Behavioral Medicine
What is Behavioral Medicine?: “Behavioral Medicine is the interdisciplinary field concerned with the development and integration of behavioral, psychosocial, and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation." (Society of Behavioral Medicine)
Uses of Behavioral Medicine:
How and where is it used?
•Areas of research and practice: cancer, diabetes, HIV/AIDS, obesity, sports medicine, biofeedback, biobehavioral therapy, rehabilitation, preventive medicine, Alzheimer’s treatment, etc.
•Settings: HMOs, outpatient clinics, schools, universities, etc.
•New areas of research and practice: integrating behavioral medicine strategies into managed health care, increasing public awareness of behavioral strategies, including behavioral interventions in clinical practice guidelines, etc. (Society of Behavioral Medicine)
Uses of Behavioral Medicine:
How and where is it used?
•Areas of research and practice: cancer, diabetes, HIV/AIDS, obesity, sports medicine, biofeedback, biobehavioral therapy, rehabilitation, preventive medicine, Alzheimer’s treatment, etc.
•Settings: HMOs, outpatient clinics, schools, universities, etc.
•New areas of research and practice: integrating behavioral medicine strategies into managed health care, increasing public awareness of behavioral strategies, including behavioral interventions in clinical practice guidelines, etc. (Society of Behavioral Medicine)
ABA in Health & Medicine
As you can see by the graphic on the left the science of applied behavior analysis can and has been put into practice across a wide variety of sub-fields within the medical field. ABA has been used in gerontology to increase compliance medical treatment recommendations. Rehabilitation has used the practice of applied behavior analysis to help addicts stop using drugs by setting up contingency management packages. Finally, behavioral pediatrics is a topic that we will cover in-depth in this section. Behavioral pediatrics has used ABA to increase compliance with medical treatments, reducing food and fluid consumption difficulties, and decreasing other undesired behaviors to name a few. For more information on the various applications of applied behavior analysis please refer to the following links and please see additional links located under the additional resources tab:
Gerontology:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308081/pdf/jaba00026-0012.pdf
http://abaiconference2009.blogspot.com/2009/05/preparing-for-aging-tsunami-behavior.html
http://seab.envmed.rochester.edu/jaba/articles/2011/jaba-44-03-0687.pdf
Gerontology:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308081/pdf/jaba00026-0012.pdf
http://abaiconference2009.blogspot.com/2009/05/preparing-for-aging-tsunami-behavior.html
http://seab.envmed.rochester.edu/jaba/articles/2011/jaba-44-03-0687.pdf
Applied Behavior Analysis and Behavioral Pediatrics:
The use of applied behavior analysis within pediatrics has been used with a wide variety of issues that parents and medical professionals face not only with children with autism but also with typically developing children. For the purpose of the training manual we are going to be focusing on issues that will be seen at home as well within the center such as food consumption and fluid consumption issues, dealing with visiting the doctor, and providing guidance to parents dealing with common issues such as bedtime issues. For more information on the use of applied behavior analysis within the field of behavioral pediatrics please refer to the "Behavioral Pediatrics" links that can be found in the additional resources tab.
Common Issues
As previously mentioned there are various issues within behavioral pediatrics that have been addressed by using the science of applied behavior analysis in practice. We will begin by discussing a very common issue that children with autism face, which is food and fluid consumption issues. There are various reasons as to why children with autism have such difficulties with feeding and fluid consumption but the most prevalent reason is due to the sensory deficits the child has.
Feeding Issues:
A common method that has been used to increase food consumption in young children with autism and typically developing children is a program based out of the United Kingdom called "Food Doods". This program uses the principle and technique of positive reinforcement and modeling to increase eating healthy foods such as fruits and vegetables. Children first watched videos that starred two animated characters, Jess and Jarvis. The videos showed Jess and Jarvis enthusiastically eating the two target foods. At the start of the intervention, the children received a letter from Jess and Jarvis that explained the experimental procedures. On subsequent days, the students received letters from Jess and Jarvis that contained general feedback pertaining to the pervious day's food consumption and that reiterated the reinforcement criterion. The following video is a youtube video that highlights the procedures used to implement the "Food Dudes" program. The video that will immediately follow will show how children received their "rewards" or reinforcers for eating healthy foods. As you will begin to see while watching the videos that this program is a method that is more suitable for higher functioning children with autism who can understand the criterion that has been set to obtain their desired reinforcers. Other procedures will be highlighted that can be used with children who are having a more difficult time eating and "Food Doods" is not working for them.
Feeding Issues:
A common method that has been used to increase food consumption in young children with autism and typically developing children is a program based out of the United Kingdom called "Food Doods". This program uses the principle and technique of positive reinforcement and modeling to increase eating healthy foods such as fruits and vegetables. Children first watched videos that starred two animated characters, Jess and Jarvis. The videos showed Jess and Jarvis enthusiastically eating the two target foods. At the start of the intervention, the children received a letter from Jess and Jarvis that explained the experimental procedures. On subsequent days, the students received letters from Jess and Jarvis that contained general feedback pertaining to the pervious day's food consumption and that reiterated the reinforcement criterion. The following video is a youtube video that highlights the procedures used to implement the "Food Dudes" program. The video that will immediately follow will show how children received their "rewards" or reinforcers for eating healthy foods. As you will begin to see while watching the videos that this program is a method that is more suitable for higher functioning children with autism who can understand the criterion that has been set to obtain their desired reinforcers. Other procedures will be highlighted that can be used with children who are having a more difficult time eating and "Food Doods" is not working for them.
This video shows how the "Food Doods" program has been implemented in elementary schools across the country.
This video shows how the reinforcement criterion was presented to the children and the various items that could be earned by each child. Again this procedure may not be suited for all children with autism however, it is up to the case managers to decide case by case what procedure is best suited for a child who does exhibit difficulties with eating. Please refer to the following link for an article that used the "Food Doods" procedure:
http://www.fooddudes.co.uk/en/evidence/documents/Horneetalpre-school2011.pdf
http://www.fooddudes.co.uk/en/evidence/documents/Horneetalpre-school2011.pdf
There are other methods that can be implemented to help children who are having an especially hard time increasing their food consumption and trying novel foods. In these cases, a shaping procedure may be used to help the child with feeding. In a food shaping procedure, successive approximations (or small steps) towards the target behavior are reinforced. Food shaping procedures can also resemble a negative reinforcement procedure because the child is escaping from the aversive situation by emitting the target behavior. A typical food shaping procedure can resemble the following:
***NOTE 2: Please DO NOT run the feeding protocol during a session with a child if you have not received training.
***NOTE 3: If you have not been trained on the feeding protocol please the case manager immediately in order to be trained.
Another important feature of this procedure is in order for the child to receive reinforcement (escape from the undesired situation) they must remain calm at each step. It is recommended that each step be performed correctly three times before moving on to the next step. Also, the above procedure is just an example that we have given, each protocol will look different for different food for the same child and will look different for each child. Additionally, the start and stop steps will vary on each given day depending on the food and the child's affect during lunch/snack time. Finally, it is important to keep this experience as POSITIVE as possible for the child. Shaping procedures have a high risk of causing harm if they are not performed correctly, an example of which is the child will stop eating all together because the process of eating has become a very negative event for them. Below we have provided some tips to help keep this process a positive one:
http://www.jeabjaba.org/jaba/articles/2006/jaba-39-03-0399.pdf
Bedtime Resistance:
As a therapist you will come across many children who exhibit resistance to bedtime. Some reasons as to why children display resistance can include attention, scared of the dark, they are not tired, etc. In order to handle resistance to bedtime, parents will be trained by the case manager on a procedure to help their children overcome resistance to bedtime. However, we find it beneficial that every therapist know and understand the programs that are in place for the children that you work with even if some of the programs are only implemented at home. A procedure that has been used to decrease undesired behaviors (i.e., getting out of bed, repeatedly leaving the bedroom, calling out to mom or dad after being tucked in, etc.) associated with bedtime is the use of a bedtime pass. The following illustrates the protocol in list form and will be followed by two YouTube videos that depict how the procedure should ideally look and what parents should do when the child displays undesired behaviors:
- Have the child touch the plate
- Have the child touch the food item (for ease sake, we will say the child is having trouble eating a graham cracker)
- Have the child pick-up the graham cracker
- Child touches graham cracker to their lips
- Child touches graham cracker to teeth
- Child holds graham cracker in open mouth (does not need to bit down or touch the cracker to their tongue at this step)
- Child touches graham cracker to their tongue
- Child bites down on graham cracker (Child does not need to bit through the cracker at this step)
- Child bites all the way through the graham cracker (At this step, the child can spit the cracker out after they have remained calm following the bite)
- Child chews the graham cracker bite for 3 seconds (following the 3 seconds, the child can spit the bite out)
- Child chews the graham cracker bite for 5 seconds (following the 5 seconds, the child can spit the bite out)
- Child swallows graham cracker bite
***NOTE 2: Please DO NOT run the feeding protocol during a session with a child if you have not received training.
***NOTE 3: If you have not been trained on the feeding protocol please the case manager immediately in order to be trained.
Another important feature of this procedure is in order for the child to receive reinforcement (escape from the undesired situation) they must remain calm at each step. It is recommended that each step be performed correctly three times before moving on to the next step. Also, the above procedure is just an example that we have given, each protocol will look different for different food for the same child and will look different for each child. Additionally, the start and stop steps will vary on each given day depending on the food and the child's affect during lunch/snack time. Finally, it is important to keep this experience as POSITIVE as possible for the child. Shaping procedures have a high risk of causing harm if they are not performed correctly, an example of which is the child will stop eating all together because the process of eating has become a very negative event for them. Below we have provided some tips to help keep this process a positive one:
- Be aware of the child's affect
- Reinforce approximations using tons of social reinforcement and removing the food item immediately
- Try to refrain from being greedy: It is very difficult to keep from becoming greedy especially when the child is doing well. It is better to stop while you are ahead to keep the child performing at a high level.
- If a child is having a hard time completing a step DO NOT try to force the child to complete the step. Move back to a step that the child can complete so that they can obtain reinforcement
- When in doubt, call the case manager. If you do not feel comfortable implementing the protocol on your own, please call the child's case manager. They will be more than happy to observe and provide feedback while you implement the program.
- REMEMBER TO FOLLOW THE CHILD'S LEAD DURING IMPLEMENTATION OF THIS PROTOCOL: It is better to not make very much progress or to have slow progress then to run the risk of the process becoming so aversive that the child will stop eating all together.
- Cigna Feeding Difficulties PowerPoint: http://www.cigna.com/assets/docs/behavioral-health-series/autism/2013/behavioral-feeding-handouts.pdf
- Fading Procedures:
http://www.jeabjaba.org/jaba/articles/2006/jaba-39-03-0399.pdf
- Differential Reinforcement:
Bedtime Resistance:
As a therapist you will come across many children who exhibit resistance to bedtime. Some reasons as to why children display resistance can include attention, scared of the dark, they are not tired, etc. In order to handle resistance to bedtime, parents will be trained by the case manager on a procedure to help their children overcome resistance to bedtime. However, we find it beneficial that every therapist know and understand the programs that are in place for the children that you work with even if some of the programs are only implemented at home. A procedure that has been used to decrease undesired behaviors (i.e., getting out of bed, repeatedly leaving the bedroom, calling out to mom or dad after being tucked in, etc.) associated with bedtime is the use of a bedtime pass. The following illustrates the protocol in list form and will be followed by two YouTube videos that depict how the procedure should ideally look and what parents should do when the child displays undesired behaviors:
- The child is given the bedtime pass and the parents explain the rules of using the bedtime pass. The rules are stated to the child as follows: "Tommy, here is your bedtime pass, you can use it one time tonight to get out of bed for three-minutes. After your three-minutes are over, you will give me the bedtime pass and get back into bed. Don't worry, you will get another bedtime pass to use tomorrow night but once you have used it tonight, no more getting out of bed."
- As stated in the rules, the child can use the bedtime pass once that night after being put into bed for a short activity (i.e., one more hug, going to the bath, etc.) that lasts no longer than three minutes.
- The child will give their parents the bedtime pass AFTER completing the activity and will get back into bed.
- The expectation is the child will not get out of bed after using the bedtime pass. However, if the child does continue to exhibit challenging behaviors (i.e., continues calling out, repeatedly leaves the bedroom, etc.) the parents are directed to ignore the all challenging behaviors and guide the child back into the bedroom while maintaining neutral affect and not saying anything to the child.
- Remind the parents that it may be very stressful for them but it is vital that they remain CALM and keep NEUTRAL AFFECT. Under no circumstances should the parents show anger or hostility towards their child and to not say anything whatsoever to the child (this is the extinction portion of the procedure).
- After a few nights of the child successfully using the bedtime pass and remaining in bed following handing the pass over to their parents, fading of the bedtime pass should begin. Again, when to begin fading will vary depending on the child. Additionally, the child may have a week of successfully using the bedtime pass and the parents begin to fade the time the child can remain out of bed while using the pass (i.e., from three minutes to two minutes) and the child begins to display challenging behaviors again after using the pass. In this case, it is recommended that the parents first, contact the case manager and second it may be necessary to fade the duration the bedtime pass can be used with smaller steps (i.e., from three minutes to two and a half minutes or even smaller steps).
Bedtime Resistance:
As a therapist you will come across many children who exhibit resistance to bedtime. Some reasons as to why children display resistance can include attention, scared of the dark, they are not tired, etc. In order to handle resistance to bedtime, parents will be trained by the case manager on a procedure to help their children overcome resistance to bedtime. However, we find it beneficial that every therapist know and understand the programs that are in place for the children that you work with even if some of the programs are only implemented at home. A procedure that has been used to decrease undesired behaviors (i.e., getting out of bed, repeatedly leaving the bedroom, calling out to mom or dad after being tucked in, etc.) associated with bedtime is the use of a bedtime pass. The following illustrates the protocol in list form and will be followed by two YouTube videos that depict how the procedure should ideally look and what parents should do when the child displays undesired behaviors:
- The child is given the bedtime pass and the parents explain the rules of using the bedtime pass. The rules are stated to the child as follows: "Tommy, here is your bedtime pass, you can use it one time tonight to get out of bed for three-minutes. After your three-minutes are over, you will give me the bedtime pass and get back into bed. Don't worry, you will get another bedtime pass to use tomorrow night but once you have used it tonight, no more getting out of bed."
- As stated in the rules, the child can use the bedtime pass once that night after being put into bed for a short activity (i.e., one more hug, going to the bath, etc.) that lasts no longer than three minutes.
- The child will give their parents the bedtime pass AFTER completing the activity and will get back into bed.
- The expectation is the child will not get out of bed after using the bedtime pass. However, if the child does continue to exhibit challenging behaviors (i.e., continues calling out, repeatedly leaves the bedroom, etc.) the parents are directed to ignore the all challenging behaviors and guide the child back into the bedroom while maintaining neutral affect and not saying anything to the child.
- Remind the parents that it may be very stressful for them but it is vital that they remain CALM and keep NEUTRAL AFFECT. Under no circumstances should the parents show anger or hostility towards their child and to not say anything whatsoever to the child (this is the extinction portion of the procedure).
- After a few nights of the child successfully using the bedtime pass and remaining in bed following handing the pass over to their parents, fading of the bedtime pass should begin. Again, when to begin fading will vary depending on the child. Additionally, the child may have a week of successfully using the bedtime pass and the parents begin to fade the time the child can remain out of bed while using the pass (i.e., from three minutes to two minutes) and the child begins to display challenging behaviors again after using the pass. In this case, it is recommended that the parents first, contact the case manager and second it may be necessary to fade the duration the bedtime pass can be used with smaller steps (i.e., from three minutes to two and a half minutes or even smaller steps).
In this section, we have only highlighted some of the applied behavior analysis procedures that have been used in behavioral pediatrics. There are numerous way in which these techniques have been used in the medical field. For more information, please refer to the additional behavioral medicine links located in this section and under the additional resources tab.