Using In Vivo Desensitization to Decrease Anxiety-Provoking Situations for Children with Autism

Written by Catherine Czerwonka B.A., BCaBA

For some children with autism, many self-care and grooming tasks (i.e. teeth brushing, nail clipping, haircuts, etc.) as well as basic medical procedures (i.e. getting their temperature taken or getting a shot) can be extremely anxiety-provoking.  They may have had an aversive (negative) experience in one of these situations in the past or may have sensory issues that make certain aspects of the task uncomfortable.  Often times, escape/avoidance behaviors such as crying, whining, or aggression are observed in these situations or in the presence of items or people associated with these situations.  Typically, parents are left to either force the child through the task (thus potentially making the task more aversive) or avoid the task altogether.

For these children, a procedure called in vivo desensitization is recommended in which children are gradually exposed to the fear-producing stimuli (Miltenberger, 2008).  The first step involves creating a hierarchy of fear-producing stimuli that will be used to expose the child to each step of the process.  For example, the task of nail clipping can be broken down into the following:

1. Nail clippers on table next to child

2. Adult holds clippers 1 foot away from nail

3. Adult holds clippers in front of child

4. Adult holds clippers up to hand, no clip

5. Adult holds clippers up to 1 nail for 1 sec, no clip

6. Adult holds clippers up to 1 nail for 5 sec, no clip

7. Adult clips 1 nail

8. Adult clips 2 nails

9. Adult clips 3 nails

10. Adult clips 4 nails

11. Adult clips 5 nails

12. Adult clips all nails on both hands

Depending on the complexity of the task and the severity of the escape/avoidance behaviors exhibited by the child, some steps may need to be combined or expanded.  It is important that the hierarchy be tailored for each child to prevent moving too quickly through the task. 

Once the hierarchy is developed, it’s time to choose a reinforcer for cooperative behavior.  It is best to choose a reinforcer that the child is highly motivated for such as their favorite toy or snack.  It may be helpful to restrict their access to the reinforcer at all other times so that their motivation for it remains high. 

Next, begin with the first step. If the child is successful (i.e. no problem behavior), provide the reinforcer.  Once the child is successful 2-3 times in a row (we recommend across different days), move to the next step.  Continue this process until the child can tolerate all steps of the task.  If the child has problem behavior more than 2-3 times in a row on any given step, go back a step and reinforce until the child is comfortable again.  It is important that you do NOT provide reinforcement if the child is exhibiting problem behavior!

Other tips:

• Before physical contact is made between the child and the anxiety-provoking stimulus (i.e. before step 4 in the above hierarchy), it may be helpful to let the child touch the stimulus on his/her own terms.  This means letting them handle a nail clipper, touch a hair clipper that is turned off, etc. 
• In the beginning steps, no attention should be called to the stimulus.  If the child notices it, say, “It’s only a _____. It’s just going to sit next to us.  We’re not using it today.” 
• At later steps that involve physical contact with the stimulus, say, “We’re going to do _____ with the _____.  It won’t hurt, and you can earn _____ for having good hands and a quiet voice.”
• For some fear-provoking situations such as flying on an airplane, it may not be possible to gradually expose your child to each step in the process in the actual setting.  Depending on the skill set of your child, a procedure called systematic desensitization may be appropriate which involves the child visualizing himself/herself engaging in each step and the reinforcer being provided if the child is calm during the visualization activity.