Using ABA to facilitate the Implementation of Biomedical Interventions Practical Solutions for teach

1
Using ABA to facilitate the Implementation
of Biomedical InterventionsPractical Solutions
for teachingPill Swallowing, FeedingOvercoming
fear of HBOT chambers,IV treatments and Shots
Center for Autism and Related Disorders, Inc
Doreen Granpeesheh, Ph.D.. B.C.B.A
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Pill Swallowing

• My child doesnt swallow pills or capsules
• It takes me 45 min each morning to crush his
  pills and mix them with food!
• It takes me 30 minutes to get him to eat these
  foods because they taste so bad!
• We are ALWAYS late to school because of this
  morning routine!
• I get totally stressed out before 8am every day!
• And I have to repeat the whole process every
  night as well!

3
My child has Autismand these are the
supplements I give E V E R Y D A Y !!!

• Multi-vitamin
• Multi-mineral
• CLO
• EPA/DHA
• Calcium
• Probiotic
• Melatonin
• GABA

• Transfer Factor
• Antioxidants
• Antifungals
• Antivirals
• Antibacterials
• Folinic Acid
• 5HTP
• Colostrum

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Feeding

• My child is very selective about what he eats!
• He will only eat foods that are a particular
  texture!
• He gags and vomits foods that he hasnt event
  tried once!
• He is really underweight and Im worried about
  his health.
• He doesnt take his meds because he doesnt eat
  anything.
• His doctor wants to put him on a G-tube because
  he wont eat!

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Feeding

• My child needs to be on a restricted diet but
• He doesnt like the foods that his diet allows
• Im afraid he wont eat at all if I take away his
  favorite foods
• He loses out on a lot of social activities
  because he tries to eat foods that make him sick
• He wont even try to taste the foods that hes
  allowed to eat

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HBOT

• Theres this wonderful treatment that I want for
  my child but.
• He wont sit or lie down in a chamber for an hour
  every day
• Hes really scared of tight spaces
• He wont keep a mask on for long periods of time
• Hes afraid of the chamber, even though he has
  never been in one!

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IV Treatments MB12 Injections

• I have to give my child MB12 Shots and he hates
  it!
• I need to chelate my child and he fights when the
  nurse wants to set up the IV
• My child needs IV glutathione and I cant give it
  to him!
• I hate holding my child when hes screaming and
  crying for a 20 minute IV treatment
• Hes had so many bad experiences that I cant
  even get him to the doctors office anymore

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• This presentation will teach you some very simple
  procedures to help your child
• Swallow pills and capsules
• Improve feeding skills
• Tolerate IV treatments and shots better
• Stay in a Hyperbaric Chamber without anxiety

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What is ABA?

• Applied Behavior Analysis is
• A series of techniques that help change behavior!
• Everything we do is Behavior
• Swallowing a pill is behavior
• Eating food is behavior
• Hitting people to get away from a shot is
  behavior
• Crying to avoid an HBOT chamber is behavior
• Behaviors can be good, bad or neutral
• The way we classify behaviors is subjective!
• Goal is to teach behaviors that are adaptive!

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Every Behavior has an antecedent and a
consequence!
Antecedent
Behavior
Consequence
Andy gets toy
Andy wants toy
Andy hits sibling
Dan eats a food
Dan avoids that food
Dan vomits
Jeff gets scared and cries whenever he goes to
docs office
Jeff avoids other treatments
Jeff gets his shots at the doctors office
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ABA tells us we can

• Change any behavior if we change the
• Antecedent
• or
• Consequence
• or
• Both!

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How do we change behavior?

• Change behavior by changing the antecedent or the
  consequence or both!

Teach Andy to ask when he wants toy
Andy will not hit sibling
Andy gets toy
Andy wants toy
Andy hits sibling
Andy does not get toy
Andy will not hit sibling
Jeff doesnt avoid the shot
Jeff Avoids shots
Jeff cries and tantrums
Jeff gets MB 12 shot
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If we want to change a behavior, we need to
know why the behavior happens to begin with
What is the Function of the Behavior Why do we
do what we do?

• Everything we do is to
• GET GOOD STUFF
• or
• AVOID BAD STUFF
• or both!

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Reinforcers

• Some good things we want to get
• Praise
• Money
• Prestige
• Power
• Attention
• Tangibles
• Some bad things we want to avoid
• Punishment
• Failure
• Embarrassment
• Work

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We do behaviors that bring us good consequences
and let us avoid bad consequences!
Antecedent
Behavior
Consequence
You want to learn about Autism
You get useful information
You come to DAN!
You decide to try MB12 shots
You give your child a MB12 shot
He screams and cries
You decide to try MB12 shots
You give your child a MB12 shot
Your child improves significantly
Wait a minute! This is the same behavior and it
has both of these consequences! So what will
happen? Will the Behavior decrease or increase?
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Sometimes we cant avoid bad consequences.

• Getting an IV or a shot is bad stuff
• Laying in a tight space (a chamber) is bad stuff
• Eating food you dont want is bad stuff
• Swallowing pills that make you gag is bad stuff
• HOW CAN WE MAKE THESE CONSEQUENCES MORE POSITIVE?

Get IV
Feel Pain
Get in Chamber
Cant move around
Eat Food
Feel GI Pain
Swallow Pill
Gag on Pill
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Some ways to change consequences
Reinforcement
Response Cost
- Reinforcement
Punishment
Extinction Give NO Consequence! Ignore the
behavior all together!
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Rule Number 1

• List your childs Reinforcers (these are things
  you can give more of)
• Foods or Drinks
• Toys
• Activities
• Praise
• People
• Places
• More TV/Computer time
• Things to avoid (these are things you can take
  away or reduce)
• Less homework
• No bath tonight
• No Vegies tonight

Is it ok to give more Reinforcers on MB12
days? Or let your child do less homework on these
days!
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Antecedents also control our behavior!

• Antecedents are powerful because they help us
  predict when we will get good stuff and avoid bad
  stuff!

Video, Topical Anesthetic
Jeff gets MB 12 shot
Jeff experiences Pain
Doctors office
Lollypop
Pain is bad stuffso, by association, the doctors
office becomes bad stuff too!
You cant avoid the pain BUT You can change the
antecedents consequences to balance the
reinforcers!
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Some ABA terms for changing Antecedents and/or
Consequences

• Enriched Environment
• Clear and concise instructions and rules
• Shaping/Chaining
• Stimulus Fading
• Differential Reinforcement of Alternative
  Behaviors (DRA)
• Escape Extinction
• Systematic Desensitization

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Enriched Environment

• Watch a favorite TV show while doing treatment
• IPOD playing favorite music
• Lollypop given at entrance
• Decorations in Docs office
• Stickers on Docs stethoscope
• Cute and funny plates and cups

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Clear and Concise instructions

• If you take 1 shot, you get to watch wiggles
• 1 spoon of peas, you get a lollypop
• When the timer rings, you get candy

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Shaping and Chaining

• Shaping Reinforce behaviors that are closer and
  closer to the behavior you want
• Reinforce for going to the docs office, without
  getting shots
• Reinforce for allowing spoon to pass the lips,
  without any food
• Chaining Break the behavior down to smaller
  units and reinforce each unit
• Reinforce getting out of car, reinforce going in
  docs office, reinforce putting sleeves up,
  reinforce sitting in room, etc.

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Stimulus Fading

• Start with a stimulus that is acceptable to the
  child and gradually increase from there

• Graduated Exposure Injection Procedure
• 1. Seated in examination bed/chair
• 2. Arm extended for required time duration
• 3. Pre-draw preparation
• Rubber tourniquet
• Alcohol swab
• 1, 2, 3 Mock penetration with a large marker
• 1, 2, 3 Mock penetration with pen end
• 1, 2, 3 Mock penetration with pen tip
• 1, 2, 3 Mock penetration with mock needle
• 1, 2, 3 Mock penetration with real needle
• 1, 2, 3 In-vivo short-term penetration with
  real needle
• 1, 2, 3 Injection/IV (20 mins) w/time expansion

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Differential Reinforcement of Alternative
Behaviors (DRA)

• Replacement Behaviors
• Dont wait until he is crying and screaming, give
  him something else that he can do, and reinforce
  that
• Most of the time, we wait a little too longour
  child fails at the task, and we freak out and
  give a lot of negative attention
• Require behaviors that your child CAN do!
• One drop of food instead of a plate
• One tiny pill instead of a huge capsule
• One foot in the chamber for 1 min instead of
  whole body for an hour

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Escape Extinction

• Dont let your child avoid the behavior!
• This is tough, so be prepared
• When he cries to get away from the needle, dont
  let it happen

Jeff doesnt avoid the shot
Jeff gets MB 12 shot
Jeff cries and tantrums
Jeff Avoids shots
When he tries to push food away, dont let him do
it
When he spits out the pill, start again
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Its all about making it fair.

• Start with small expectations, and big
  rewardsthen increase your expectations and
  reduce your rewards!

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Using ABA to facilitate Biomedical Interventions

• Lets see how the same techniques we talked about
  can be used to teach just about
  anythingincluding
• Feeding
• Pill Swallowing
• Tolerating IV and Shots
• Staying in a chamber

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Feeding

• Prevalence of Feeding Problems
• 25 of typical children
• 33 of children with DD
• 90 of parents surveyed reported child with ASD
  to exhibit a feeding problem

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Types and Characteristics

• Types of Feeding Problems
• Failure to thrive
• Rumination
• Pica
• Food Selectivity
• Often accompanied by challenging behaviors
• Tantruming
• Expelling food
• Gagging
• Vomiting
• Pushing/throwing food/utensils away

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Causes of Feeding Problems

• Biological Variables
• Medical conditions (e.g., gastroesophageal
  reflux, food allergies)
• Physiological abnormalities (e.g., cleft palate)
• Oral-motor delays
• Environmental Variables
• Getting good stuff (desired consequences increase
  behavior)
• Avoiding bad stuff (removal of undesired
  consequences also increases behavior)
• Combination of Environmental and Biological
  Variables

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Biological Environmental

• How Environmental Variables Influence
  Biologically Based Feeding Problems
• Biological variables
• Child with GI disorder eats gluten
  pain/discomfort tantruming
• Environmental variables
• Child gets good stuff for tantruming (desired
  consequences increase tantruming)
• Or, child avoids bad stuff for tantruming
  (removal of undesired consequences also increases
  tantruming)
• Lets look at how this happens

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Biological Environmental

• Example Child tantrums when food is associated
  with an undesirable event (pain) until eventually
  the food alone leads to a tantrum

Days 1-3
Jacob eats food with gluten
Jacob feels pain or discomfort
Jacob tantrums
Day 4
Jacob sees food with gluten
Jacob tantrums
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Biological Environmental

• Example Child getting a desired consequence
  AND/OR avoiding an undesired consequence for
  engaging in food selective behavior

Jacob sees food
Jacob tantrums
The undesired food is removed AND/OR Jacob
gets a desired food
When the undesired food is removed AND/OR Jacob
is given a desired food as a consequence of Jacob
tantrumingWhat will happen to the future
frequency of tantruming in similar situations?
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Biological Environmental

• Lets Review How Environmental Variables
  Influence Biologically Based Feeding Problems
• Child with GI Disorder eats gluten
  pain/discomfort tantruming
• Tantruming child parent removal of undesired
  foods
• Short-Term Outcome child learns that his/her
  parent will take away undesired foods when s/he
  tantrums parent learns that to avoid tantruming,
  s/he should not require his/her child to eat the
  undesired foods
• Long-Term Outcome child eats only a few foods
  and is considered to exhibit food selectivity
  parent is unhappy but does not know what to do
  about it
• Note child will probably choose to avoid any
  novel foods even if they were never associated
  with pain/discomfort (i.e., the child will play
  it safe)this is how the child becomes selective

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Biological Environmental

• What happens to food selectivity when the childs
  GI disorder is treated with a GFCF diet or
  anti-inflammatory drugs?
• Child is likely to continue exhibiting food
  selectivity
• Why?
• Child thinks foods that were associated with
  pain/discomfort in the past pain/discomfort now
• Thus, child continues to be selective
• Parent does not force the child to eat novel
  foods
• What does this mean?
• Childs feeding problem was initially due to
  biological variables (GI disorder)
• GI disorder improved as a result of diet and
  medical treatment
• Childs feeding problem is continuing to occur
  due to an environmentally learned interaction

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Practical Solutions Changing the Antecedents

• Structure the way food is presented
• Timing
• Present foods at consistent times each day
• Separate meals by several hours
• Texture
• Start with pureed or mashed texture if needed
• Children who dont eat regular table foods
• Children with oral-motor delays
• Move into higher textures slowly and
  systematically
• Set time limits for children who eat slowly
• Slow eating can be a form of food refusal
• Decide how long you think it should take to eat
  the meal and set a timer
• End the meal when the timer buzzes and do not
  provide snacks between meals
• If the child eats what is required, provide a
  reinforcer

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Practical Solutions Changing the Consequences

• Change the consequences for eating
• Give your child desired stuff when s/he eats
• Reinforcement (should only be available when your
  child does whats expected, not other times)
• Simultaneous reinforcement
• Demand Fading
• Give your child desired stuff when s/he eats and
  remove desired stuff when s/he doesnt eat
• Enriched environment response cost
• No longer allow your child to escape from eating
• Nonremoval of the spoon (NRS)
• Escape Extinction

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Practical Solutions Changing the Consequences

• Reinforcement
• Identify what your child likes
• Needs to be high-preferred to increase motivation
• Restrict access to the identified high-preferred
  items to only after your child has eaten the
  foods targeted during meals
• How you determine what your child likes
• Preference Assessment
• Present an array of foods or toys
• Say Pick one
• Let your child consume or play with the item s/he
  picks
• Repeat
• The items chosen most often are likely to be
  reinforcers
• Decide whether to use foods or toys as reinforcers

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Practical Solutions

• How to provide reinforcement
• Provide a rule at the beginning of the meal
• Take a bite and youll get (reinforcer)
• Present one bite of food at a time on a utensil
  and say take a bite
• Initially, provide the reinforcer every time your
  child takes a bite
• Provide the reinforcer immediately
• Pair praise with the tangible reinforcer
• What if my child refuses to eat a bite or becomes
  disruptive?
• Do not interact with your child verbally
• Do not repeat the rule, reprimand, or say
  anything at all
• Do not make eye contact with your child
• Neutrally block attempts to disrupt food
  presentation
• Neutrally remove reinforcer if child spits foods
  out
• Wait for your child to be quiet and undisruptive
  before removing the refused bite
• Repeat steps until all bites have been presented

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Practical Solutions Changing the Antecedents and
Consequences.

• Demand Fading
• Plan to present only one small bite of food on a
  utensil at first
• Say, Take a bite and place the spoon of food
  passed the plane of your childs lips
• Even if your child spits the food out, provide a
  ton of praise and a plate full of high-preferred
  foods and end the meal
• After 3 meals of acceptance (spoon passing the
  plane of the lips), require your child to swallow
  the one bite of food before providing praise and
  a plate of high-preferred foods
• Slowly and systematically increase the number of
  bites required for consumption in order to
  receive high-preferred foods and end the meal
• Slowly and systematically decrease the number of
  bites of high-preferred foods that are earned for
  eating nonpreferred foods until a dessert is
  being earned

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Enriched EnvironmentResponse Cost

• Sit your child at the table with high-preferred
  toys
• Present a small bite of food on a utensil and
  say, Take a bite
• If the bite is consumed, throw a party and
  present another bite
• If the bite is refused, remove the toys
• After 30 seconds removal, the toys are
  represented along with the instruction to Take a
  bite
• Process is repeated until all bites have been
  presented
• If no food is eaten, meal ends and no food until
  next meal
• Access to high-preferred toys is restricted only
  to mealtime

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Reinforcement and Non-Removal of Spoon
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EE Jaw Prompt with Re presentation
Acceptance
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Intake
Meal Duration
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Feeding Sessions

• Parent attempts feeding
• Baseline Ground Food
• Baseline Chopped Food
• Post Intervention 1
• Post Treatment Chopped complete

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Case study Jenny learning to eat

• Jenny was a four year old girl with developmental
  delay and total food refusal
• She was born 3 months premature, with zero chance
  of survival
• She never learned to suckle, let alone eat
  through her mouth in any way
• She received all of her food through a g-tube
  from the very beginning of her life
• Previous attempts at getting her to eat baby food
  failed because of tantrums

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Case study Jenny

• Why didnt Jenny eat?
• Her life was better in the short-term by not
  eating
• She never had to be hungry because she got all
  her food from the g-tube
• Eating was scary because she didnt know how to
  do it refusing food felt safer than trying to
  eat
• Why didnt her parents make her eat?
• They were afraid of making her choke
• They didnt want to make her sad, especially
  after all her medical difficulties

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Case study Jenny

• The longer-term consequences for not eating were
  very serious
• Jenny was significantly under weight
• Her growth was significantly delayed
• Formula is not considered sufficient nutrition
  for ones whole life
• Many medical risks because of g-tube
• Could be bad for Jennys social development
  other kids eat food orally, etc.

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Case study Jenny

• What did we do?
• Have a medical doctor assess the safety of her
  trying to eat. Will she choke? Does she have the
  physical capacity to eat?
• How can we motivate her to try to eat?
• Make her life more fun in the short term if she
  makes an effort at eating then if she doesnt
• Make the rules simple and clear
• Start small
• Be consistent

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Case study Jenny

• What did we do?
• Sit her at a table with a bowl of baby food and a
  spoon
• Let her pick anything she wanted out of all of
  her toys and videos
• Give her the toys that she chose
• Turn on the video that she chose
• Put one very small bite of baby food, on a
  child-sized spoon in front of her mouth and asked
  Jenny, take a bite please
• If she took a bite, huge praise and a big party,
  no more food that day
• If she didnt take a bite, turn off the video and
  take away the toys
• Give it all back as soon as she tried to take the
  bite

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Case study Jenny

• Why would this work?
• She gets good stuff (all her favorite toys and
  videos, lots of praise, and is proud of herself)
  by trying to eat
• She doesnt get all that same good stuff if she
  doesnt try to eat
• We made it very easy for her by requiring only
  the very smallest attempt at taking a bite
• Overall, it was easier for her to just try and
  take the bite then it was to refuse

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Case study Jenny

• Is it mean to take a disabled childs toys away,
  just because she didnt do what you asked her to?
• What if her parents were okay with it?
• Would it be worth it if it worked?
• Did it work?
• Yes
• She took the bite on the first day

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Case study Jenny

• Who cares about one bite? Thats not fixing the
  problem
• After Jenny became good at eating one very small
  bite, we started presenting a regular sized (age
  appropriate bite)
• When she got good at that, we changed it to two
  bites before the meal was over
• When she got good at that, we changed it to
  three, and so on

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Case study Jenny

• That sounds like it would take forever
• It did. But, one year later she was eating age
  appropriate sizes of meals, with no problems
• Is this practical for the parents? Can you
  operate a remote control?
• Eventually, her parents were able to give her a
  normal portion of food and then ask her to eat it
  in the next 20 minutes, and the video would be
  turned off at that point if she didntit worked
  very well

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Case study Jenny

• Then we had to teach her to chew
• How did we do that?
• We gave her small pieces of very easy-to-chew
  foods and modeled chewing
• How long did that take? Another year
• Was it worth all the effort?
• Two years after starting treatment, she ate her
  first piece of pizza the whole thing, in her
  typical classroom, with her friends
• Six months later, her g-tube was permanently
  removed
• She now eats normally, with no special assistance

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Frequently Asked Questions

• What foods should I target first?
• How do I add more and different foods?
• Should we work on feeding during normal
  mealtimes?
• How big should the first bite be?
• Should I use other preferred foods as rewards? Or
  just toys?
• What are some things I can do to make my child
  more willing to try new foods?
• How will I know if my intervention is working?

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Pill SwallowingCommon Problems

• Some liquid medications taste bad
• Some medications are not available in liquid form
• Some children are texture sensitive and wont
  accept certain type of liquid medications
• All result in the child avoiding the medication
• Pills are often crushed
• Alteration of the chemical compound and
  absorption rate
• Pills are hidden in food, can result in food
  becoming aversive (reverse conditioning)

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Swallowing TabletsHints and Practical Solutions

• Heavier than water
• Do not float
• Tablet is placed in the mouth (tongue)
• Fill the mouth with a small amount of water
• Head and upper part of the body is tilted
  backward
• Tablet will float anteriorly
• Tablet is swallowed

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Swallowing CapsulesHints and Practical Solutions

• Lighter than water
• Floats because of the air trapped inside the
  gelatinous shell
• Capsule is placed in the mouth (on tongue)
• Fill the mouth with a small amount of water
• Head and upper part of the body is tilted forward
• Capsule will float posteriorly
• Capsule is swallowed

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Common Training ProceduresSame stuff we learned
about earlier!

• Positive Reinforcement
• Shaping
• Modeling
• Relaxation Training
• Corrective Feedback
• Capsule size shaping
• Oralflo cup

62
Capsule Size Shaping

• Cake decorating sprinkles
• Button-dot candies
• Tic-Tac candies
• Size 5 capsules
• Size 4 capsules
• Size 3 capsules
• Size 2 capsules
• Size 1 capsules
• Size 0 capsules
• Cod Liver Oil (estimated 000)
• Endoscopy Pill Camera

• Capsule size volume in ml.
• All capsules were
  filled with cellulose

63
Initial Medical Screen

• Videofluoroscopic study (modified barium swallow)
  of the oral and pharyngeal swallowing mechanism
  is conducted
• moving radiographic images
• recorded on videotape
• x-ray of the mouth and throat while the child is
  eating and drinking.
• Objective assessment of the swallowing function
  to help determine an appropriate management and
  treatment plan
• Rule out aspiration
• Identify source of non-aspiration swallowing
  symptoms (pain, pressure, sticking, etc.)

64
Operational Definitions

• Acceptance
• the whole pill is deposited inside the childs
  mouth within 5 seconds from the initial
  presentation
• Mouth Clean
• the child swallows the pill within 10 seconds
  after it was initially placed into his/her mouth
• Chewing
• each time the child bit the capsule with a
  chewing motion of the mouth, with or without
  sound
• Refusal
• each time the child turns his/her head upon the
  presentation of a pill, pushing the pill away,
  crying or verbal refusal (e.g., I dont want to
  do it)

65
Baseline

• One session three trials (e.g., one trial one
  size 0 capsule)
• Child seated at a table adjacent to the therapist
• Present a size 0 capsule (standard-sized gelatin
  capsule) and a glass of water in a cut-out cup
• Child asked to take the pill and swallow
• You are going to take the pill and swallow.
• Are you ready? On your mark, get set, go!
• Enthusiastic social praise contingent on pill
  swallowing within 10 seconds
• The request to swallow the pill terminated
  contingent on refusal behaviors (head turns,
  pushing the pill away)
• 1-2 minute breaks between trials

66
Intervention

• Identical to baseline, except the smallest pill
  size (or candy) introduced first
• Pill size increased by one size, contingent on a
  session with 2/3 trials of successful swallowing
• If child fails, go back to smaller size and begin
  again

67
Participants

• Matt
• 5-year-old diagnosed with autism
• Receiving 11 ABA through CARD (average 10
  hrs/week)
• Receiving biomedical interventions through
  Thoughtful House
• Matts brother Gary (typically-developing)
• Sessions conducted at home
• Sara
• 4 year old diagnosed with PDD NOS
• Sessions conducted in-clinic
• Felix
• 6 year old diagnosed with language delay
• Sessions conducted in-clinic
• All services were provided free-of-charge

68
Baseline
Treatment
Matt
69
Baseline
Treatment
Parent-Implemented
Skittles Gum
Crying, CBT
white TicTacs
Sara
70
Baseline
Treatment
Parent-implemented
dropped capsule
Parent-Implemented w/ therapist present Home
Generalization
Stimulus generalization
Felix
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Results

• Matt
• Total training time 30 mins across 3 days
• Gary learned in one baseline trial via
  observational learning
• Sara
• Total training time 5 days (typically 3-4
  minutes, except during the first Vitamin session)
• CBT recognizing unreasonable/irrational patterns
  of thinking, then modifying them with more
  realistic, adaptive ones
• Felix
• Total training time 65 mins across 16 days
• Check-off chart presented from first
  parent-implemented session onwards
• Achievement certificate given following the last
  session
• Follow-up
• Per parental reports, all three children continue
  to swallow pills without a problem

72
Desensitization to HBOT Chamber

• Claustrophobia Anxiety disorder
• Fear of enclosed or confined spaces
• Common Treatments
• Anti-anxiety medication
• Cognitive behavior therapy
• Systematic Desensitization
• Systematic Desensitization
• Stage 1 Teach child response that is
  incompatible with Anxiety
• Behavioral Relaxation Training
• Stage 2 identify hierarchy of least to most
  anxiety provoking stimuli
• Pair Stage 1 with Stage 2

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Stage 1Behavioral Relaxation Training

• Whats incompatible with anxiety for a child?
• Can be deep breathing exercises
• Can be visualizing a funny scene from a movie
• Can be watching a favorite movie
• Anything that will help the child relax

74
Stage 2Anxiety Hierarchy

• A hierarchy that goes from lowest to
• highest in provoking anxiety
• Being in chamber 5, 10, 15, etc minutes
• Closing the chamber once you are inside
• Laying down in a chamber
• Actually sitting in a chamber
• Seeing others get into a chamber
• And hearing the zipper open
• Seeing an HBOT chamber

75
Stage 3Pairing

• Start with the lowest item on the hierarchy (the
  least anxiety provoking)
• Teach child to engage in the relaxation training
  activity that helped calm him down while
  visualizing or actually doing the first step of
  the hierarchy
• Once he is calm and able to handle the first
  level, keep moving up the hierarchy

76
Desensitization to IV Treatments and Injections

• Many children fear IV treatments because of the
  pain associated with these treatments
• Often this fear is enormous because the child has
  received many unpleasant treatments or shots at
  the doctors office and now associates the office
  or the doctor with pain

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IV Treatments Practical TipsSame stuff we
learned earlier!

• Graduated Exposure
• DRA reinforce for compliance
• Escape Extinction ignore refusal behaviors and
  dont let child escape the situations
• Enriched Environment decorate with stickers,
  toys, etc.
• Non Contingent Reinforcement Increase the
  reinforcers that are readily available

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Graduated Exposure

• 1. Seated in examination bed/chair
• 2. Arm extended for required time duration
• 3. Pre-draw preparation
• Rubber tourniquet
• Alcohol swab
• 1, 2, 3 Mock penetration with a large marker
• 1, 2, 3 Mock penetration with pen end
• 1, 2, 3 Mock penetration with pen tip
• 1, 2, 3 Mock penetration with mock needle
• 1, 2, 3 Mock penetration with real needle
• 1, 2, 3 In-vivo short-term penetration with
  real needle
• 1, 2, 3 Injection/IV (20 mins) w/time expansion

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Quote from a Mom.

• When my child was first diagnosed, I thought it
  was the end of my lifeI thought God had played a
  trick on me! Ha Ha you thought you would have
  perfect kids and a perfect life.
• It isnt easy being the parent of a child with
  Autismso many treatments, so many medications,
  it seemed like it would never end
• But now I can see it was all worth it! Hes
  happy, hes healthy, doing well in school, so
  popular with his friendsI just cant believe we
  made it!
• You should tell parents not to give up. Tell
  them to keep doing the things they have to do, no
  matter how hard, no matter how long, tell them to
  remember one thing
• You are the best friend your child will ever
  have!

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• Recovery