ANXIETY DIOSRDERS & ABA

• As the name implies it is applied and therefore is based on practice rather than theory and focuses on changing the observable behaviour of the individual and how it affects a particular situation. ABA is a form of almost pure behaviourism.• Applied behaviour analysis (ABA) is the

application of the principles of operant learning theory to socially-significant behaviours.

APPLIED BEHAVIOURAL ANALYSIS

• Anxiety is the most common psychological condition displayed in children and adolescents. There are a variety of specific anxiety disorders that may be present in children. The predominant theme of all the anxiety disorders is “uncontrollable worry”.

ANXIETY DISORDER

• Applied Behavioral Treatment (ABT) involves systematic and structured attempts to increase the level of meaningful activity in a person’s everyday life, thereby helping clients to contact sources of positive reinforcement for behaviors that correspond with clinical improvements • ABA techniques are applied in order to reduce anxiety by

increasing positive reinforcement. • It is application of principles of operant psychology including

positive and negative reinforcement.

APPLIED BEHAVIOURAL TREATMENT

• The anxiety disorders differ considerably, so techniques should be tailored to your specific symptoms and concerns.

• The length of intervention will also depend on the type and severity of anxiety disorder. However, many anxiety therapies are relatively short-term. According to the American Psychological Association, many people improve significantly within 8 to 10 therapy sessions.

1 Separation Anxiety Disorder

Overwhelming fear of harm or loss significant figure.

2 Selective Mutism persistent failure to speak in public situations where speaking is expected, despite speaking in other situations

3 Social phobia Marked and consistent fear of performing publicly4 Specific Phobia Intense fear of a particular object or situation5 Generalized Anxiety

DisorderExcessive worry and anxiety about a number of events and activities

5 Agoraphobia Intense fear of being in public places where escape might be difficult.

7 Panic Disorder Uncontrollable panic attacks with significant fear about future attacks

• Comprehensive ABA Interventions are aimed at producing changes in specific skills that impact global measures of functioning including IQ, adaptive skills, and social functioning in children with autism.

• Typically, such treatment is provided for an extended period (often spanning several years) and is often a home- or center-based program (sometimes in an educational setting).

• These programs rely on the use of clear instructions, reinforcement, teaching small units of behaviour, and repeated trials to maximize learning opportunities.

• Focused ABA Interventions are generally more time-limited in nature because they are designed to address specific behaviour deceleration concerns including aggression, self-injury, disruptive behaviour, pica, and other challenging behaviours. 

• Focused interventions can also address other concerns such as anxiety and skills deficits (i.e., social skills and self-care deficits).

• Anxiety shares functional similarities with depression because (anxious) individuals who report high levels of anxiety respond to a relatively high frequency of negative reinforcement where avoidance behavior is commonplace. • Avoidance is a key feature of the diagnostic criteria for an anxiety-

related disorder (American Psychiatric Association (APA), 2000).

ANXIETY DISORDER & ABA

• Increased access to response-contingent positive reinforcement for approach behavior with concurrent decreases in negative reinforcement for avoidance behavior could lead to greater engagement in activities that have anxiolytic functions, with a gradual extinction of anxious responses.

SEPARATION ANXIETY DISORDER

The (DSM-V) identifies Separation Anxiety Disorder as a

“developmentally inappropriate and excessive fear or anxiety

concerning separation from home or from those to whom the

individual is attached”

Children exhibiting SAD symptoms become significantly distressed when separated from their home or attachment figure (usually a parent) and will often

take measures to avoid separation.

This fear is exhibited through

disproportionate and persistent worry about separation,

including apprehension about harm befalling a

parent or the child when they are not

together, as well as fear that the parent will leave and never

return.

Avoidance behaviors commonly associated

with SAD include clinging to parents,

crying or tantruming, and refusal to participate in

activities that require separation (e.g., play

dates, camp, sleepovers).

When confronted with situations that require separation, such as bedtime or school attendance, a child with SAD may tantrum or refuse to comply with

parents’ instructions. Oppositional behavior in the course of SAD often arises from the inadvertent

reinforcement of the child’s avoidance behaviors and misconduct.

For instance, when a child tantrums or “causes a scene,” parents may remove the child from the

anxiety-provoking situation. As a result, these actions may reinforce the disruptive, inappropriate behavior.

Emotional Security• The “cure” for separation anxiety is emotional security that is

allowed to grow over an extended period of time.  But emotional security may be elusive for a child with chronic, severe anxiety.  In many cases, this emotional security can be done by parents through social reinforcement, habit repetition and schedules of reinforcement.

Extinction• Extinction occurs when you withhold or remove the CSE that is

reinforcing the client’s maladaptive behavior.

SOCIAL ANXIETY DISORDER

Social Anxiety Disorder, also called social phobia, in which a person has an excessive and unreasonable fear of social situations. Anxiety (intense

nervousness) and self-consciousness arise from a fear

of being closely watched, judged, and criticized by others.

A person with social anxiety disorder is afraid that he or she will make mistakes, look bad,

and be embarrassed or humiliated in front of others. The fear may be made worse

by a lack of social skills or experience in social situations.

• Various forms of exposure (imaginal, in vivo), social-skills training, or combinations of these can be used.• Behavioral approaches emphasize prolonged

exposure to social stimuli both within and between sessions via homework assignments (e.g., Newman, Hofmann,Werner, Roth, & Taylor, 1994).

SOCIAL ANXIETY DISORDER

FadingFading involves taking a behavior that occurs in one situation and getting it to occur in second situation by gradually changing the first situation into the second.

Exposure therapyExposure therapy involves a controlled environment in which patients are gradually exposed to situations that would normally cause anxiety in them. The purpose is to slowly desensitize them to those triggering situations until those triggers become manageable, or completely eliminated. As a result, the patient has less panic or fewer anxiety attacks over time.

• Agoraphobia is an intense fear of being in public places where you feel escape might be difficult.

Entering shops, crowds, and public places.Travelling in trains, buses, or planes.Being on a bridge or lift.Being in a cinema, restaurant, etc, where there is no easy exit.Being anywhere far from your home.• They all stem from one underlying fear. That is, a fear of being

in a place where help will not be available, so you tend to avoid public places, and may not even venture out from home.

AGORAPHOBIA

• Behavioural therapy aims to change any behaviours which are harmful or not helpful.

• For example, with phobias your behaviour (your response to the feared object) is harmful, and the therapist aims to help you to change this.

• Various techniques are used, depending on the condition and circumstances. For example, in agoraphobia, the therapist will usually help you to face up to feared situations, a little bit at a time.

• A first step may be to go for a very short walk from your home with the therapist who gives support and advice. Over time, a longer walk may be possible, then a walk to the shops, and then a trip on a bus, etc. The therapist teaches you how to control anxiety when you face up to the feared situations and places. For example, by using deep breathing techniques. 

TREATMENT THROUGH ABA

• Mostly positive reinforcement is used in combination with exposure therapy.

• Behavioural treatments (e.g., exposure in vivo) similarly have been shown effective when compared to other psychological interventions. Clum, Clum, and Surls (1993) reported.

• In vivo exposure refers to the direct confrontation of feared objects, activities, or situations by a patient.

• Panic disorder is a condition where you have recurring panic attacks.• A panic attack is a severe attack of anxiety and fear which occurs suddenly,

often without warning, and for no apparent reason. In addition to the anxiety, various other symptoms may also occur during a panic attack. These include one or more of the following:

A thumping heart (palpitations). Sweating and trembling, Dry mouth. Hot flushes or chills, Fear of dying or going crazy. Feeling short of breath, sometimes with choking sensations. Chest pains., Feeling sick (nauseated), dizzy, or faint. Feelings of unreality, or being detached from yourself.

PANIC DISORDER

• Behavioral theories of anxiety disorders (e.g., Mowrer, 1960) posit that pathological fears are acquired through classical conditioning processes and maintained through operant conditioning (i.e., reinforcement) of avoidance behavior. • With repeated and prolonged exposure, anxiety responses

gradually diminish, a process known as habituation (Wolpe, 1958).• Other theorists (e.g., Foa & Kozak, 1986) have postulated that

exposure procedures work by providing the patient with corrective information about the dangerousness of feared situations.

TREATMENT TROUGH ABA (PANIC DISORDER)

• Exposure to feared bodily sensations (i.e., interoceptive exposure), is used to treat panic disorder

• Specifically, interoceptive exposure is designed to help individuals directly confront feared bodily symptoms often associated with anxiety, such as an increased heart rate and shortness of breath.

• The therapist may assist this by having the client (in a controlled and safe manner) hyperventilate for a brief period of time, exercise, or hold his breath.

• Selective mutism refers to a persistent failure to speak in public situations where speaking is expected, despite speaking in other situations (American Psychiatric Association, 2000). • Children with selective mutism commonly fail to speak

in situations outside their home and especially in places such as school, restaurants, stores, and recreational settings. From a diagnostic perspective, selective mutism must last at least one month. 

SELECTIVE MUTISM

• Behavioral strategies: refers to coming up with a step-by-step plan where the child gradually does more and more difficult speaking-type behaviors, as well as coming up with a system of positive reinforcement whenever the child is able to accomplish those behaviors.• Contingency management involves positive reinforcement of (or

rewarding for) verbal behavior with initial reinforcement of nonverbal communication like pointing and whispering• Shaping reinforcement is provided for approximations of the target

verbal behaviors (e.g., mouthing words, whispering, talking on the telephone) and later for normal speech. A reinforcement menu (what types of rewards the child wants to earn and for what behaviors) is first developed in collaboration with the child.

TREATMENT TROUGH ABA (SELECTIVE MUTISM)

• Stimulus fading interventions build on the success of contingency management and shaping by gradually increasing the number of people and places in which speech is rewarded. For example, the child may first be rewarded for speaking to a classmate to whom s/he already speaks outside of school. Gradually, other students are introduced into the group until the child is able to speak in the presence of a large group of peers. Stimulus fading can also be used in problematic situations that occur outside of school (e.g., talking to grandparents, ordering in fast food restaurants).

• Systematic desensitization traditionally involves the use of relaxation skills along with gradual exposure to successively more anxiety-provoking situations. In this type of intervention a hierarchy of feared speaking events is constructed and therapy consists of a series of imaginal and in vivo (real-life) exposures to feared situations

• Social skills training may also be used to reduce anxiety and facilitate speech with peers and involves learning what to say to initiate conversations, how to take turns, making eye contact, and learning how to understand another person’s nonverbal behavior.

• (self-) Modeling involves making video and/or audiotapes that have been edited to depict the child speaking in settings in which he or she has previously remained mute. The tapes are played repeatedly throughout the intervention, with the expectation that the child will become accustomed to hearing him- or herself speaking in these settings and will begin to believe in his or her ability to do so.

• A single-case within-subject experimental (A/B/C) design was used for evaluating treatment effects on the reported anxiety levels of each participant. The A phase was baseline; B phase was treatment; and C phase was maintenance/follow-up. Standardised repeated measures of anxiety were collected during each phase and the participants were required to self-monitor their anxiety-related behaviours daily. • During baseline, each participant was required to complete daily

self-monitoring of anxiety and activity levels using diaries developed for this study. • The duration of phase B (treatment) was 84 days for all

participants.

STUDY WITH ANXIETY PATIENTS EXPERIMENTAL DESIGN

• The aim of study was to increase the amount of approach-oriented, socially important behaviors in the participant’s daily life (positive reinforcement) while decreasing the frequency of habitual avoidance behaviours (negative reinforcement). • This was achieved by helping participants bring their overt behaviors

more under the control of life goals and related scheduled daily-activities. • The duration of phase C for each participant was 84 days (3 months) and

the phase commenced immediately after the completion of the treatment phase B. The aim was to observe participant behaviour independent of the structural variables inherent in the earlier baseline and treatment phases.

• Frank’ was a 51-year-old male reporting a history of chronic anxiety with repeating periods of abdominal discomfort, tightness in the throat area, hot flushes, sweating, rapid breathing, and intense worry occurring since adolescence. • He reported that he often engaged in worry about his relationships,

work, his long-term life direction, and anxiety itself. • Frank met DSM-IV (APA, 2000) criteria for Social Anxiety Disorder

(SAD; generalised) and Generalised Anxiety Disorder (GAD).

CASE 1: GAD(GENERALIZED ANXIETY DISORDER)

• “Mary” was a 62-year-old female who reported strong anxiety in relation to road- and vehicle - related activity. She stated that she had never driven independently, did not have a driving licence, had “always been nervous” when travelling in cars and buses, and experienced fear when walking adjacent to or crossing highly-populated roads and traffic intersections. • She reported that she had been fearful of cars and car -travel since

she was a child although she couldn’t explain why. • Mary met DSM-IV (APA, 2000) criteria for Specific Phobia

(situational) and Generalised Anxiety Disorder (GAD).

CASE 2: SPECIFIC PHOBIA

• Decreased scores in self-reported anxiety were obtained in each case and the improvements were maintained during a 3-month no treatment maintenance phase.• Compared to baseline, each participant also recorded increases in

activity levels in some key life areas during the treatment phase.• These preliminary findings suggest that increased activation in

functionally positive areas is associated with reported decreases in anxiety• positive reinforcement and negative reinforcement could be an

effective stand-alone treatment for anxiety in adults.

THANK YOU!!!