1. Behavioral Strategies: Overcoming Phobic Avoidance and Escape of Necessary Health Services William Tim Courtney Outreach Service Of Indiana Dr. Eb Blakely Quest Inc.

4. Percentage of Individuals With I/DD Meeting Diagnostic Criteria for a Specific Phobia 17.5 {Dekker and Koot, Journal of the American Academy of Child and Adolescent Psychiatry, 42, 915-922}

5. Percentage of Individuals General Population Meeting Diagnostic Criteria for a Specific Phobia {Kessler et al., Archives of General Psychiatry, 62, 617-627} 8.7

7. 3838 Number of Studies listed in PsycINFO and PubMed databases between 1970 and February 2007 {Jennett and Hagopian, 2008, Behavior Therapy, 39, 151-161}

8. 7 Main Treatment Components {Jennett and Hagopian, 2008, Behavior Therapy, 39, 151-161}

9. In Vivo Exposure

10. Fear Hierarchy

11. Contingent Reinforcement

12. Prompting

13. Modeling/Video Modeling

14. Extinction/Blocking

15. Distraction

16. If a response inhibitory of anxiety can be made to occur in the presence of the anxiety-evoking stimuli it will weaken the bond between these stimuli and anxiety... Joseph Wolpe

18. Fear Hierarchy

27. Escape/Avoidance Hierarchy Medical procedures can be ordered in terms of… ★ Their occurrence in time ★ Their unpleasantness Why “Escape/Avoidance”? ★ These steps involve situations/activities that people try and get out of ★ Some people resort to extreme behavior to do so

28. Task Analysis 1. Sit in chair for 5” 2. Sit in chair for 10" 3. Sit in chair for 15" 4. Sit in chair with T holding tools 5. Sit in chair with tools within 1" 6. Touch tools to mouth 7. Tools in mouth for 5" 8. Tools in mouth for 10" 9. Tools in mouth for 15" 10. Recline with tools in mouth for 5" 11. Recline with tools in mouth for 10" 12. Recline with tools in mouth for 15" 13. Recline with tools in mouth for 20" 14. Recline with tools in mouth and feet 15. Dental visit: parking lot 16. Wait calmly in the waiting room for 5“ + 17. Enter the dental room 18. Sit in dental chair for 5" 19. Sit in dental chair for 1 minute 20. Sit for x-rays (approx 2 minutes) 21. Sit in dental chair for cleaning (break every 3-4 minutes) 22. Sit in chair and breath through nose for gas inhalation-I 23. Accept injection of local anesthetic-i 24. Sit for extraction-i 25. Sit for deep cleaning-I 26. Sit for Novocain 27. Sit for bridge work 28. Sit while bridge is installed 29. Sit for follow-up visit and assessment

29. Escape/Avoidance Procedure Pre-Tx Conduct an assessment Divide task into steps Identify potential reinforcers

30. Escape/Avoidance Procedure Intervention Instructions and briefing Start with step #1 Then #1-#2 Then #1-#2-#3, etc Problem behavior – no escape Reinforcers for appropriate behavior Preferred items Escape from situation – sometimes to previous step

31. Escape/Avoidance Data Baseline