Behavior Analysis for the Behavior Analyst in Training

Maybe you have noticed that there has been a decrease in frequency of posts during the past month. This is due in part to a shift in attention to studying for my upcoming Board Certified Behavior Analyst (BCBA) examination.  I love posting rambling essays on whatever topic on my interest of the day, but I had this reality check regarding the upcoming exam; only 46% of those who sit for the exam get a passing score.  Yowzers.  Less than half.  I am a reasonably confident person, and I have a good track record in regards to test-taking, but less than half?!? 

After a sufficient period of worry and anxiety (about two days) I decided that this information was good news.  Fewer people receiving the BCBA credential means that my future credential will be more valuable.  A high pass rate would mean that my certification would be meaningless, the money I’ve spent would be wasted, job opportunities would be scarce, and the title would have no prestige or recognition.  Of course this view is anchored in the belief that I will pass this exam.  Maybe not on the first try, or the second, but I will pass this exam. 

How am I going to make sure that this happens? I am going to use the principles of behavior analysis to help me become a behavior analyst.  Although it is a minor area in the overall discipline of Applied Behavior Analysis (ABA), Self-Management is a fascinating topic.  Most of ABA is concerned with how behavior is modified through the manipulation of socially mediated or automatic (aka sensory) antecedents and consequences.  Typically, the behavior of students or individuals with disabilities is modified by teachers or therapists, but that is just a reflection of how ABA is currently being utilized.  The principles of Behaviorism apply not only to all people, but to all organisms.  The current boom underway in the field is due to the increased prevalence of autism and the well-documented effectiveness of ABA in educating these students, but ABA was developed to apply to anyone.  Even myself. 

Self-Management is defined as “the personal application of behavior change tactics that produces a desired change in behavior.” A typically dry and broad textbook definition, but for me it was a real wake-up call.  I don’t have to wait to apply all of the techniques and principles I have learned – I can use them on myself!  What better way to improve my study habits than to use what I am studying to get myself to study more often and more efficiently!

Easier said than done, but the last month has been very successful. (I’m going to throw some ABA terms around just to make myself feel like I know what I’m talking about – I have to get some use out of these hours of studying!)  After conducting an informal “stimulus preference assessment” on myself, I found that checking things off a list is very reinforcing.  To utilize this as reinforcement, I made a daily star chart similar to what you would see in a classroom, in which I give myself a star for 12 daily tasks that I need to accomplish, several of which involve studying different ABA material.  I have arranged “antecedent stimuli” in places around the apartment to make it easier to engage in the behavior and have eliminated “discriminative stimuli” for interfering behaviors, such as Facebook or listening to my iPod.

Those terms are fun to use, but most of what I did was common sense.  I wrote down my goals, kept track of completion, put my stuff out in the open so I would remember to study, and made sure there weren't any distractions.  Most people successfully implement behavioral self-management techniques every day.  Most people could also benefit from improved self-management (myself included).  Think about someone who overeats.  The person knows that overeating causes them to be obese, and they really don’t want to be obese.  Barring some medical issue, all they would have to do is eat less and exercise more and they would lose weight.  This is the case for millions of people, so what stops people from doing what they know they need to do to reach their goals?  The problem lies in the contingencies of behavior.  The desired behavior – eating a light meal – produces no immediate reinforcement, but the problem behavior – overeating on rich foods – produces immediate and powerful reinforcement.  Each individual act of overeating does not cause one to be overweight, and one single instance of healthy eating does not cause one to reach a desired weight.  Behavior Analysis has proven in countless studies that it is the more immediate of contingencies that influences behavior patterns.  The same principle applies to smoking.  Everyone knows that smoking causes cancer and emphysema, but that consequence is in the distant future and smoking a cigarette produces very powerful and immediate reinforcement.   

How can Self-Management help people to achieve desired behavior change?  By “designing and implementing contrived consequences to compete with the ineffective natural consequences”.  Not smoking a cigarette is extremely important in achieving the goal of improved health, but it does not provide any natural immediate consequences, especially not compared with smoking a cigarette.  In a self-management program, you would develop a contrived consequence for not smoking a cigarette.  For example, for every hour you go without a cigarette, you give yourself ten minutes of your favorite activity.  Conversely, you can arrange for a punitive consequence for smoking, such as paying a dollar into a jar for each cigarette smoked.  The success of self-management relies on the individual honestly implementing the consequences, but the individual can also put someone else in charge of distributing reinforcement and punishment, such as a spouse or roommate. 

In my case, studying for the BCBA exam provides no immediate reinforcement, despite the fact that it has an important long-term benefit.  I had to create a short-term contingency that would make reinforce daily studying.  Luckily, I am very compulsive and can’t go to bed without getting every checkmark, so a simple list works for me.    To ensure that I exercise daily, I reward myself with an extra-large lunch.  I don’t exercise; I don’t get as much to eat.  I exercise to improve my overall health and to keep my weight down, but those consequences are too long-term and vague to be effective in reinforcing a daily routine. 

Since Applied Behavior Analysis is filling my mind these days, it may be what fills the next few blog posts.  I did not intend for this post to be so lengthy, but I have enjoyed rambling on this topic.  Hopefully I have struck the right balance between being technically accurate and using common-place language to describe the topic.  If you have any behavioral question for me – please ask!  I am anxious to use this knowledge on something other than flashcards! 

The Very Good "The Good Earth"

The classics of the literary canon (ie. Those books that everyone is “supposed” to read, typically given out as required reading assignments in intro English classes) do not typically hold my interest.  In my experience, if a book was written over fifty years ago, despite all of its laudable literary merit, I find myself bored and can finish it only with a grim sense of responsibility.  There have been a few exceptions, and The Good Earth is definitely one of them.

During one of my outings with Abel, we visited a used bookstore/café with a good selection of English titles.  I managed to inhale my fish tacos (not surprisingly, they were disappointing, but I just had to try fish tacos in Taiwan!) before Abel started to get a bit fussy.  That gave me about two minutes to choose a book from the stacks, so when I grabbed The Good Earth, it ticked all the right boxes – about China, written in English, and very cheap.

Once I had some time to inspect it, I was disillusioned that it was written in the 1930’s. I also gathered that it was about pre-revolutionary China written by the daughter of a missionary. Yawn.  I immediately assumed the language would be out of date, the content would be irrelevant and the characters would be stodgy. 

Wow, was I wrong. 

I was glued to the book for a solid week.  The first three days I whizzed through chapters, picking it up every spare minute I could find.  The next three days went by without reading a word because I wanted to save the last chapter and savor the unfinished story.  When I finally indulged in the last chapter, I was glad that I had waited;  it was the perfect ending to a brilliantly crafted narrative.

It is a classic story of survival, love, and struggle.  The writing style is extremely straightforward, just as the characters are very direct in their intentions and aspirations.  This does not mean it is boring, but rather that the beauty of the novel is not found it literary flourishes or fancy devices of the language. The book’s beauty is found in the simple story and believable characters.  While the book does contain a lot of interesting insights into the life of a peasant in rural China, the story and characters are timeless and universally understandable.   Everyone can learn something about themselves and the meaning of life from this humble book.

I actually think I’m pretty good at judging a book by its cover, or at least judging whether or not I will like a book based on its cover, but reading The Good Earth was an important reminder that some old worn paperbacks in their twentieth printing may have a lot of relevance to modern life. I’m back into more contemporary literature for now (reading “Speed of Dark” by Elizabeth Moon), but I’m going to fit in more classics to my reading list from now on.

Delinquent Dad or Astute Risk Manager?

I have only been in Taiwan for about three months and I am already taking the city for granted.  

Abel and I were both very wound up last night, not at all ready for bed despite the late hour, so I decided we should go for a walk.  I strapped him into the carrier and headed out the door to Da’an Park, Taiwan’s version of Central Park.  Da’an is large, wooded, and right in middle of the city.  The park is only about a block away from our apartment, but luckily there is a 7-11 on the way, so I stopped and bought a refreshing adult beverage (Busch – which I don’t like in the US, but find myself liking while in Taipei).  Abel and I strolled around the darkened park as he drifted off to sleep and I relaxed in the cool autumn air.  As I walked, I realized what I was doing.  I was in middle of a major city, at night, in a dark park, drinking alcohol, with a baby strapped to my chest.  Am I completely irresponsible or is Taipei just that safe?

I may not be a perfect Dad, but I’m pretty sure the answer to the previous question is that Taipei is just that safe.  There is virtually no random street crime.  Muggings, shootings, kidnapping – these are all incredibly rare for a city as large as Taipei. I have been searching for some statistics to back me up on this claim, which is taken as common knowledge among expats, but have found very little.  This could be due to my rusty research skills, but it is also partly due to the fact that the only clearinghouse of international crime data is the United Nations. Since Taiwan is not recognized by the UN, it is not included in its reports.   Since I have no quantitative data to share, here are some more anecdotal reports of crime rates in Taiwan:

• You could walk around dropping money and someone would collect it all and politely hand it back. Taipei is one of the safest cities in the world.
• It is also one of the safest cities in world,and locals are friendly and helpful to foreigners. All in all, Taipei is a city where travelers will not feel stranded.
• Taipei is a very safe city. Violent crime is nearly non-existent,
• CRIME: Although the overall violent crime rate in Taiwan is low, you should avoid high crime areas, namely areas where massage parlors, barbershops, and nightclubs operate as covers for prostitution and are often run by criminals. 
• Few report being victims of crime, which is a common complaint and concern for tourists worldwide.
• A summary of the above reports – stay away from prostitution rings and you will have to try really hard to be victimized in Taipei. 

As for the open container I enjoyed while walking in the park – individual beers are sold in every corner store 24 hours a day in Taipei and open containers are not banned in public.  I did not believe this initially because I have still NEVER witnessed a Taiwanese person drinking while in a public space.  I assumed that since no one does it, it must be illegal, but social conformity is so strong here that no law is needed to regulate when and where you can drink.  If there were no regulations in the US on drinking in public parks or on the street, you would see drunks stumbling all over the place.  In fact, you do often see drunks stumbling around with beers in the few places where you can have open containers.  Public drunkenness is very uncommon in Taipei – so far I’ve seen a handful of red-faced old guys who are really smiley after hitting the sauce in restaurants.  More restrictive alcohol laws are simply not needed here because binge drinking and the associated vices are just not common.  A very foreign concept for this reformed frat boy from the Midwest.

My confidence that I was not an anti-social risk-taking delinquent dad was strengthened during my walk when I came across two young women in their twenties pushing strollers with sleeping babies.  If it is safe for them to wander around the park at night, who is going to mess with a bearded guy drinking a big American beer?

Feeling Shaky

Disaster preparedness is one of those items that usually resides somewhere at the bottom of my to-do list.  Feeling our apartment building sway back and forth last night bumped the “figure out what to do in an earthquake” task to the top of my list. 

Not to worry, the earthquake we experienced was minor and as far as I know did not disrupt life in any way here in Taipei.  The physical sensation was much different than I expected, probably due to watching too many Hollywood style earthquakes in movies.  I felt instantly dizzy and almost drunk because of the building subtly swaying back and forth.  It wasn't a shake or even a quake as I had expected.  This may be because we are on the 5^th floor – I’m not sure how it felt on the ground. 

 The quake registered a 4.7 on the Richter scale, which would make headlines back home in Missouri, but hardly made the news here in Taiwan. In 1999, there was a massive quake in central Taiwan that killed thousands and injured tens of thousands.  Over 50,000 buildings were completely destroyed, causing USD$10 billion in damage.  It was the worst earthquake in 100 years and exposed the country’s lack of preparedness.  Since that terrible quake, known as the “921 Earthquake”, construction and emergency preparedness have greatly improved.

Damage after the 921 earthquake

  Since we are now living on the “Pacific Ring of Fire”, we should probably figure out what the heck to do with ourselves if we experience a major quake while we are here.  Luckily, there is an emergency shelter underneath the large park that is very near to our apartment.  Other than that, we’ll make sure to have extra food and water in case of water lines being broken and electricity outage that will make food purchases difficult.  Should keep a helmet on Abel’s head 24/7 just in case? Probably not, but hopefully I won’t be caught as off guard next time the building sways.

Betel Nut Buzz

I love new cultural experiences.  The excitement of trying anything for the first time gives me a thrill, so I was very excited to try Betel Nut since it packs a very tangible high aside from the novelty of the experience.   \

First and foremost – Betel Nut is not only completely legal in Taiwan, but chewing it is an extremely common practice here that dates back hundreds if not thousands of years.  All over Taiwan there are little booths lit up with neon lights that sell bags of betel nut to taxi drivers, truckers, and anyone else looking for a little pick-me-up. Apparently these booths are often staffed by scantily clad women in other parts of Taiwan, but this practice has been banned inside Taipei. Every betel nut vendor I have seen is staffed by a grumpy older man who is, thankfully, not wearing reveling clothes.

The betel nut buzz is nothing like that of alcohol or marijuana – it is much more akin to a strong cup of coffee.  Chewing a little right now, I can attest that the effects come on much quicker than caffeine, but are more short-lived.  How does it taste?  Somewhere between god-awful and just plain terrible.  It is extremely bitter - an acquired taste to say the least.  Since I have a fondness for most bitter flavors, I don’t find it as offensive as most first-time users probably do.  Even though I don’t mind the bitterness, I have gum ready to chew after I spit out the remainder of the pulp. 

The downside to chewing betel nut is that it has been identified as a carcinogenic.  This applies mostly to processed betel nut, not the natural preparation that you can find here in Taiwan.  However, the World Health Organization does officially classify it as a cancer risk factor for habitual users.  I figure that chewing a few times a month this year can’t be too deadly since I see plenty of cab drivers in their 60’s chewing it almost constantly. 

Although I don’t think occasional use will do me in, this is one part of Taiwan’s culture that I won’t be bringing back with me to the US.  I’ll stick to my coffee and tea.

Couldn't Have Said it Better Myself

I love it when I come across writing that makes me scream, “that is exactly what I’m trying to say!”  It is satisfying to read my thoughts in concise and articulate language, but it also makes me strive to improve my writing to such a level.  This is an introduction to a paper titled, “Diverse Contexts of Human Infancy” by Barry Hewlett which summarizes the ideas I was struggling to convey in the previous two “Going with your Gut” posts.

American parents are unique cross-culturally in that they usually do not know very much about infancy until they have their own baby. In many parts of the world, individuals grow up with infants around them because of high fertility or living with an extended family. Children in many parts of the world are expected to assist their mothers or female relatives with infant care, so by the time they become parents they are aware of basic needs of infants and know how to respond appropriately to them. American mothers and fathers, on the other hand, seldom, if ever, have had the opportunity to care for a baby until they have their own. First-time parents are often overwhelmed because babies take an enormous amount of knowledge and time. How many hours should an infant sleep, when is a good time to introduce solid foods, and should parents sleep with their infants are common questions. Since first-time American parents do not have this knowledge and do not live with someone who has the information, they often turn to “experts” for guidance. A handful of infant books and regular visits to the pediatrician are common.

One limitation to expert advice is that it is provided in the context of American culture. The expert usually does not have the time to read about infancy in other parts of the world, but gives the impression that the advice is based upon studies of infants around the world. This is seldom the case and can lead to inaccurate views of the abilities or development of human infants.

This chapter examines American and Western European biases in descriptions and characterizations of infants by examining infancy cross-culturally and placing infant care-giving practices in their cultural contexts. This approach to human infancy provides a broader understanding of human infancy. Understanding the diversity of cultural contexts of infancy can possibly develop a greater tolerance and respect for variability in baby care beliefs and practices, as well as identify options that might be available for enhancing infant development.

Here is a link to the full paper.

I have also come across another source of parenting information, “Parenting Science”, which is in sync with my own concepts of how to approach raising children in our culture.  The author, Gwen Dewar, is an anthropologist, but not one who recommends that we return to the lifestyle of hunters and gatherers.  She takes a more empirical approach to controversial parenting issues that is based on scientific studies, but where those studies are vague or absent she looks to case-studies from traditional cultures that shed light on humans natural development grounded in our evolutionary past. It is interested reading – give it a look!  

The Greatest Wealth is Health

I never thought that I would spend so much time worrying about health insurance, doctor visit copays, and dental coverage – a sure sign of getting older.  Now that Jess and I have a little guy to watch out for, quality healthcare is extremely important to us.  In fact, affordable access to healthcare is one of the reasons why I am writing this blog post from Taiwan.  If we were to “downshift” in the US by having one of us stay home with Abel and the other teach full time, the working spouse would have to pay $650 per month to cover the health insurance premiums for the family.  As a public school teacher, that is a huge expense which makes it nearly impossible to spend a year at home with a baby.  Luckily, Taiwan has a much more efficient and affordable healthcare system that even welcomes foreigners!

We had an up close and personal experience with healthcare in Taiwan just the other day when we took Abel in for his four month immunizations.  We have spent countless hours researching online, emailing with family doctors, and we even met with a travel health doctor while in Austin.  We were very nervous about the whole process, but we were happy to learn that our worries were unfounded.  I won’t say it was a pleasant experience, I doubt giving shots to a baby can ever be anything but miserable, but I did marvel at the efficiency of the clinic and its staff. 

The contrast between pleasantness and efficiency pretty well sums up one of the most interesting aspects of healthcare in Taiwan – not terribly pleasant, but extremely efficient.  The unpleasantness does not come from substandard care or unfriendly staff, but from is a byproduct of the system which does not sacrifice one iota of efficiency for the sake of privacy.  My other experience with the Taiwanese healthcare system was when I had to get a “health check” at the city hospital so that I could apply for the resident certificate.  During this check, I had blood drawn at a counter with 20 people lined up behind me, changed into a hospital robe and waited in line for my number to be called, and had a chest extra in front of 20 other strangers after they announced my name over the intercom.  No HIPA (Health Information Privacy Act) here in Taiwan.  My chart containing test results and other sensitive information was passed around to volunteers and left on counters.  Of course I had nothing to hide, but it is very different than the extreme privacy afforded at US hospitals.

Privacy may not be paramount in Taiwan, but equitable access to quality healthcare certainly is a top priority.  Every citizen, and even alien residents like us, is provided with free health coverage. The system is similar to Medicare, but expanded to the entire population.  Working folks pay a tax similar to Medicare tax that is a percentage of income, and there are small copays for visits, usually just a few dollars.  The poor, elderly, and veterans are all covered for free.

What makes this equitable access to care possible?  Efficiency.  Taiwan does more with less by cutting administrative costs and streamlining care delivery with the single payer system.  Also, record keeping and billing are extremely streamlined due to the health care card that is embedded with a smart chip that contains a summary of health information and records.  These streamlined measures help to make the Taiwanese system one of the most affordable and efficient in the world. While the US spends 15% of its GDP on health care, Taiwan spends only 6%.  That means that the average amount spent per person per year in the US on healthcare is $7000, but only $2000 in Taiwan.  That is an enormous difference considering that there is very little difference in quality.  

The amazing part is that people access healthcare services more often in Taiwan than in the US.  “Health seeking behaviors” are very high in Taiwan and people go to clinics, Chinese medical offices, acupuncturists, and massage therapists for even minor ailments.  And it is all covered! It seems to me that if you make healthcare affordable, then people will seek medical help for minor ailments before they become more severe, which will save everyone a lot of money in the long run.  Financial barriers to healthcare cause people in the US to put off going to the doctor, which leads to more chronic illnesses and acute conditions that require expensive and invasive procedures after they become more serious, which is part of the reason why the US has the highest per capital healthcare costs in the world. 

If the whole purpose of healthcare is to help us live longer healthier lives, then Taiwan is getting a lot of bang for their buck – the average Taiwanese lives over a year longer than the average American. We spend over three times as much and don’t live as long.  The Taiwanese studied our Medicare system to find inspiration for their healthcare system, now maybe it is time that we study Taiwan’s National Health Insurance system to find ways to improve the health of our country.