Fluent Essays

After reading Fong (2016) and Kornack, Cernius, & Persicke (2019), describe how you will become more culturally aware in your behavior analytic practice. Discuss how cultural competency will benefit your clients. Is it unethical if a behavior analyst does not develop cultural awareness skills? List all applicable ethics codes. Provide the rationale for the chosen code(s). Behavior Analysis in Practice (2019) 12:879–886 https://doi.org/10.1007/s40617-019-00377-y SPECIAL SECTION: DIVERSITY AND INCLUSION The Diversity Is in the Details: Unintentional Language Discrimination in the Practice of Applied Behavior Analysis Julie Kornack1 & Ariana Cernius2 & Angela Persicke3 Published online: 9 August 2019 # Association for Behavior Analysis International 2019 Abstract Individuals with limited English proficiency face more challenges accessing applied behavior analysis (ABA) than their English- speaking counterparts. Many federal and state laws have been enacted to ensure the civil rights of protected classes, and Section 1557 of the Affordable Care Act (ACA, 2010) builds on those laws and explicitly establishes a cause of action (i.e., a basis to sue) against health care providers, including ABA providers, who discriminate against patients on the basis of race, color, national origin, sex, age, or disability. A patient’s language falls under the scope of national origin, and most health care providers, including behavior analysts who deliver ABA as medically necessary treatment, have a duty to ensure that patients who are Limited English Proficient (LEP) have the same access to the provider’s services as English-speaking patients. Knowledge of this provision of the ACA is critical to its compliance and, more importantly, to ensuring that behavior analysts rise to the challenge that the goal of true diversity represents. Note: Many terms are used interchangeably to describe insurance carriers, insurance issuers, health plans, and managed care organizations, as well as practitioners of applied behavior analysis. In this article, insurance carriers, insurance issuers, health plans, and managed care organizations are referred to as payors, and practitioners of applied behavior analysis are referred to as behavior analysts or ABA providers. Keywords Applied behavior analysis, ABA . Autism, ASD . Affordable Care Act, ACA . Obamacare, Section 1557, diversity, interpreter, health care, discrimination . LEP, Limited English Proficient How we define diversity likely informs how we manifest it in our lives and in the practice of behavior analysis. If diversity is defined too narrowly or contemplated too briefly, unintention- al discrimination may adversely impact access to health care for patients with limited English proficiency, including indi- viduals seeking access to applied behavior analysis (ABA). Simply put, if an English-speaking patient can access ABA services more easily than a non-English-speaking patient, then a discriminatory practice is likely in place. Ensuring diversity in the practice of health care, including ABA, is especially This manuscript has not been previously published and has not been or will not be submitted elsewhere during the review process. * Julie Kornack [email protected] 1 Center for Autism and Related Disorders, 21600 Oxnard Street, 18th Floor, Woodland Hills, CA 91367, USA 2 Bet Tzedek Legal Services, Los Angeles, CA, USA complex, replete with ethical and practical implications for patient access to care, best practices, and provider sustainability. The field of ABA and the population it serves have histor- ically endured discrimination to such an extent that nonprofit organizations, advocacy groups, bodies of law, and even re- search exist purely to ensure that people who need ABA have access to it (Unumb & Unumb, 2011). With a focus on indi- vidualized, data-driven treatment, goals, and priorities to ad- dress each patient’s unique challenges and deficits, behavior analysis would seem inherently diverse; yet, data show that individuals who are limited English proficient (LEP) access ABA later, less often, and for shorter durations than their English-speaking counterparts (Zuckerman et al., 2017). LEP is defined to include “individuals who do not speak English as a primary language and who have a limited ability to read, speak, write, or understand English” (LEP.gov, n.d.). The percentage of LEP families varies broadly from state to state and from one community to the next. Yu and Singh (2009) report that nearly 14\% of children come from house- Pepperdine University, Malibu, CA, USA holds where the primary language is not English. Patients and 3 http://crossmark.crossref.org/dialog/?doi=10.1007/s40617-019-00377-y&domain=pdf http://orcid.org/0000-0003-1446-727X mailto:[email protected] https://doi.org/10.1007/s40617-019-00377-y 880 Behav Analysis Practice (2019) 12:879–886 their families who speak English are likely to encounter fewer barriers to accessing ABA. This more challenging access for LEP families raises important questions about which practices currently in place may be discriminatory and draws attention to potential legal and ethical issues for ABA providers. Given that patients who receive ABA earlier, at greater intensity, and for a longer duration are more likely to have better outcomes (Eikeseth, Smith, Jahr, & Eldevik, 2007; Granpeesheh, Dixon, Tarbox, Kaplan, & Wilke, 2009; Linstead et al., 2017; Virues-Ortega, Rodríguez, & Yu, 2013), equal access to ABA across all demographics is not only a requirement under federal law (Affordable Care Act [ACA], 2010) but also an important goal in the effort to ad- vance diversity in ABA among providers and patients alike. The next frontier, in other words, is to ensure that access to ABA is the same for both English-speaking and LEP populations. Although ABA is used to treat a variety of diagnoses, a majority of behavior analysts treat the behaviors and deficits associated with the core diagnostic criteria of autism spectrum disorder (ASD), and predictions for growth in the field of ABA rely on the preservation and expansion of autism insur- ance reform laws and on data regarding autism prevalence rates (Deochand & Fuqua, 2016). As such, this discussion about ABA providers in the context of a benefit covered by health insurance and Medicaid is primarily—and necessari- ly—focused on access to ABA by individuals diagnosed with ASD and their families. Disparity in Access to ABA Autism insurance reform, the ACA, and clarification that ASD treatment is a covered benefit for Medicaid’s pediatric population have collectively increased access to ABA (ACA, 2010; Cernius, 2016; Mann, 2014;). Yet, families frequently face practical barriers to accessing ABA therapy programs for their children despite their legal right to coverage. Many of the barriers experienced by patients (e.g., lack of insurance, excessive cost sharing, difficulty understanding and nav- igating the health care system, provider shortages) are not typically within the control of an ABA provider. Once a patient contacts an ABA provider, though, fed- eral law mandates that the patient must be able to com- municate with the behavior analyst and his or her staff regardless of the patient’s language (ACA, 2010). Indeed, Yu and Singh (2009) cited “linguistically concor- dant providers” and access to interpreters as two potential variables that may increase access to medically necessary treatment for children from LEP homes. Zuckerman et al. (2017) identified English proficiency as a significant variable in access to autism treatment in Spanish-speaking families, meaning that LEP families encounter more barriers to treatment than their English-speaking counterparts. In a retro- spective review of 152 children with ASD, St. Amant, Schrager, Pena-Ricardo, Williams, and Vanderbilt (2018) identified language as a potential barrier to health care for children in the study whose parents’ primary language was not English. Role of Behavior Analysts in Ensuring Equitable Access to ABA With increasing recognition of the effectiveness of ABA and the growing prevalence rate of ASD (Baio et al., 2018), be- havior analysts may find themselves with an abundance of prospective patients. Indeed, behavior analysts qualified to treat ASD are in short supply (Behavior Analyst Certification Board, 2018). That abundance of patients may make it less likely for a behavior analyst to have a practice that reflects his or her community demographics. For example, if a behavior analyst only speaks English, then she or he may be inclined to treat only those patients who speak English and may very well build a successful practice serving only English-speaking patients. That is, ASD’s high prevalence rate may contribute to a process in which ABA providers have the option to be selective about the patients they treat. Yet, what may be viewed by an ABA provider as an efficient business practice or professional focus may, in fact, be dis- crimination, both in the eyes of the federal government and in the experience of the LEP community. Quite possibly, in an effort to comply with the Behavior Analyst Certification Board’s Professional and Ethical Compliance Code for Behavior Analysts (2017, Code 1.05[b–c]), a behavior analyst who encoun- ters an LEP patient may determine that she or he is unable to “use language that is fully understandable to the recipient of those services while remaining concep- tually systematic with the profession of behavior analy- sis” or obtain the appropriate “training, experience, con- sultation, and/or supervision necessary to ensure the competence of their services” and will refer the patient to another provider. An ABA provider may view this practice as an effort to honor the compliance code, but Section 1.05(d) of the compliance code clearly states that behavior analysts may not “engage in discrimina- tion against individuals or groups based on . . . national origin . . . or any basis proscribed by law.” Behavior analysts should take necessary steps to understand their responsibility to ensure that patients who seek medically necessary ABA have equitable access to treatment, irre- spective of their primary language. In addition to the clear ethical duty to provide such access, most behavior analysts are required by law to take proactive steps to ensure equitable access to the services they provide. 881 Behav Analysis Practice (2019) 12:879–886 Overview of the ACA and Section 1557 In 2010, Congress passed the Patient Protection and Affordable Care Act and, shortly after, the Health Care and Education Reconciliation Act of 2010. Together, these acts became known as the Affordable Care Act (ACA), commonly known as Obamacare, setting in motion a major overhaul of the health insurance system in America, with many implica- tions for health care and insurance coverage (Unumb & Unumb, 2011). Section 1557 is the nondiscrimination provi- sion of the ACA that extends nondiscrimination protections to individuals in accessing health care by building upon long- standing and well-known federal civil rights laws, such as Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color, and national origin; Title IX of the Education Amendments of 1972, which pro- hibits discrimination on the basis of sex; Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on the basis of disability; and the Age Discrimination Act of 1975, which prohibits discrimination on the basis of age (Department of Health and Human Services [HHS] Office for Civil Rights, 2016). Section 1557 is meant to advance and protect the ACA’s goals of widening access to health care and coverage, eliminating barriers, and reducing health dis- parities (HHS Office for Civil Rights, 2016). By creating new obligations for covered health care providers and payors to ensure that people have equitable access to health care ser- vices and do not face discrimination, Section 1557 extends the protections of civil rights laws to the U.S. health care system (Seng, Jakubowski, & Compton-Brown, 2016). In relevant part, Section 1557 provides that an individual shall not . . . be excluded from participa- tion in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving Federal financial assis- tance, or under any program or activity that is adminis- tered by an Executive Agency or any entity established under Title I of the Act or its amendments. (Nondiscrimination in Health Programs and Activities, Final Rule, 2016) In simpler terms, under Section 1557, most health pro- grams and activities, including most medically necessary ABA, are prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability (HHS Office for Civil Rights, 2016). Although Section 1557 has always existed as part of the ACA law that was passed in 2010, implementing regulations were not finalized until 2016, extending the principle of non- discrimination to health care and health insurance. In May 2016, HHS issued a rule describing precisely what cov- ered providers must do in order to comply with Section 1557 (Seng et al., 2016). These regulations, t i tled “Nondiscrimination in Health Programs and Activities, Final Rule” and found at 42 CFR Part 92, became effective on July 18, 2016, and offer guidance as to which populations are protected under Section 1557, which health care providers are required to comply and how they may do so, and the various remedies individuals may seek if they experience dis- crimination from covered entities. Understanding Section 1557 and Its Relevance to ABA The first step to understanding the impact of Section 1557 of the ACA is to understand which ABA providers are covered under its command. Section 1557 applies to all health pro- grams and activities that receive federal financial assistance from HHS and that are administered by HHS or by entities created under Title I of the ACA (HHS Office for Civil Rights, 2016; Nondiscrimination in Health Programs and Activities, Final Rule, 2016). Essentially, ABA providers who participate to any extent in federally funded programs (e.g., TRICARE, Medicaid, managed care organizations administering Medicaid benefits, most commercial plans, etc.) are subject to Section 1557 and are required to comply with its nondis- criminatory mandate. Although the autism community recognized early on that Section 1557’s nondiscrimination provisions have great po- tential to eliminate age discrimination in the funding of ABA-based treatment, resources to increase awareness of pro- vider responsibilities under Section 1557 have not been wide- ly disseminated in the field of ABA (Lello, 2015). Compliance with Section 1557 requires thoughtful planning, development of new policies and procedures, employee edu- cation and training, and implementation of an ongoing com- pliance program. Additionally, the costs associated with com- pliance with Section 1557 should be contemplated when ABA providers contract with payors to provide services. As the population seeking ABA grows, ABA providers should be conscious of the linguistic diversity that exists within the pa- tient base they serve and of any duties they may have to improve the accessibility of their services to LEP families, whom the law incorporates and protects under the category of national origin. Compliance The Section 1557 provision outlines clear guidance and spe- cific steps to help covered providers deliver health care to the populations they serve in a way that is equitable and nondis- criminatory. Under Section 1557, a covered provider may not “segregate, delay or deny services or benefits based on an http:parities(HHSOfficeforCivilRights,2016).By 882 Behav Analysis Practice (2019) 12:879–886 individual’s race, color or national origin, or delay or deny effective language assistance services to individuals with lim- ited English proficiency (LEP)” (HHS Office for Civil Rights, 2016; Nondiscrimination in Health Programs and Activities, Final Rule, 2016). Covered providers, including ABA pro- viders, have a duty to take reasonable steps to provide “mean- ingful access” to care and coverage for each individual with LEP who is eligible to be served or likely to be encountered in their health programs and activities (Nondiscrimination in Health Programs and Activities, Final Rule, 2016). Examples of reasonable steps include the provision of lan- guage assistance services, such as oral-language assistance or written translations (HHS Office for Civil Rights, 2016). Given the importance of complying with Section 1557, both to serve the diverse population that comprises those seeking ABA therapy and to avoid trig- gering the legal ramifications of violating this nondis- crimination provision, it is critical for covered ABA providers to understand the steps that must be taken to comply with the law. To meet the language access re- quirements to communicate with families who are LEP, covered entities must: & provide oral interpretation and written translation services at no cost to the individual and in a timely manner (Nondiscrimination in Health Programs and Activities, Final Rule, 2016; Schuh, 2017); & adhere to certain quality standards in delivering language assistance services—for instance, a covered entity may not require an individual to provide his or her own inter- preter; rely on a minor child to interpret, except in a life- threatening emergency where there is no qualified inter- preter immediately available; rely on interpreters that the individual prefers when there are competency, confidenti- ality, or other concerns; rely on unqualified bilingual or multilingual staff; or use low-quality video remote interpreting services (HHS Office for Civil Rights, 2016; Nondiscrimination in Health Programs and Activities, Final Rule, 2016; Schuh, 2017); & post notices of nondiscrimination in offices, on websites, and in any significant publications and communications (Center for Medicare and Medicaid Services, 2016; Nondiscrimination in Health Programs and Activities, Final Rule, 2016); and & post translated taglines (short statements in non-English languages spoken in the state in which the entity is located or conducts business) in significant publications and post in prominent locations and on its website, indicating the availability of language support services (Center for Medicare and Medicaid Services, 2016; HHS Office for Civil Rights, 2016; Nondiscrimination in Health Programs and Activities, Final Rule, 2016; Schuh, 2017). Additionally, covered providers who have 15 employees or more must: & appoint or hire a Section 1557 compliance coordinator to carry out the provider’s compliance efforts and responsi- bilities, including the investigation of any grievance com- municated to it alleging noncompliance with Section 1557 (Nondiscrimination in Health Programs and Activities, Final Rule, 2016); and & adopt grievance procedures that provide for the prompt and equitable resolution of grievances alleging violations of Section 1557 (Nondiscrimination in Health Programs and Activities, Final Rule, 2016). Sample notices, taglines, and other materials drafted by the HHS Office of Civil Rights (OCR) are included in the appen- dices following the regulations 42 CFR Part 92. If ever a question is raised about a covered provider’s com- pliance with Section 1557, many factors are taken into con- sideration to determine whether the provider has met its obli- gations, such as the “nature and importance of the health pro- gram or activity and the particular communication at issue to the individual with [LEP],” whether the provider has “devel- oped and implemented an effective written language access plan that is appropriate to its particular circumstances,” and whether the provider has demonstrated an effort to meet its obligations to take reasonable steps to provide meaningful access to LEP families (Nondiscrimination in Health Programs and Activities, Final Rule, 2016). With this in mind, ABA providers should evaluate their compliance with Section 1557 and make adjustments as necessary. Consequence of Noncompliance Covered ABA providers should be aware of the consequences of noncompliance with Section 1557. Section 1557 explicitly establishes a cause of action (i.e., right to sue) against health care entities, including ABA providers, who discriminate against patients on the basis of race, color, national origin, sex, age, or disability (Rosenbaum, 2016). If an individual ex- periences discrimination in accessing health care services by a health care provider or insurer covered by Section 1557, the law affords him or her several remedies, including (a) pursuing a civil suit against the covered provider, (b) reporting instances of discrimination by a covered provider to the OCR for investiga- tion, (c) having the OCR revise the policies and procedures of the covered provider, (d) requiring the covered provider to pay compensatory damages to the individual who experienced dis- crimination, (e) suspending or terminating federal financial as- sistance allotted to providers who refuse to take corrective ac- tion, and/or (f) referring the covered provider to the U.S. Department of Justice for further enforcement action (HHS 883 Behav Analysis Practice (2019) 12:879–886 Office for Civil Rights, 2016; Nondiscrimination in Health Programs and Activities, Final Rule, 2016). Costs Associated with Section 1557 In addition to administrative costs, the primary cost arising from the effort to ensure equal access to ABA for LEP families is the cost of the interpreter, but whether the provider or payor is responsible for that cost can depend on a number of vari- ables, including the state where the services are delivered, the funding source, and the inclination of the payor to incentivize providers to make their services accessible to the payor’s LEP population (Jacobs, Shepard, Suaya, & Stone, 2004; Nondiscrimination in Health Plans and Activities, Final Rule, 2016). Both the behavior analyst and the payor have a duty to ensure that patients can access treatment regardless of their primary language. In many instances, payors will provide access to an interpreter service when the health care provider requests it. Prior to identifying a patient’s funding source, however, behavior analysts should be prepared to communi- cate with prospective LEP patients. Therefore, employees who initially communicate with pro- spective patients or their families should be trained and equipped to communicate with and collect information from English-proficient and nonproficient patients alike at the ABA provider’s expense. Once a patient’s funding source is identi- fied, the cost of the interpreter may shift to the payor. Importantly, though, the failure of a payor to provide an inter- preter does not relieve the behavior analyst of the duty to ensure equal access to ABA by LEP patients and their families. HHS makes clear that its preference is for the cost of the interpreter to be borne by the payors but stops well short of imposing any sort of requirement on the payors to bear that cost. In the Final Rule implementing Section 1557, HHS reminds payors that the ACA requires qualified health plans to incentivize providers for “the implementation of activities to reduce health and health care disparities, including through the use of language services” (Nondiscrimination in Health Programs and Activities, Final Rule, 2016). HHS goes on to encourage payors to “con- sider health care providers’ expenses in providing language as- sistance services” when structuring reimbursement rates. State Medicaid agencies have the option of securing matching federal funds for the cost of the interpreter, but the National Health Law Program (NHeLP) reports that only 14 states and the District of Columbia appear to have taken advan- tage of this resource, including Connecticut, Iowa, Idaho, Kansas, Maine, Minnesota, Montana, New Hampshire, New York, Texas (sign language interpreters only), Utah, Vermont, Washington, and Wyoming (Youdelman, 2017). Additionally, Arizona Medicaid explicitly requires the managed care organi- zations administering its Medicaid benefit to pay for the inter- preter (Arizona Health Care Cost Containment System [AHCCCS], 2017). Anecdotally, providers report state Medicaid agencies, in addition to those identified by NHeLP, as providing access to interpreter services funded by the state or managed care organization contracting with the state to deliver the Medicaid benefit, including California, Colorado, Louisiana, Michigan, Minnesota, Oregon, and Washington. Behavior analysts who contract with payors as in-network providers should address Section 1557 requirements in the contracting process to ensure that reimbursement rates reflect the projected cost of providing services to the payor’s benefi- ciaries in compliance with Section 1557. Although all patients who require an interpreter must have access to an interpreter when contacting their payor, the process to sustain that access continues to evolve as health care providers seek guidance from the payors and become more familiar with their respon- sibilities under Section 1557. Considerations Section 1557 is replete with positive implications for ensuring equitable access to ABA across diverse populations. Compliance with Section 1557 requires providers to take spe- cific steps (see Appendix Table 1). Even so, as the field of behavior analysis endeavors to comply with Section 1557, existing and new processes and procedures should be evalu- ated to ensure that best practices are not diluted. Length of Visit with Interpreter Involvement Several studies evaluate the increased duration of clinic visits associated with the use of an interpreter and report minimal to no increase in visit length (Fagan, Diaz, Reinert, Sciamanna, & Fagan, 2003; Jacobs, Ryan, Henrichs, & Weiss, 2018). Behavior analysts who use interpreters for assessment, parent/caregiver training, or one-to-one ABA may be in a position to collect and disseminate data specific to the use of interpreters in the delivery of ABA to help the field identify whether the use of an interpreter significantly extends the duration of a service. To ensure that LEP patients have access to the same intensity of treatment as their English-proficient counterparts, ABA providers may want to seek additional hours or flexibility from payors to avoid inadequate treatment authorizations. Additionally, the need for interpreters may be minimized if ABA providers undertake intentional efforts to hire and train individuals who reflect the cultural and linguis- tic diversity of the community in which they practice. Separate Billing Codes and Modifiers If the payor has agreed to pay for the interpreter, ABA pro- viders should be cognizant of billing codes and modifiers associated with the interpreter activity to ensure proper claims http:service.To 884 Behav Analysis Practice (2019) 12:879–886 submissions and timely reimbursement. If the cost of the in- terpreter is borne by the provider, providers may want to ask their accountants to check for tax subsidies and/or tax credits that may be available for such expenditures. Medically Unlikely Edits Medically Unlikely Edits (MUEs), developed by CMS for most billing codes to reduce the number of erroneously paid claims, set the likely number of units for each billing code in a day (Center for Medicare and Medicaid Services, 2018). An MUE is the maximum number of units that a provider is likely to report for one patient in one day. Interpreter services should not be counted toward the MUEs for the billable service that requires the interpreter. If payors do not offer a separate billing code or modifier for the interpreter service, ABA providers should be alert to the possibility of rejected claims that require an appeal and the delay associated with such a process. MUEs should not be used to limit medically necessary treatment, regardless of the language status of the patient. Rate Negotiations Rate negotiations should be undertaken only with a full un- derstanding of whether the payor or provider is financially responsible for the interpreter and translation of medical re- cords and forms, where necessary. Staff training, interpreter, translator, and development of materials represent some of the costs that should be contemplated when negotiating rates. If the cost of the interpreter is not explicitly denoted in the con- tract, seek clarification and update the contract to reflect any clarification provided. Absent sufficient rates or clarification, providers should be wary of contracts that do not allow them to make informed decisions that ensure the sustainability of their ABA practice. Conclusion The realm of health care is an area where lack of diversity is particularly visible, often because the serious consequences that arise from inadequate access to quality health care ser- vices have measurable deleterious effects for years to come. As ABA providers increasingly comply with the requirements of Section 1557, access to ABA is likely to become more equitable and more likely to reflect the diversity of the … Behav Analysis Practice (2016) 9:84–94 DOI 10.1007/s40617-016-0111-6 DISCUSSION AND REVIEW PAPER Developing the Cultural Awareness Skills of Behavior Analysts Elizabeth Hughes Fong1 & Robyn M. Catagnus2 & Matthew T. Brodhead3 & Shawn Quigley4 & Sean Field5 Published online: 4 February 2016 # Association for Behavior Analysis International 2016 Abstract All individuals are a part of at least one culture. These cultural contingencies shape behavior, behavior that may or may not be acceptable or familiar to behavior analysts from another culture. To better serve individuals, assessments and interventions should be selected with a consideration of cultural factors, including cultural preferences and norms. The purpose of this paper is to provide suggestions to serve as a starting point for developing behavior analysts’ cultural awareness skills. We present strategies for understanding be- havior analysts’ personal cultural values and contingencies and those of their clients, integrating cultural awareness practices into service delivery, supervision, and professional development, and becoming culturally aware in everyday practice. Keywords Culture . Cultural awareness . Applied behavior analysis . Diversity Skinner (1953) defined culture as variables Barranged by other people^ (p. 419). That is, humans control contingencies of Elizabeth Hughes Fong, Robyn M. Catagnus, and Matthew T. Brodhead shared first author * Robyn M. Catagnus [email protected] 1 Arcadia University, Glenside, PA, USA 2 The Chicago School of Professional Psychology, Chicago, IL, USA 3 Purdue University, West Lafayette, IN, USA 4 The University of New Mexico Medical Group, Albuquerque, NM, USA 5 Western Michigan University, Kalamazoo, MI, USA reinforcement and punishment that affect the behavior and learned reinforcers and punishers of a person or a group of people. Culture may be further defined as Bthe extent to which a group of individuals engage in overt and verbal behavior reflecting shared behavioral learning histories, serving to dif- ferentiate the group from other groups, and predicting how individuals within the group act in specific setting conditions^ (Sugai et al. 2012, p. 200). Distinguishable stimuli and re- sponse classes that occur in cultures include race, socioeco- nomic class, age, religion, sexual orientation, ethnicity, dis- ability, nationality, and geographic context (Sugai et al. 2012). An individual’s unique set of distinguishable stimuli and response classes are collectively referred to as an individ- ual’s cultural identity. One benefit of determining cultural identity is it can allow behavior analysts to develop an aware- ness of a client’s personal cultural values, preferences (i.e., learned reinforcers), characteristics, and circumstances (contingencies at the third level of selection; Skinner 1981). There are possible benefits for society, too, such as to better guide assessment and intervention practices. By acknowledg- ing the importance of culture, behavior analysts can help achieve socially meaningful goals such as reducing disparities in access to services and improving the quality of services for diverse populations in behavioral health systems (U.S. Department of Health and Human Services 2001). Culturally aware behavior analysts should understand their own cultural values, preferences, characteristics, and circumstances and seek to learn about those of their clients. That is, behavior analysts should be aware about their own personal biases and how they compare to and may affect their relationship with their client. This awareness of both self and clients may be important because, as Spring (2007) suggests, evidence-based services require a combination of clinical ex- pertise and knowledge of the client’s preferences and learning histories. Behaviorally, cultural awareness may be defined as http://crossmark.crossref.org/dialog/?doi=10.1007/s40617-016-0111-6&domain=pdf mailto:[email protected] http:skills.We 85 Behav Analysis Practice (2016) 9:84–94 the discriminated operant of tacting contingencies of rein- forcement and punishment administered by a group of indi- viduals. In other words, a behavior analyst who is culturally aware is able to identify the reinforcement and punishment contingencies that have been established by themselves, their colleagues, their family, and any other social group they may belong to or identify with. Behavior analysts’ ability to tact contingencies for self and others may facilitate development of a behavior change program that is informed by their clients’ specific cultural contingencies. Further, cultural awareness may be important because be- havioral patterns that are viewed as problematic in our own culture may be the norm in other cultures (Goldiamond 2002; Vandenberghe 2008). Consider the following example of a child who was referred for a functional assessment for Bwithdrawn^ behavior. The behavior analyst and a special education observed the student became Bwithdrawn^ after re- ceiving verbal praise. In fact, the student ultimately stopped engaging in any appropriate behavior which lead to the verbal praise. While collaborating with the family to gather data dur- ing the functional assessment, they determined that the stu- dent’s Bwithdrawn^ behavior occurred because of child’s lack of comfort with receiving individual attention. In the child’s culture, the whole (i.e., community) comes before the individ- ual. However, neither the behavior analyst nor the special education teacher questioned their personal assumption that the behavior is inappropriate for the classroom or their prefer- ences about how children should act after receiving praise. Because the student’s withdrawn behavior is maintained by a lack of attention, the behavior analyst and special education teacher suggest administering praise privately. In this case, their lack of understanding about how the cultural contingen- cies support the client’s Binappropriate behavior^ may have resulted in a treatment recommendation that was incongruent with cultural values. However, a culturally aware intervention, which seeks understanding of client values, characteristics, preferences, and circumstances would honor the client’s cul- ture and allow the client to successful in a given environment. A thorough behavior analytic intervention may be effective with individuals across various cultures (Kauffman et al. 2008; Tanaka-Matsumi et al. 1996). However, skilled, thorough, and well-trained behavior analysts may not always consider client culture. When assessing an individual’s or a group’s behavior, behavior analysts often collect data about motivating opera- tions, antecedents, behaviors, and consequences. However, common functional assessment data collection strategies and interview forms may not thoroughly explore cultural prefer- ences and norms. Behavior analysts may consider the intersec- tion of a cultural and linguistic context with the terms, concepts, and science of behavior analysis (Jones and Hoerger 2009). It is possible that, without information about cultural preferences and norms, behavior analysts may unintentionally provide less than optimal service delivery. Consider an example of a behavior analyst who provided in-home and community services to the family of a child with severe autism. The family, to whom church is very important, attended a weekly three hour church service. The behavior analyst, who did not attend church and was not a religious person, failed to inquire in detail about the family’s and child’s experience at church. Eventually, the family specifically asked the behavior analyst to teach the child the necessary skills to participate in the church service. However, the behavior ana- lyst still did not assign a high priority to teaching the child the skills needed for successful church attendance. The behavior analyst’s choices demonstrated a lack of understanding of the client’s values, characteristics, preferences, and circum- stances. In contrast, a culturally aware behavior analyst may be aware that Bthe selection of target behaviors is an expres- sion of values^ (Kauffman et al. 2008, p. 254) and that paren- tal expectations of children are likely controlled by cultural contingencies (Akcinar and Baydar 2014). In addition to the previous two examples, being culturally aware may also increase the probability that behavior analysts will engage in behaviors that are socially acceptable to people from diverse cultural backgrounds. These behaviors include selecting culturally appropriate treatments (see Rispoli et al. 2011), recognizing that Bparenting styles that are culture spe- cific could lead to distinct behavioral consequences for a child^ (Akcinar and Baydar 2014, p. 119), and implementing culturally appropriate language acquisition programs (see Brodhead et al. 2014). Cultural awareness could also ensure that behavior analysts treat service delivery as Balways a two- way street^ (Bolling 2002), meaning that the relationship be- tween the behavior analyst and the stakeholders should in- clude input about what cultural contingencies and values may contribute to an effective relationship and intervention. Finally, increasing cultural awareness may also decrease the probability of behavior analysts expecting the clients they serve to conform to their own cultural and scientific values and contingencies. The science of applied behavior analysis (ABA) is a unique cultural system (see Glenn 1993). Given that the science of ABA inherently embodies a certain set of values such as a Westernized model of science and health care, the cultural values and contingencies of ABA may not always align with those of the client. As Bolling (2002) noted, It is difficult for people in the US cultural mainstream, including researchers, to believe that there are any assump- tions other than their own about how the world works, what a ‘person’ is, how we function, how time works, what feelings are, how to use language, what the goal of life is, how people interrelate, [and] how and where it is appro- priate to show feelings or to seek help. (p. 22) Awareness of cultural differences and similarities may al- low for programmatic modifications that result in more 86 Behav Analysis Practice (2016) 9:84–94 culturally appropriate models of behavior analytic service delivery. In summary, there may be many important reasons for be- havior analysts to develop cultural awareness skills. Although there is a growing interest in conceptual (e.g., Brodhead et al. 2014; Fong and Tanaka 2013) and applied strategies for administering behavioral interventions for cli- ents from diverse cultural backgrounds (e.g., Padilla Dalamau et al. 2011; Rispoli et al. 2011; Washio and Houmanfar 2007), there is little guidance concerning how practicing behavior analysts can become culturally aware or further develop that awareness. Therefore, guidance on how to become culturally aware may be an important resource for behavior analysts. The purpose of this paper is to offer suggestions that can serve as a starting point for how behavior analysts may further increase their cultural awareness. We believe that cultural awareness, as described herein, reflect Baer et al. (1968) state- ment that the Bbehavior, stimuli and/or organism under study are chosen because of their importance to man and society^ (p. 92). Individuals participating in behavior change programs and those who provide significant support for them should determine what is important to them, to their society, and to their culture. In this paper, we discuss strategies for under- standing a client’s cultural values and contingencies, as well as those of the behavior analyst. Then, we describe strategies for embedding cultural awareness practices into behavior an- alytic service delivery, supervision, and professional develop- ment. Finally, we conclude with additional discussion and considerations for becoming culturally aware in everyday practice. Strategies for Developing Cultural Awareness The following two sections describe how behavior analysts can become more aware of personal cultural values and con- tingencies and how they can develop skills to learn about their clients’ cultural identities. We will refer to cultural values and contingencies as the cultural system, except where values or contingencies play an independent role in our analysis of de- veloping cultural awareness. We will refer to cultural identity as characteristics that extend beyond individual differences to those traits that members of a given culture share with one another (Adler 1998). For example, an individual from Africa may express their cultural identity through their belief struc- ture, attire, foods eaten, or hair style. Even though this indi- vidual might identify as African, there are subcultures to which they might further identify with. Our suggestions are meant to serve as a starting point for furthering a behavior analytic understanding of cultural awareness and how that awareness can be integrated and improved upon in everyday practice. It is recommended that behavior analysts concurrently engage in cultural awareness practices concerning their own behavior as well as those of their clients. It is important to be aware of one’s own biases or preconceived notions as a behavior analyst, as well acknowl- edging limitations in one’s cultural knowledge. Lastly, our suggestions are not intended to result in a rigid set of rules or practices. Rather, our hope is the suggestions will lead to broad practices that develop and continually refine cultural awareness, which will hopefully allow behavior analysts to be more open and flexible to the various cultures that will be experienced. Openness and flexibility in the presence of var- ious cultures will hopefully result in better outcomes for those we serve. Developing Cultural Awareness of Self From a behavior analytic perspective, self-awareness can be defined as verbal discrimination of our own behavior (Barnes- Holmes et al. 2001). Sugai et al. (2012) describe culture as common behaviors related by comparable learning histories, social and environmental contingencies, contexts and stimuli, so self-awareness might also include verbal discrimination of these aspects of personal experience. An understanding of our own cultural system may be an important first step toward correcting biases that affect our interactions with others (Lillis and Hayes 2007). The American Psychological Association’s (APA) (2003) multicultural guidelines encour- age clinicians to Brecognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are eth- nically and racially different from themselves^ (p. 382). Developing self-awareness may prevent our biases from im- peding how we serve culturally diverse clients. One strategy to enhance cultural self-awareness is talking about our diverse client interactions with a professional com- munity in group discussions, written forums, journals, men- torship meetings, verbal feedback sessions, or self-reflective exercises (Tervalon and Murray-Garcia 1998). Skinner (1974) emphasized the relationship between self-awareness and con- trol over our own behavior,and proposed that talking about our behavior is how we achieve self-awareness. Recent be- havior analytic research indicates that when individuals ver- bally describe their own behavior, the behavior may change (Tourinho 2006). Discussion with mentors and colleagues may help behavior analysts learn about themselves and also change their cross-cultural interactions for the better. Another suggestion is to be Bmindful^ by attending fully and alertly, in the moment, to client interactions and our own private events, without judging or evaluating the events as they occur (Bishop et al. 2004; Hayes and Plumb 2007; Vandenberghe 2008). We recommend practitioners hone their ability to attend closely to clients and self, in context, for two reasons related to self-awareness. First, such attention may http:awareness.We 87 Behav Analysis Practice (2016) 9:84–94 help enhance skills of self-observation and self-description regarding our overt and covert behavior. Also, while we can remain committed to overtly behaving in ways consistent with values of multiculturalism, even in the presence of values and contingencies that create bias, mindfulness may reduce the biases that produce thoughts, feelings, and reactions to cultur- ally diverse people (Lillis and Hayes 2007). Attending closely to our clients and being active and alert is good practice for building rapport, too. Clinicians can engage in more culturally aware practice by assessing, collecting data, and testing hypotheses rather than accepting their own experiences and biases as the norm (Sue 1998). Scientific mindedness is a characteristic of clinicians and human service providers who develop theories about cli- ent behaviors by analyzing data rather than by dependence on their personal assumptions (Sue 1998), and may reduce bias and foster better understanding of client behavior. A reliance on scientific, behavior analytic knowledge when working with clients is also required by the Professional and Ethical Compliance Code for Behavior Analysts (BACB 2015). While mindful attention focuses on the interaction between the behavior analyst and the client/family, scientific minded- ness is a focus on interpreting information from the client and family; both characteristics facilitate culturally aware practice. For example, a behavior analyst consults to a family of a child with a sleep disorder, and learns that the mother sleeps in her five-year-old child’s bed while the father sleeps in a larger room, alone. The practitioner may notice, and be able to co- vertly tact, that this is not the norm of the cultural majority nor congruent with his personal experience or values. The analyst may assume that the mother should not sleep in the child’s bed or notice thoughts of judgment he feels. Lillis and Hayes (2007) recommend practitioners accept that such reactions may be normal, given our cultural systems and the human tendency to evaluate, but remain committed to acting positive- ly based on our values. Through a process of assessment and covert verbal behavior, the practitioner might accept the co- sleeping arrangement to be culturally appropriate for and pre- ferred by the family, and choose to develop an intervention that keeps the arrangement in place. A blend of both self- awareness and reliance on scientific knowledge is likely to produce the most culturally aware assessment and intervention. Finally, there are several self-assessment tools that behav- ior analysts can use to become more aware of their own cul- tural identity. We recommend the use of assessment tools for measuring and reflecting on the clinician’s own cultural biases, values, and understanding. One assessment tool, the BDiversity Self-Assessment,^ that can be utilized during the intake process allows team members to examine their under- standing of diversity (Montgomery 2001); this tool asks users to reflect on their own assumptions and biases by answering 11 questions. Another assessment tool that may be useful is the self-test questionnaire entitled BHow Do You Relate to Various Groups of People in Society?^ (Randall-David 1989). This questionnaire asks respondents how they might respond to individuals of various cultural backgrounds—by greeting, by accepting, by obtaining help from, by having background knowledge about, and/or by advocating for the individuals. The 30 types of individuals in these questions are then organized into five categories: ethnic/racial, social issues/ problems, religious, physically/mentally handicapped, and political, and a concentration of checks within a specific cat- egory of individuals or at specific levels of response may then indicate a conflict that could prevent the respondent from pro- viding effective treatment. Behavior analysts can then consid- er how their biases might affect treatment and may consider other courses of action, such as making referrals to other be- havior analysts. A final potentially useful measure is the Multicultural Sensitivity Scale (Jibaja et al. 2000), a 21-item self-assessment tool developed as a valid and reliable way to measure multicultural sensitivity. This tool was originally used to assess the multicultural sensitivity of teachers and was later adapted to be used by physician assistant students (Jibaja-Rusth et al. 1994). Altogether, the behavior analyst may find these assessments helpful in further developing their own cultural awareness in order to further develop culturally competent methods of service delivery. Developing Cultural Awareness of Clients The above section describes strategies for how a behavior analyst may learn about his or her own cultural system. Below, we describe how behavior analysts may learn more about their client’s cultural system through assessment prac- tices. Culturally aware assessment practices may allow behav- ior analysts to obtain important cultural information about clients in order to understand their worldviews. Culturally aware assessment may also allow behavior analysts to identify any potential cultural barriers such as modalities of commu- nication and expression of emotions (see Garcia et al. 2003). To increase the probability that assessment will identify cultural variables, Vandenberghe (2008) recommends focus- ing on functional relations and behavioral principles rather than topography. For example, Filipino families often live with extended family members, and the household situation can seem chaotic by Western living standards. If a child has difficulty sleeping, a behavior analyst may advise the parents that they should separate the sleeping room from the living room. People of Filipino descent may be shy about responding to someone in a position of authority, so they may say Byes^ to the behavior analyst. However, during the following session, it might be revealed that the parents did not change anything and that the child is still sleep deprived. In this case, a natural reaction may be to become frustrated with the lack of parental follow through. However, lack of follow through may also be http:turalidentity.We 88 Behav Analysis Practice (2016) 9:84–94 interpreted as an indicator that the intervention recommenda- tion may not have been culturally appropriate. Vandenberghe’s (2008) description of functional analytic psychotherapy may also be a useful resource for determining how to provide culturally aware behavior analytic practices. Vandenberghe (2008) emphasizes the need for a behavior ana- lyst to be aware of differences that may exist, including cultural differences, between the behavior analyst, client, and their fam- ilies. Specifically, behavior analysts should be knowledgeable about the client’s culture, differentiate between an unfamiliar cultural norm and a pathology, and take culture into consideration during the therapeutic process. Finally, Hymes (1962) noted that communicative competence is related to an individual’s awareness of the laws of language structure and language use within a given culture. Therefore, behavior ana- lysts should be skilled in sending and receiving cultural com- munications. Specific recommendations are described below. Recommendations Consider the Language of Assessment Our first recommen- dation, which applies to all phases of assessment and treat- ment, is that behavior analysts should reflect on the spoken and written language he or she uses and how it will be per- ceived by the client. We recommend behavior analysts avoid the use of behavior analytic jargon, as it may confuse clients and their families, and possibly lead to their failure to imple- ment interventions. This recommendation is consistent with the Professional and Ethical Compliance Code for Behavior Analysts (2015). For example when the phrase Bfunctional analysis^ is used, Japanese families assume that it is mathe- matical jargon rather than a reference to a behavior analytic assessment process. Avoidance of excessive or complex be- havior analytic jargon may eliminate such problems. It is important throughout assessment and treatment to communicate in a manner easily understood, culturally aware, and does not include terms that are culturally inappropriate or confusing (Rolider and Axelrod 2005). Furthermore, it may be important to consider who will be completing service related forms (e.g., intake paperwork) and whether the level of liter- acy and comprehension of the language used in the forms are similar. If a person lacks adequate language comprehension, completing paperwork may be difficult, embarrassing, or in- timidating. In such a case, behavior analysts may consider giving the person the opportunity to complete the forms orally or have another person help with the form completion. They may also consider using an interpreter or providing forms in the person’s native language. Additionally, we agree with Vandenberghe’s (2008) recommendation that the language used to define problem behaviors should be carefully exam- ined to ensure the behaviors are communicated in a positive manner using multiple forms of communication that are sen- sitive to potential cultural differences in eye contact, wait time, meanings of words, non-vocal body language, personal space, and quality of voice. Understand Cultural Identity Our second recommendation is to consider that the client, and the client’s family and com- munity, are important sources for acquiring an understanding the cultural identity of the individual. Therefore, we recom- mend conducting an analysis of cultural identity with stake- holders immediately after service initiation with the client and/ or family. The cultural identity analysis should inform the assessment process and the designing of interventions. During intake, the behavior analyst may, with proper consent, gather input from key community members familiar with the client, in addition to those whose feedback is typically sought (e.g., teachers, professionals, administrators, and family). Additionally, the behavior analyst should seek recommenda- tions from the family regarding additional parties (e.g., other community members) who should be involved. Family and community members may be able to provide the most valu- able information regarding the client’s culture, language, and sociocultural framework (Salend and Taylor 2002). These dis- cussions will allow members of the team to acquire a mutual understanding of the client’s cultural system, which may result in increased cultural awareness. It is important to highlight that the client/family’s language is an important cultural variable that should be understood in addition to collaboration with stakeholders. For example, be- havioral patterns may be similar across cultures, while the language and concepts that are used can differ (Vandenberghe 2008). In Japan, parents and teachers may use the word Bpanic^ to describe a child’s behavior, and this may imply a Btantrum^ or Bmeltdown.^ Because the word Btantrum^ is often associated with baby colic behavior, par- ents and teachers may prefer to use Bpanic^ to describe the aggressive behavior of older children. Without knowing this, a behavior analyst may initially misunderstand what the client’s challenging behavior is. It is therefore important for behavior analysts to clarify what the client or family actually mean by the terms they use. The behavior analyst should also consider accounting for what treatments are appropriate, preferable, or considered norms within a culture. As illustrated by the example of the Filipino family at the beginning of this section, identifying cultural norms may be important for successful assessment and effective treatment. Information about what is acceptable within a person’s culture is also ideally obtained beginning with the intake process (and later during the assessment pro- cess) by including stakeholders in the process and ensuring that background information includes input from multiple sources of information (assessments and interviews; Sugai et al. 2012). For example, the grandparents rather than the parents may be the primary caregivers in an Indian family. Therefore, it would be important to include the grandparents http:ceivedbytheclient.We 89 Behav Analysis Practice (2016) 9:84–94 during intake in order to obtain information. During later phases of the intervention, it may also be beneficial to contin- ue to involve the family in development of the data collection and to make changes in the intervention based on the family’s interactional style. In designing the intervention, the team will then be able to include culturally appropriate reinforcers and skill building, again taking into account strategies that are appropriate to the client’s culture and belief system. It may also be important to …