CHAIRPERSON : Dr.

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.

It was first published in 1995

Alan S Bellack, University of Maryland School of

Medicine, USA

2016 Impact Factor: 1.455 2016

Ranking: 73/121 in Psychology, Clinical

LONG PRESENTATION ONE
 Marina Gershkovich

(Columbia University Medical Center/New York State Psychiatric Institute, New York, NY, USA)

James D. Herbert (Drexel University, Philadelphia, PA, USA)

Evan M. Forman (Drexel University, Philadelphia, PA, USA)

Leah M. Schumacher (Drexel University, Philadelphia, PA, USA)

Laura E. Fischer (Drexel University, Philadelphia, PA, USA)

 Social Anxiety Disorder (SAD) is characterized by an intense, excessive, and persistent fear of being
negatively evaluated by others in one or more social situations.

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

psychoeducation and therapeutic concepts, time flexibility, and convenience.

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

reducing symptoms and improving quality of life.

1. To assess the efficacy of an Internet-based guided self-help intervention in reducing
social anxiety symptoms and improving indices of functioning.

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

The sample (n = 42)

Overall the sample was not treatment naive. Most of the participants (26/42, 61.9%) had received some type of

counseling or psychotherapy in the past.

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

2. A primary diagnosis of the generalized subtype of SAD

3. Not taking psychotropic medication, or on a stable dose of psychotropic medication

4. Agreed to refrain from receiving other psychological treatment for the duration of the study

5. Fluency in English

6. Access to a computer with internet and web camera.

7. Ability to receive and send text messages

8. Residence in one of the permitted states.

1. Active suicidal ideation.

2. History of psychotic symptoms, bipolar disorder, or a developmental disability.

3. History of substance dependence within the past 6 months; or

4. History of prior CBT treatment.

 Initial Screening Assessment Enrollment

Contacted site to
inquire about Telephone Screen Diagnostic Randomization (n
study (n = 83) Assessment (n = 52)
(n = 126) = 42)

Did not meet inclusion

Failed telephone screen (n
Did not schedule criteria (n= 3)
= 18) due another
screening/were not Another primary
primary disorder
available (n = 43) disorder (n = 2)
Not interested (n = 4)
Receiving
Did not schedule/attend
treatment (n = 1)
assessment(n = 9)
Did not attend
pretreatment (n = 7)
 Allocation

Allocated to Internet Only

Post-Treatment (n = 11)
(n = 22)

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

an average duration of 30 min per module.

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

complete each week.

Before starting the subsequent module, participants were prompted to enter the percentage of exposure

assignments that they completed in the past week.

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

monitored on a weekly basis.

Participants in both groups also received brief homework feedback, with the goal of providing encouragement

and reinforcement for completed work.

 Participants in the therapist support condition completed the same program described above.

Also had a scheduled weekly therapist check-in using a videoconferencing platform.

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

Mini International Neuropsychiatric Schedule (MINI; Sheehan et al., 1998).

Anxiety Disorders Interview ScheduleRevised (ADIS-R; DiNardo & Barlow, 1988).

The Clinical Global Impressions Scale (CGI; NIMH, 1985).

Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu, & Stanley, 1989).

Liebowitz Social Anxiety Scale (LSAS-SR; Baker & Hofmann, 2002; Liebowitz, 1987).

Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998).

Beck Depression InventoryII (BDI-II; Beck, Steer, & Brown, 1996).

Quality of Life Inventory (QOLI; Frisch, Cornell, Villanueva, & Retzlaff, 1992).

Sheehan Disability Scale (SDS; Leon, Olfson, Portera, Farber, & Sheehan,1997)

Client Satisfaction Survey (CSS; Dalrymple & Herbert, 2007)

 Forty-two participants began the program, and 27 completed the post-treatment assessment,

resulting in a 69% completer rate.

Multiple imputation was used for missing data. Completer and intent-to-treat analyses (ITT)

were conducted. ITT analyses are reported.

Table. Means, Standard Deviations, and Effect
Sizes (ITT) on Outcome Measures.

A series of 2 (groups) 3 (assessment:

pretreatment, mid-treatment, and post-
treatment) mixed factorial ANOVA, with
repeated measures on the last factor, were used
to examine changes on the outcome measures
between the two groups.
For all measures, there was a main effect for
time (with symptom improvement from pre- to
mid- to post time points)
There were no significant group-by-time
interaction effects.
 While the two groups experienced similar rate of

symptom reduction across the time points,

inspection of the pre- to post effect sizes within
each condition revealed that the Internet only
group experienced slightly larger effect sizes on
most outcome measures in the ITT analysis
(Table 3).
 The severity of participants symptoms was rated as significantly lower from pre to Post-treatment (p = .003).

Much Improved Minimally Improved Very Much Improved

12%
48%

40%
Treatment Adherence and Satisfaction

Of the eight modules, the mean number completed was 6.40.

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:

Very Helpful Neutral Somewhat Helpful Not Helpful

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

study design or to the assessment point.

Although only one group received therapist support, both groups received feedback on their homework

assignments which may have obscured the differences between groups.

Preference of participants were not enquired before study.

Text messages in the therapist support group was found to be ineffective.

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

which may ensure cost-effective allocation of resources.

The treatment program used in the present study is multicomponent, consisting of various

acceptance-based strategies (mindfulness, defusion, values-work) and exposure principles.

Component control studies are needed to determine the extent to which these components

individually contribute to symptom change.

 The Internet offers a potentially efficient and cost-effective medium to facilitate
dissemination of evidence-based treatment, there were no differences in symptom
reduction for the completers between the two groups. However, therapist support is
strongly related to adherence to the program
LONG PRESENTATION TWO
 Kelly B. Kearney (Florida Atlantic University, Boca Raton, USA)

Michael P. Brady (Florida Atlantic University, Boca Raton, USA)

Kalynn Hall (Florida Atlantic University, Boca Raton, USA)

Toby Honsberger (Renaissance Learning Academy, West Palm Beach, FL, USA)
 Students with developmental disabilities often require explicit training in the personal safety skills

required to maintain physical well-being.

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

household injuries and accidents.

Children with developmental disabilities are significantly more at risk of unintentional injuries than their

typical peers. This risk also increases with age.

 Safety skills refer to a wide variety of skills needed to maintain physical well-being, One class of safety skills,
basic first aid, has long been identified as an essential skill set required for people with disabilities to live
independently.

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

LBBI: Literacy-based Behavioral Interventions

 The purpose of this study was to determine the effectiveness of a peer mediated LBBI to teach a first aid

safety routine, cleaning and dressing a wound.

This study was designed to explore further the LBBI research by examining the impact of LBBI

instructional packages on safety skill acquisition.

The study also provided a further exploration of the role of peers in delivering the multiple components

of an LBBI instructional package for skill acquisition and maintenance.

Research Question 1: Will a peer-mediated LBBI increase the acquisition of a first aid routine by

adolescents with autism and ID?

Research Question 2: If students acquire the first aid routine, will they maintain their skills after the

peer-mediated LBBI is removed?

Participants

Three adolescents (aged 15-17) with developmental disabilities.

Who attended a public charter school for students with autism spectrum disorder

All three students also scored below average on standardized IQ tests,

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

lunch and other activities at the school.

Miguel was chosen as the peer facilitator due to his ability to read at or near grade level, his ability to

follow adult directions, and his interest in participating.

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

and dryer, several microwaves, and a stove.

Although the cafeteria was used for instruction and meals throughout the day, no other students or

staff were present during the study.

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.

The task analysis was comprised of 14 steps

Data were collected individually for each student while observing the student clean and apply gauze to a simulated
wound on the peer facilitator.

Each step was scored by a data collector as

(a) correct and independent

(b) correct but required a prompt from the peer, or

(c) no attempt made.

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

photograph of hands under a sink faucet.

The photographs were taken by the data collectors prior to baseline;

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.

A third observer collected data for IOA purposes

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

students dependent measure during baseline, intervention, and follow-up.

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

participants baseline and intervention differences.

BASELINE.

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

they indicated verbally or physically that they were done helping.

PEER TRAINING.

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

improvements would maintain in the absence of the intervention.

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

sessions for Tim.

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

Pre-intervention Assessment and Observation

Development of Task Analysis and LBBI Booklet

Peer Training

Intervention

Follow Up
 Intervention Effects

Percentage of correct independent

steps of task analysis for cleaning and

dressing a wound.
FINDINGS IN BASELINE.

During baseline, data remained low and stable, with no student accurately completing more than 7% of

the steps in the first aid routine.

Randy was able to complete one step accurately, but Derek and Tim did not initiate any steps in the task

analysis during baseline.

FINDINGS IN INTERVENTION.

When the peer-mediated LBBI instructional activities were introduced, all participants began completing the

routine with more accuracy.

However, due to Randys variability, the LBBI was enriched with the correction procedure described earlier during

the seventh intervention session.

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

increase in skill accuracy, reaching 100% on the third intervention session.

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%.

His follow-up data remained stable during these two observations.

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%).

Tim showed a greater decrease once the intervention was removed.

His accuracy decreased from 100% during his final intervention sessions to 79% during the first follow-

up session, and then returned to 86% on the second follow-up session.

The investigators developed a social validity measure to evaluate the perceptions of professionals and
students on the LBBI as an instructional strategy and on students ability to perform first aid

A. LBBI will help students learn skills and routines (3.75 of 4.0)

B. LBBI Increase student willingness to learn new skills(3.25 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

wound (2.5 of 4.0)

 The purpose of this study was to determine whether a peer-mediated LBBI that includes multiple instructional

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.

This study is only the third examination of LBBIs delivered by peers.

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

to clean and dress the simulated wounds sterile.

Study limited the intervention to a single set of stimulus materials and intervention

procedure, delivered by a single peer.

LBBIs have been investigated and shown to be effective for their positive impact on people
with developmental disabilities and typically been used as a strategy to reduce problem
behavior and as an instructional strategy to teach new skills.

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.