Behavioral Treatment for Specific Fears and Phobias

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Fears and phobias are increasingly common in children. A fear of needles is a particularly common fear that usually starts in early childhood and can result in significant avoidance of  medical procedures in general.

What Research Says

A recent NPR story describes a research study published in 2012. The researchers surveyed over 800 parents and 1000 children. In the study, 24% of the parents and 63% of the children reported a fear of needles! This is concerning because specific fears and phobias can lead to avoidance of health-related procedures.

Cognitive Behavior Treatment

Luckily, there is behavioral treatment for specific fears and phobias. Behavior therapy or cognitive behavior therapy (CBT) can help children overcome their fears. The most effective behavioral treatment for specific fears and phobias is called graded exposure therapy. In graded exposure therapy the child is introduced to the feared situation or object in small steps until they are able to participate in the situation on their own.

For example, if a child has a fear of going to the dentist, the treatment can start out with the child reading a book about the dentist, looking at a picture of a dentist’s office, and observing a parent participate in a dental visit. Then the situations are gradually increased until the eventual goal of participating in a dental procedure is achieved. Kids with specific phobias and fears benefit from parent participation in the treatment process.

Practice at home will provide faster progress. Depending on the age and learning history with the feared object or situation, treatment can progress quickly or may take more time to break down the situation into smaller steps. Either way, behavior therapy or cognitive behavior therapy can help a child overcome their fears and phobias.

My Child Just Got Diagnosed with Autism, Now What Do I Do?

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A diagnosis of autism can be an uncertain time for a family. Many parents are sent into a whirlwind of emotions and left wondering unanswerable questions: Why is this happening? How did this happen? What will their future look like? What do I do now?

Some questions are easier to answer than others. First, knowing which specialists are available to help can bring peace of mind. Some services are evidence-based, versus “fad treatments” or experimental treatments with no research supporting their use or effectiveness. Evidence-based treatments are interventions that have been supported by peer reviewed studies that have been replicated, often through years of research. When a provider tells you they can help your child with autism, don’t be afraid to ask them, “Can you tell me about the research supporting your services?” and “Is your treatment recommended by the National Institutes of Health for treating people with autism?”

Children with autism often receive a variety of support from different sources; evidence-based services include ABA therapy from a Board Certified Behavior Analyst (BCBA), speech therapy from a Speech Language Pathologist (SLP), ongoing care from a pediatric neurologist, and possible treatment with a doctoral psychologist or psychiatrist.

Wow, that’s a long list! Does my child need all of those services?

The answer is each child is different, and your child’s needs will change over time so it’s best to know what options are out there! Some services may require more time than others. ABA therapy, or applied behavior analysis therapy, typically ranges from 10 to 40 hours per week depending on a child’s needs. The programs are intensive, which requires a higher number of therapy hours. Research indicates a lower number of therapy hours does not produce meaningful outcomes, hence the greater time requirement (Granpeesheh et al, 2009).

Search for ABA centers in your area to learn more.

Speech therapy with a private SLP typically ranges from 1 to 2 hours per week. Many provide in-clinic and in-home services. To find a private speech therapist, search for speech language pathology clinics in your area. Public schools in Texas also offer speech therapy, typically about 30 minutes per week. Contact your child’s teacher and school psychologist to see if they are eligible to receive services at school. If they are currently not eligible, inquire if the school can evaluate them to see if they need support (they can!). Pediatric neurologists provide initial diagnoses and ongoing screenings or check-ups one to two times per year. If additional diagnoses are warranted, they can evaluate your child and refer you to recommended specialists if need be. Neurologists can diagnose developmental disorders, seizure disorders, brain injuries, and nerve-muscle disorders. Psychiatrists and licensed psychologists can also provide a diagnosis of autism. Psychiatrists can provide treatment through medication if severe behavioral issues (such as severe self-injury or aggression) persist in spite of intensive ongoing behavior therapy. Licensed psychologists can provide a variety of therapy options, including PCIT, or Parent-Child Interaction Therapy. PCIT is a type of evidence-based therapy that teaches parents effective ways to engage their children to produce meaningful behavior change and skill acquisition.

Collaboration is Key

Hands down, collaboration among all specialists will result in better outcomes for your child. Encourage your child’s team to communicate on a regular basis! For example, BCBAs or speech pathologists can attend doctor visits with the neurologist or psychiatrist to discuss specific behaviors that are observed during day-to-day therapy. Doing so will give doctors more complete information and allow them to make the most informed decisions. Also, BCBAs can include recommendations from a psychologist in their skill acquisitions programs and individualized behavior plans. The two specialists can also discuss if other evidence-based treatments are needed, for instance in a child has multiple diagnoses that require a variety of behavior therapies.

Moving Forward

In addition to knowing how to navigate through the sea of specialists, many families benefit from reaching out to one another. Parent support groups that connect parents of children with special needs are a great place to find compassion and understanding for a process that can be emotionally taxing. Further, many states have conferences, such as Texas Parent to Parent Conferences that provide parents with information and foster connections with other families. You’re not alone, don’t be afraid to reach out! Learn more about reducing stress in your life with these simple techniques and tips.

Preference Assessment

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A preference assessment is conducted to identify potential reinforcers.  Note, we don’t know that these things are actually reinforcing until we see if applying the items increases a behavior.  To determine if a potential reinforcer is actually reinforcing, we can do a reinforcer assessment.

Ways to identify potential reinforcers:

  • Ask the person about their preferences.  This is an indirect method.  It can also involve asking care givers, parents, teachers or friends about the person’s preferences.  This method can be done by asking open-ended questions, choice format or rank-ordering.
  • Another method is to offer a pre-task choice.  Ask the person before they work on a task what they would like to “earn” for completing the task.  The participant can pick from 2 to 3 items presented.
  • Free operant observation is a way to identify potential reinforcers.  Basically, stay observant and see what the individual gravitates to and plays with in an unrestricted room.  The total duration of the time that the person engages with each item or stimulus is recorded.  The longer that the individual engages with the sitmulus, the stronger the case that the item is preferred.  This method can be contrived (contrived free operant observation), where the environment is seeded with hypothetically reinforcing items, or conducted in a natural environment (naturalistic free operant observation) such as a child’s play room.
  • Trial-based methods are formal methods to determine potential reinforcers.
    • Single Stimulus is also called successive choice method.  This is the most basic trial-based method.  Basically, a stimulus is presented and the person’s reaction to it is noted.  This is helpful with individuals who may have trouble between selecting between two or more items.
    • Paired Stimuli is also called the forced-choice method.  Each trial consists of presenting two items and recording the person’s choice of the two.  Data is recorded on how many times an item was chosen and then items are rank ordered.  This method takes the most time to implement and is said to be the most accurate.
    • Multiple Stimuli is where many items are presented at one time.  This is an efficient method.  There are two variations:  Multiple Stimuli with Replacement (MSWR) and Multiple Stimuli without Replacement (MSWOR).  In MSWR, the item chosen remains in the array and all other items that were not selected are replaced by other items.  In MSWOR, the item chosen is taken out of the array and the array diminishes in size on each selection.  MSWOR is the fastest method.

Classifying Reinforcers

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Unconditioned Reinforcer is also called a primary reinforcer.  These are reinforcers that do not need to be learned, such as food, water, oxygen, warmth and sex.  These are all primary drives that we have for basic survival and if they are deprived in any way, gaining access to these reinforcers is very motivating.

Conditioned Reinforcer is also called a secondary reinforcer.  It is something that needs to be learned through pairings with unconditioned reinforcers.  For example, money is a learned reinforcer.  By itself, money is a useless piece of paper, but with the pairing of money and access to unconditioned reinforcers, money becomes a valuable thing.

Generalized Conditioned Reinforcer

Reinforcers can be classified by their attributes:

  • Edible Reinforcer – Highly preferred food items.  If you don’t like it, it wouldn’t serve as a reinforcer.  It has to be yummy.
  • Sensory Reinforcer – Anything that effects pleasure to the senses to the individual.  Again, it has to be something that the person likes, otherwise, it is not going to be a reinforcer.  This can include massage, music, or a beautiful painting.
  • Tangible Reinforcer – Any tangible item that the person values.  This can be money, stickers or tokens.
  • Activity Reinforcer – The opportunity to have some fun.  This is anything the person enjoys doing: going fishing, watching TV, jumping on a trampoline.
  • Social Reinforcer – Any positive or desired attention or interaction with another person can serve to reinforce.

These reinforcer types remind me of the “5 Love Languages.”  The premise behind the Love Language book is that people find different things reinforcing and they want to receive positives from others in different ways.  The Love Languages are like Reinforcers in that everyone has different things that they find desirable and therefore reinforcing.

In order to find what is reinforcing to an individual, a preference assessment can be performed.

Premack Principle (Grandma’s Law)

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The Premack Principle is also known as “Gradmas’s Law.” Parents (and Grandmas) use it naturally all the time. It is the principle that offering something that happens often in a free operant situation to be contingent upon something else that happens with low frequency. So, for example, “You can watch television after you have finished your homework.” Or, “You can have ice cream for dessert after you’ve eaten all your broccoli.”

In 1974, Timberlake and Allison came up with response-deprivation hypothesis. This gives us a model to predict whether access to one behavior (the contingent, awesome behavior) will be reinforcing for another behavior (the instrumental response, or the broccoli).

The idea is that restricting access to a behavior creates a deprivation for that more probable behavior (I want ice cream!) and acts as an establishing operation (EO), making the opportunity to engage in that behavior a reinforcement for the less probable behavior (Ugh, broccoli).

Ivar Lovaas

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Quotes by Skinner

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“Education is what survives when what has been learned has been forgotten.”

“A failure is not always a mistake, it may simply be the best one can do under the circumstances. The real mistake is to stop trying.”

“The real problem is not whether machines think but whether men do.”

“A person who has been punished is not thereby simply less inclined to behave in a given way; at best, he learns how to avoid punishment.”

Reinforcer “does not need to be contrived for instructional purposes; it is unrelated to any particular kind of behavior and hence always available.  We call it success.”

Contingency-Shaped vs. Rule-Governed Behavior

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In About Behaviorism, B.F. Skinner says, “Rule-following behavior is said to be the veneer of civilization, whereas behavior shaped by natural contingencies comes from the depth of the personality or mind.”  Skinner continues to note, “Doing good because on is reinforced by the good of others (contingency-shaped)  is more highly honored than dong good because the law demands it (rule-governed).”

A difference between rule-governed and contingency-shaped is one of knowledge.  To understand the rules, we must be taught the rules and commit them to memory and then learn when to apply them.  Contingency-shaped behavior is learned because of the reinforcement or punishment that the individual is exposed to by their actions.  Their future actions are modified in a way based on that past experience of reinforcement and punishment.

In the case of rule-governed behavior, it is dictated by the stated/written consequences (i.e., the “rule”), not necessarily by consequences that one may have experienced personally.  You an tell when a behavior is the result of a rule when there has never been any punishment or reinforcement for the behavior, including automatic reinforcement, but there is a rule in effect.  Rule-governed behavior can also be characterized by one instance of reinforcement causing a large increase in the frequency of the behavior, behavior changing without reinforcement, consequences not being immediate, or no immediate consequence is apparent.

Someone learning a language by reading grammar books and memorizing the dictionary (rule-governed) will have a different experience of the language than someone who has learned it from the verbal community (contingency-shaped).

Charles Darwin

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Charles Darwin (1809-1882) was an English naturalist who developed the theory of biological evolution.  Biological evolution states that species develop and change over time through a series small variances that increase the species likelihood of survival and reproduction.  These small variances are passed down from one generation to the next with the variances that give the most competitive advantage expressing itself over time in the species.  Darwin’s theory of evolution is called Darwinism or Darwinian theory.  He published his theory in a 1859 book called Origin of Species.  The evolution of a species is referred to as Phylogenetics.

Modeling

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Modeling is learning behavior by seeing someone else do the behavior and then copying it.