What is anxiety in the first place?
Individuals with Autism and Intellectual and Developmental Disabilities struggle with anxiety the same as any of us. When working with these individuals, behavioral and mental health, education, and medical professionals struggle to effectively treat anxiety. Let’s begin with a scene common to those working with these individuals before getting to what behavior analysis has to offer as a treatment.
When Maria walked up the stairs it was awful to see. She trembled, sweated, turned red, and could hardly walk at all. If staff prompted her to move quickly she became visibly upset and sometimes struck out at staff. AS someone who did not talk, Maria could not tell us what the problem was, but it certainly looked like she was terrified of going up the stairs.
Anxiety is a common experience for all of us: We should all be scared of some things. Clearly anxiety and fear are highly adaptive in some situations, although sometimes anxiety becomes non-adaptive when is it pervasive or related to non-threatening stimuli. Behavior analysis has addressed this topic many years ago. Estes and Skinner (1941) showed that stimuli that in the past have predicted aversive stimuli some to suppress ongoing adaptive behavior in a similar way that we freeze or slow down as we approach a scary situation.
Most of us know how to deal with anxiety independently. We behave bravely in the face of threats. We “screw up our courage” to tell the boss the bad news or make ourselves be brave and walk along the scary cliff path. For others, anxiety is more severe and disabling and people often seek help through psychiatry typically using anxiolytic medication or through various mental health professions, usually through a package of cognitive behavior therapy. More severe forms of anxiety are associated with problematic behavior such as avoidance and abuse of alcohol and other anxiolytic substances. There is a very extensive research literature on the treatment of anxiety with adolescents and adults in the general population.
Anxiety with Autism and Intellectual and Developmental Disabilities
For individuals with autism and intellectual disabilities, anxiety disorders are also common. Behavior analysis has much to offer. Dating back to the work of Wolpe, various forms of exposure therapy are often powerfully effective for many fears, phobias, and trauma-related anxiety disorders. People have extended this work to individuals with autism and intellectual disabilities with considerable success. Examples include exposure therapy for individuals scared of needles, dental procedures, etc. Some important differences include challenging behavior that occurs in the presence of stimuli that predict fear and are probably reinforced by the removal of the fear-eliciting stimuli. Recent work on the disruption of rituals has been an interesting development in this area. Outside of behavior analysis, researchers have been active in evaluating cognitive behavior therapy, especially with adolescents with Asperger syndrome, but such packages almost always involve some element of exposure therapy.
What does behavior analysis have to offer to treat anxiety in these cases?
Behavior analysts should know about the functional assessment and analysis of anxiety and fear disorders in individuals with autism and intellectual disabilities because such problems are highly disruptive in the lives of some individuals and their family members and staff. We also have effective therapies to offer that can make a unique contribution to the lives of the people we work with.
After observing Maria’s behavior carefully we could not figure out any triggers that made the problem better or worse. We did work out a simple exposure program. We reassigned her to a downstairs room on a temporary basis. We learned that she calmed down with her favorite music and certain staff. After practicing this for a few weeks we gradually re-exposed her to the stairs – literally one step at a time – only progressing on to the next step when she appeared comfortable at the current step. It took a few weeks, but Maria had conquered her fear with the help of behavior analysis.
Professor Peter Sturmey, Ph.D.
ABAC Resident Speaker
If you are interested in learning more about the treatment of anxiety in individuals with ID or DD, please join Professor Peter Sturmey for a new 3-hour webinar dedicated to this topic on Thursday, September 20, 2018, at 6:00 pm eastern. Learn more