ERIC EJ750849: Stimulus Fading and Differential Reinforcement for the Treatment of Needle Phobia in a Youth with Autism

2006·0.18 MB·English

by  ERIC

JOURNALOFAPPLIEDBEHAVIORANALYSIS 2006, 39, 449–452 NUMBER4 (WINTER2006)
STIMULUSFADINGANDDIFFERENTIALREINFORCEMENTFORTHE
TREATMENT OF NEEDLE PHOBIA IN A YOUTH WITH AUTISM
DANIEL B. SHABANI AND WAYNE W. FISHER
MARCUSINSTITUTE
Stimulus fading in the form of gradually increased exposure to a fear-evoking stimulus, often
combined with differential reinforcement, has been used to treat phobias in children who are
otherwisenormalandinchildrenwithautism.Inthisinvestigation,weappliedstimulusfading
plusdifferentialreinforcementwithanadolescentwithautismanddiabeteswhoseneedlephobia
hadprevented medical monitoring ofhis blood glucose levels for over 2 years. Results showed
thatthetreatmentwassuccessfulinobtainingdailybloodsamplesformeasuringglucoselevels.
DESCRIPTORS: autism, diabetes, fading, medical non-compliance, needle phobia,
systematic desensitization
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The serious and sometimes deadly complica- fear response), as well as differential reinforce-
tions of diabetes(e.g., kidney failure, blindness) ment of (a) approach responses (DRA) or (b)
canoften be mitigatedthroughappropriate diet the absence of an avoidance response (DRO).
in combination with insulin therapy, which Treating needle phobia with behavioral tech-
requires regular blood drawings to monitor niques may have the advantage of not only
glucose levels (Davidson, 2004). Medical treat- reducing the child’s fear but also of facilitating
ments that require regular blood drawings are treatment of the child’s medical condition
compromisedwhenachildpresentswithneedle without major side effects. As a somewhat
phobia (or phlebophobia; Zambanini & Feher, related example, Jones and Friman (1999)
1997) and can be compromised further when showed that math performance was impaired
thechildalsohasadevelopmentaldisabilitylike in the presence of bugs for a child with insect
autism (Love, Matson, & West, 1990). In fact, phobia and that math performance improved
when individuals with autism show fear or following graduated exposure plus differential
avoidance reactions to medical procedures (e.g., reinforcement. We attempted to extend these
dental examination), medical professionals have prior studies by treating needle phobia in
sometimes found it necessary to employ re- a youth with autism using stimulus fading plus
strictive procedures such as sedation or general DRO to allow appropriate monitoring of his
anesthesia (e.g., Braff & Nealon, 1979), which blood glucose levels.
pose additional risks to the patient (cf.
McDowell, Scher, & Barst, 1995).
METHOD
Behavioral treatment of childhood phobias
often involves stimulus fading in the form of Participant, Setting, and Materials
gradually increased exposure to a fear-evoking Oliver was a large (height, 6 ft 1 in.; weight,
stimulus (designed to produce extinction of the 280 lb)18-year-oldboywhohadbeendiagnosed
with autism, mental retardation, and Type 2
WethankBeckyKelso,AprilKisamore,AshleyGlover, diabetes.Heattendedanoutpatientclinic4 days
and John McCollough for their assistance in data
per week for treatment of noncompliance with
collection. DanielShabani is nowat theLovaas Institute.
Reprints may be obtained from Wayne Fisher, who is medical procedures related to his diabetes.
now at the Munroe-Meyer Institute, 985450 Nebraska Specifically, he had not allowed medical profes-
Medical Center, Omaha, Nebraska 68198 (e-mail:
sionals to draw blood in over 2 years. Previous
[email protected]).
doi:10.1901/jaba.2006.30-05 attempts at drawing blood resulted in responses
449
450 DANIEL B. SHABANI and WAYNE W. FISHER
indicativeofdistressandavoidance(twoessential Experimental Design and Procedure
components of phobias) that ranged from A variation of an ABAB reversal design was
whimperingandcryingtoscreaming,elopement, used. During all conditions, the experimenter
self-injury, and aggression. Oliver could follow sat approximately 0.5 m from Oliver and
simple instructions (e.g., ‘‘sit down and place positioned the lancet in front of him at
your hand on the table’’); however, he had no previouslydetermineddistances.Thehorizontal
vocal speech and communicated through a few distance from the tip of the lancet to the tip of
idiosyncratic manual signs. Approximately six to Oliver’s index finger varied based on condition,
nine 10-trial sessions or probes were conducted and the vertical distance (i.e., how far above
during each 2-hr outpatient visit. There were Oliver’s finger) from the tip of the lancet to the
a total of nine visits that occurred four to five tip of Oliver’s finger remained consistent at
times per week over the course of 2 weeks. approximately 8 cm to 10 cm. The starting
Sessions were conducted in a treatment room distance during baseline trials remained con-
(3 m by 3 m) that contained tables, chairs, and stant at 61 cm, whereas the starting distances
assortedreinforcers(e.g.,cookies).Generalization during fading trials were determined prior to
sessions were conducted in a nurse’s station.
each trial and ranged from 1 to 61 cm. The
Blood samples were drawn using an Accu-Chek
initial distance of 61 cm was selected because
SoftclixH lancet device, and blood glucose levels
Oliver neither withdrew his hand nor showed
were measured using an Accu-Chek AdvantageH
signs of distress (e.g., crying) when the lancet
monitor. Inserting a test strip with a sample of
was at least 61 cm away.
blood operated the monitor. After insertion, the
Baseline. Oliver was given a verbal and gentle
monitor provided a reading of blood glucose
physical prompt to place his left hand and arm
levels within 3 to 5 s.
between the outline drawn on the posterboard
at the start of each trial. The therapist then
Response Measurement and
slowly moved the lancet toward Oliver’s index
Interobserver Agreement
finger. Immediately upon initiation of move-
The primary dependent measure was the
ment toward his arm (approximately 60 cm
percentage of successful trials, defined as Oliver
from his arm), he began to pull away. Baseline
movinghisarmnomorethan3 cmduringa10-
trials were terminated if Oliver pulled his arm
strial.Hewastaughttoplacehishandandarm
away or if a blood draw was successfully
between an outline of his hand and arm drawn
completed. Baseline trials consistently lasted
on posterboard that was attached to the top of
10 s or less.
the table. If he moved his arm more than 3 cm
from the outline in any direction, the trial was Stimulus fading plus DRO. During the first
immediately terminated and scored as unsuc- fadingstepofthiscondition(F1),thelancetwas
cessful. Trial-by-trial interobserver agreement horizontally positioned approximately 61 cm
was assessed during 27% of sessions and was from Oliver’s index finger for 10 s. If Oliver
always 100%. kept his hand and arm between the outline on
the posterboard for the entire 10-s interval, he
Preference Assessments immediately received access to the food item
Prior to each session, potential food re- identified during the presession preference
inforcers were identified using a multiple-stim- assessment. If he moved his arm more than
ulus-without-replacementpreferenceassessment 3 cmfromtheoutlineinanydirection,thetrial
(DeLeon & Iwata, 1996). Cookies, potato was immediately terminated, all the materials
chips, popcorn, and soda were the most were removed, and the experimenter turned
frequently chosen foods. away for 10 s. Distances from the tip of his
NEEDLE PHOBIA 451
Figure1. Percentage oftrials inwhich Oliver laid his hand andarm on atable for 10s during baseline (BL) and
stimulusfadingplusDRO.ThearrowsandlabelsF1throughF9showwhenfadingstepswereinitiated. Opencircles
representsessionsinwhichbloodwasdrawnandglucoselevelsweremeasured.Theopentriangle(Session21)represents
aprobe session inwhich attempts todrawblood occurredduring eachtrial.
indexfinger were delineatedon the posterboard RESULTS AND DISCUSSION
on which he laid his hand and arm. We
progressed from one fading step to the next The percentages of successful trials during
after the percentage of successful trials was baseline and treatment are presented in Fig-
100% for two or three consecutive sessions. ure 1. During the initial baseline, Oliver pulled
Except for Session 21, Steps F2 through F7 his hand and arm away every time the
differed from Step F1 only in the distance experimenter attempted to draw blood with
betweenthelancetandOliver’sindexfinger;the the lancet. During F1 (M 5 97%) and F2 (M
distances were 46, 31, 15, 8, 5, and 1 cm for 5100%),Oliverconsistentlykepthishandand
Steps F2 through F7, respectively. During arm within the outline drawn on the poster-
Session 21, each trial began with the lancet board. During a return to baseline, he contin-
8 cm from his finger, and we probed whether ued to pull his hand and arm back when the
hewouldkeephishandstillforablooddrawon experimenter attempted to draw blood. Fading
each trial. wasreintroduced,andOlivercontinuedtokeep
In Step F8, we conducted 10 trials with the his hand and arm within the posterboard
lancet 1 cm above his finger and then at- outline. During the probe session (i.e., Session
tempted to draw blood on the 11th trial. Step 21), Oliver consistently pulled his hand back.
F9wasidenticaltoStepF8exceptthatattempts During the remainder of Step F5 and Steps F6
to draw blood occurred intermittently, some- and F7, he continued to keep his hand still. In
times after 10 trials with the lancet held 1 cm Step F8, a blood draw attempt was initiated
above his finger and sometimes after 20 trials. following Session 30 (the first session in Step 8
452 DANIEL B. SHABANI and WAYNE W. FISHER
in which Oliver was successful for 100% of the Anecdotally, he showed clear signs of distress
trials). In Step F9, his hand remained still (whimpering, crying, and other negative vocal-
during 100% of trials for all sessions except the izations) during the baseline phases and at the
first one (Session 32, 80%). In addition, all start of treatment, and these responses were
attempts to draw blood in Step F9 were absent at the end of the treatment and during
successful, and glucose levels were obtained. In follow-up. Future investigations should include
addition, one of the blood draws took place in objective measures of both avoidance responses
another setting (the nurse’s station), and the and distress (the two essential components of
trials and blood draws conducted at a 2-month phobias) when evaluating the effects of behav-
follow-up visit were all successful. Oliver’s ioral interventions for phobia among children
mother also reported that she was able to draw who do not speak.
blood and measure glucose levels on a daily
basis with no problems. REFERENCES
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One limitation of the current investigation is
McDowell, R. H., Scher, C. S., & Barst, S. M. (1995).
that we did not conduct a component analysis
Total intravenous anesthesia for children undergoing
to determine the independent contributions of brief diagnostic or therapeutic procedures. Journal of
ClinicalAnesthesia,7,273–280.
the stimulus fading and DRO components,
Zambanini,A.,&Feher,M.D.(1997).Needlephobiain
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Received March 4,2005
ing his hand) but we did not specifically
Final acceptance January8, 2006
measure his level of distress during each trial. Action Editor,Douglas W.Woods