Faculty ofcognitive Sciences and Human Development

Transcription

1 Faculty ofcognitive Sciences and Human Development EFFICACY OF NEUROFEEDBACK TRAINING ON SENSORY, COGNITIVE AWARENESS AND BEHAVIOUR AMONG AUTISM SPECTRUM DISORDER (ASD) CHILDREN AND YOUNG ADULTS Nurul 'Atiqah Binti Mustafa ~amal 'RC 553 Bachelor of Science with Honours ASS (Cognitive Science)

2 BORANG PENGESAHAN STATUS TESIS Gred: JUDUL: Efficacy of Neurofeedback Training on Sensory, Cognitive Awareness and Behaviour among Autism spectrum Disorder (ASD) Children and Young Adults SESI PENGAJlAN :2010/2011 Saya NURUL 'ATIOAH BINT! MUSTAFA KAMAL mengaku membenarkan tesis * ini disimpan di Pusat Khidmat Maklumat Akademik, Universiti Malaysia Sarawak dengan syarat-syarat kegunaan seperti berikut: 1. Tesis adalah hakmilik Universiti Malaysia Sarawak. 2. Pusat Khidmat Maklumat Akademik, Universiti Malaysia Sarawak dibenarkan membuat salinan untuk tujuan pengajian sahaja. 3. Pusat Khidmat Maklumat Akademik, Universiti Malaysia Sarawak dibenarkan membuat pendigitan untuk membangunkan Pangkalan Data Kandungan Tempatan. 4. Pusat Khidmat Maklumat Akademik, Universiti Malaysia Sarawak dibenarkan membuat salinan tesis ini sebagai bahan pertukaran antara institusi pengajian tinggi. ** sila tandakan (..J ) D D SULIT TERHAD (Mengandungi maklumat yang berdarjah keselamatan atau kepentingan seperti termaktub di dalam AKTA RAHSIA RASMI 1972) (Mengandungi maklumat Terhad yang telah ditentukan oleh organisasi/badan di mana penyelidikan dijalankan) I]] TIDAK TERHAD ~ (TANDATANGAN PENULIS) (TANDATANGAN PENYELIA) Alamat Tetap: No 45, lorong melikai 3, Kawasan 8, Kampung Raja Uda, 42000, Pelabuhan Klang,Selangor Tarikh : \\ 'f't\ ~ ~~ Tarikh: Catatan: * Tesis dimaksudkan sebagai tesis bagi Ijazah Doktor Falsafah, Sarjana dan Sarjana Muda

3 Statement of Originality The work described in this Final Year Project, entitled "Efficacy of Neurofeedback Training on Sensory, Cognitive Awareness and Behaviour among Autism Spectrum Disorder (ASD) Children and Young Adults" is to the best of the author's knowledge that of the author except where due reference is made. (Date submitted) (Student's signature) Nurul 'Atiqah binti Mustafa Kamal 22014

4 Pu ell hi mal M8 1 mat AkaJ 'm;k. UNl VE IT MALA la S"tlA t( P.KHIDMAT MAKLUMAT AKADEMIK 1llIllIlIrilr~ EFFICACY OF NEUROFEEDBACK TRAINING ON SENSORY, COGNITIVE AWARENESS AND BEHAVIOUR AMONG AUTSIM SPECTRUM DISORDER (ASD) CHILDREN AND YOUNG ADULTS NURUL 'ATIQAH BINTI MUSTAFA KAMAL This project is submitted in partial fulfilment of the requirements for a Bachelor of Science with Honours (Cognitive Science) Faculty of Cognitive Sciences and Human Development UNIVERSITI MALAYSIA SARA W AK (2011)

5 This project entitled 'Efficacy of Neurofeedback Training on Sensory, Cognitive Awareness and Behaviour among Autism Spectrum Disorder (ASD) Children and Young Adults' was prepared by Nurul 'Atiqah binti Mustafa Kamal and submitted to the Faculty of Cognitive Sciences and Human Developement in partial fulfillment of the requirements for a Bachelor of Science with Honours (Cognitive Science) Received for examination by: /0.;tL4 < f}v7 / Gred 11

6 ACKNOWLEDGEMENT I would like to take this opportunity to convey my sincere appreciation to the valuable contribution of several individuals in making this research report a success. I would not have accomplished this project without their precious contribution of time and effort. First and foremost, I would like to express my thankful to Allah S.W.T for blessing me throughout the completion of this Final Year Project. I am sincerely grateful for the abundant love received. From the deepest of my heart, I wish to extend my profound gratitude to my mentor and supervisor, Associate Professor Dr. Norsiah Fauzan for her continuous guidance, wonderful suggestion, constructive advices, wise opinions, endless support, understanding, and encouragement that were provided to me in accomplishing this study. She was a cheerful person, optimistic, caring and helpful. I learned a great deal from her throughout of this course. Besides that, I would like to express my deepest appreciation and gratitude to my co supervisor, Drs Muhamad Sophian Nazaruddin for his thoughtful and creative comments, constant guidance and skills taught in neurofeedback training. Without his assistance, I may not able to complete this study.. Meanwhile, I would like to extend a special thank you to my most beloved parents for giving me their constant support, undivided love, endless patience, encouragement and financially. Without them I would not have the strength and motivation to complete this study. In addition, I would like to convey my heartiest appreciation to my project partner, Nurul Aina bt Mohd Mahayuddin, Nur Hidayah bt Ali and also Nurfaizah bt Abd Razak who have giving me a support, creative comment and valuable suggestion to throughout this study. Thank you for being generous enough to share the knowledge the knowledge and skill with me, which helped me a lot during preparation of this study paper. Last but not least, I wish to express my gratitude Kuching Autistic Association, committee members, parents and teachers that had given the time and cooperation in this study. Not to forget to thank to all the lecturers of Faculty Cognitive Science and Human Development in UNIMAS for giving me the support to conduct this study. Once again, thank you all very much. III

7 "'_'-,.. t\.... Jt.. s. r.... ;\ IIr-d (t. LlN1VERStTl MALA" 11\ TABLE OF CONTENT Page Acknowledgement Table of Contents List of Figures List of Tables Abstrak Abstract 111 IV IX xi XIV XV Chapter1 Introduction 1.0 Introduction 1.1 Background of Study Autism Sensory in Autism Cognitive Awareness in Autism Physical and Behaviour in Autism 1.2 Statement of Problem 1.3 Research Objective General Objective Specific Objective 1.4 Research Hyphoteses 1.5 Conceptual Framework 1.6 Definition of Term! Variables Autism Spectrum Disorder (ASD) Neurofeedback Training (NFT) iv

8 1.6.3 Autism Treatment Evaluation Checklist (ATEC) Sensory in Autism Cognitive Awareness in Autism 1.7 Significance of Study 1.8 Limitation of Study 1.9 Summary Chapter 2 Literature Review 2.0 Introduction 2.1 Autism 2.2 Sensory 2.3 Cognitive Awareness 2.4 Neurofeedback Neurofeedback Combined with Metacognitive 2.5 Meta-Analysis 2.6 Connectivity Chapter 3 Methodology Introduction Research Design Research Informant Instrumentation Autism Treatment Evaluation Checklist (ATEC) v

9 Importance of ATEC Neurofeedback Training Validity Reabilty Procedure of Data Collection Interview and Document Analysis Procedure of Data Analysis Data Analysis from Autism Treatment 41 Evaluation Checklist Data Analysis from Neurofeedback 42 Training Qualitative Analysis Descriptive Analysis Inferential Analysis ANOVA Paired Sample t-test Independent t-test Summary 47 Chapter 4 Finding and Discussion 4.0 Introduction Descriptive Analysis of Participant Demographic Background Gender Age Ethnic Hair Tissue Mineral Analysis (HTMA) 53 vi

10 4.1.5 Have Medication Food Diet General Symptoms Reading Ability Writing Abilty Colouring Ability Finding Analysis of Improvement on Total Score Analysis of Improvement on Weightage 62 Score Sensory and Cognitive Awareness Analysis of Improvement on Weightage 64 Score Behaviour 4.3 Analysis of Result Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Null Hyphoteses Discussion Improvement in Sensory and Cognitive 80 Awareness Improvement in Behaviour 82 Vll

11 4.4.3 Factor that Affect Efficacy of Neurofeedback Training Number of Training Session Bipolar Montage Sequential Specific Region of the Brain and 79 Electrode Placement Food Dietary Sensorimotor Rhythm (SMR 86 Training) 4.5 Summary 87 Chapter 5 SUMlVlARY, RECOMlVIENDATION AND CONCLUSION 5.0 Introduction Summary Recommendation Training Session of Neurofeedback in Specific 93 Region of Brain Supported from Parents and Teacher More assessment guidance such as QEEG Care about Food Dietary among ASD children Report the Intensively Observed Behaviour 96 Changes. 5.3 Conclusion 96 References Appendix 98 viii

12 LIST OF FIGURES Figure 1.1 Conceptual Framework 14 Figure 2.1 Pattern of Brainwaves 26 Figure 2.3 Meta-Analysis 28 Figure 2.4 Connectivity changes 30 Figure 4.1 Pie Chart of Distribution of Participant by Gender 49 Figure 4.2 Pie Chart of Distribution of Participant by Age 50 Figure 4.3 Pie Chart ofdistribution of Participant by Ethnic 52 Figure 4.4 Pie Chart of Distribution of Participant by have Hair Tissue Mineral 53 Analysis (HTMA) Figure 4.5. Pie Chart ofdistribution of Participant by Taking Medication 54 Figure 4.6 Pie Chart of Distribution of Participant by Food Diet 55 Figure 4.7 Pie Chart ofdistribution of Participant by General Symptoms 56 Figure 4.8 Pie Chart of Distribution of Participant by Reading Ability 57 ix

13 Figure 4.9 Pie Chart of Distribution of Participant by Writing Ability 58 Figure 4.10 Pie Chart ofdistribution of Participant by Colouring Ability 59 Figure 4.11 Bar Graph oftotal Score Pre-test and Post Test 61 Figure 4.12 Bar Graph Percentage of Improvement for Each Participant 61 Figure 4.13 Bar Graph Weightage Score Sensory and Cognitive Awareness 62 Figure 4.14 Bar Graph Percentage of Improvement for Sensory and Cognitive Awareness 63 Figure 4.15 Bar Graph Weightage Score of Behaviour 64 Figure 4.16 Bar Graph Percentage of Improvement for Behaviour 64 Figure 5.1 Colour map of brain functioning 95 x

14 LIST OF TABLES Table Table of Scale ofthe Score Distribution Table The Gantt chart Table Table of Range of Scores Table 3.4 Types of test used for the sensory and cognitive awareness analyses 45 data. Table Types oftest used for the behaviour anajyses data Table Distribution of Participants by Gender Table Distribution of Participants by Age Table Distribution of Participants by Ethnic Table 4.4 Distribution of Participants by Have Hair Tissue Mineral Analysis 53 (HTMA) Table Distribution of Participants by Taking Medication Table Distribution of Participants by Food Diet Table 4.7: 56 Distribution of Participants by General Symptoms XI

15 Table 4.8 Distribution of Participants by Reading Ability Table 4.9 Distribution of Participants by Writing Ability Table 4.10 Distribution of Participants by Colouring Ability Table4.11 Significance Difference between Pre-test and Post-test Total Score Table 4.12 Significance Difference between Pre-test and Post-test Weightage Score in Sensory and Cognitive Awareness Table 4.13 Significance Difference Gender and Post-test Weightage Score m Behaviour Table 4.14 Significance Difference between Gender and Post-test Weightage Score in Sensory and Cognitive Awareness Table 4.15 Significance Difference between Gender and Post-test Weightage Score in Behaviour Table 4.16 Significance Difference between Gender and Post-test Weightage Score in Sensory and Cognitive Awareness Table 4.17 Significance Difference between Gender and Post-test Weightage Score in Behaviour xii

16 Table 4.18 Significance Difference between Ethnic and Post-test Weightage Score in Sensory and Cognitive Awareness Table 4.19 Significance Difference between Gender and Post-test Weightage Score in Behaviour Table 4.20 Significance Difference between Medicine and Post-test Weightage Score in Sensory and Cognitive Awareness Table 4.21 Significance Difference between Gender and Post-test Weightage Score in Behaviour Table 4.22 Summary of Results of Hyphoteses Testing in part of Sensory and Cognitive Awareness Table 4.23 Summary of Results of Hyphoteses Testing in part of Behaviour Xlll

17 ABSTRAK KEBERKESANAN LATIHAN NEUROFEEDBACK PADA SENSOR, KOGNITIF DAN TINGKAHLAKU DI KALANGAN KANAK-KANAK DAN REMAJA AUTISM. Nurul 'Atiqah binti Mustafa Kamal Penyelidikan ini bertujuan untuk menilai keberkesanan latihan neurofeedback (NFT) pada sensor, kognitif dan tingkahlaku dalam kalangan kanak-kanak dan remaja Autism dengan menggllnakan ATEC yang dihasilkan oleh Bernard Rimland dan Stephen M. Edelson daripada Autism Research Institute. 34 orang peserta telah dipilih daripada Persatuan Autism di Kuching, Sarawak. Kajian ini menggunakan kaedah eksperiment quasi iaitu perubahan sebeilim dan selepas kajian bagi setiap peserta diperhatikan. Ia telah dijalankan sekitar 24 sesi bagi setiap kanak-kanak dan remaja Autism. Tiga jenis protokol yang telah diggunakan di dalam kajian ini ialah protocol jenis Delta, Alfa dan beta. Pemerhatian sebelum dan selepas kajian bagi setiap peserta selama enam bulan digunakan sebagai instrumen untuk mengumpul data. Selain itu, kebanyakan kanak-kanak dan remaja Autism yang lemah dari segi sensor, kognitif dan tingkahlaku akan menunjukkan sifat hiperakt(j; lemah didalam kognitif dan fine motor. Skor ATEC telah menunjllkkan perubahan yang positif darpada aspek sensori, kognitif dan tingkahlaku. Ujian Statistik paired sample t-test telah memmjukkan keputllsan signifikan diantara latihan neurofeedback dengan pentbahan kesellinthan kanak-kanak dan remaja Autism (t (33) =9.122, p= Dapatan in; menunjukkan skor ATEC sebelum dan selepas latihan bagi kanak-kanak dan remaja Autism yang telah menjalani latihan ini dengan menggunakan tiga jenis protokol yang disarankan. Selain itu, dapatan Autism simtomatologi termasllklah signifikan di antara skor weightage sensor dan skor ATEC selepas latihan (t (33) = 4.875, p = 0.000) dan skor weightage tingkahlaku dan skor A TEC selepas latihan (t (33) = 2. 03, p = 0.000). Perubahan positif di dalam kajian ini boleh dikaitkan dengal) hasil pengurangan kesambungan yang cergas di serebrum melalui tiga jenis protocol iaitu delta untuk menghalang frekuensi beta, dan diikuti dengan at/a untuk sesi relaksasi and beta lintuk membantu kanak-kanak foklls. Kajian ini juga menggunakan bipolar sequential montage atau interhemispheric montage bag; setiap individu. Keseluruhannya, kajtan ini telah menunjukkan perubahan yang memberang, angkan bagi setiap peserta yang lemah daripada aspek sensori, kognitif dan tingkahlaku. xv

18 ABSTRACT EFFICACY OF NEUROFEEDBACK TRAINING ON SENSORY, COGNITIVE AWARENESS AND BEHAVIOUR AMONG AUTISM SPECTRUM DISORDER (ASD) CHILDREN AND YOUNG ADULTS. NURUL 'ATIQAH BINTI MUSTAFA KAMAL The research aims to evaluate the efficacy of neurofeedback training on their sensory, cognitive awareness, and behavior among autism spectrum disorder (ASD) children and young adults using the A TEC developed by Bernard Rimland and Stephen M. Edelson from Autism Research Institute. 34 participants were purposely selected fromkuching Autism Association (KAA). A quasi experimental study using pre test and post test design (within subjects) was conducted in an average of 24 sessions for ASD children. The three major steps in the treatment protocols used for the training were Delta, followed by Alpha and Beta training. There were series of observations for each participant before training and a series of observations after the training within the duration of six months study. Most ASD children lacked sensory, cognitive awareness and behavior. The children were characterized with hyperactive symptoms, lack of motor fine and lack of cognitive. A TEC score showed positives improvement in terms of sensory, cognitive awareness and behaviour. Paired Sample t-tests indicated statistical significant overall improvement in Autistic children (t (34) =9.122, P =0.000) who received NFT using the three steps treatment protocol as indicat~d by ATEC scores taken before and after the training. Other major findings in core ASD symptomatology includes a significant difference in weightage scores in sensory and cognitive awareness (t (34)=4.865,P=0.000), behavioral/health t(33)=2.03.p=0.000). Positive treatment outcomes could be associated with the reduced cerebral hyperconnectivity resulted from the three treatment protocols such as delta to inhibit the beta frequency, followed by Alpha training for relaxation and finally Beta protocol to help the children focus. Protocols included primarily sequential (bipolar) or interhemispheric montages individualized for each participant. Our treatment experience is showing remarkable improvements in the participant's cognitive, sensory and behavior. XVI

19 Chapter 1 INTRODUCTION 1.0 Introduction The purpose of this study is to assess the efficacy of neurofeedback training on the their sensory and cognitive awarenss among ASD children and young adults using ATEC This chapter will detailed out background of the study, statement of problem, objectives of the study, research question, significance of study, limitation of study and definition of tenn. It is also focusing the lack of sensory, cognitive awareness and behaviour among ASD children and the young adults.

20 1.1 Background of Study The purpose of the study is to evaluate the efficacy of neurofeedback training (NFT) on their sensory, cognitive awareness, and behaviour at the Kuching Autism Association (KAA) using Autism Treatment Evaluation Checklist (A TEC). It is located at the Bampfield road, in Kuching Sarawak. The training was conducted by an expert in NFT who trained the teacher to conduct the NFT in KAA. 34 participants were involved in the training Autism According to the Health Ministry statistics, one out of 600 children in Malaysia is autistic (Malaysian Psychiatric Association, 2010). Autism is defined as a neurodevelopmental disorder characterized by qualitative impairment in the development of social interaction and communication skills and restricted patterns of behavior and interests. Further research indicates that Autism can be categorized as part of a spectrum of heterogeneous disorders. This continuum of disorders is characterized by a broad range of abilities and levels of severity. Autism is one of a range of related Pervasive Disorders including: Asperger's Disorder, Pervasive Developmental Disorder-Not Otherwise Specified (PDD NOS), Childhood Disintegrative Disorder (CDD), and Rett's Disorder (Medical Rese~ch Council, 200 l). While there is no cure for autism, traditional behavioral treatments and medications have been the traditional option (or ASD. This includes Applied Behavioural Analysis (ABA) that has been widely used in many parts of the world. ABA uses a behavioural approach based on theories developed by B.F. Skinner and John B. Watson. It involves behavioural support and modification as well as discrete trial training, which breaks down teaching objectives into the smallest unit and teaching these units one by one. Others are Structured Teaching, Pivotal Response Training, and augmentative communication such as 2

21 sign language and Pictures Exchange Communication System (PCEs). They also need speech and occupational therapy as well as sensory integration therapy. Neurofeedback or neurotherapy (EEG or brainwave biofeedback) is a vital part ofthe treatment plan for these children, adolescents and adults. This is not a substitute for behavioral and social treatment approaches but it works in combination with the traditional options making it more effective. Nonverbal children begin to use language, making eye contact and increase their social interaction dramatically. The word "autism" was first used in the English language by Swiss psychiatrist Eugene Bleuler in a 1912 issue ofthe American Journal ofinsanity. It comes from the Greek word for "self," autos (autos). Autism was actually confused with schizophrenia during the early stages of observation. Bleuler used the term to describe schizophrenics' seeming difficulty in connecting with other people. However, the medical classification of autism as a separate disorder or disease did not occur until 1943 when psychiatrist Dr. Leo Kanner of the Johns Hopkins Hospital in Baltimore, Maryland reported on 11 child patients with striking behavioural similarities and introduced the label "early infantile autism." He s~ggested the term "autism" to describe the fact that the children seemed to lack interest in other people, emphasizing "autistic aloneness" and "insistence on sameness". Kanner's first paper on the subject was published in the journal The Nervous Child (no longer in publication), and almost every characteristic he originally described is still regarded as typical ofthe autistic spectrum ofdisorders diagnostic triad ofbehavioural impairments or dysfunctions: 1. impaired social interaction, 2. impaired communication and 3. restricted and repetitive interests and activities. 3

22 Leo Kanner's contemporary in Austria, Dr. Hans Asperger, made similar observations, although his name has since become attached to a different form of autism known as Asperger's Syndrome. Widespread recognition of Asperger's work was delayed by World War II in Germany. His seminal paper was not actually translated into English for almost 50 years and the majority of his work was not widely read until Autism is a disorder of neural development characterized by impaired social interaction and communication, and by restricted and repetitive behavior. These signs all begin before a child is three years old. Autism affects information processing in the brain by altering how nerve cells and their synapses connect and organize; how this occurs is not well understood. It is one of three recognized disorders in the autism spectrum (ASDs), the other two being Asperger syndrome, which lacks delays in cognitive development and language, and Pervasive Developmental Disorder-Not Otherwise Specified (commonly abbreviated as POD-NOS), which is diagnosed when the full set of criteria for autism or Asperger syndrome are not met (CenterSite, 1995). Autistic children tend to shy away from others and have problems sharing their feelings and otherwise understanding the emotions of others. Autistic children also tend to have a lot of repetitive behaviours as well such as preferring to rep~t behaviours, motions or certain words or motions. They may even insist on having repetitive routines in their days. Changes in routines can seem traumatic to autistic children. Specialists in autistic children have noted that these repetitive types of behaviour can frequently be seen at play. These symptoms can be seen as early as 18 months of age and frequently by the age of 2 years. Most of the participants were having speech delayed and difficulty in comprehension. They lose interest in conversation or often repeat words that are being said to them instead of engaging in conversation. It is also common for one to use the same words over and over. Autistic people also have a difficulty in understanding emotion and facial expression. For example, someone is joking or 4

23 \, ' i. ":'u,'k v l ~. V~RS r! IVAn4,.", ',n' V\ no using humour or laughing, an autistic person may be confused and not understanding their conversation. Autism spectrum disorders are a set of disorders that can affect children either behaviourally, socially or through communication. These disorders are called a spectrum of disorders as they consist of a group of disorders that have very similar types of issues. Symptoms may range from mild to severe but they are still in the same spectrum of disorders Sensory in autism Extreme sensory issues are very common in autism. Some autistic children cannot tolerate sounds or hugs, while another is oblivious to sounds and craves hugs. One autistic child may have an explosive and exaggerated reaction to loud noises, while another may not react at all. Autistic children with sensory issues have difficulty filtering sensory input. The nervous systems do not know how to block out or amplify. The research says they are indeed two separate and distinct disorders. Dr. Lucy Jane Miller, author of Sensational Kids conducted one study in which 40 children with high functioning Autism or Aspergers were tested for SPD. Results show~ 78% of the children with Autism or Aspergers also had significant signs ofspd, 22% did not (Miller LJ., S. Schoen, J.Coll, B. Brett-Green, & M. Reale, 2005). Sensory integration activities address au!istic children's sensory needs by either decreasing or amplifying the intensity of various forms of sensory stimulation that children receive. Most sensory integration activities work with children's vestibular, proprioceptive and tactile sensory systems. 5

24 The vestibular sensory system The vestibular sensory system helps people to stand upright and coordinate their movements. It involves sensory input from vision, and also from special sensory organs located in the inner ear. Activities that stimulate the vestibular system involve movement; swinging, jumping and spinning are good examples. Children with hypoactive sensory systems may engage in such activities as a means of self-stimulation. A therapist looking to help children with hypoactive sensory systems might engage them in learning alternative structured movement exercises which would meet their sensory needs, while helping them stay within socially acceptable bounds. The proprioceptive sensory system Auti tic children with hyperactive sensory systems have very adverse reactions to many forms of stimulation. They would fare better with sensory activities that address their proprioceptive systems. The proprioceptive sensory system helps people to have information concerning their body positioning. Feedback from the proprioceptive system helps people coordinate fine motor activities like coloring within the lines or buttoning a shirt. It is also involved in motor planning, or the ability to coordinate different motor tasks to complete an activity. Activities that stimulate the proprioceptive system include hugging and climhi.ng. The tactile sensory stimulation Tactile sensory stimulation involves the' sensation of touch and texture. Autistic children with tactile sensory issues may have difficulty tolerating the sensations generated as they dress or groom themselves, or even as they chew food. Therapists may work with tactile-sensitive autistic children to desensitize them to unavoidable textures and touch sensations. This is accomplished gradually over time by teaching affected children to be able to tolerate ever increasing durations of contact with avoided sensations. 6