CHAIRPERSON: Dr. Neha Sayeed Presenter: Mr. Muhammed Ali PK
CHAIRPERSON: Dr. Neha Sayeed Presenter: Mr. Muhammed Ali PK
Neha Sayeed
PRESENTER : Mr. Muhammed Ali PK
. For three decades, researchers and practitioners have
turned to Behavior Modification for current scholarship
on applied behavior modification.
(Columbia University Medical Center/New York State Psychiatric Institute, New York, NY, USA)
SAD is one of the most common psychiatric disorders in the United States.
Although empirically supported treatments for SAD exist, only 20% of those with social anxiety seek
and ultimately receive professional help of any kind. (Grant et al., 2005).
Among those who do seek treatment, many find that there are additional barriers to receiving state of
the-art cognitive-behavioral therapy (CBT), including geographic location, availability of CBT-trained
therapists, financial cost, and long waiting lists (Shafran et al., 2009).
For these reasons, it is imperative to improve access to care for individuals with SAD.
The Internet offers a potentially efficient and cost-effective medium to facilitate dissemination of evidence-
based treatment.
It offer advantages over traditional treatment formats, including ready accessibility, standardized delivery of
American Psychiatric Association criteria for evaluating the empirical evidence for treatments, Internet-based
programs are classified as well-established for depression, social anxiety, and panic disorder (Hedman et al.,
2012).
Acceptance and Commitment Therapy is a form of CBT that deemphasize cognitive restructuring techniques
in favor of interventions targeting mindfulness and acceptance of internal experiences (Herbert & Forman,
2013).
Both in-person and online acceptance-based CBT treatments for depression have been shown to be effective in
2. To explore the necessity of therapist support by comparing the program with versus
without adjunctive minimal therapist support, delivered via videoconferencing once per
week and supplemented by daily texts.
Participants
Overall the sample was not treatment naive. Most of the participants (26/42, 61.9%) had received some type of
Five participants were on a stable dose of psychotropic medications throughout the study, and none of the
participants reported having previously received any form of acceptance-based or exposure-based therapy.
Although SAD was determined to be the primary diagnosis, 40.5% (17/42) of the sample had other comorbid
conditions, including a mood disorder (23.8%), generalized anxiety disorder (14.3), and obsessive-compulsive
disorder (2.4%).
1. 18 to 65 years of age
4. Agreed to refrain from receiving other psychological treatment for the duration of the study
5. Fluency in English
Contacted site to
inquire about Telephone Screen Diagnostic Randomization (n
study (n = 83) Assessment (n = 52)
(n = 126) = 42)
Randomization (n = 42)
Allocated to Internet +
Therapist Support
(n = 20) Post-Treatment (n = 16)
All participants received the same Internet-based self-help intervention.
The program was derived from an acceptance-based CBT that utilizes traditional behavioral strategies (e.g.,
exposure) within the context of a model emphasizing mindfulness and psychological acceptance, inspired
by ACT.
The program was comprised of eight modules in the form of online audio-narrated presentations, with
These were supplemented by reading materials, exercises, video clips, and homework assignments.
The content of the modules focused on introducing and illustrating core treatment concepts and skills
In addition, the intervention emphasized behavioral principles that are not exclusive to ACT, including
exposure to feared situations, limiting the use of safety behaviors, and improving social skills.
Participants were instructed to work through the modules in sequential order, completing one per week.
Each module provided a brief review of the content from previous weeks
After each module (starting with Module 2), the participant was instructed to self-assign exposure exercises to
Before starting the subsequent module, participants were prompted to enter the percentage of exposure
Other assignments included reading articles/handouts and completion of various self-monitoring assessments.
Using the built-in computerized statistics of the interface, completion of modules for each participant was
Participants in both groups also received brief homework feedback, with the goal of providing encouragement
The weekly check-in sessions were limited to 10 to 15 min except in the event of a crisis.
Check-ins were spent providing support, clarifying treatment concepts as needed, addressing
technological questions, troubleshooting exposure assignments, and discussing general issues with
treatment; no new information was introduced.
Participants in the therapist support group also received daily text messages. Messages were limited
to a brief prompt regarding the exposure assignment, a concept that was introduced that week, or
encouraging and supportive messages designed to motivate the participant.
The number of texts was limited, On average, participants only received one text message. If they did
not reply to the initial text message, no further text messages were sent.
Participants were asked to complete an online questionnaire packet before treatment, mid-treatment (i.e., following
completion of four treatment modules), and post-treatment. Using the measures described below.
Measures
Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu, & Stanley, 1989).
Liebowitz Social Anxiety Scale (LSAS-SR; Baker & Hofmann, 2002; Liebowitz, 1987).
Quality of Life Inventory (QOLI; Frisch, Cornell, Villanueva, & Retzlaff, 1992).
Sheehan Disability Scale (SDS; Leon, Olfson, Portera, Farber, & Sheehan,1997)
Multiple imputation was used for missing data. Completer and intent-to-treat analyses (ITT)
12%
48%
40%
Treatment Adherence and Satisfaction
Participants in the Internet plus support condition completed significantly more modules than participants in
the Internet only condition.
Chi-square tests were used to examine potential differences in post-treatment survey responses regarding
participants perceptions of engagement with the treatment program.
There were no differences between groups in satisfaction with the program, perceived effectiveness for fear
reduction, perceived effectiveness for reduction of avoidance, or prediction of severity 1 year.
From program completion. Similarly, there were no significant differences between groups on ease/difficulty of
receiving Internet-based treatment or in perceived engagement.
Among completers in the Internet only group (n = 12), 50% of participants stated that they would have
benefited more from the program had they received therapist support.
Among completers in the Internet therapist support group (n = 16), 93.8% of participants were satisfied
with the therapist support that they received and 87.5% found the weekly videoconferencing session to be
helpful.
Some reported that they found the videoconferencing anxiety-provoking (e.g., being on video was torture
for me).
There was greater variability in the perceived utility of daily text messages:
18%
24%
36% 22%
Acceptance-based approaches in an Internet guided format have not yet been explored for SAD.
In addition, the present study is the first to utilize videoconferencing as a medium for therapist support in a guided self-
help intervention, and to combine videoconferencing sessions with daily text messaging.
The intervention was associated with significant reductions in social anxiety symptoms and improvement in quality of
life and other indices of psychosocial functioning.
The majority of participants believed that the program decreased both their fear and avoidance of social situations.
The results suggest that Internet interventions based on acceptance-based behavior principles, consisting of only eight
modules, are feasible to implement and may be as efficacious as traditional CBT programs for some individuals.
This method of delivery could be used to overcome some of the barriers associated with the dissemination of evidence-
based treatments, specifically to those who may not have access to in-person treatment, to those who may be hesitant to
seek in-person treatment due to social fears and avoidance, and to those who have restricted schedules and/or those
who desire anonymity.
These findings suggest that therapist support is related to adherence to the program
However, there were no differences in symptom reduction for the completers between the two groups.
the support is related to adherence to the program. These findings echo the results of Berger and
colleagues (2011)
Both the Internet only and Internet plus support groups experienced a similar reduction in symptoms
and improvement in psychosocial functioning in those that completed the program.
This suggests that support may be particularly useful for those who may be expected to have difficulty
adhering to the program.
In the Internet plus support condition, the text-messaging component was perceived to be less helpful
than the videoconferencing sessions.
The attrition rate across the two groups was larger than expected (31%).
Although independent assessors were used to evaluate clinical improvement, they were not blind to the
Although only one group received therapist support, both groups received feedback on their homework
Treatment modal is fixed other than accommodating individualistic flexibility and changes.
Assessing preferences for therapist support and participants level of motivation prior to the program
The treatment program used in the present study is multicomponent, consisting of various
Component control studies are needed to determine the extent to which these components
Toby Honsberger (Renaissance Learning Academy, West Palm Beach, FL, USA)
Students with developmental disabilities often require explicit training in the personal safety skills
many teachers and parents have assumed that students with disabilities either have these skills or are
incapable of learning them if they do not even though other daily living and personal skills are
frequently integrated into students curricula.
The absence of safety skills training leaves students with developmental disabilities vulnerable to
Children with developmental disabilities are significantly more at risk of unintentional injuries than their
Incorporating first aid skills into education and rehabilitation programs facilitates independent living during
adulthood.
Researchers have demonstrated that students with developmental disabilities are capable of learning a wide
range of complex first aid skills when these skills are explicitly taught by educators.
LBBIs provide a literacy context with print or pictures, along with discrimination training and rehearsal, to
guide instruction within a storytelling environment (Bucholz & Brady, 2008).
LBBI is a term that describes an assortment of interventions that uses pictures, written scripts, and stories,
along with behavioral rehearsal of the routines and stories in a step-by-step format, to teach novel tasks.
In a school-based follow-up study, Brady, Hall, and Bielskus-Barone (2016) investigated peer-mediated
LBBIs to teach hand washing to elementary- aged children with severe disabilities
This study was designed to explore further the LBBI research by examining the impact of LBBI
The study also provided a further exploration of the role of peers in delivering the multiple components
Research Question 1: Will a peer-mediated LBBI increase the acquisition of a first aid routine by
Research Question 2: If students acquire the first aid routine, will they maintain their skills after the
Who attended a public charter school for students with autism spectrum disorder
Reading comprehension for all three students was at the first-grade level.
A fourth student, Miguel, served as the peer facilitator for all the target students.
Miguel was enrolled in the same school and also had a primary eligibility of ASD.
Miguel was in 11th grade and working toward a standard high school diploma.
Miguel was known to the target students and had interacted with them prior to the study during
Miguel was chosen as the peer facilitator due to his ability to read at or near grade level, his ability to
All students provided verbal and written assent to participate in the study.
Parents of all students provided written consent prior to the beginning to the study, and the study
received formal approval from the universitys human subjects review board.
Table 1: A summary of
participant characteristics.
First aid skills were identified as a needed area of instruction for all participants.
An assessment of the first aid routine was conducted prior to initiating the study.
During this assessment, students were asked to help an adult with a simulated wound by cleaning and dressing the
wound.
All bandaging materials were on a cafeteria table, and the request was initiated by the adult pointing to the wound
and saying, Im hurt. Can you help me?
During this pre experiment assessment, none of the target students were able to complete the first aid routine
independently.
Based on these results, instruction on the first aid routine was deemed important.
Cleaning and dressing a wound is commonly taught in first aid classes because most other first aid skills build upon
this routine, and it is a skill required to live independently.
All instruction took place in the school cafeteria.
The cafeteria was approximately 100 100 ft square with tables, attached benches, a sink, a washer
Although the cafeteria was used for instruction and meals throughout the day, no other students or
All materials needed to complete the first aid routine were stored in a first aid kit located on a counter
in the cafeteria.
All baseline, intervention, and maintenance observations took place in this setting.
A task analysis was created for the first aid skills of cleaning and dressing a wound on another person.
Data were collected individually for each student while observing the student clean and apply gauze to a simulated
wound on the peer facilitator.
A prompt was delivered to the student only in response to the student making an error, or not initiating a step
within 30 s.
A prompt was defined as the peer facilitator delivering feedback to the student to remember what the story said
while turning to the page in the story, and then reading the page again.
After creating the task analysis an LBBI storybook was created.
The storybook contained 15 pages, one page matching each step of the task analysis
Each page contained one simple sentence written in first person, and one matching photograph.
For example, on the first page was written I wash my hands with soap and water and had a matching
All photographs were taken from the students point of view, within the school cafeteria.
Figure 1 for a sample page from the LBBI storybook.
Data were collected by one of two observers using paper data sheets created by the authors.
All observers were trained to use the data sheets prior to beginning the study.
Agreement was determined by counting the steps of the task analysis scored the same by both observers,
and dividing that number by the total number of steps observed, then multiplying by 100.
Agreement between the two observers across all students and sessions (combined) was 99%. For
individual students across conditions, agreement was 99.6% for Randy, 97.6% for Derek, and 100% for
Tim.
Data were analyzed first using traditional visual inspection procedures.
Next, data were summarized by calculating measures of central tendency and ranges for each
Two post hoc analyses were conducted to supplement the visual inspection procedures for the
graphed data.
Tau-U coefficient provided a single, omnibus effect size based on the weighted average of each
During baseline, the peer facilitator was present in the room, but did not interact with the
participating students.
The peer had a simulated cut on his forearm created by making a 2-inch mark with a red felt-tip
marker.
An investigator gestured to the cut and said to the student, Hes hurt. Can you do first aid?
No additional assistance was provided to the student (or the peer) during baseline.
A baseline session ended if students did not initiate any steps of the first aid routine after 30 s, or if
Before beginning the intervention with the students, an investigator taught the peer to use the LBBI with
students to show them how to implement a first aid routine to clean and dress a wound.
Peer training was conducted over 2 days, for approximately 20 min each day.
The peer was taught to read the sentence on each page of the storybook, point to the picture, gesture to an
item, and provide praise after the student completed each step correctly.
Before implementing the LBBI procedure with any of the students, the peer performed these steps for
each page of the storybook with the investigator, and demonstrated the ability to implement the
intervention accurately.
When the intervention was delivered with each student, the peer rehearsed the intervention steps with the
investigator daily, prior to the participants entering the room. However, no formal data were collected on
fidelity of the LBBI delivery by the peer reader.
INTERVENTION.
When the intervention was implemented, the peer sat next to each participating student, and held the
book in front so they could both see each page.
As a storybook-based intervention, the LBBI was designed to be delivered as a table-top activity, without
the interruption that would ensue from students moving to various locations to obtain materials, use the
sink, clean up, and so forth.
In this study, these LBBI components were delivered in the following way.
First, the peer read aloud the sentence on each page, pointed to the picture, and then gestured to designated
items (e.g., gloves, gauze pad).
When the peer finished reading the story, the investigator gestured to the simulated cut on the peer and
said, Hes hurt. Can you do first aid?
If the student did not initiate a step within 30 s, an investigator asked the peer to go to the corresponding
page in the storybook and prompt the student with, Remember what the story said. The peer then
reread the sentence, pointed to the picture, and requested the student to perform the step again.
If the student responded but made an error on a step, the same correction was provided, but the
correction was prompted by the peer without an investigator prompt.
FOLLOW-UP.
During the follow-up condition, the LBBI was removed to determine whether any of the skill
The criterion for removing the LBBI was successful completion of 12 of the 14 steps (86%) for four
consecutive sessions.
The LBBI was removed after 14 intervention sessions for Randy, 12 sessions for Derek, and six
Follow-up observations were conducted for Randy 10 and 19 days after intervention; follow-up
observations for Derek were held seven and 16 days after the intervention was removed, and 12 and
21 days after Tims last intervention session.
Selected 3 Adolescents with ASD
Peer Training
Intervention
Follow Up
Intervention Effects
During baseline, data remained low and stable, with no student accurately completing more than 7% of
Randy was able to complete one step accurately, but Derek and Tim did not initiate any steps in the task
When the peer-mediated LBBI instructional activities were introduced, all participants began completing the
However, due to Randys variability, the LBBI was enriched with the correction procedure described earlier during
While receiving the enriched LBBI, Randy steadily increased until he reached 86% accuracy for 4 days in a row.
Prior to adding the correction procedure with Derek, his performance was low but accelerating.
Derek produced a significant increase in accurate completion of steps after the correction procedure was added
(during his fifth intervention session), reaching 86% accuracy for 4 days in a row.
Tim received the LBBI package with the correction procedure immediately after baseline and had a significant
He continued to perform 100% of the steps accurately and independently for four consecutive days.
FINDINGS IN FOLLOW-UP.
Upon the removal of the peer-mediated LBBI, Randys skill accuracy continued to improve, increasing
to 93%.
Dereks performance during the follow-up observations was slightly more variable, decreasing slightly
during his first follow-up observation, before returning to his previous performance (86%).
His accuracy decreased from 100% during his final intervention sessions to 79% during the first follow-
A. LBBI will help students learn skills and routines (3.75 of 4.0)
C. Professionals would also recommend using LBBI instructional packages to others (3.5 of 4.0).
D. A student peer deliver the lessons would be an effective way to teach this population (1.5 of 4.0).
E. Students would be willing to perform the first aid routine of cleaning and bandaging another persons
activities would increase the acquisition of a first aid routine by adolescents with developmental disabilities, and
to establish whether any acquired skills would maintain after the intervention was removed.
All students who received the peer-mediated LBBI improved their ability to clean and dress a wound.
All students maintained the skill after the intervention was removed during the follow-up sessions.
To date, story-based interventions have been implemented primarily by teachers, parents, and other professionals.
As a third investigation showing the effectiveness of peers in implementing LBBIs, these findings extend the
literature base on LBBIs, and create future options for other extensions of this intervention.
Study did not have a generalization focus (other than maintenance).
Researchers did not assess whether the students were successful in keeping the items used
Study limited the intervention to a single set of stimulus materials and intervention
The peer-mediated LBBI instructional package was effective as a teaching procedure for
safety skills, and hold promise for teaching other safety skills and routines to adolescents
and adults with disabilities.