Today’s post is a follow-up to this post from last July: Panic! Terror! Meltdown! If you haven’t already read that, you should check it out now before reading this one. I’ll wait until you come back.
All done? You didn’t read it, did you? That’s OK. I never bother to click on links in blog posts, either. To sum it up, last July I wrote a post describing SB’s intensely high anxiety level whenever anything didn’t go his way. If we got stuck in traffic, sat at a long traffic light, his board game didn’t work exactly right, the Wii remote didn’t work the first time, his brother took longer than 5 seconds to fasten his seatbelt, etc., then he became so intensely upset that he would irrationally freak out by screaming, yelling, and hitting or throwing things, and could not pull himself back together. The panic had become so frequent that we couldn’t get through a day without at least several of these irrational freak outs.
So we did what we always do when we have a problem with either child: we turned to our trusted ABA therapist, who usually seems to have a logical answer or approach that we didn’t consider. (We have repeatedly asked her to move in with us, but for some reason she always declines!) And she came up with a plan that involved systematically exposing SB to situations that she knew would upset him, and then teaching him skills to cope with these situations that were out of his control. Because let’s face it, no matter who you are, you are going to come across situations in life that are out of your control and do not go the way you planned! What follows is an outline of her treatment plan for him. It may be a little technical to read, but I hope it gives you a good idea of what the therapist was doing with him to help him get over his anxiety. I summarize each phase in my own words, if that helps with the technical-speak.
Target Behavior: Anxiety response to situations out of his control.
Definition: Including but not limited to heavy breathing, crying, whining, screaming, verbal refusal, elopement, and/or stimming.
Relaxation strategies: Taking three deep breaths, counting to ten, and/or saying, “I can stay calm. I will be OK.”
Appropriate escape request: Verbally requesting “Can I be done?” or “Can I be finished?” with calm body posture, tone, and volume appropriate for the environment, in the absence of the Target Behavior.
Specific aversive scenarios/objects targeted: The game Operation, playing a game that is not working correctly, playing the Wii with either no batteries in remote, game not working, or playing partner having trouble playing the game, parking, traffic, traffic lights.
Successful Trial: Using the relaxation strategies and appropriate escape request when given a verbal cue from the clinician within 3 seconds of prompt in the absence of a maladaptive behavior.
Graduated Desensitization Phases:
1. Client will participate in a preferred activity for no specified duration while across the room from an aversive target or scenario. Client can have immediate escape from aversive target with an appropriate escape request.
2. Client can have a 3-minute high preference activity break between successful trials
3. Client can have a 5-minute escape break (but not the high preference activity) between unsuccessful trials.
4. 10 consecutive successful trials to move onto next phase.
Mindy’s summary of Phase 1 – SB just has to be in the same room while something upsetting is going on, such as the therapist having trouble getting the Wii to work (because she took the batteries out of the remote.) He is not playing the Wii at this phase. He is playing something else that he likes on the other side of the room. If he asks her to stop appropriately without freaking out, she stops, and he gets a highly preferred reward. If he gets upset and does NOT ask her appropriately, he still gets a break, but he does not get the highly preferred reward. There is no specified amount of time that he has to tolerate the upsetting activity in this phase. When he can do this 10 times in a row, he moves to Phase 2.
Client will participate in a preferred activity at half the distance from the aversive target scenario/object. Immediate escape from aversive target with an appropriate request.
Mindy’s summary of Phase 2 – Phase 2 is the same as Phase 1, except that SB has to be physically closer to the upsetting thing.
Client will participate in a preferred activity next to the aversive target scenario/object. Immediate escape from aversive target with an appropriate request.
Mindy’s summary of Phase 3 – Phase 3 is the same as Phases 1 and 2, except that SB has to be sitting directly next to the upsetting thing.
Client will participate in each aversive target scenario/object. Immediate escape from aversive target with an appropriate request.
Mindy’s summary of Phase 4 – SB now has to participate with the therapist in the upsetting game or activity, such as playing Wii with her while she purposely has difficulty choosing the right menu or game options and has to keep going back and redoing the game setup. But still, she will stop immediately and let him have a highly preferred reward if he asks her to stop calmly and appropriately.
Client will participate in each aversive target scenario/object. Escape from aversive target with an appropriate request after tolerating the aversive target for 15 seconds.
Mindy’s summary of Phase 5 – SB has to participate in the upsetting activity, has to calmly and appropriately request to stop, AND the therapist will continue the aversive activity for 15 seconds after his request before she stops and gives him a reward.
Client will participate in each aversive target scenario/object. Escape from aversive target with an appropriate request after tolerating the aversive target for 30 seconds.
Mindy’s summary of Phase 6 – Phase 6 is the same as Phase 5, except that SB has to wait 30 seconds before the therapist stops the activity. He still has to ask to be done with the activity calmly and appropriately, and has to stay calm for the entire 30 seconds. The last phases are the same as Phase 5, but the time that he has to wait before the therapist stops the aversive target gradually increases to 3 minutes.
Our therapist worked with SB on these goals 1-2 times per week for about 3 months. The first clue we had that things were getting better was when we went to visit Santa Claus at West Springfield High School’s “Breakfast With Santa” event in December. Hoping to get in with Santa before the crowds got big, we arrived as soon as the event began and went straight for the line to see Santa. Unfortunately, everyone else seemed to have the same idea, and the line was pretty long. We figured that it wasn’t going to get any better as the day went on, so we got in the line and hoped for the best. We waited THIRTY MINUTES before we got to sit on Santa’s lap and pose for pictures, and SB made it! Oh, he whined a bit, and we heard several choruses of “How many more minutes?” and “When are we gonna get there?” He was fairly calm, though, and we felt that the whining was very age-appropriate for the first 20 minutes. After waiting about 20 minutes, however, he started to stim with his fingers with fury. He held his fingers close to his face and flipped them around furiously, faster even then normal. Although I don’t love the stimming, and it was causing him to get weird looks from the little girl in front of us in line, I let him be, because I knew that he was getting frustrated and needed SOME way to cope. Most importantly, there was no crying, no falling to the floor, no panic, and no lashing out or throwing things. My husband pointed this out to me after our quick visit with Santa was over, and I happily realized that he was right. Just 6 months ago there was NO WAY we could have waited in a line that long, in a strange and unusual setting, without some sort of panic.
On a side note, I realized that I’ve used the phrase “stimming with his fingers” in several posts lately, and I wonder if some of you know what I mean by that. Both of my kids do this frequently. AB learned it from SB, I’m sure. I thought I would include a little video to show you what it looks like.
Later in December, we traveled to the Midwest to visit my family for the holidays. We had a pretty complicated itinerary for our trip, which first involved flying to Chicago. I was performing at a conference with the Air Force Band, so I had to fly earlier than the rest of my family. When Charlie and the boys left for the airport on their travel day, he allowed plenty of time to get to the airport. Or so he thought. We do live in Washington, D.C., you know! He got stuck behind an accident on the highway, and after 25 minutes, he finally broke through the traffic only to get stuck behind ANOTHER accident for 40 minutes more. My poor husband grew more and more frustrated during the hour of painful stop-and-go traffic. He wanted to shout, scream, and pound the steering wheel, but he restrained, because he didn’t want to model bad behavior for the kids. How did SB handle this traffic nightmare? Again, there was some whining and complaining about the traffic, but there was no panic and no behaviors that were irrational. Part of the time, he sat there in the back seat, bopping around to his music. Compare that story to the traffic story from the July blog post: Panic! Terror! Meltdown! (I’m not going to summarize it this time. You’ll have to actually read it this time if you want to compare.) SB was like a completely different person, able to stay calm and not freak out, even though he didn’t know how long the traffic would last. (They made the plane, by the way. BARELY!)
We didn’t use any strategies or methods to help SB with his panic issues other than the ABA plan above. This success makes me want to stand on my roof and shout to the world about how great I think ABA is. And yet, I still come across people, both in person and online, who do not have ABA for their autistic children because they don’t believe that it works. I started to write more in this post about why I think ABA is a great therapy for children with autism, and it got so long I realized it was a completely separate post. So more on that later, and hopefully soon!
Treatment plan by LEARN Behavior Consultation Services