A Family-Centered Care Approach to Behavior-Analytic Assessment and Intervention.

A Family-Centered Care Approach to Behavior-Analytic Assessment and Intervention - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Behav Anal Pract . 2022 Nov 18;19(1):126–142. doi: 10.1007/s40617-022-00756-y Search in PMC Search in PubMed View in NLM Catalog Add to search A Family-Centered Care Approach to Behavior-Analytic Assessment and Intervention Katherine R Brown Katherine R Brown 1 Sorenson Center for Clinical Excellence, Utah State University, 6405 Old Main Hill, Logan, UT 84321 USA Find articles by Katherine R Brown 1, ✉ , Alyssa M Hurd Alyssa M Hurd 1 Sorenson Center for Clinical Excellence, Utah State University, 6405 Old Main Hill, Logan, UT 84321 USA Find articles by Alyssa M Hurd 1 , Kayla R Randall Kayla R Randall 2 Georgia Southern University, Statesboro, GA USA Find articles by Kayla R Randall 2 , Thomas Szabo Thomas Szabo 3 Touro University, Henderson, NV USA Find articles by Thomas Szabo 3 , Daniel R Mitteer Daniel R Mitteer 4 Severe Behavior Program, Children’s Specialized Hospital–Rutgers University Center for Autism Research, Education, and Services (CSH–RUCARES), New Brunswick, NJ USA 5 Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NY USA Find articles by Daniel R Mitteer 4, 5 Author information Article notes Copyright and License information 1 Sorenson Center for Clinical Excellence, Utah State University, 6405 Old Main Hill, Logan, UT 84321 USA 2 Georgia Southern University, Statesboro, GA USA 3 Touro University, Henderson, NV USA 4 Severe Behavior Program, Children’s Specialized Hospital–Rutgers University Center for Autism Research, Education, and Services (CSH–RUCARES), New Brunswick, NJ USA 5 Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NY USA ✉ Corresponding author. Accepted 2022 Oct 28; Collection date 2026 Mar. © Association for Behavior Analysis International 2022. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. PMC Copyright notice PMCID: PMC13083665  PMID: 42005053 Abstract An essential aspect of behavior-analytic services is collaborating with stakeholders to develop interventions that incorporate stakeholder preferences, needs, and contextual variables in addition to those of the client. Recent research has illuminated a gap in practitioners’ use of compassionate care to develop interventions that take into account family values and dynamics. Family-centered care is an approach that emphasizes the client as part of a larger family system and is used in a variety of medical and mental health services to promote family–provider collaboration and improve care. Given the importance of collaboration, shared decision making, and consideration of contextual variables when implementing behavior-analytic services, we introduce an adaptation of the family-centered care approach for behavior analysis. We provide practical resources for behavior analysts to assess and address family contextual variables, tools for promoting collaboration throughout service delivery, and a framework for navigating misalignment among client, family, and practitioner preference. Keywords: Family-centered care, Compassionate care, Collaboration, Caregivers Behavior analysts often collaborate with stakeholders, such as a client’s legal guardians and other caretakers (e.g., teachers) during assessment and intervention. Developing an intervention involves a unique process by which practitioners must use their technical skills to assess and select an intervention while simultaneously considering how these assessments and interventions are an appropriate fit for the preferences, needs, and context of the client and stakeholders (ethics standard 2.14; Behavior Analyst Certification Board [BACB], 2020 ). Although much of the BACB’s ( 2017 ) task list and related coursework focuses on teaching aspiring behavior analysts how to assess and treat target behavior precisely using behavioral principles and concepts, one task-list item, H-3, describes the softer side of client care: behavior analysts should recommend intervention goals based on factors like client or caregiver preference, supporting environments, constraints, and social validity (BACB, 2017 ). To accomplish this task, behavior analysts must be skilled at applying techniques of compassionate care, such as perspective-taking, listening, and collaborating (Taylor et al., 2019 ). Despite the importance of applying techniques of compassionate care, there is a known gap in meeting this standard in the provision of behavior-analytic services. For example, Beaulieu et al. ( 2019 ) surveyed caregivers and found only a small percentage reported intervention goals generated by the behavior analyst consistently aligned with their family values (see also Lambert et al., 2022 ). Likewise, Taylor et al. ( 2019 ) found approximately half of caregivers reported their behavior analyst did not consider family dynamics during services. Applying techniques of compassionate care is even more important given that caregivers demonstrate clear preferences for working with individuals who engage in these techniques (Callahan & Foxx, 2020 ; Callahan et al., 2019 ; Chadwell et al., 2019 ), even to the extent of selecting less empirically supported interventions in favor of therapists who use these techniques (Chadwell et al., 2019 ). Not only is integration of client and caregiver input a responsible thing to do in practice and part of the BACB’s Ethics Code ( 2020 ), but failure to consider this input may result in poor caregiver adherence, meaning the caregiver fails to implement the practitioner’s prescribed intervention consistently or precisely (Allen & Warzak, 2000 ). Adherence to prescribed interventions is critical to maintain intervention gains outside of the intervention setting and may be high stakes in some cases, such as for individuals who engage in severe problem behavior (e.g., aggression, self-injurious behavior, elopement). For example, adult deviations in delivering reinforcement or implementing extinction—common components of interventions for problem behavior—can produce significant relapse of the problem behavior or disruption of a newly learned adaptive behavior (Brown et al., 2020a ; Fisher et al., 2018 ; Mitteer et al., 2021 ; St. Peter Pipkin et al., 2010 ). Though variables related to caregiver intervention adherence are multifaceted (Allen & Warzak, 2000 ), engaging in strategies that promote effective, collaborative partnerships with caregivers is predictive of adherence (Moore & Amado, 2021 ; Moore & Symons, 2011 ; Taylor et al., 2019 ) and can increase family satisfaction and involvement (Beach et al., 2006 ; Horst et al., 2000 ). One strategy used in other disciplines to promote collaboration and improve outcomes is the family-centered care (FCC) approach (Allen & Petr, 1996 ; Horst et al., 2000 ; Prelock et al., 1999 ). The core of FCC is ensuring intervention is planned around the whole family, not just the individual client (Shields et al., 2006 ). For example, FCC key principles include exchanging complete and unbiased information, collaborating with the family at all levels of care, and honoring the diversity of families (Shelton & Stepanek, 1994 ). This approach improves interpersonal relationships between the provider and family (Beach et al., 2006 ; Beatson, 2008 ; Schneider et al., 2004 ), which has led several major organizations, such as the American Academy of Pediatrics, to adopt and promote this model of care. Although this model has primarily been used in medical settings, it can be applied across populations, ages, and settings (Kokorelias et al., 2019 ) and has been shown to improve outcomes for individuals with disabilities and their families (Dempsey & Keen, 2008 ). Despite the benefits of engaging in FCC practices, the relevance of this approach has remained largely undiscussed in behavior-analytic circles. The absence of FCC models in behavior analysis is not surprising, given our origins. From inception, behavior analysis has been characterized by an assumption that problems of social significance are best solved by technical experts trained in the management of human behavior. This technocratic orientation is observable in Skinner’s work and reflects the scientism of his era. Thus, it is unsurprising that behavior analysis adopted a scientist-as-expert framework from which to operate. However, as the majority of behavior analysts have moved out of the lab working with animals and into clinical spaces working with humans, the lack of training for behavior analysts on how to engage in therapeutic soft skills, compassionate care, and incorporation of contextual variables (e.g., family, community) has become apparent. Although there is a growing number of behavior-analytic articles that discuss compassionate care and soft skills as they relate to the development and maintenance of therapeutic relationships (LeBlanc et al., 2020 ; Rohrer et al., 2021 ; Taylor et al., 2019 ), no studies have discussed the importance of FCC and how to adapt this approach into behavior-analytic practice and settings. This gap is apparent by the growing body of literature illuminating the lack of and need for formal training for practitioners to engage in FCC practices (e.g., LeBlanc et al., 2020 ; Rohrer et al., 2021 ; Taylor et al., 2019 ). These practices include: (1) effective information-sharing; (2) respecting and honoring client and family differences; (3) collaboration; (4) negotiation; and (5) care in context (Knafl et al., 1992 ; Kuo et al., 2012 ; Shelton & Stepanek, 1994 ). Thus, the focus of this article is to fill the gap on how behavior analysts can implement FCC approaches in their practice. In the following sections, we will discuss each principle of the FCC approach and how it relates to behavior-analytic assessment and intervention. We will discuss practical ways to enhance collaboration using an FCC approach, provide tangible resources to improve stakeholder and client involvement and acceptability at multiple levels of care, provide resources and tools for self-evaluation, as well as equip readers with a framework for navigating when there is disagreement between collaborators (e.g., practitioner and stakeholder, client and stakeholder). Principle 1: Acknowledge the Child in the Context of the Family The first principle of FCC requires practitioners acknowledge that although the client’s needs and preferences are the foundation of any intervention, the client is just one part of the family unit. As such, behavior-analytic services provided to the client must address the therapy goal while incorporating the value and context of the family who are pivotal in caring for the client. This includes viewing the client in the context of the family, valuing stakeholder input throughout the therapeutic process, and providing equal 1 decision-making power to stakeholders. This approach moves from providing families with information about a selected intervention and recruiting feedback, to actively involving the client and family in the decision-making process about assessment and intervention procedures (Shelton & Stepanek, 1994 ). Part of our ethical responsibility as practitioners is to incorporate client and stakeholder preference and important contextual information when designing, selecting, and implementing interventions (ethics standard 2.14; BACB, 2020 ). Client choice is a hallmark feature of behavior analysis (Bannerman et al., 1990 ) and is common in some aspects of services (e.g., preference assessments; Fisher et al., 1992 ). In addition, social validity measures to ascertain consumer preference and acceptability of procedures are common (Ferguson et al., 2019 ). Although important, these measures are not adequate to capture the complete contextual framework as it pertains to the family. In behavior analysis, contextual variables have been described as setting events. These setting events include motivation and deprivation (Bijou, 1996 ; Michael, 1982 ; Skinner, 1957 ), physiological parameters of the individual (Gewirtz, 1972 ; Skinner, 1931 ), and historical variables (e.g., conditioned stimulus control, rule-governed behavior; Morris, 1988 ; Sidman, 1986 ). The commonality in these definitions is that contextual variables outside the three-term contingency affect the effect of stimuli and consequences on behavior (Nicolson, 1998 ). In clinical settings, contextual variables can include family dynamics (e.g., a sibling with a disability, single parent), parenting practices and values, and contextual information (e.g., stressors, strains, deficiency of resources; Fixsen et al., 2005 ; McIntosh et al., 2015 ; Patterson, 1988 ). These contextual variables are critical given that the success of any prescribed intervention hinges on its alignment with the values, goals, contextual needs, and preferences of the implementer (Fixsen et al., 2005 ; Kelleher et al., 2008 ; Moore & Amado, 2021 ). For example, Gilroy and Kaplan ( 2020 ) found caregivers were more likely to select a less effective intervention if it directly aligned with their preferences. Their results highlight how contextual information (e.g., number of children in the home, level of problem behavior) correlates with caregiver preference. Despite the importance of considering contextual variables, practitioners often do not make intervention recommendations that account for family dynamics and values (Taylor et al., 2019 ), and few published studies have reported modifying interventions to account for these contextual variables (see Brown et al. 2020b ; Doyle et al., 2013 , for some exceptions). To give an example of a contextual variable that remains absent in behavior-analytic literature, consider parenting practices. One reason for this is perhaps this contextual variable is difficult to conceptualize or translate into practice. However, if we view “parenting practices” as observable behaviors that parents engage in with their children and the parent’s self-identification as a group member for that set of parenting behaviors (Darling & Steinberg, 2017 ; Kuppens & Ceulemans, 2019 ; Mak et al., 2020 ), this contextual variable allows us to glean important information about parents who prescribe to a set pattern of behaviors. For example, a parent who identifies with an attachment parenting philosophy (Sears & Sears, 2001 ) will likely find extinction-based interventions unacceptable and be unwilling to adhere to these recommendations outside the clinic. Consideration of contextual variables is multifaceted and requires gathering information on family dynamics and values, stressors, resources, and supports. Although there are several high-quality discussion articles that provide conceptual frameworks on the importance of contextual variables (e.g., Allen & Warzak, 2000 ; Moore & Amado, 2021 ), there remains a gap in meaningful ways practitioners can carry out this important standard. To this end, Table 1 provides a list of assessments practitioners may consider incorporating into their practice to gather this information. This table includes resources to ascertain family dynamics and structure (e.g., family practices, values), stress and coping strategies, and resources and supports (e.g., community, financial). In subsequent sections, we will discuss how these contextual variables may be considered in the course of services. Table 1. Contextual-variable resources Resource Source Description Norms or Comparative Data Available Link to Assessment & Scoring Information Family Dynamics and Structure American Family Strengths Inventory DeFrain & Stinnett ( 2008 ) Strengths and areas for growth based on interpersonal relationships between family members None https://bit.ly/DeFrain The Family Time and Routine Index * McCubbin et al. (1986/ 1996c ) Type of activities and routines family practices and values CD https://bit.ly/McCubbin1986 Family Stress and Coping Family Inventory of Life Events and Changes * McCubbin et al. (1983/ 1996e ) Index of family stress N & CD https://bit.ly/McCubbin1983 Family Pressures Scale Ethnic McCubbin et al. (1993/ 1996f ) Adaptation of the Family Inventory of Life Events and Changes for families of color CD https://bit.ly/McCubbin1993 Coping Health Inventory for Parents * McCubbin, McCubbin et al. (1981/ 1996b ) Caregiver coping responses when managing a family with a child with serious or chronic illness CD; M & SD https://bit.ly/McCubbin1981b Parenting Stress Index Abidin, R. R. ( 2012 ) Evaluates stress in the parent–child system N https://www.parinc.com/products/pkey/333 Stress Index for Parents of Adolescents Sheras et al. ( 1998 ) Identifies stress in parent-adolescent interactions N https://www.parinc.com/Products/Pkey/412 Family Resources and Community Family Inventory of Resources for Management * McCubbin et al. (1981/ 1996a ) Assess family’s available social, community, psychological, and financial resources M & SD https://bit.ly/McCubbin1981a The Social Support Index * McCubbin et al. (1982/ 1996d ) Available community support for family CD https://bit.ly/McCubbin1982 Comprehensive Family Model Family Adjustment and Adaptation Response Model Patterson ( 1988 ) Model of family functioning based on resources and stressors N/A N/A Open in a new tab N = norms; CD = comparative data; M & SD = means and standard deviations * Assessment is available in multiple languages Principle 2: Facilitate Family–Professional Collaboration Equipped with information on important contextual variables, practitioners are better positioned to implement Principle 2 of FCC which is to facilitate family–professional collaboration. Several articles have discussed the importance of collaboration between practitioners and other professionals (Gasiewski et al., 2021 ; Kelly & Tincani, 2013 ; Newhouse-Oisten et al., 2017 ). However, there are fewer resources on how to facilitate collaboration between the practitioner and family (e.g., Moore & Amado, 2021 ; Rohrer et al., 2021 ). Thus, we aim to offer practical suggestions to facilitate family–professional collaboration and discuss how to manage the many different kinds of disagreements that can occur among behavior analysts, family members, and clients. To start a collaborative relationship with caregivers, practitioners should clarify roles, expectations, and rights during their first meeting. For example, practitioners should explicitly state their intention to be collaborative and share decision making with the client and/or stakeholder, inquire of the family’s history with collaboration and shared decision making with other service providers, and establish a clear plan to ensure collaboration throughout all levels of care (Moore & Amado, 2021 ). Part of this plan should entail regularly scheduled meetings with stakeholders throughout service provision for the explicitly stated purpose of engaging stakeholders in the decision-making process, recruiting information, and making decisions together. In addition, these meetings provide an opportunity for practitioners to regularly check with stakeholders and engage in important empathetic and compassionate behaviors, such as providing reassurance that things will improve and acknowledging stakeholder experiences and feelings (e.g., overwhelmed, stressed, hopeless; see Taylor et al., 2019 , for discussion). By engaging in this process, behavior analysts can start to address a known concern of poor therapeutic relationships (LeBlanc et al., 2020 ; Rohrer et al., 2021 ; Taylor et al., 2019 ) and positively influence intervention outcomes (e.g., Beach et al., 2006 ; Ciechanowski et al., 2001 ; Wilson & Brookfield, 2009 ). Second, collaboration in behavior analysis is frequently understood as social validity (Biggs & Hacker, 2021 ; Taylor & Taylor, 2022 ; Wolf, 1978 ), a technical skill for which all practitioners receive formal education (H-3; BACB, 2017 ). Social validity and collaboration often consist of informal measures such as questionnaires and rating scales (Carr et al., 1999 ; Ferguson et al., 2019 ; Kennedy, 1992 ) that can inform various stages of services, such as using the Reinforcer Assessment for Individuals with Severe Disabilities to identify items to include in a preference assessment (Fisher et al., 1996 ) or a Likert rating scale to ascertain acceptability of intervention procedures and outcomes (e.g., Rajaraman et al., 2021 ). It is interesting that although repeated continual measures have been recognized and adopted for other important measures in behavior analysis (e.g., reliability, procedural integrity; Belfiore et al., 2008 ; Kennedy, 2005 ), social validity measures have largely remained a stagnant, one-time administration (D’Agostino et al., 2019 ). This is problematic because single measures of social validity may not provide a comprehensive measure of acceptability (Finn & Sladeczek, 2001 ) and several variables can affect social validity throughout the therapy process (e.g., response effort of the intervention, competing contingencies for the stakeholder, exposure to implementing the intervention). To address these potential concerns, we encourage practitioners use several different measures of social validity, repeat these measures throughout the therapeutic relationship, and include indices of overall satisfaction with intervention progress and therapeutic relationships. In addition, as others have noted, collaboration is more comprehensive than measures of social validity and should include ongoing conversations with stakeholders to obtain qualitative information regarding the client’s intervention and service delivery. Conversations should encourage open communication such as identifying barriers to implementing the selected intervention, comfort level with intervention procedures, and any modifications to best suit the client and family (Rohrer et al., 2021 ). Finally, practitioners are known to miss opportunities to compromise during disagreements (Taylor et al., 2019 ). Perhaps this is a product of a lack of formal training and/or resources on how to respond in these crucial moments. Of course, there are limits to incorporating stakeholder preferences, such as including procedures that could result in undue harm to the client (ethics standard 2.15; BACB, 2020 ). But, outside of these extreme circumstances, behavior analysts should view disagreements as an opportunity to incorporate stakeholders and collaborate. Engaging in noncollaborative behaviors such as disputing feedback or debating the effectiveness of a procedure are unlikely to yield positive outcomes. In fact, studies have shown stakeholders do not place the same value on empirical support as practitioners (Chadwell et al., 2019 ; Gilroy & Feck, 2022 ; Gilroy & Picardo, 2022 ) so these strategies are likely to be more harmful to the therapeutic relationship than helpful. Rather, practitioners should focus the conversation on the shared goal of the practitioner and stakeholders, which is meeting the needs of the client. The behavior analyst should engage in a productive conversation with stakeholders, using compassionate care and soft skills to understand caregiver perspective, discuss potential solutions, share in decision making, and evaluate client outcomes and stakeholder satisfaction. Then, as the client makes progress towards the shared goal, the behavior analyst could provide education of evidence-based practices to the caregiver in a meaningful and compassionate manner. Another potential for disagreement is between client and stakeholder. For example, Owen et al. ( 2021 ) examined the efficacy and preference of three different interventions for escape-maintained problem behavior with three clients and their caregivers. The interventions were equally effective at decreasing problem behavior, but researchers found client and stakeholder preferences differed. Practitioners may struggle in these situations to carefully consider whose preference should be weighed most heavily and how to account for the preferences of all individuals. Although there are few instances of reported disagreement between client and stakeholder preference in the literature, this is likely a result of few studies collecting and reporting this information rather than a consistent finding of agreement between parties. As such, this conversation is germane to behavior analysts. Figure 1 provides a decision-making model for behavior analysts to use when client and stakeholder preferences do not align. This model emphasizes identifying effective intervention approaches, assessing client and stakeholder preference, identification of the variables contributing to unmatched preference, and modifying or changing procedures until the behavior analyst reaches alignment with client and stakeholder preferences (see Owen et al., 2021 , for an applied example of this model). Fig. 1. Open in a new tab Clinical Decision-Making Model for Matched and Unmatched Preferences Principle 3: Exchange Unbiased, Complete Information and Share Decision Making The third principle of FCC directly aligns with the ethical responsibility of behavior analysts to consider relevant factors such as risks, benefits, potential side effects, efficacy, and costs of various intervention approaches (ethics standard 2.14; BACB, 2020 ). Families need as much information as possible about their child’s prognosis, probable outcomes, and intervention options to allow them to share equal decision-making power with the practitioner. To accomplish this task, the practitioner needs to enhance transparency by clearly communicating the purpose, procedures, expectations, and rights of the client and caregiver at each level of service. To communicate clearly and effectively, practitioners should avoid technical language, which can impede collaboration and effective dialogue (Becirevic et al., 2016 ; Critchfield et al., 2017 ; Jarmolowicz et al., 2008 ). In addition, we encourage practitioners to adopt the use of analogies, visual representations, or demonstrations with real world exemplars to enhance communication. For example, Hanley ( 2012 ) used the analogy of an allergy test to explain that each test condition of a functional analysis is like an allergen poke to the skin with reactions indicative of which allergen is responsible for the patient’s allergies. Akin to this analogy, “reactions” during a functional analysis are indicative of the condition(s) responsible for maintaining the client’s problem behavior. Other therapy approaches, such as acceptance and commitment therapy (Hayes et al., 2012 ), have long recognized the benefits of using this type of metaphoric language to introduce new therapeutic principles to make abstract concepts more concrete through a story-like experience (Stoddard & Afari, 2014 ). With a toolbox of potential metaphors and nontechnical language to facilitate clear communication, practitioners should provide a comprehensive overview of potential assessment and/or intervention options to the family. A core principle of FCC is allowing equal decision-making power between the family and practitioner. To accomplish this requires behavior analysts use their technical skills to identify procedures that are conceptually consistent, evidence-based, and rely on reinforcement (ethics standard 2.14; BACB, 2020 ). Then, the behavior analyst can present these options in a manner that equips the family to share fully in the decision-making process (using the recommendation above). It may be the case that although a behavior analyst would select the most evidence-based or efficient approach, the caregiver would prefer an evidence-based intervention that is slightly less effective, or takes slightly longer to obtain desired effects based on important contextual variables. Thus, when possible, behavior analysts should present multiple assessment or intervention options in tandem with variables for caregivers to consider, such as effectiveness, pace of observing intervention effects, likelihood of evoking emotional responding (for the child or caregiver), and implementation response effort. To accomplish this aim, practitioners may consider using visuals that depict various procedures and relevant variables. Figure 2 shows a blank data sheet as an example of how this type of visual could be constructed. Figure 3 shows hypothetical use of this visual for increasing two common classes of behavior (cooperation and continence), both of which have several evidence-based interventions. For example, the top panel of Fig. 3 depicts three different interventions that can increase cooperation using nontechnical language, guided cooperation (differential reinforcement with extinction), wait them out (differential reinforcement with extinction), and free breaks (noncontingent reinforcement). The visual also displays how these interventions vary in terms of potential emotional responding for the client and caregiver, predicted effectiveness, and time to desired intervention effects. Using this type of visual, the behavior analyst can clearly communicate the various approaches, their strengths and weaknesses, and allow the family to share in the informed decision-making process. If visuals are an appropriate communication tool, the behavior analyst should adjust the visuals used to communicate based on the individual’s learning history, culture, and preference. If visuals are not an appropriate communication tool, the behavior analyst can consider other formats such as fact sheets that allow a side-by-side comparison of various approaches or brief videos that discuss and depict each approach. Finally, when possible, the behavior analyst may consider facilitating opportunities for family members to experience (i.e., role play with a therapist or their child) intervention arrangements prior to making decisions. Fig. 2. Open in a new tab Blank Example Visual. Note. A blank template of a visual tool practitioners can use to communicate important intervention information to caregivers Fig. 3. Open in a new tab Visuals for Compliance and Continence Interventions. Note. Examples of how a visual presentation of intervention variables for compliance (top panel) and continence (bottom panel) can be communicated to caregivers Principle 4: Honor the Diversity of Families Honoring the diversity of families has been described as cultural sensitivity, competency, responsiveness, and humility (Beaulieu & Jimenez-Gomez, 2022 ; Fong, 2020 ). Failure to honor the diversity of families can negatively affect assessment and intervention (Lang et al., 2011 ; Rispoli et al., 2011 ). Beaulieu and Jimenez-Gomez ( 2022 ) emphasize a critical starting point for behavior analysts to honor the diversity of families is self-assessment and ongoing training (see Beaulieu & Jimenez-Gomez, 2022 , for a list of self-assessment tools). Honoring the diversity of families in behavior-analytic services encapsulates many behaviors such as using appropriate communication, awareness, training, and incorporation of family input (Fong et al., 2016 ; Fong, 2020 ; Rohrer et al., 2021 ). Fortunately, there has been an increase in available resources for practitioners on how to accomplish this important task in the last 5 years (e.g., Beaulieu & Jimenez-Gomez, 2022 ; Weiss et al., 2020 ). We urge readers to use the available resources to engage in practices that honor the diversity of the families they serve, because this is paramount to an FCC approach. These available resources provide a pathway on how behavior analysts can engage in culturally aware practice. For example, the behavior analyst may engage in self-assessment to understand their own learning histories as it relates to interacting with others who are ethnically or racially different than themselves. Next, they may engage in practices that help them understand their client’s cultural system. Finally, they would consider how to incorporate practices in assessment and intervention that honor the family’s culture. Principle 5: Understand the Different Ways of Coping and Be Responsive Families who have children with complex needs, such as intellectual and developmental disabilities, often experience significant levels of stress (Kahng et al., 2002 ; Lloyd & Kennedy, 2014 ; Tutton et al., 1990 ). Using an FCC approach, behavior analysts should identify caregiver behaviors that may be functioning as coping strategies. Coping strategies are behaviors that provide escape from discomfort (Kahn et al., 1964 ) and vary in terms of the usefulness in reaching the client’s therapy goals. After this, the behavior analyst can help the caregiver to evaluate whether the coping strategy is helpful or not. For example, caregiver coping behavior can unwittingly worsen a clinical concern (e.g., reinforcing problem behavior; Mitteer et al., 2018 ; St. Peter Pipkin et al., 2010 ), create new undesired behaviors (e.g., learned helplessness; Bruzek et al., 2009 ), prevent the acquisition of prosocial behavior (e.g., continuous noncontingent access to a preferred item), or inadvertently cause harm to an individual (e.g., overuse of medication, physical abuse; Kempe et al., 1962 ; McGillivray & McCabe, 2005 ). Principle 5 of FCC requires behavior analysts view coping strategies as functional behavior in response to the environment. In doing so, practitioners can identify environmental events that may impede intervention progress or threaten maintenance of intervention effects and provide functional supports for the coping behavior. For example, imagine a single-parent who provides their child noncontingent access to electronics for several hours each day and rarely engages in direct interactions with their child who frequently engages in problematic behaviors to seek attention. The practitioner comes to learn the caregiver is overwhelmed and engages in this behavior to accomplish necessary household tasks and access self-care time. Viewing this coping strategy as a functional behavior, the behavior analyst could then engage in behaviors toward the caregiver that convey empathy and compassion while collaborating to find functional supports. For example, the behavior analyst may gently discuss age-appropriate recommendations for electronics and work with the caregiver to create a family media plan (Shifrin et al., 2015 ) to decrease electronic time and improve caregiver–child interactions. The behavior analyst can simultaneously help the caregiver access resources that provide a break from continuous caregiving responsibilities (e.g., respite-care services, connection to a family network for babysitters, recreational programs, childcare programs). Based on reported contextual variables and coping behavior, behavior analysts can identify areas in which the client and family would benefit from additional supports. An FCC approach to understand and address coping behavior should be nonjudgmental (i.e., views coping behavior as functional), consider contextual variables, and provide functional supports that are likely to create an environment that produces long-term sustained behavior change (Biglan, 1995 ). Supports can take the form of educational/informative, financial, environmental/material, and emotional (see Shelton & Stepanek, 1994 , for a comprehensive review of these supports). Table 2 provides resources behavior analysts can use to identify supports for a client and family. Table 2. Example of a national resources list for families Resource Description Link to Resource Relias Learning ABA tutorial videos to understand basic principles and work with children https://bit.ly/ReliasABA Autism Speaks Resource Guide Wide variety of resources for individuals with autism and their families https://bit.ly/AutismSpeaksRG Family Financial Education Foundation Financial skills training materials https://bit.ly/FFEFresources Office of Child Care Financial Assistance for Families Financial assistance programs for families by state of residency https://bit.ly/ChildCareFR Big Red Safety Box Toolkit to prevent and respond to elopement https://bit.ly/NAASafetyBox Danny’s Wish iPads for Autism Program Lottery program for children to receive an iPad for communication https://bit.ly/iPadsforAutism Step Up For Mental Health Support helpline to get connected to local mental health resources https://bit.ly/SUFMH Parent to Parent USA Parent support networking program to provide emotional support and connect to resources https://bit.ly/ParentToParent Open in a new tab Principle 6: Encourage and Support Family-to-Family Networking Families with children who have chronic medical conditions or disabilities often have higher levels of stress and feelings of isolation (Beckman, 1996 ; Beckman & Boyes, 1993 ; Lloyd & Kennedy, 2014 ). Family-to-family networking provides better support to families (e.g., sharing of local resources and programs, companionship) than formal support provided by service providers (Beckman et al., 1993 ; Dunst et al., 1988 ; White & Hastings, 2004 ). Given the value of family-to-family networking, we propose several strategies behavior analysts can use to engage in this principle. First, practitioners should compile and review a list of local resources for family networking and support. By engaging in this practice, behavior analysts can quickly help connect families with valuable resources available in their area, such as support groups, parent training programs, material resources (e.g., elopement prevention kits), and advocacy networks. There are also several national resources available to which providers can connect families (e.g., Autism Relias, 2022 ; Speaks, 2022 ). When possible, we encourage practitioners to collaborate with individuals who specialize in connecting families with local resources (e.g., resource coordinator) and guiding the family through complex processes (e.g., obtaining Supplemental Security Income benefits in the United States). Second, behavior analysts can support family-to-family networking by developing mentoring models or ambassador programs. These programs connect families of former and current clients to share stories and experiences, assist each other in navigating services, and provide encouragement (Shelton & Stepanek, 1994 ). Practitioners should consider all family members in their development of family-to-family networks, including siblings of clients. For example, there are several national resources designed specifically for siblings of individuals with developmental and/or intellectual disabilities that provide educational materials, workshops, trainings, and networking opportunities (e.g., Autism Speaks, 2022 ; Sibling Support Project, 2022 ). Finally, practitioners should be mindful in considering potential barriers to families accessing family-to-family supports such as lack of childcare, transportation, or meeting space. By facilitating solutions such as recruiting volunteers to provide childcare, arranging carpools or providing local resources for free- or reduced-cost transportation, arranging virtual family supports, and providing clinical space for meetings, families will be able to partake in these important supports. Principle 7: Develop Policies, Practices, and Systems Consistent with Family-Centered Care Families of children with disabilities experience higher stress levels than those without disabilities (Boyce et al., 1991 ), are more likely to belong to marginalized groups, and tend to live below the poverty threshold (Young & Crankshaw, 2021 ). However, a lack of coordination or comprehensive services can exacerbate this stress, as well as limited accessibility to services (Shelton & Stepanek, 1994 ). Unfortunately, these problems are all too common for families seeking behavior-analytic services, which can be costly (Lindgren et al., 2016 ; Sharpe & Baker, 2007 ) and require lengthy waits to access (Jones et al., 2017 ), all of which can further increase family stress levels (Rivard et al., 2014 ). To address this concern, FCC approaches focus on building policies and systems that are flexible, accessible, and comprehensive to meet the needs of all families (Shelton & Stepanek, 1994 ). In behavior-analytic settings, practitioners could consider meeting this need by increasing access to services within their organization. For example, a practitioner may find the population they serve often receives speech and language therapy and consider hiring a speech-language pathologist to serve clients within the organization. Multidisciplinary teams could be composed of psychologists, psychiatrists, speech and language pathologists, resource coordinators, and more. This type of multidisciplinary approach has been found to improve quality of care and increase access to resources (Hochstadt & Harwicke, 1985 ; Moran et al., 2007 ; Wertheimer et al., 2008 ). We recognize there are many barriers for behavior analysts to provide this type of comprehensive service. In these circumstances, behavior analysts can establish an infrastructure for connecting families to external resources using established referral networks and maintain collaborative efforts, a component often missing in behavior-analytic services (Taylor et al., 2019 ). Practitioners may also consider working with external resource coordinators and/or social workers who are knowledgeable on local and national resources for their service population. In addition, policies and systems of FCC should be comprehensive enough to support the ongoing, evolving needs of the client. Without ongoing supports, intervention progress can stall or regress (Starr et al., 2016 ; Vinen et al., 2022 ). For example, Starr et al. ( 2016 ) reviewed studies that followed children who received early intervention services and found that ongoing supports were necessary to maintain acquired skills. Likewise, problem behavior can reemerge following intensive behavior services and require additional support. For example, Brown et al. ( 2022 ) reviewed over 250 cases at a university-affiliated severe behavior program over a 10-year period and found that 40% of families either (1) reinitiated services with the organization; (2) sought services with another provider for behavior concerns; or (3) requested some form of additional behavior support (e.g., generalizing intervention into a school setting). These data reflect the importance of ongoing supports following intensive behavior-analytic services, a model that has long been adopted in other clinical services (e.g., eating disorders; Cockell et al., 2004 ; Treasure et al., 2005 ; substance abuse; Connors et al., 2013 ).We encourage practitioners to titrate services from the level needed to accomplish desired behavior change to a lower, ongoing level of service to maintain intervention effects and provide continued support to families. Practitioners may consider providing biweekly or monthly follow-up appointments to check for intervention maintenance and regularly contacting families via phone or email to discuss needs for additional support following discharge and reassess social validity as the intervention is implemented in a wider range of contexts and setting events. To help behavior analysts adopt an FCC approach, we encourage them to conduct a self-evaluation of their current perceptions and practices surrounding FCC. Likewise, for behavior analysts in leadership positions within their organizations, we encourage an organizational self-assessment to determine organizational policies and practices that may be targeted for improvement. Finally, for behavior analysts in teaching and training positions, we recommend the use of assessment tools to identify to what extent FCC approaches are reflected in training and education and identify any areas for improvement. Table 3 outlines several self-assessment resources practitioners and organizations may explore. Table 3. Resources to assess individual and systems-level FCC practices Resource Source Description Link Checklist for Collaboration Between Families and Professionals Shelton and Stepanek ( 1994 ) For practitioners to self-evaluate how their current practices reflect FCC - Checklist for Professional Training Programs Shelton and Stepanek ( 1994 ) For training programs to evaluate how their curriculum and practices promote FCC - A Checklist for Attitudes About Patients and Families as Advisors © Institute for Patient- & Family-Centered Care ( 2010a ); adapted from Jeppson and Thomas ( 1994 ) For practitioners to evaluate their attitude about client and family as part of the intervention team https://bit.ly/IPFCCAttitudes Organizational Self-Assessment Institute for Patient- and Family-Centered Care ( 2010b ) For organizations to evaluate current use of family-centered practices https://bit.ly/IPFCCOrganization Open in a new tab As a note, we recognize behavior analysts may be unfamiliar and/or lack formal training on various aspects of an FCC approach, such as the use of formal assessments to ascertain family values and skills to build relationships (LeBlanc et al., 2020 ). We strongly encourage behavior analysts to operate within their scope of practice (ethics standard 1.05; BACB, 2020 ), seek out continuing-education and formal-training opportunities, and connect with a mentor with the necessary training and expertise to support the use of an FCC approach when necessary. Principle 8: Incorporating Normalization Many of the principles listed above require additional empirical data to support their incorporation. Most of the extant literature cited in this article supporting these principles was produced in the last 25 years, and a majority of the works were published in the last 5 to 10 years. Although a few studies in the early years of behavior analysis focused on family members mediating intervention in their homes (e.g., Wahler, 1969a , 1969b ; Zeilberger et al., 1968 ), these efforts operated from an expert-based approach in that the interventions were developed by experts and parents were taught to mediate the intervention. This earlier era may not have placed large emphasis on collaboration between parents and practitioners, consideration of the client within the context of a family system, or the family in its unique, diverse cultural context. Rather, much of the research at that time was focused on establishing behavior analysis as a science-based clinical authority within congregate care institutional settings (e.g., Ayllon & Azrin, 1968 ; Hopkins, 1968 ; Leitenberg et al., 1968 ; Winkler, 1970 ). Although conceptual work on family-professional collaboration and FCC dates back to the late 1960s and early 1970s (Bank-Mikkelsen, 1969 ; Nirje, 1969 ; Wolfsenberger et al., 1972 ), the predominant model of disability during this time was the medical model. The medical model of disability attributes disability as inherent to the individual and ignores societal, cultural, and environmental variables that contribute to disability (Chown et al., 2017 ). As a result, interventions stemming from this model largely focus on obtaining individual outcomes that result in some approximation of normality. The medical model of disability has since been criticized for an overfocus on impairments that requires the expertise of health experts and an underemphasis on challenging perceptions related to normative behavior and functioning (Reindal, 2008 ). In recent years, behavior analysis has received extensive criticism for aligning with a medical model of disability and critics have described behavior-analytic interventions as symptom-focused, mechanistic, and lacking a person-centered and contextual approach (Shyman, 2016 ). In contrast with the medical model, the social model of disability posits that individuals are not impaired by their disability, but rather barriers imposed by society (Oliver, 1983 ). This model challenges that assumptions about normality cannot be made outside of a social context (Marks, 1996 ). Consistent with this social model of disability, conceptual theorists for FCC (i.e., Bank-Mikkelso, 1969 ; Nirje, 1969 ; Wolfsenberger et al., 1972 ), argued that as a matter of equality and human rights, people with support needs (e.g., people with disabilities) should be offered every opportunity to participate in activities that mirrored those of the mainstream. Normalization, a principle that was adapted from the Danish normalisering , referred to the need to make institutional settings the same as those that were common in the community and that supports should be drawn from the natural environment (as opposed to arbitrary supports; Perrin, 1999 ). For example, family members, classmates, and co-workers could be taught to provide necessary supports to many who in the past required hospital care (e.g., Murphy et al., 2005 ). Early FCC models emphasize the importance of normalization and viewing the client in the context of their family and culture (e.g., Prelock et al., 1999 , cites Shelton et al., 1987 , and Thomas, 1991 ). The process of normalization is one method by which a social model of disability is upheld by creating environments and interventions that are person- and family-centered to support individuals with disabilities. The difference between expert-based and FCC models of care may seem intractable, but we suggest two paths moving forward. First, the methods of behavior-analytic research could be focused upon the quality of outcomes under different family-practitioner collaboration arrangements. For example, studies need to examine expert-based versus FCC approaches and how these methods may vary in achieving long-term behavior change for the client, as well as socially valid outcomes for the family. Future studies should also examine how these approaches may differentially affect consumer perception of behavior analysts’ soft and compassionate care skills. Second, investigations are needed to identify patterns in the unique ways families from a variety of diverse backgrounds elect to use or reject aspects of behavior-analytic intervention. Understanding these patterns will help practitioners develop interventions that better fit the preferences and needs of those they serve. Future studies should also consider the development of practical tools to gather this information from families in a systematic and meaningful manner, some of which is underway (e.g., Pacia et al., 2022 ). In short, the growing body of evidence for greater family–practitioner collaboration and nesting of services in culturally sensitive, family-centered arrangements suggests that it may be time for behavior analysts to reconsider and incorporate normalization practices. To the extent that the word “normalization” evokes behavior focused on evaluating intervention for its contextual fit within the lives of clients in their families and families in their communities, and to the extent that its use is reinforced by a culture becoming more adaptive to the interests of individuals with support needs, we argue that behavior analysts have something to contribute to the scientific analysis of normalization. Summary We hope to communicate the usefulness of an FCC approach in behavior-analytic services and provide practical resources behavior analysts can embed within their service provision. In doing so, behavior analysts may achieve more socially valid outcomes that create long-lasting behavior change and positive impacts for the families they serve. We recognize the challenges that may be present when adapting an FCC approach into behavior-analytic settings. This model requires robust collaboration and assessment of contextual variables, which may not always be feasible or economically supported. Nonetheless, we hope behavior analysts can identify at least one FCC principle they could begin incorporating into their practice. We provide a few examples of how behavior analysts may do so under resource constraints. First, behavior analysts could consider maximizing the allowed billable time for the behavior identification assessment (CPT 97,151). In addition to conducting client-specific assessments (e.g., ABLLS), incorporating family and contextual assessments (Table 1 ) at this initial meeting can be pivotal at establishing a FCC practice (e.g., Principles 1, 2, 3, and 4). The 97,151 code allows behavior analysts to be reimbursed for non-face-to-face time (e.g., analyzing data, preparing the report), which ensures the time spent by the behavior analyst to conduct, score, and report the findings is financially compensated. Second, we encourage behavior analysts to maximize each clients’ allowed family adaptive treatment guidance (CPT 97,156) to provide ongoing support and training to caregivers. This time is crucial to adopt FCC principles aimed at consistent and ongoing interactions with the family (e.g., Principles 3, 5, and 6). Often a behavior analysts time can be constrained with other responsibilities, such as treatment planning and supervision of registered behavior technicians. To help alleviate some of these constraints, board certified behavior analysts may consider delegating some of their responsibilities (e.g., supervision of registered behavior technician) to a board certified assistant behavior analyst, as funders allow. Finally, initial steps towards implementing several principles (e.g., 6, 7, and 8) can be taken outside the context of client care. These steps could entail creating space (within or outside of an organization) to assess individual and organizational FCC practices (Table 3 ), read and discussion published articles on compassionate and family-centered practices, and generate resources and collaborative networks for clients and families. We acknowledge changes in economic, social, and cultural contingencies are necessary to promote sustainable large-scale adoption of this model. Our hope is this article starts conversations at multiple levels (e.g., clinical, legislative, training/universities, and membership organizations) with the goal of beginning to incorporate this approach into practice and training for behavior analysts. Empirical research is needed to explore methods and implications of our recommendations. It is our view that an FCC approach is harmonious with compassionate care, even if challenging and uncomfortable. In the meantime, to steal a maxim from popular culture, we invite our readers to begin the process of becoming comfortable with being uncomfortable. Data Availability Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. Declarations Conflicts of Interest None of the authors have conflicts of interest to disclose. Footnotes 1 The extent of equal versus equitable decision-making authority that stakeholders exert in FCC will necessarily vary along multiple intersecting dimensions. Family members may differ in intellectual capacity to evaluate options, time to do so, and willingness to engage in the process. Some have previously been disenfranchised and may ask for more authority in the current context than would be allotted simply on the basis of capacity to make healthy decisions. To redress a long history of disempowerment and its resultant learned dependency. 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Data Availability Statement Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. 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