected].