Episode 348 - Medical Toleration

Summary

ABA Inside Track – Episode 348: Medical Toleration

Release Date: June 24, 2026
Hosts: Robert Perry Crews (Rob), Jacqueline "Jackie" McDonald, Diana Perry Cruz

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Episode Overview

This episode explores “medical toleration,” with the hosts discussing behavior analytic research focused on helping individuals, particularly children with autism and developmental disabilities, tolerate necessary but potentially aversive medical procedures. The episode centers on practical approaches, research findings, and the real-world importance of compliance with medical routines. Three peer-reviewed articles serve as focal points: training compliance during physical exams, increasing compliance with nail trimming, and behavioral support for EEG procedures.

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Article Summaries & Discussion

1. Training Compliance with Physical Exams (Kuvo et al., 2010)

• [03:29–26:46]
  Main Idea: Implementing a comprehensive, multi-component intervention to train children with ASD to tolerate a standard 10-step physical exam.

Key Points:

• Background: Children with autism and developmental disabilities often face challenges in complying with medical routines, leading to aversion, distressed behavior, and riskier care.
• Why It Matters:

  "Individuals with a lot of disabilities may also have a lot of health-related problems... pair that with... challenges... higher rates of problem behavior, it makes compliance with medical procedures difficult." — Rob [08:02]

• Method:
  • Participants: Children (ages 3–6) with ASD; all with prior non-compliance in physical exams.
  • Intervention:
    • Big ‘package’ intervention:
      • Contact desensitization
      • Video priming (puppet dinosaur DVD)
      • Photo prompts & modeling
      • Shaping & prompt fading
      • Differential reinforcement (DRO)
      • Escape extinction
    • Delivery: Mostly by BCABAs/graduate students in a university clinic setting, with post-tests run by a physician’s assistant.
    • Steps Targeted: Entering/exiting exam room, sitting/lying on table, stethoscope use, "Say ah," ear/nose/throat inspection, play breaks.
• Findings:
  • All but one participant mastered nearly all exam steps.
  • Generalization observed to both new examiners and the actual clinic setting (some required additional practice).
  • Varied idiosyncrasies: Practice effects and response to video priming; unclear reinforcement application (per step? per session?).
• Caveats:
  • Replication Challenge:

    "Did they describe exactly what all of these treatments looked like? Not exactly... not as replicable as I would've wanted." — Rob [06:24]

  • Component Uncertainty:

    "They didn’t do a component analysis... You do not need all of these." — Rob [26:36]

  • DVD Use:

    "Did kids like the DVD? Some really did... some tried to eject it from the machine or cover their ears." — Rob [23:13]

  • Notable Moment: General amusement at the “dinosaur DVD” and speculation on its contribution to the treatment package.

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2. Increasing Compliance with Nail Cutting (Dowdy et al., 2018)

• [30:23–41:52] Main Idea: Using positive reinforcement (edibles) and stimulus fading—without extinction—for nail cutting in two adolescents with ASD.

Key Points:

• Background:
  • Nail cutting is often aversive, leading to resistance and escape-maintained behavior.
  • Extinction (blocking escape) isn't advisable due to risks (e.g., accidental clipping, escalating distress).
• Method:
  • Two adolescent males in a residential school, both non-vocal, with long-standing resistance to nail trimming.
  • Reinforcer:
    • Jackson: Reese’s Peanut Butter Cups
    • Stephen: Whoppers

    "Maybe they borrowed Rob's grab bag bag, put all the reinforcers in it, and are just distributing them willy-nilly." — Diana [37:00]

  • Procedure:
    • Baseline: Attempt nail cutting; escape permitted for problem behavior.
    • Treatment: “For each nail I cut, you will get a snack.” If the participant resisted, escape granted for 5 seconds, then retried until session ended or all 10 nails were cut. No escape extinction.
    • Sessions occurred every 2+ weeks to allow nails to regrow.
• Findings:
  • Jackson achieved 100% compliance; Stephen made significant visible progress.
  • Some escape responses remained but dropped over time.
  • Graphs were “really pretty” and demonstrated clear treatment effects.
• Reversal Design:
  • Demonstrated maintenance and immediate regression to noncompliance if reinforcement was removed.
• Extensions:
  • Didn’t attempt to fade “one snack per nail,” but session frequency (every 2 weeks) limited excessive edible use.
  • Would’ve liked family/caregiver generalization.

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3. Facilitating Compliance with EEG Procedures (Slipher et al., 2008)

• [42:11–55:50] Main Idea: Multi-component behavioral intervention (differential reinforcement, counter-conditioning, shaping, staff training) for EEG toleration in children with epilepsy and developmental disabilities.

Key Points:

• Background:
  • EEGs involve 20+ leads attached to the head, can last 1 hour (day) or overnight.
  • Tolerance is difficult due to duration, sensory sensitivities, and potential for distress.
  • Medical sedation is not recommended (can affect results).
• Participants: 7 children (with ASD, blindness, other DDs), all with failed prior EEG attempts.
• Procedure:
  • Extensive task analysis (steps from entering room to letting all leads be applied); often 100+ steps.
  • Treatment package included:
    • Preferred items as distractors and comfort, and some secondary rewards.
    • Differential reinforcement: “Cooperation, instruction following, tolerating procedures.”

      “Reinforcers were videos, music, and stories... if they saw the child start to not comply, then they paused them." — Diana [52:03]

    • Escape extinction: Gentle interruption of removal attempts; redirecting to alternative activities.
    • Counter conditioning: Gradual exposure while engaging in enjoyable activities (often visual, hands-on).
    • Modeling and training for family and medical staff (including organization for minimal “waiting around”).
• Design:
  • Not experimental; described as a “case analysis” (essentially A–B).
  • Success measured by full completion of all steps and significant drop in escape behavior.
  • T-test compared first and last session across participants.
• Findings:
  • Nearly all children mastered the entire procedure rapidly (in as few as 3–10 sessions).
  • Escape behavior decreased steadily; six of seven ultimately completed a real EEG.

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Notable Quotes & Memorable Moments

• On Compliance as Quality of Life:

  "Let's assume medical procedures are things that are medically necessary, ergo compliance with those tasks is important for quality of life." — Rob [08:23]

• On Reinforcement Overload:

  "You took ten deep breaths, here's a reinforcer... get all the reinforcers because you're helping a child learn to do something and have it not be so unpleasant." — Rob [17:17]

• On Multi-Component Packages:

  “All of these studies are kind of just an A design, but they did do a T test…” — Diana [54:08]
  “It seems as though it's a pick and mix. There's maybe several things.” — Diana [59:13]

• On Generalization:

  “It is good to see that there was some generalized responding across these different steps.” — Rob [21:30]

• Humor on Merchandising:

  “We should do classic grab bag. Everything's got to be in before 1970.” — Diana [02:22]

• On the Package Approach:

  “Do a preference assessment and then a big old package with contact desensitization and stimulus fading and shaping and video priming and photo priming and…” — Rob [25:08]

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Key Insights and Recommendations

• Shaping and Reinforcement Are Central:
  Across studies, shaping (successive approximations) and consistent, meaningful reinforcement were most responsible for compliance—not necessarily the full “grab-bag” of extras.
• Component Analysis Needed:
  Studies often relied on complex packages; future research should isolate which elements are essential and which are “nice to have” but not necessary.
• Escape Extinction Not Always Necessary (or Safe):
  For procedures involving sharp objects or strong aversion, positive reinforcement and fading can outperform extinction.
• Visual and Video Supports May Help, But...
  Video or picture schedules (even narrated by charming dinosaurs) may enhance engagement, but evidence on their independent effect is lacking.
• Staff Training and Real-World Generalization:
  Involving caregivers and medical staff is vital for generalization, but little is known about translating research procedures into insurance-reimbursed, real-world practice.

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Timestamps for Key Segments

• Episode Theme & Article List: [00:57–04:47]
• Physical Exam Compliance (Kuvo et al.): [06:19–26:46]
• Discussion on Reinforcement/Components: [16:48–19:19; 25:08–26:51]
• Nail Clipping Compliance (Dowdy et al.): [30:23–41:52]
• EEG Toleration (Slipher et al.): [42:11–55:50]
• Dissemination Station (Big Picture Takeaways): [55:52–59:59]
• Pairings & Related Episodes: [60:57–62:58]

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Related Episodes Mentioned

• Dental Exam Tolerance (Ep. 148)
• Tag Teach (Ep. 5)
• Safety Skills (Ep. 325)
• DRA Minus Extinction (Ep. 249)
• Anxiety Assessments (Ep. 192)

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Final Thoughts & Tone

The hosts approach the subject with both scientific rigor and their trademark levity, bringing warmth and humor to a serious, practical problem faced by many behavior analysts and families. They praise the practical benefits of shaping and positive reinforcement, call for more component analyses, and repeatedly foreground the importance of making medical routines accessible and trauma-free for vulnerable individuals.

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Notable Snack Pairing

• Safety Pop: Classic doctor’s office lollipop, chosen for its medical nostalgia and “safety” relevance. [62:10]

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This episode is valuable for practitioners, caregivers, and researchers seeking effective, compassionate, and evidence-based approaches to teaching medical toleration. Even those new to the literature will walk away with actionable insights and a solid grasp of the research landscape.

Transcript

[A]

Foreign.

[B]

Hey, everybody. Welcome to ABA Inside Track, the podcast that's like reading in your car, but safer. I'm your host, Robert Perry Crews, and with me, as always, are my fabulous co hosts.

[A]

Hi, it's me, Jacqueline McDonald. People call me Jackie.

[B]

Sounds like you didn't do that Lionel Richie song. Hello.

[C]

I love. I thought you're doing. It's me.

[A]

Oh, yeah, hi. There's all of those things I was just making on my own, but I like this. The Lionel Rushie one isn't me you're looking for. You guys.

[C]

Are you looking for me?

[A]

I'm right here.

[B]

Jackie is. Jackie has blown out and clipped the mic twice now. Once before recording, once during her.

[A]

That's my job.

[B]

Congrats.

[C]

And it's me, Diana Perry Cruz. Hello.

[A]

Hello.

[B]

Wow, Diana, that was. You unclipped the mic. I think with that. That hot take. Welcome. This isn't our etiquette Mike podcast. This is a podcast about behavior analysis and behavior analytic research where every week we pick a topic and discuss some relevant research articles. And this week we're going to be talking all about medical toleration. Like, how do we tolerate each other in this crazy podcast world of ours that tells you medically.

[C]

Medically.

[B]

Medically, Yeah.

[C]

I feel like this is a really important topic. It's one we haven't really talked about very much before, but it is just highly applicable to many, many folks out there.

[B]

So like a sequel to dental desensitization?

[C]

Well, yeah, there is that, but that'll come up in pairings. But we don't have many articles that are sort of predecessors to this. We don't even have an article on shaping.

[A]

Guys, that's ridiculous. No, I think we did.

[B]

Totally did.

[A]

We did the horse loading trailer. Oh, no, I did it on grab Bag once.

[C]

Right? Yeah, we do have tag teams.

[A]

The original.

[B]

We never did that on a grab.

[A]

Yeah, we did.

[B]

When.

[A]

When I did it.

[B]

I don't think that's loading the problem.

[C]

Loader.

[B]

Yeah, we've never talked about that on this show.

[C]

I'm not sure. I don't know. Maybe.

[A]

Maybe in my dreams. Maybe that's my next grab Bag.

[C]

That's been a horse episode. Yeah, all horses.

[A]

All horses.

[B]

We should do classic. Classic grab bag. Everything's got to be in before 1970.

[C]

I was actually thinking about that. We should. We should do like a. An oldies.

[B]

We just did a grab bag theme. Maybe grab bags become a themed thing. That's. That's the 2026, 2027 grab bag.

[C]

Can't help it.

[B]

Themed Grab bags all around.

[C]

I can't help it. My brain just wants to make connections.

[B]

I think we should just sell it. We should. You know, we should sell.

[C]

Know.

[B]

This is Undo Medical Dentition. We should get a merch and we should have a little bag. And you put your articles in the little bag. It's like a little drawring bag. Say ab ins. I track on it. It's a grab bag.

[C]

Oh, yeah. No one prints out articles ever.

[B]

I do.

[C]

Except you.

[B]

I have binders and binders of them. Someday they'll fall on me. That'll be the end of me. No, I. I think. Is that merch I'm going to sell or merch I just want someone to give me? I just want my own grab bag.

[C]

A grab bag bag.

[B]

I want a grab bag bag. But we're not doing grab bag.

[C]

Doing grab bag.

[B]

That last week. Two weeks. That was two weeks ago. Two weeks ago. We're listening to us talk about medical toleration and it's starting off with a bang. Diana, why don't you take us out of this tail spin and tell us what articles we'll be discussing today.

[C]

Oh, sure. I can do that. We have three different articles to talk about today, all covering different aspects of what we're terming medical toleration. They include training children with autism spectrum disorders to be compliant with a physical exam by Kuvo, Reagan, Ackerlund, Huckfeld and Kelly. And that was published in the research. Sorry, in Research in Autism Spectrum Disorders in the year 2009. Or maybe 2010.

[B]

It's 2010.

[C]

2010. Also, effects of Reinforcement Without Extinction on Increasing Compliance with Nail Cutting, A Systematic Replication by Dowdy, Tinkani, Nipe, and Weiss. That was in Java 2018.

[A]

So gross.

[B]

Nail stuff is no, no good.

[A]

But I'm so glad we're doing it.

[B]

I'll be leaving the room when we do that.

[C]

It's not your favorite. It looks like your nails are really important.

[A]

Yeah.

[C]

Yeah. And finally, Behavioral Intervention to Increase Compliance with Electroencephalographic Procedures in Children with Developmental Disabilities by Slipher, Avis and Frecci. That was published in Epilepsy Behavior. That was the year 2008.

[B]

I'm second guessing all your citations. Yes.

[C]

Yeah, I realize it became available online or something in 2010, but it was originally 2008. I'm pretty sure it's a little bit confusing.

[B]

I love after 10 years we have like these like, really efficient procedures. But then Diana still finds the PDFs to read the title rather than the full citation. That is in our notes. It's like, that's just the way she wants to do it.

[A]

The way she wants.

[B]

The way she wants to do it.

[C]

The way I want to do it.

[B]

I. I find this is. I'm going to sidetrack again. I find a lot of modern journal publications I have been finding the way they do their citations and the abbreviations, like the lengths they go to, to abbreviate their title has gotten worse and worse. Like, there are journals you've, like, I don't know the name of this. It's like, it's like, oh, it's like the Journal of Epilepsy and Neurology, Britain. You didn't know that? It's like, No, I didn't like. Oh, what volume is it all? Volume 11. What page? Oh, Z2. That's how you cite it? Z2, of course. What year? It hasn't come out yet, but we published it anyway.

[C]

It is getting hard.

[B]

It's. It's. I don't understand. How is it harder? It should be easier. Oh, well. Oh, my blood pressure is rising. Do we have an article about blood pressure lowering medical tolerance? All right, well, I'll just. We'll just make do. Why don't I kick us off then switch topics to the actual topic? I'm going to be leading our discussion on Kuvo et al. Training children to be compliant. Well, sorry. With autism spectrum disorders. To be compliant with a. With a physical exam. And boy, if you were like, I want an article that has all the treatments in one package.

[A]

This.

[B]

This is the article for you. Did they describe exactly what all of these treatments looked like? Not exactly. Which is weird because their results are. Every participant gets a lot of description, which again, is interesting, but also, paradoxically, didn't feel as replicable as I would have wanted for the level of detail they gave to every single result. I'm not quite sure why they didn't add some of those things in. I also don't appreciate when articles throw in an EG with a term that they then use later, but they never really define the term until some later in the discussion. Define your terms early, please. In any case, this is a nice, straightforward article overall. I wanted a little more details, though. And the reason I want more details is because it really is a large package intervention with, like, small modifications here and there based on hypothetical functions, which is fair. You know, you could knock the article and say, well, they didn't do an fa. All of these participants escape maintained behavior. Or is it a skill acquisition problem? But at the same time, I think we do need, when we're working with medical professionals, we do need to really be focused on how do we come up with a treatment that can generalize to the settings efficiently or we can easily train medical professionals to use because the harder it is and the more additional types of assessment you need just to have the treatment in place in these settings, you're just going to get a lot of yeah, yeah, we'll just deal with it, we'll just, we'll just get through it, it's fine. Which again is not going to always be good. Why is that? Well, certainly individuals with a lot of disabilities may also have a lot of health related problems than their peers. Means more medical visits, more procedures. And when you pair that with lots of challenges that can come from having a disability, like challenges with cognition or communication or, you know, sensitivities, stimulus sensitivity that might lead to higher rates of problem behavior, it makes compliance with medical procedures difficult. We're not going to have a long discussion about compliance and knows it good to have compliance. Medical. Let's assume medical procedures are things that are medically necessary, ergo compliance with those tasks is important for quality of life.

[C]

Yep, I am comfortable with that.

[B]

Awesome. But the issue is with all of these potential challenges, it can make a trip to the doctor and following through even with basic care procedures and very challenging for caregivers, for medical professionals, and of course for the individual themselves who may not quite understand what the procedure is asking of them. They may not have the skills regarding what they need to do with following doctor instructions, or it may simply be some sort of an escape, avoidance, maintained behavior. They have a history of, you know, those stimuli being aversive. And if you've been to the doctor a lot, it can be incredibly aversive. So what the authors here decided the best thing to do would be to think of healthcare as just a sequence of behaviors. And, and when you do that, you can operationally define what is happening in this sequence and then focus on what are the procedures that can make compliance with each of those various steps possible. You can do small analyses, compliance analyses at each step in that chain and then you can develop function based treatments or skill acquisition programming around that. Pretty simple. And pretty much that's the theme of every single article we're going to be discussing today. Not exactly the same.

[A]

Not exactly the same, but pretty close similar. Yeah.

[B]

So the reason again, we talked about some of the reasons of healthcare refusal. They could be related to sort of actually health factors. They could be mos that being in the Presence of medical equipment evokes escape behavior. Or it could just be a learned pattern of behavior. Or like I said, could be challenges with like listener responding. You know, open your mouth, say ah. You may not understand those instructions. Or you may do it. Open your mouth and then say ah really fast and then close your mouth again and then be frustrated. Like, why are you asking me to open and close my mouth? Move multiple times, not quite understanding what. Well, the doctor not being clear as to what open your mouth say actually means. Or if you ever had that fun thing at the dentist when they like stick out your tongue and they grab your tongue with a piece of gauze and then they look at the back of your tongue. I hate that so very much. It makes me want to. My teeth are getting all. Anywho. So a lot of healthcare related behaviors are going to require some sort of a response. But many of them are sort of just passively tolerate. Just wait and then this procedure will be over at some point. But some of them are going to require things like visual discrimination. Think about an eye exam. Or it might require, you know, more complex listener response repertoires. Like, how do you take, you know, what's a deep breath? How do you know you're taking a deep breath? How do you take five deep breaths?

[C]

Right. I always start to feel like I'm hyperventilating when I do that.

[A]

Oh, I need to teach you a better way.

[C]

Yeah, okay. Like how many deep breaths

[A]

you went too fast. If you feel like you're hyperventilating, you're going too fast.

[C]

But I don't want to waste the doctor's time.

[A]

No, that's their problem, paying for it.

[B]

So there are lots of package interventions that have been used. Again, we mentioned dental desensitization. That comes up a lot. There are other package interventions, some of the ones that we'll be talking about today, but in this case, the goal is just to teach compliance with a 10 step medical procedure that goes along with a physical exam. I recently took one of our kids to the doctor and I was thinking through how many steps are in this exam?

[A]

Oh, yeah, there's so many.

[B]

We added some extras because then we had some specific questions related to, you know, things, you know, specific to his health and development. It's going to change across the lifespan. But basically, if you've got the 10 steps here, you are probably okay to handle most basic physical exams. And they used a package intervention. When I say package, you are a lucky little boy on Christmas with the package you're getting. With this Treatment, let me tell you. Did you want some contact desensitization? What about video priming? How about prompting? How about dro? How about escape extinction? They're all there.

[C]

It's all here.

[B]

All there for you. All of these exams happen at a clinical, clinical service for children who are receiving services from Southern Illinois University's Autism Center. They all had a diagnosis of autism or PDD NOS and a history of non compliant behavior. During their medical exams. They all could follow simple instructions and were able to follow a visual schedule and were of three to six years in age. I do love that the majority of the experimenters were BCABAs in the study. We don't see that too often.

[A]

They were probably master's students.

[B]

Yeah, well, no, there were also some behavior analyst graduate students, so. So they actually had more training than the graduate students. Well, I don't know if they have more training, but again, they were certified at the time.

[C]

Got it.

[B]

And then there was a physician's assistant who helped out with the pre test and then the post test. Because again, it's a great procedure if your BCBA can run it. It's not so great if a medical professional can't run it.

[C]

True, yes, generalization is very important.

[B]

But this mostly was a let's learn it all in one setting and then hope for the best in the medical setting. And actually that worked out pretty well for the majority of participants here. They took data on compliance to each of the components of the exam. Exactly what that meant would vary between sort of. Was it data on their tolerance of. To actively complete a step? Because there were, you know, 10 different steps. They each had different sort of steps in their hierarchies and their topographies. And then also data on partial interval recording, data on, you know, rates of problem behavior. Mostly was just sort of protesting or escape avoidance. There was no aggression, they kept mentioning that occurred. And then you get a little multiple probe across responses in two cohorts of three different participants. And that's what you're gonna get for your graph. So the overall procedure was starting with a parent questionnaire to confirm that the participants would be appropriate for this study. They had challenges with medical procedures in the past. Then they did a baseline 10 component exam which included an examination of major body organs. They looked at their lungs. So, you know, put the stethoscope on, take a breath, heart, same thing on the back, abdomen. You know, the doctor squishes your tummy, look at the nose, throat and mouth and ear using the otoscope, which I think is just it's just that like little mirror, magnifying glass with a little light on the end of it.

[C]

No, it's the pointy one.

[B]

You've got a light, like a little funnel.

[C]

Yes.

[B]

Yeah, but then it's got a magnifying glass.

[C]

Yeah, yeah.

[B]

If we're just a pointy thing you stuck in your ear, what would the doctor learn from that?

[C]

You're not supposed to do that. I learned that.

[B]

How much stuff. Something jammed in your ear. Yeah, I think they figured that one out in medical science a long time ago.

[A]

I still love the cotton swab in my ear though. I'm not gonna lie. Oh, yeah.

[C]

Oh, it's like one of my small joys.

[B]

Every morning if you're not careful, you will jam your earwax.

[A]

I know, I know.

[B]

It's not good.

[A]

I know.

[C]

It does feel good though. It feels good.

[B]

Well, that part, short term thinking, folks, that's not in the, in in the chain of events here.

[C]

Right.

[B]

They also included four behaviors that you just kind of had to do because you can't do an exam unless you know how to enter the room, play for three minutes. That one you don't have to do. But that was part of their procedure.

[C]

You wanted it to be 10. Okay.

[B]

Sit on the exam table and lie down on the table. Which one participant was actually seemed very stressful. Just the lying down on the table.

[C]

You're very vulnerable and you're usually in your underpants.

[B]

Yeah. They did not mention if they were in underpants or if they were fully closed. I assume they were fully clothed during the practice in the center. I don't know. With the medical professional.

[C]

Okay.

[B]

They started every session by showing the instruments that were going to be used. They had a picture of a peer who was modeling the terminal step of each step in the 10 components plan or the. Sorry, the 10 component exam. And then in the pre test, they sort of just prompted and the individual. They gave them access to toys throughout the exam and that was it. That was their pre test. They looked at rates of non compliant behavior. They looked at the parent responses and they kind of generated a loose hypothesis, but kind of basically just came down to if a participant didn't do something but didn't have any sort of emotional responding or sort of pushing away the doctors or the clinician's hand. No, it's physician's assistant proposed test. Sorry, their. The hand. They assumed it was probably a skill deficit if they did engage in emotional or physical responses when they were prompted to do something in the exam or they put the instruments in front of them. So maybe they cried. They hypothesized it's probably escape or avoidance. There you go.

[C]

I like that.

[B]

Yeah. So just kind of a nice light fba. Nothing too fancy. You're not going to write home about that. But just generally to give them an idea of what the treatment interventions would look like. And then they had the big package. And even though they did sort of do this extra little level of hypothesis, you sort of got the same treatment regardless. It just was sort of a matter of are you shaping responses through successive approximations and reinforcement to learn how to engage in the skill or. Or are you doing some sort of a fading in of aversive stimuli in the presence of the preferred stimuli, which are going to look pretty similar, though again, the terminal goal is a little bit different. One is just about continue staying here without the emission of some sort of problem behavior versus I need you to do something in the presence of this. Of this tool. So what were the components that you might have seen in your package? Well, they had photo prompts.

[C]

Right.

[B]

Here's the photo of what it's going to look like when this step is done. They had verbal instructions which included what to do, as well as praise statements and access to preferred items. They were a little unclear of where reinforcement came in. It felt like reinforcement was throughout but also contingent on certain things. And it was a little mixed up to me as to which one was happening. When. Or were they talking about multiple stimuli?

[A]

I felt that some of them were.

[B]

This is the. You took ten deep breaths reinforcer. This is that you made it through the session reinforcer. This is the DRO reinforce. They really weren't very clear as to exactly which reinforcers were happening.

[C]

My study was like that too.

[B]

There were tons of reinforcers. They were just talking about this poor kid. And then.

[C]

Better than none.

[B]

No, better than none. But again, one for get all the reinforcers. Because you're helping a child learn to do something and have it not be so unpleasant. It's another thing when I need to read your article and potentially replicate exactly what you did.

[C]

Dude, they're like, do it all.

[B]

Yeah, just do all the things. It'll be fine. Some of the participants had a contact desensitization plan. So they. Again, here it is. They had access to pervert stimuli and then they faded in proximity to the aversive medical stimuli. Sometimes they just have the photo and the tools where they were playing. Then they'd sort of come closer and closer, you know, with the otoscope or whatever. They were using the stethoscope. And then eventually it was you got the toys after you were sort of allowing the, the tolerance of the use of the tool for that part of the exam. And then they sort of switched from toys all the way through to toys after the session. So maybe that's where some of the confusion came in is they sort of lumped it all together and they would sometimes do shaping, just sort of increasing the number of responses, like how many breaths you need to take or like how wide you have to open your mouth sort of things again. And then we have reinforcement. They also had a DRO procedure with varied intervals where you'd give preferred Items without. With 30 seconds without problem behavior. But, but again, how many items are they using? They are. They're not specifying which ones happen. Like juggling reinforcers. Like it's been 30 seconds.

[C]

Good.

[B]

Hey, you got the otoscope near your face for five seconds. Great. Hey, you followed my instruction for two deep breaths. Here's a different. Like what does it look like that. Was it that dizzy?

[C]

They also not.

[A]

Probably not.

[B]

Probably not. Then they just did not describe it quite as well. Cuz that's the picture I have.

[A]

Maybe they had lots of different reinforcer bags maybe and they were just like, oh we use this one. Oh we use this one.

[B]

That's what I just said. Sports bag said that's not what they did. We will never know. Sports bags kuvo right in. They also used escape extinction as response consequence. So pretty much just whatever this averse stimulus is that you're slightly upset about it, stay in there until you 10 seconds of tolerance, which I'm, I'm sort of. I always wonder, people say oh yeah, we used escape extinction no problem for 10 seconds. Was it no problem. Because escape extinction doesn't always look that clean. I'm kind of curious.

[C]

Yeah. And they did know that these were not participants who were going to be aggressive.

[B]

Well, they could have been. They just never were aggressive.

[C]

Well, they were not in this study. So maybe you would need to take that into consideration.

[B]

Yeah. Again, another factor. I want a little more on there. And then after an individual had sort of done maintenance pros with each of the steps, put all the steps together, they would do a post test with the physician's assistant in a medical clinic. Only one cohort I think did a stimulus generalization test also with a different examiner. So like the first group, they just pretty much you got it, time to go to the doctor. One cohort. They actually had different, different therapists run the Procedure. And then they went and went to the clinic, medical clinic. They went through every single participant in a. In a decent amount of detail, but still probably not enough detail for me to say, I think I could 100% replicate exactly what you did. AKA where are the reinforcers coming in? There's like falling out of the sky. But, you know, everything was a little idiosyncratic in terms of who needed what, who needed a longer hierarchy here, who spontaneously learned the next step in the exam, when. But yeah, so it basically boiled down to everybody eventually aced the post test, except for one participant who only did nine out of ten steps. But still, I say that's pretty close. Five out of five. Pretty good. Or four. 4.9 out of five. Okay, pretty good. Usually you got some sort of a practice effect with the reinforcement. And then they'd be like, all right, let's present it at 5 seconds. Let's print it at 5 seconds. Let's Print it at 6 seconds. Let's do a probe. Wow, we got the 15 seconds. We're done with this one. Now let's do the next skill. Maybe it's the heart. Ch. Oh, wow. You did that one the first time, even though you didn't do it in baseline. So you definitely saw a lot of learning and generalized responding across the different exam steps, which is always good to see because if you told someone, all right, there's a hundred steps and ten total. We got to go through every single one. And then maybe it'll generalize to the doctors, like, ooh, no, thank you, I do not want your treatment. So it is good to see that there was. There's some generalized responding across these different steps. Usually they got generalization across the examiners. Sometimes they even got it to the post test medical setting. Sometimes they did have to then take their hierarchy and practice it some in that new setting. But it seemed like it wasn't a big deal for the physician's assistant to help out with that.

[C]

That's okay, because otherwise they're just doing train and hope. Yeah, yeah, right.

[B]

I, I mean, a little bit of training hope in this. But they were right to hope. Their faith was well placed.

[C]

But it's not uncommon that you might need to then also do some training in, in the generalization setting in order to ensure responding is going to occur there. So I think that it's okay that, that, that they took that approach.

[B]

Yeah. And then if you look at the graphs, some, some participants just sort of get this little stepwise responding that you would get when you're doing some sort of a shaping procedure or a fading in of aversives and. And then all of a sudden it'll be like whoop, long line to the end. They, they mastered the skill, you know, a couple trials later when they did a probe.

[A]

Yeah.

[C]

And by aversives you just mean like components of the exam that you like just to make sure we're being poke

[B]

in your ears things that, you know, maybe a stethosis.

[C]

Yeah, all of the things that we're going to talk about today have aversive components because they are people getting all up in your grill and many people don't like that.

[B]

Now one thing I just remembered, I completely forgot to mention as part of the package intervention and maybe it was important, maybe it was utterly worthless. However, we had a video priming DVD which the parents were given and they said you should watch this with your child every day after they completed their baseline assessment and let us know whether they watched it, whether they paid attention to this dvd. The DVD was sort of like here are the different medical procedures. Great. But guess who narrated this dvd?

[C]

Barney.

[B]

It was a puppet dinosaur.

[C]

That was pretty close.

[B]

Did kids like the dvd? Some really did. And they'd quote the dinosaur at length about all the things they were talking about. Some tried to eject it from the machine or cover their ears at certain points. They also didn't really control for like who watched it that much because some people watched it like every day. Some people watch five times total and there were a lot of trials. So five times total feels like a little, not a lot.

[A]

Well, I would love it if that video became someone's reinforcer.

[C]

Yeah, right, right.

[A]

Go to the doctor.

[C]

Now that kids dentist, they have this, I think he's a dinosaur, but he has like a full set of like human dentures like built into his mouth. I have seen him, seen him scary. And they use him to show kids how to brush their teeth. So I'm imagining that guy. But in this video, like hey kids,

[B]

what are the production values on this puppet? I love to see.

[C]

Yeah, I mean we know from like the Sam the Eagle's handgun video with melted burger that generally videos in that capacity probably don't work.

[B]

No.

[C]

Now, but we don't know because it's a package.

[B]

They didn't do much in terms of like look at this kid, he watched the video a ton and then look at this graph. So my interpretation, looking at the sort of written results and then looking at sort of the graph pattern was like some of the kids who sounded like they Watched it a ton. Did tend to have that sort of faster response that kind of like rise, run. Like real fast, rise, run. So it is possible that watching the video more was an important component of this. However, you also then have to ask yourself, was it that they like just liked videos, they had like higher cognitive or listener skills that made it easier for them to learn the routine of the medical exam and that's why they liked the video, or was it that the video actually like, oh, I'm not scared anymore, this dinosaur has helped me. Right? You don't really know because again, it's a big package, so maybe it was totally irrelevant.

[C]

So the doctor dress up as a dinosaur.

[B]

No, that did not happen. That's ridiculous.

[C]

That's a different study.

[B]

I would be better have written that in the procedure. We need a giant dinosaur costume stat. So do you want to teach a child to comply with a set of 10 step medical exam procedures? Well, great. Do a preference assessment and then a big old package with contact desensitization and stimulus fading and shaping and video priming and photo priming and use gesture and physical prompts and model and use verbal instructions. Use a DRO procedure. Use escape extinction and eventually you'll get there too. Usually you're going to get some amount of generalization, though maybe not always. So you might want to prepare for additional training in that relevant context. You know, just make sure you have the time for that as well. And again, the generalization, when it did occur, nobody quite knows why. It could have been because they were using the exact same materials. So the individual was not finding the doctor aversive so much as just the various tools in that setting. And we once that was no longer a problem. Well, they'll engage in the same behaviors with that person, especially if the reinforcers are there. And again, how long the length of time, the frequency of escape avoidance. Really the more that occurred during training, the more likely it didn't do any like conditional probabilities or anything like that. But the more likely you probably need to do additional practice in that terminal setting. They don't really know why. Training in some components, generalized untrained components for some, it didn't do it for others, but it did in a lot of the cases and it maintained for at least up to one month. So here you go. If you want to study, I would take this one and do a component analysis because my guess is you do not need all of these.

[A]

Maybe that's what I'll do.

[C]

Yeah.

[A]

All right. Thanks, Rob.

[B]

I'd probably get rid of dinosaur video first. That's an easy one.

[A]

I won't.

[B]

Okay, that's the only thing you're going to use.

[A]

I will be the dinosaur in the video.

[B]

All right, well, now that we're ready for our trip to the doctor, let's take a break while we drive over there. And when we get there, we're going to be doing some nail clipping and

[C]

nannies and petties.

[B]

Right back.

[A]

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[B]

And we are back talking about medical toleration research. But before we continue our discussion, I want to remind our listeners that Aba InsideTrack is ACE and Kwaba approved. By listening, you're able to earn one learning credit. All you need to do is finish listening and go to our website, abainsidetrack.com or you can just click on the link in your podcast player to be whisked away, where you'll find all sorts of great links to the articles discussed, a transcript, and a little quiz you need to take. Some of the questions require you to have some knowledge of what it is we're talking about. But two of them are special, special code word questions. So if you don't know those code words, you are out of luck. No cel. The first of those is Mary M A R Y. Like Mary Worth?

[C]

No. Who's Mary Worth?

[B]

She's like a comic lady. Is she a nurse?

[C]

And Sally fourth.

[B]

That's Sally Fourth. It's one of those, like, boring comic strips.

[C]

Oh, I think you're right. I think that is A person, too.

[B]

But maybe Mary Worth is something different. Maybe that's, like, related to Rhoda. Remember those? She's like, Rhoda. Maude. I don't know.

[C]

I do remember Rhoda. Rhoda was a Mary Tyler Moore spin off.

[B]

Oh, I'm thinking of something.

[C]

So you're thinking of Mary Tyler Moore. I'm not thinking of either of those people.

[B]

Okay.

[C]

With reference to this.

[B]

I don't know what the reference.

[C]

You want me to tell you.

[A]

Yeah, there's something about Mary.

[C]

No, no, I'm thinking about Mary J. Blige. Oh, yes. Because this song makes me think. Don't need no hateration. Toleration. Medical toleration.

[B]

I do not think it's holleration.

[C]

It's not tolerance. Okay. Yeah.

[A]

Wow.

[C]

Yeah.

[B]

Glad we waited for that story. It was worth every moment. Mary, you're welcome.

[C]

Totally there.

[B]

Let's pretend it was Merry Worth after all. All right, let's. Let's just get it over with. We're going to talk about nail trimming.

[C]

Yeah. Nail trimming. Yeah. Rob does not like nails.

[A]

No. So we're going to talk about this in. Rob. So many people, including those with developmental and intellectual disabilities, do not like to get their nails cut. Right. This can be a hard thing to do, but it also can compromise personal safety if you don't do it right. So I one time forgot to cut my child's nails.

[B]

I don't want to hear this story. This story can end right now.

[A]

Close your eyes.

[B]

Close my ears. I have to listen. I'm doing the production, too.

[A]

It.

[C]

Her.

[A]

Her toenails got so long that they circled around each other.

[C]

Oh, God.

[A]

And then when I finally looked, I was like, oops. And then I cut them.

[C]

Oh, God.

[A]

But, yeah, it was gross.

[C]

Yeah. Well, you can get ingrown.

[A]

Yeah. You can get in. You can breed infection.

[B]

Right.

[C]

You can get in and then can

[A]

get caught, and then it's just not good.

[C]

Sorry, Rob. We haven't discussed it.

[B]

Let's just have puke sounds for the rest of this episode.

[A]

So, for me, typically, with nails and toes, right, if they. If people don't like to get the nails cut, they're probably going to engage in some problematic behavior to escape. Right. The tactile stimulation of you touching your nails and making the sound. Right. The nail sound.

[C]

The clunk sound of the nail clipper.

[A]

Yeah. So sometimes, right when you're thinking about doing these types of hygiene skills, you might see a lot of problem behavior. So extinction may not be a viable treatment option when Dealing with personal hygiene due to the heightened risk of personal injury. Right.

[B]

You don't want to do escape extinction with something that can cut like right near, like really sensitive parts of your body, like nails.

[A]

And then you can make it worse next time.

[C]

Right.

[A]

If you like accidentally cut the skin, which I have done to myself and someone else. My kid.

[C]

Right.

[A]

And my friend.

[C]

And like with your, you know, with your little kids, you're like, don't pull back, don't move. I'm doing this. Right. But if someone doesn't have a lot of language ability, they can't understand that.

[A]

Right.

[C]

So it can be very dangerous.

[A]

It can be. So previous research looked at Dras for compliant behavior, and they said that might be a viable treatment when extinction cannot be used. So previous research showed a decrease in escape maintained behavior and an increase in compliance when edibles were delivered contingent on compliance, whereas escape attention could not be implemented or was not effective. So they looked at research using positive reinforcement and stimulus fading without extinction for other, like, potentially dangerous behaviors such as blood drawing, tooth brushing. And it was effective for those specific participants. And they saw follow up. They saw skills maintained in follow up. Right. So the present study here was a systematic replication of those two previous studies on toothbrushing and blood draw. So they evaluated the use of nail cutting of two adolescents with ASD who resisted nail cutting. Right. So they had two male adolescents. They lived in a residential facility. One was Jackson. He was 16. They had multiple diagnosis and syndromes. I'm not going to tell you all of them. There was just like so many to count, but there's a lot. He was non vocal and had an AAC device and followed most instructions during the day but resisted toenail cutting. So they said, I'm going to cut your nails. He was like, no.

[C]

Yeah.

[A]

Well, he didn't say it because he was right.

[C]

He made it clear, though.

[A]

He made it clear. Right. The second participant was Stephen. He was 12. He also had multiple diagnosis and syndromes that I don't need to tell you about. There was a lot of them, more than two. He was non vocal also. He could follow one step directions such as sit down, but also resisted fingernail cutting.

[C]

Okay.

[A]

They didn't tell me if he also resisted toenail cutting, but I imagine like,

[C]

we're just gonna start with his fingers.

[B]

I can't imagine. No, toenail's no problem. It's just the fingers for summer.

[A]

So sessions occurred in the classroom and in the residential setting, and their day was organized into 30 minute blocks. So there were a lot of Things that took place during the day in the classroom. But personal hygiene was one of those blocks. So this is something that they were working on at the school and in the residence facility. Materials included nail clippers, sanitizing wipes to sanitize the nail clippers. Glad they put them in there. And edibles for participants. So they collected data on the escape response. That's what they called the problem behavior of each participant and included any behavior that was meant to block or get away from the toe or nail clipping. So they didn't have to specify. Right. And if you just pushed away, if you said no, if you tried to like use your hand to block it, that's all. That all counts as escape behavior. And remember, this is without escape extinction. So if that happened, they were allowed to escape.

[C]

Yeah.

[A]

Cool. They also collected data on a nail cut. So that was defined as when the nail was successively cut. This may include many tries. That's what they said. So it's not the first one. It's not a minus. And so they looked at the frequency of escape responses to responses per minute and nail cuts were the percentage. They looked at the percentage of nail cuts over 10. And I love that they put in parentheses because there's 10 nails. Because I was like, why 10?

[B]

You know what? I want this level of precision when I'm trying to at a procedure. You want to know?

[A]

Yeah. It's so nice.

[C]

Right? So last night we were watching TV and the characters on the T is a cartoon and the characters on the TV show said high 10. And they did a high 10. But I was like, but they only have three fingers and a thumb, so they should have said a high eight. That's true.

[A]

Right. So.

[C]

So you can never be too sure.

[A]

Right.

[C]

So I'm glad they included it.

[A]

I just didn't know what the 10 was either. So when I saw the parenthesis, I actually stopped and said, maybe 10 trials. And then I was like, no, 10 toes or 10 fingers. IOA was good and PI was assessed. So they had. That was also very good. They had a really description, a really good description of procedural integrity. So if someone's like, I wonder what that could look like. You should go to this article and look at it. It's really good.

[B]

Cool.

[A]

They use a reversal design. Each session ended after five minutes in length or after all the participants nails were cut. Whatever came first, consecutive sessions were divided by at least two weekend or two sessions. Two weeks, two weekends, two weeks. To allow the nails to grow in between cuttings, which I think is impressive. Right. They weren't trying to like cut them down to the wick. I don't know if that's what you call ours, but that's what you call dogs.

[C]

The quick, quick.

[A]

Oh, maybe it's not wick. Anyway, so they had a pre experimental assessment where they did an MSWO and found some edibles. For Jackson, it was Reese's peanut butter cups.

[C]

Excellent choice.

[A]

And Stephen Whoppers, also good.

[B]

I love these young gentlemen. Know. Know where it's at with the candies.

[A]

You know, maybe those. Maybe some dark chocolate. Yeah.

[C]

Right. Because I know I have a. We have another episode where I talk about how I don't think we want to be using edible reinforcement generally. Right. However, in these situations, types of the studies that we're reviewing right now, these would be the ones we were like, we're pulling out all the stops. They borrowed Rob's grab bag bag, put all the reinforcers in it and are just distributing them willy nilly.

[A]

Right.

[C]

And I think this is working with the edibles in there and I'm okay with that too. Is there anything better than a Reese's peanut butter cup?

[A]

I don't know. I don't think so. I don't think so.

[B]

Actually, one of the best candies pieces are pretty great.

[C]

No, no. There's no actual chocolate.

[A]

Yeah.

[C]

Do you know that there's no peanut butter?

[A]

Okay. Anyway.

[C]

Anyway.

[A]

During baseline, Snickers all they did sneakers are actually really good. Not as good. During baseline, they asked the participant to go to the chair and they said, I'm going to cut your nails. Then the therapist then held, raised and moved the clippers toward the participant's first target nail. So if they did any of the escape behaviors at all, they provide. They provide escape for five seconds and then kept re presenting. I'm going to cut your nails. Right. Until five minutes has elapsed. It's interesting to note that no one tried to leave the chair during baseline or treatment.

[B]

Maybe their response was so quick they just pulled back. Okay, fine, I'm not doing it. That it was like, I'm comfy in this chair.

[C]

Yeah.

[A]

Right.

[C]

Or maybe they trusted their experimenter. Right.

[A]

It was hurt though. Right. I thought that was nice. So the treatment is the easiest treatment I have ever read. For each nail I cut, this is what the therapist says. For each nail I cut, you will get a snack. You'll get a piece of snack for every nail that I cut.

[C]

Okay.

[A]

And then they go in and cut the nail.

[B]

They were very detailed about how much like they had to cut all around the nail.

[A]

So it could be multiple cuts, and that's why.

[C]

Multiple question. Right.

[A]

Could be multiple tries, but you had to do the whole nail. And then once the whole nail was done, you got your snack.

[C]

Right. So you don't want to leave, like, a sticky up part. That. Those are dangerous.

[A]

And again, the. If they did any escape behavior, they still have five seconds. Right. So the results are amazing. Jackson did not cut any nails during the baseline, and the last three treatment sessions could cut all of his nails.

[B]

Nice.

[A]

He had lower levels of escape responses, but they still occurred. Which is important to note. Right. Like, while they're doing it.

[C]

Yeah.

[A]

He still engaged him in some escape responses, but they still were able to cut all of his nails, which is. Okay.

[C]

They all.

[A]

He got them all cut during maintenance as well.

[C]

Yeah.

[A]

So that's really nice. And Steven had a slight increase during baseline, but a big increase during treatment. And he could cut all of his fingernails during treatment too. And that treatment effect across two settings. And it would have been nice if the primary caregivers could do it too, but they didn't. It was just the.

[B]

I thought they were in a residential program.

[A]

They were, but they had parents.

[B]

No, I know. I don't know how much they were cut. Like, I don't know if they're coming to visit. They're like, oh, I can't wait to cut your nails when I'm done.

[A]

I know. It just would have been nice.

[B]

Better things to do.

[A]

Yeah. So. But the graphs are really pretty.

[C]

Right.

[A]

And I think the important thing to note here is that they got it done without causing emotional responding, and escape could still occur, just not for a long time. Yeah.

[C]

Right.

[A]

Right. So if you were feeling a little bit stressed, you just take a little five seconds and then keep going. Keep going.

[C]

I find it interesting that they did it as a reversal.

[A]

I know. I thought so too.

[C]

Yeah. Like staggered initial baseline. So they could have just done this as a multiple baseline cross participants.

[B]

Or across types of nails.

[A]

Right. But they just wanted to show that the snacks were important.

[C]

Yeah.

[A]

Right.

[C]

That really was important.

[A]

The reinforcer for that nail cut was why the behavior was.

[C]

Yeah.

[A]

Engage and maintained.

[C]

Yeah.

[B]

But.

[C]

But Jackson was like, the minute they went back to baseline, he's like, no. He's like, absolutely not. You can't.

[A]

Right.

[C]

Cut even one single nail.

[B]

But then they didn't. They didn't try to fade out or.

[A]

Well, I don't think they have to get the.

[C]

It's when you get the reason.

[B]

Right.

[A]

I don't think you need to Fade it out.

[B]

But did they leave it as every. Because it was each nail I cut.

[A]

Right.

[B]

They didn't go to like, when I've done all your nails. When I've done two nails?

[A]

No, they didn't. I. I mean, they could have, but there's.

[B]

There's your extension. There's your baseline across. Type a nail and fade the edible for more nails. Can you get all 20 before you're still 20?

[A]

Yeah, I guess they didn't do that, but I'm okay with that. I'm okay with it because it's such a hard skill.

[B]

I mean, it's an important life skill. That's. But that's the other. So, you know, you get it, get it early. It's good. But at the same time, that's. It's a lot of reason. I mean, I'm assuming they cut the. The Reese's peanut butter cups up per finger.

[A]

Well, I would still take that.

[C]

Can you imagine eating ten Reese's cups?

[B]

So it could be like two packs per fingernails. But you know, it might be too many.

[C]

You're right. Too many.

[A]

That is too many.

[C]

I think you would satiate.

[A]

Right.

[B]

Once a one pack a week, four nails. Yeah, that's fine, but it's.

[A]

It's. It's after two weeks.

[B]

Yeah. Okay.

[A]

Sessions. Really?

[B]

One pack every two weeks. Oh, that's not a problem at all.

[A]

That's. It's like a special treat. It's like, oh, it's my time.

[B]

Yeah.

[A]

All right. So that was mine.

[C]

Okay. And I feel like in the title they say it's a systematic replication, but they mean of other medical procedures.

[A]

Right. Of other medical procedures. Which is interesting.

[C]

I'm surprised, like that they added that part.

[A]

Yeah, me too.

[C]

It's like, oh, what's the original nail cutting study? There was this one.

[A]

It's this one.

[B]

It's this one.

[A]

Yeah.

[B]

We have two nail cutting studies. I think our field's big enough.

[C]

I think it is too. Okay. And then for this one, we had to go outside of the behavioral journals to find this, but they are behavior analysts who are publishing this paper. So this is about teaching individuals to tolerate the EEG pieces that go on. And that's electroencephalographic gram encephalogram, which really sounds to me like elephant and pachyderm, like, mixed together. So I always think about that, but I know that that's not what it's related to. And then the other thing I want to tell you before I tell you about the article is that Slipher has a whole line of research in. In varied types of medical tolerations. And Slipher is one of the authors on the Iwata, Dorsey, Slipher, bauman and richmond, 1982.

[A]

Oh, wow.

[C]

Oh, there you go. So that's what he did with his time after that article was do a whole bunch of medical toleration studies. And he works at Kennedy Krieger. So I think that was like his jam was like making sure kids could tolerate that. Yes, I know. Good.

[A]

Good put together.

[C]

I know. And so, but the. Those that research is published all over the place, not just in behavior analytic literature, because it's really, you know, widely useful, I guess.

[B]

Is that our new. Is that our new trivia. Trivia game Inter fulfillin of the classic article? Everyone knows it's Iwata and. Oh, God. Oh, no. Who are the rest of those?

[C]

I got it.

[B]

Yeah, you did.

[C]

This girl got it.

[B]

But you're doing the trivia, that's why.

[C]

Oh, fine. Okay. So let me tell you about this study. You might need to get an EEG if you experience seizures or have a diagnosis of epilepsy. Epilepsy is the abnormal electrochemical firing in the brain that can produce tonic clonic or monoclonic seizures and cause general disruption to the brain. The general rate of epilepsy in the larger population is about 5 in 1000. But in the population more specifically that has ASD, it is thought to be about 30% of that group.

[B]

Yeah, that seems very high.

[A]

It does.

[C]

Oh, I've heard that statistic elsewhere as well. Yes, it is very high. So it's very likely that you might work if you work with this population, that you work with someone who has some type of seizure disorder. So epilepsy needs to be monitored. One of the ways to monitor is via this eeg, which is the electroencephalogram, and that monitors electrical patterns in the brain to look for abnormalities that could therefore be potentially treated or at least followed. So the EEG involves putting about 20 different electrodes on the upper face, scalp and forehead. And these are going to be used to take those readings. You can have either a daytime EEG, which is takes about an hour, or you could have a nighttime EEG that's obviously overnight and you're supposed to be asleep for it.

[B]

Has anyone had an eeg? No, I had an overnight eeg. It was terrible. It is very boring. You can't move very much and you're like, I guess I better go to sleep in a new bed with all this crap on my head.

[C]

Yeah, that doesn't surprise me. That it's hard to do. Right.

[B]

So my results were inconclusive because I couldn't sleep all night. Then they said, do you want to try it again? I said, nope, I'm fine. And I moved on with life. The question's the fine part of that.

[C]

Yeah. So I think that it's obvious, therefore, that this procedure could be very difficult for individuals with any type of developmental disability to tolerate because it's extremely intrusive. It takes even one hour. You're like, oh, it's only one hour. Well, yeah. Right, right. Like, trying to get someone to wear something for 10 seconds can be hard. So try to get them to wear for one hour is asking a lot.

[B]

Especially if you have, like. Like hypersensitivity to things on your skin. It's like, no, no, we're just gonna put a lot of things on your skin.

[C]

Yeah. And then it didn't.

[B]

And wires kind of just dangling off and touching you all over.

[C]

I've also. And I. I have done a type of desense for this with students. And we would also have them, like, put a weight in a backpack, because if you are, what, moving around, you have to carry that part with. With you. And that didn't come up in this study, but I don't know when we practiced it that we included that. Yeah. So they also talk about how medical sedation or restraint could be used here, but it's not recommended because it can affect the brain waves. If you're doing sedation. Right. So that could impact it. And then. Or on the flip side, being overly physiologically aroused because someone is trying to hold you down, that's also going to impact things. The medication can produce side effects, and the whole experience is going to be potentially quite aversive, which is the opposite of what we are looking for. So instead, what if we did some variation on desensitization and. Or shaping. This has been highly effective across a whole bunch of studies in a whole bunch of areas. Slipher specifically has done them on radiation treatment, receiving subcutaneous injections, and fmri.

[B]

Wow. That's a weird hospital medical procedure. Slipher is there to teach you to it.

[C]

So you can check those out if you want to view his oeuvre of work. And then I also.

[B]

I bet they're a lot like this article.

[C]

Yeah. And then just one other one to note, folks. Dahlquist et al did this process for gynecological exams back in 1984.

[B]

Whoa.

[C]

Yeah, I know. Who would have thought? So let's do this for the eeg. In this study, there were seven children. Everyone had epilepsy or a seizure disorder and some level of developmental disability. One student additionally was blind and hearing impaired, one had autism, and all had previous difficulty tolerating the EEG procedure. So they had attempted it and failed. There were two dependent variables here. The first one was completion of the steps of the task analysis and also the number of escape and avoidance behaviors, which was defined basically exactly like yours was in the attempt to escape is how they defined it. And the steps. There were a lot of steps. They actually just gave us, like a snippet of it in the table in the paper, because every time that they put one of the sensors on that was like a step that would be a lot. And they said that they. They call them leads because it's like a little sticker but also has like a wire coming out of it. And so they said they did 16 to 25 of those. But the beginning steps were like, enter, sit down. Have let someone touch your head. Let someone put a Q tip on your head. Let someone put a Q tip with the skin prepping gel on your head, then placing the lead on and then doing that for every single step. So this to do that for 20. This whole thing is like a hundred steps long, basically.

[A]

And they're like. And look at the appendix.

[C]

Yeah. Now, what is a little bit interesting here is do we really have an experimental design? Not. Not really. And that's okay. So this was. And they were upfront about it, a

[B]

graph of skill acquisition.

[C]

Yeah. So they're like, this is a case analysis. And we didn't really do a baseline. They called it an AB design in that A was the beginning of treatment and B was the end of treatment.

[A]

Love it. Love it.

[B]

I think that's just.

[A]

That's okay.

[B]

An A design.

[A]

I love it.

[C]

However, they did end with. For six of seven, they ended with an actual EEG instead of just the practice run. So maybe that's the B.

[A]

You know what I love? I was like. I bet he was like, suffer's like, I really want to get this published in A Behavioral Journey. But I don't have an experimental design, so I don't need to put it there. I can put it somewhere else.

[C]

Yeah.

[B]

Also, who's going to be reading and be like, man, I really need to learn about how to help my patients with their EEGs, because I'm a doctor of epilepsy. I do a lot of epilepsy care. I'm going to read Epilepsy Behavior. And I'm like, I wonder if Jabba's got something for me.

[C]

Yeah, I know. No, I think he was right in, in that approach. And the issues that we would have with respect to the design are. Are probably pretty esoteric in terms of the actual considerations and getting this literature out there to help people. So everybody, like, they did have an initial baseline because everybody failed their initial eeg. They just don't. Didn't have those data. You. Yeah, so. So all of that happened. And then they did a treatment package. So, Rob, you. You thought yours had a lot of components, but mine might rival yours because they included antecedent conditions. These antecedent conditions included having favorite items available that were used to distract and comfort the individual. But also there were little rewards that were available afterwards. But they listed them as antecedents. But those sound to me like consequences then.

[B]

Well, that were they. Were they. I couldn't remember if. I couldn't tell if they were contingent or they were just at the end.

[C]

Some of them were. Some. Yeah. Some of them were, yeah. Then we also had the behavioral intervention, which they considered to have two parts. The first part was differential reinforcement, and they told us all what differential reinforcement was and everything like that. Because this wasn't an ABA journal, that reinforcement was provided differentially for cooperation, instruction, following, and then tolerating, getting the medical components, like, applied to the head. And those reinforcers were videos, music and stories. And how they described it is they were kind of like always going. But then if they saw the child start to not comply, then they paused them.

[B]

So it was more like simultaneous reinforcement than differential reinforcement, although, I mean, I guess simultaneously.

[C]

But then it was differentially applied because if then they did not cooperate, then they paused it and then they resumed it when they started cooperating.

[B]

The same as simultaneous reinforcement, but it's under the umbrella, I guess, of Dr. Yeah.

[C]

And then they also did have an escape extinction component here. It seemed pretty mild in that they just gently interrupted attempts to remove the stickers or the leads and they were given an incompatible activity to do. So basically, they're like, do this other thing with your hands so that you can't try to remove the leads. Like, oh, here, why don't you play with this thing?

[B]

Why don't we have more escape extinction where there's something fun to do.

[A]

Yeah.

[C]

So, I mean, it's like, it's exactly what you would see in this. In any of these types of contexts. Right. It doesn't. It was fairly low key, as far as I could tell. And then they also, within this treatment package, they had what they called Counter conditioning, which is not really a word I'm familiar with.

[B]

It was in the Kuvo article as well, and they sort of hid the definition.

[C]

Yeah, so it's just. I don't know. I just quoted what it was. Exactly. So counter conditioning involves modifying conditioned anxiety by carefully planned graduated exposure to the feared or non preferred stimulus while engaging the patient in a distracting, relaxing, or otherwise pleasurable activity. That.

[A]

Exactly it. Yeah.

[C]

So, I mean, it makes sense, but I just. It's like, okay, that has a special name. And then within that category, this is where they listed shaping, where they reinforced successive approximations of the behavior. And they also put underneath this. This area, caregiver and medical staff training. So the therapist modeled all of the techniques I just mentioned for the parents and the caregivers. And then they also just noted here that they asked the medical staff to have everything ready when the student came into the room, because waiting around was

[B]

like part of their training was latency to getting all your materials together. Yeah, Dinah, that's a lot in a package. I didn't see dinosaur narrated dvd, so.

[C]

No, we didn't have that.

[B]

Looks like Kuvo is the winner.

[C]

As far as I know, there was no video component here, so. Yeah. So all of these studies are kind of just an A design, but they did do a T test where they compared the percentage of steps completed in the first session to the percentage of steps completed in the last session.

[A]

Oh, that's neat. Because they have seven participants. They have seven participants, so it's enough.

[C]

Yeah.

[A]

It's even enough to do a man Whitney U. I love the Mann. Whitney U. You only need six. Yeah, it's my favorite. Oh, wow.

[C]

I'm gonna get you a shirt that looks like it's a college Mann. Whitney, you.

[A]

Yes, I will wear it every day.

[C]

And great news. The T test produced super duper significant results.

[A]

Yes.

[C]

Because initially everyone did about zero steps. A few of them had some steps, and then at the end, everybody did a hundred steps.

[B]

Wow.

[C]

100%.

[B]

Some of them were really fat, like Susan's grab. What was it, three?

[C]

Yeah. Susan only took three.

[B]

Three trials.

[C]

Three sessions.

[B]

Three sessions.

[C]

Two others only took five sessions. One took four sessions. One took seven sessions. Yeah.

[A]

That's not a lot at all.

[C]

No. Van was the student who had the multiple disabilities. He took eight sessions, I believe. And then Jerry took 10 sessions, but he was only three. And then they also graphed how many steps of the process had escape or avoidance behavior, and that steadily decreased over the sessions down to roughly zero at the end.

[A]

Wow.

[C]

Yeah. So it was. It was very effective, and that was that.

[B]

Great.

[C]

So what do you know?

[B]

Let's move into dissemination station. I'm gonna say I think the secret to medical tolerance procedures is some sort of a shaping procedure or counter conditioning procedure, as well as maybe differential reinforcement. I'm guessing if you had to pick the magic sauce reinforcement, it's those two, right? Differential reinforcement is part of your shaping procedure.

[C]

Right.

[B]

Maybe escape extinction needs to be there sometimes, but not always. How intense does. It could just be the hand. Light hands down or light hands to preferred items. So I don't know. Let's get. Let's get that. Let's get the little component analysis out there. How many of these extra pieces, you know, what's. What's the cruft. In some of these packages? It's a lot of extra stuff. Do we need it all? Because they're all effective, so maybe we're cool with that. But making a DVD is hard if nobody cares about the pictures you took of the procedure or that doesn't lead to change in treatment. Maybe you don't need as many pictures or you show them to start and then they're available.

[A]

Yeah.

[C]

And I. I do always like the idea of having something visual for the. For this child ahead of time so that they can, you know, maybe like, see what. What it's going to be like to visit the doctor or visit the dentist and have it presented to them in a. In a way that is familiar. Because there's a good chance that that might sort of help assuage fears or lessen anxiety about that.

[B]

I mean, I think the research on social stories would tell you that it does not.

[A]

That is true.

[C]

Well, we don't necessarily know.

[B]

Right.

[C]

Like, if it's done in combination with these other things, that's.

[A]

That's effective.

[B]

Yes.

[A]

Just not alone.

[C]

We know that it's also a nice thing to do.

[B]

Well, I think it's the same as, like, why do we add validation to an extinction procedure? Because it makes us feel better and therefore we're more likely to use the procedure if, you know, you've got a fun story or a DVD to go with your experimentally sound shaping, counter conditioning, differential reinforcement, simultaneous reinforcement procedure with maybe escape extinction. Yeah. Doesn't it make it all nicer, this little movie to go along with it? Okay, sure, whatever. That's fine. But there's a difference between knowing what you have to have and knowing what is nice to have.

[C]

I stand by it, though, because I. I feel like if you're a little kid and you don't know where you're being taken and they do scary things to you there. It would be nice to know ahead of time any additional information you could be provided about what to expect.

[B]

Yeah, and I've got no problem with the videos or the books because you make one and you have it for all the kids that will need to go there. So it's very low cost and potentially is a nice addition to the meaningful treatment that will happen. And again, I think we look at social story research. I don't think we're looking at kids getting social stories who don't have either a disability or history of challenging behavior in that environment. So I don't know if we have any stats on children at large, you know, reading a social story before working hard. Oh, no, we did get. Well, that's video modeling, though.

[A]

Oh, that's true. That's true.

[C]

If you have to go potty, stop and go. Right.

[B]

I got another extension. I'm gonna do Daniel Tiger books, but not the videos.

[A]

I love that. Okay.

[B]

All right. So maybe a component analysis. Maybe we're all good with these procedures. All seem like they worked real nice. So, yeah, just package intervention.

[C]

You did it. And like in researching these, then, then we realized like how many more there are.

[B]

Yeah.

[C]

Out there.

[A]

Right.

[C]

That touch on all these other areas too. And so this is, I think, a pretty well established approach. And seems as though there, it's a pick and mix.

[B]

Right.

[C]

There's maybe several things.

[B]

One question I would be curious about has to do with insurance and insurance funding now. Well, no, I, I know that there sometimes are difficulties with like, oh, well, you can't do medical procedures if you're a bcba, but a doctor is not going to get insurance reimbursement for like, Oh, I did 70 EEGs because 69 of them were practice EEGs as I was shaping up there. You're not going to get paid for that.

[C]

No.

[B]

So I'm curious if that has been fixed, if that isn't as the problem. I thought it might be, but I know there's some, some, some situations with like, hey, look, we got this great package. It might take seven, eight hours, it might take two hours. You know, it varies.

[C]

I don't know.

[B]

I don't want to buy. Was like the longest on the. The 10.

[A]

I don't actually know the answer to that.

[C]

So I want to speak to like, what your insurance company will.

[B]

That's what. That's why I said it's a question.

[A]

Yeah, I think it's going to be Insurance specific, to be honest.

[C]

I mean, I know we used to work on tolerating medical procedures. Yeah. As goals for students.

[B]

Well, it should. Somebody should be able to get reimbursed for it because it's very, very important.

[C]

It's very.

[B]

For the lives of individuals who have a bad history with some of these medical procedures but need to have them done regularly.

[C]

So preventative care is very important and everyone should have access.

[B]

Well, by the time this podcast has come out, I'm sure no one will have access to anything anymore. Thanks. Thanks. Government.

[A]

Oh, man.

[B]

Shots fired. Government. You suck. Anyway, research. Great. Love it. DVDs. Maybe I'll. I'll give them a pass. All right, that's the end of pairings. No, that's not the end of pairings. That's the end of the dissemination station. Let's go on to pairings, shall we?

[C]

All right. Pairings is part of the show where I tell you about other episodes you might want to check out if you. It is true we haven't talked about this type of topic that altogether that much, but we do have a few. Episode one, we haven't done it all

[B]

except for these times.

[C]

Episode 148, we discussed dental exam tolerance with Dr. Kelly McConnell. One of my all time favorite episodes.

[A]

Yeah, mine too. I remember Rob and Kelly were jiving so hard.

[B]

I was like, we're, uh.

[A]

Oh, Diana's gonna lose it. Meaning her husband.

[C]

It's all good.

[B]

Episode five, that was my favorite topic.

[C]

In episode five, we talked about tag teach. So while I said we didn't have like a direct shaping episode, we do have that one. Episode 325, we talked about safety skills, which I just, I feel like are, you know, running in parallel here with these skills. In episode 249, we talk about DRA minus extinction, which might be relevant. And Then finally, episode 192, we discuss anxiety assessments with Dr. Kira Moore. I was like, we've talked about something related to this and it was in that episode. So I finally came up with it. I also like to recommend a snack to go with the episodes. A snack today is the safety pop. Do you guys remember the safe teapot?

[A]

Yeah.

[C]

Yep, it is. You get them at the doctor's office and it's a lollipop, but it has like a yarn stick that is in a loop so you can hold it on your finger. Yeah.

[A]

So you don't swallow the. The end. And it was. I remember because I used to. I used to suck on the. The bottom part and it would just disintegrate the string. Yeah, don't judge me.

[C]

That's fine. But I. I never really understood because I was like, I'm not eating the stick, I'm eating the lollipop. But if you did, it would disintegrate. Yeah, but the law, I mean, you could still choke on the lollipop, I guess. It's just you can't run and shove it down your throat if you fall. But you still could.

[A]

Yeah.

[C]

So I'm not really sure what is overly safe about it, but it's what makes me think of the Doctor, and that is pairings. Please enjoy.

[B]

All right. Thanks, Diana. And with that, we've come to the end of our ten step medical podcast procedure. We hope you enjoyed this episode of ABA Inside Track. If you haven't, we would really appreciate if you left us a review on Apple Podcasts or wherever you like to get your podcasts. Certainly if you haven't, you could also subscribe. But if you want to subscribe to something even more special, maybe you want to subscribe on Our Patreon page, patreon.com abainsidetrack where you can subscribe at the free level to get access to, you know, our polls, all the things on that page. You can also subscribe at any of the other kind of paid tiers we have, which we really appreciate helps us keep our show moving along. But Also at the $5 level, you gain access to all of our Listener choice episodes CES for free. And at the $10 level, you gain access to our book club episodes a year before everybody else, as well as two CES for all of those. That's like a lot of CES. It's every season you're getting free CES just for being a [e-mail] ABA Inside Track. And if you haven't checked, you might have missed out. I think you did, actually. By the time this one comes out, you missed out on our book club poll for the next year. But you can at least go back and see what we picked for our books. And then you've got another poll coming up. Don't worry, our listener choice polls come out every season. You still have [e-mail] abainsidetrack oh, would you like a second secret code word, everybody?

[A]

I would.

[B]

You did such a great job cutting your nails. So I'm going to give you a second secret code word. It is Percolate. P E R C O L A T E. It's like chocolate, but not as good, I guess.

[C]

Go get it. Percolate. And while we wait and say. All right. All right.

[A]

Medical to the R. Yeah.

[B]

All right. Theme thank you.

[A]

We don't need nobody.

[B]

Okay. Percolate. That was a coffee thing.

[C]

All right.

[B]

Some final thanks. Thanks to Dr. Jim Carr for recording our intro outro music, Kyle Sturry for our interstitial music, and Dan T.H. abbott of the podcast Doctors for his amazing editing work. We'll be back next week with another fun filled episode, but until then, keep responding. Bye.

[C]

Bye.

[B]

See?

[A]

Yeah.