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Text Transcript: Anxiety in Individuals with Autism Spectrum Disorder

- It's my pleasure to have the opportunity to introduce our guest speaker today.

So Dr. Patrick Friman comes to us originally from Montana by way of Nebraska.

And as you may have read in your program, he's the vice president of behavioral health at Boys Town and a clinical professor in the department of pediatrics at the University of Nebraska School of Medicine.

And I'm not going to say much more than that about Dr. Friman's bio, because you can find all of the information in your program.

And I'm sure that he'll highlight some of his work and his experience for us as he goes through the day in his presentation.

But I do want to share something with you that I've learned about Dr. Friman that you won't find in your program, but it's part of the reason that it's such a pleasure and a privilege to be able to welcome him to our symposium today.

Like those of you in this room Dr. Friman is absolutely passionate in his conviction that the work that he does has the potential to change the lives of the individuals he works with.

And he's committed to the goal of sharing the benefit of that work and that experience with others who are also working to improve the lives of individuals who face diverse challenges.

So it's a pleasure to welcome Dr. Friman to our symposium, and it asks you to join me in welcoming him this morning.

(audience applauding) - Good morning.

Thank you for being here.

Thank you Shelly for inviting me, I couldn't be more delighted to be here.

And I love being part of this.

I also like Halifax, what a lovely city.

Although other than access to the ocean, and the air, the quality of the urban experience, the quality of the folks that I've met, the sophisticated nature of the environment and the overall landscape, it's just like Omaha.

(audience laughing) So I'm Pat Friman.

So I'll tell you a little bit about me before I get started.

I'm a child, and can you hear me in the back? No.

Try volume, how about that? Now can you hear me in the back? I'm gonna go to this mic, okay? (static rustling) How about now? Do I need to start all over again? You know who I am, I'm Pat Friman from Omaha, Nebraska.

Okay, I'm Pat Friman.

I'm a child and family psychologist, but I don't have a child or a family.

Yeah, 'cause I don't want to mess up my theories with facts.

(audience laughing) Yeah.

And no one wouldn't have sex with me.

Apparently, that's a pretty important part of the process.

I got my sex education in the Catholic school system in Montana and they left out some pretty important parts.

And I don't like to touch poop.

And I'm allergic to crying.

And besides, I see the bargain, so-called bargain deal, so-called deal that you parents have made.

It doesn't look like a deal or a bargain to me.

You have a child and you have to set aside all your priorities and make the child your priority.

You lose sleep so the child can get sleep.

If the child's hungry, well, you got to feed it.

And if the child's upset, do you have to comfort it, and if it's afraid, you have to reassure it.

And you have to set aside all your ideas about how to have fun and devote yourself to how the child likes to have fun.

You have to take all that time you were going to devote to yourself and devote it to the child.

And what do you get for all this? What's your reward for all this effort? What do you get for all the sacrifice? You get an angry teenager thinks you're hypocritical, unfair, and stupid.

(audience laughing) This does not look like a good deal to me.

This looks like God is saying, "Look, I told you folks that sex wasn't supposed to be "about having fun.

"You didn't listen, so as your penalty, you get a teenager." (audience laughing) So I was recently at a conference, FABA, Florida Association for Behavior Analysis, and I did my presentation.

And they also had a cabaret in the evening.

And John Bailey who came here, who came here, I think, last year, sponsored it.

And he asked various behavioral analysts who we thought had some talent if they'd participate.

And he asked me, and I said I had no talent.

I got nothing.

I mean, I don't sing, I don't dance, I don't play an instrument.

I don't have anything.

And he said, "Well, I've attended some "of your presentations, and every once in a while, "you're humorous, so maybe you could put together "some material for us." And so I reluctantly agreed and put together 10 minutes, like a standup on why I don't have children.

And you just got 45 seconds of it.

(audience laughing) But I want to tell you the truth of the matter.

It's not funny, actually.

I know what I missed.

I know what I'm never gonna have, I know what I never had.

And those of you that are parents, you know very well what I'm talking about.

And the thing that makes me sad about it is I would be so good at it now.

I'd be such a fantastic father now, because I'm the right guy now, but I'm the wrong age.

And when I was the right age, believe me, I was the wrong guy.

Unfortunately, I had the good sense to recognize that.

And so, does that depress me? No, why? Well, because I get to get in on it.

I get to contribute.

I'm not in the game, but I'm down on the playing field assisting.

I get to assist people that are doing the most important job in the world, which is raising children.

Or assisting people who are assisting people doing the most important job in the world, which is raising children.

And the way that I assist fundamentally involves foraging.

I forage in arcane literatures that weren't written for you and I, and frankly, sometimes I wonder who they were written for, but I forged in the scientific literatures.

The psychiatry literature, the psychology literature, the behavioral literature, the developmental literature, the pediatric literature, even anthropology and philosophy.

I forage on an ongoing basis, sifting through virtually unreadable material, 90% of which appears to come out at the back end of a bull, but some of it actually is valuable.

And that's what I'm looking for.

And when I find valuable stuff, I try to package it into deliverable products that anyone can understand.

I decode it as it were, or translated as it were, and that's what I'm gonna do today.

So that's what I'm setting about here is to deliver some of the stuff that I've learned in my foraging in my quest to assist people that are doing the most important job in the world.

So anyway, there's a group I just mentioned I'm not part of, there's another group I'm not part of.

People that work with, live with, or study persons on the spectrum.

That makes me the only person in the room perhaps who doesn't work with, live with, or study persons on the spectrum, 'cause I don't.

I don't specialize in autism.

Why would they invite me to an autism conference? (audience laughing) Well, Shelly got really drunk.

(audience laughing) Called.

She took a chance, I guess.

So let's see, at the end of the day we'll know whether or not chance made sense.

But I don't specialize in populations.

I speak at autism conferences frequently, and I tell folks when they invite me that I don't specialize in autism, because I don't specialize in populations.

And people invite me to conferences that are devoted to problems too, like ADHD, for example, or anxiety, and I have to tell them I don't specialize in problems.

I don't specialize in problems, I don't specialize in populations.

But what the heck do you specialize in then? That's a good question.

Well, I specialize in people.

I work with whoever comes in the door.

And I have clients that are in their, typically developing children that are six months of age.

What kinds of psychological behavioral problems could a typically developing child six months of age have? Well, they won't do as they're told, and they don't pee in the potty, so there's work to be done there.

And I have clients that are in their eighties.

They won't do as they're told either.

And a lot of them don't pee in the potty, so there is work to be done there, but there's a lot of work to be done in the middle.

So how's it possible to specialize that broadly? What kind of hubris does it take to say you just specialize in people? Oh, it doesn't take hubris at all.

What it takes is an idea.

I'm equipped with an idea.

The most powerful idea ever invented by mankind for understanding, knowing, approaching human behavior when it's a problem.

And that's that behavior is a function of its environmental circumstances, past and present in the context.

And this idea is in competition with some really old ideas that all of us are equipped with, that have been doing damage to the human race since the Dawn of time.

This new idea is a substitute.

And equipped with this idea, I don't have to know about problems.

I don't have to know about populations, I don't even have to know about species.

What I have to know is how to observe and measure environmental circumstances, and observe and measure human behavior, and identify contingencies between the two, and have the capacity to modify those contingencies to bring about socially adaptive behavioral change.

And that's all I need to know.

Now am I saying I shouldn't learn about problems? Absolutely not, I learn as much as I can.

I mentioned I do all that foraging.

Am I saying I shouldn't learn about populations? No, I learn as much as I can.

It helps, it isn't absolutely necessary.

As we speak here today, I'm gonna reach for… I always am given a specific assignment.

Talk about this topic, talk about this group, and I agree to do that.

But I'm always reaching for general principles.

I'm always reaching for material that is relevant not just for the population at hand, or the problem at hand, but for everybody in the room.

I'm looking for something that's relevant for everybody in the room.

And so before I came this morning, I jotted down a few things that I'm gonna to aim for as I speak today.

One is, human beings are largely the architects of their own suffering when it involves emotions or psychology.

They're not the architects of their own suffering when it's physical suffering.

But if it's emotional, psychological suffering.

they're almost always the architects of their own suffering.

In other words, they are doing things that cause the suffering.

They don't do things that cause the physical suffering, but they do things with what happens to them that causes emotional and psychological suffering.

Secondly, the quality of a human life is a function of how much you can accept.

And related to that, the person that can tolerate the most discomfort always has the biggest and most successful life.

So for example, if you can tolerate and accept rejection, abundantly, you can be very, very successful in the romantic context involving the opposite sex, or the sex of your romantic interest.

If you have a hard time with rejection, it makes you too uncomfortable so you won't approach, your chances of real success are pretty limited.

But if you welcome the discomfort that comes with rejection, you could have anything you want.

Thirdly, I'm a clinical psychologist, and what I've learned over the years is that I don't work with people's problems.

They bring me their problems, but I don't work with them and it's not my target.

My target is their solutions.

And their solutions always involve ways that they behave to reduce the amount of discomfort they have in their life, because they can't tolerate it.

So for example, a person with obsessive compulsive disorder, and they have a concern about infection, a concern about bio hazards, might be very uncomfortable with the quality of the doorknob in my office, and they can't leave the office until they've scrubbed it with a wipe 37 times, that's their solution.

Well obviously, that kind of solution is going to impair their life.

So what I need to do is provide them a different solution.

So I'm not working on their problems.

I'm working on their solutions.

The depressed person solution to their discomfort is just to stay home and stay in bed.

That's not a good solution.

I need to find them a different solution.

I'm not working on their problem, I'm working on their solution.

I don't mean to egg you on here a little bit, this last one is somewhat, bear with me.

Persons on the spectrum are human beings.

Yeah, and you and I are human beings.

And so all of us are human beings.

And so there are some things that are relevant to us as humans, and not specific to them being on the spectrum.

That's what I'm aiming for here.

Human concerns, human solutions, human concepts, not autistic concepts.

Yes, we have to treat them a little differently in certain circumstances, but we have to treat one-year-olds differently than we treat five-year-olds, but they're still human beings.

And the level of concept are the same, but the level of procedures sometimes are different.

I'm aiming for the level of concept ultimately.

And at the level of concept, the behavior of persons on the spectrum is just as subject to circumstances as yours and my behavior.

And so that's what I'm aiming for.

So onto anxiety.

Is anybody in here more anxious than I am? Because I'm terrified.

You can't tell, can you? I hide it well.

I'm absolutely terrified of public speaking.

I always have been.

My solution early on, may be a solution that many of you have a utilized if you're afraid of public speaking, and that is, don't do it.

Or wait until you're not afraid, try to do anything you can to make the fear disappear.

And then you can go up and be in front of a crowd hold forth.

But until that day or until that time, or until that solution appears, well, you just hold off.

And that was my solution, and I realized when I was in my 30s I realized that when I was in my 30s that solution's never going to work.

because it's never gonna go away, and it never has gone away.

So you can't see the fear I'm talking about, you may think I'm pulling your leg and I'm not.

If you could see the internal life that I'm now experiencing, the blood pressure, heart rate, galvanic skin response and amount of cortisol in my saliva, you'd know I'm very much afraid.

What I've learned to do is behave in the presence of fear, and that is a solution that works I've learned to tolerate the discomfort that materializes whenever anybody asks me to go to the front of the room.

Not only tolerate, but utilize the energy that comes as a result of that request, because there is a fair amount of energy being generated.

It's just that the energy is being generated by my limbic system, and it only has two orders that it likes to follow when it gets activated.

Just two.

So it's bidding me to do one of these two right now.

One is to attack and kill all of you.

(audience laughing) That doesn't seem like a good solution to me, there's just too many of you.

Maybe I can get the front row.

The other one is just to get the heck out of here.

Split, run away.

That's what my limbic system wants me to do, and it's providing me the energy to do it.

That's where the elevated heart rate, blood pressure, et cetera, comes from.

It's like, it's mobilizing me to get you or get out of here.

But there's another thing to do with that energy, and I'm doing it now.

It fuels the performance, it provides like vim and vigor, and vitality.

I'm tired and I have a cold.

But I feel very, very enthusiastic about being here, and I don't even experience the fatigue or the cold.

All I'm experiencing is the desire to do this well, because the energy that I have that I would use for attacking and killing or running away, I'm using for performance.

And that's what great performers do.

They're afraid too.

You'd be surprised at how many great performers are almost paralyzed from time to time by stage fright, like Pablo Casals.

He got into a car wreck, hurt his hand.

First thought he had was, thank God.

Now I won't have to play anymore.

And he's the best cellist that ever lived.

Carly Simon routinely forgets her lyrics in the presence of a crowd because she has panic attacks, and uses the energy of the panic and the crowd support to carry through her performance.

And Bette Midler.

And it was hard for me to imagine that somebody like Bette Midler, who seemed so fearless in front of a group would ever suffer from stage fright, but she suffers from terrible stage fright.

And I've watched her perform.

I watched her perform when she's singing along, singing, singing, singing, singing, singing, singing.

And then she stops singing and looks at her arm.

Then she looks at the crowd, then she looks back at her arm, and then she goes like this to her arm, and waggles it a little.

And then she goes, "Ladies, have you ever noticed "how after the age of 40, your body takes on "a life of its own?" And I thought anybody that could do that must be absolutely fearless in front of an audience.

She's not, she's terrified.

But she uses the energy of her terror to fuel those performances, and that's what it looks like.

Barbara Streisand routinely terrified to get in front of a crowd.

These people are among the most talented human beings currently living.

And they are afraid of getting in front of audiences, but they do so on a regular basis, they're doing what I do.

They realize they're always gonna be afraid, So the only thing they have left is to perform in the presence of fear, and that's what I'm doing right now.

So the switch that got turned off in my head was my fear of fear.

As Franklin Delano Roosevelt said, "The only thing we have to fear is fear itself." I'm no longer afraid of being afraid.

I realize now I can perform pretty well when I'm afraid, and that frees me up to get up here.

So this anxiety deal, I'm gonna just spend some time talking about it as a concept.

It's a universal concern.

It's central to daily life, central to all of psychopathology.

12 distinct categories provided by the APA.

Journals dedicated just to it.

Frankly, anxiety, which we're going to define momentarily is the default state of human beings.

I mean, I mentioned I'm afraid of you guys.

You're afraid too.

I'll give you two dimensions of it, one's obvious.

I can activate your fear by taking this microphone is walking down and wandering around in the room, looking as if I'm gonna hand it to one of you.

Now there's even a deeper level of fear that's very evident to me standing here, and that is you're all fully clothed.

What are you hiding? (audience laughing) You're hiding your bodies.

You could have a beautiful body, you could have a body that has gotten out of shape, but you're all hiding them no matter how they look.

Why? Because you're afraid of being seen.

That's anxiety, because it isn't dangerous to be seen in your birthday suit, not physically dangerous.

It might be really uncomfortable if you're the only naked person in the room, but not dangerous, not inherently dangerous.

Human beings are very afraid of lots of stuff that isn't harmful.

None of the other animals concern themselves about putting on clothes to cover up their bodies.

It's just the mammals called humans to do that.

and we're the ones, the subject to anxiety.

So I'm a member of a very conservative group called behavior analysts.

And this group is, I don't know, zealous, I guess, and committed to data, committed to observation, committed to a very, very conservative approach to science, and reluctant to study things like anxiety.

So there's hardly anything, behavior analysts have done a lot for the kids on the spectrum.

A lot, the primary treatments that are used come out of behavior analysis, but they've done very little with anxiety 'cause they shun it.

So I wanna address that, because there are some flimsy aspects to the concept.

So one, it's really difficult to define.

And some of the best thinkers of the 20th and 21st century have said so, like Freud.

Freud is the person that pretty much delivered the concept.

And even he said, "I can't get this thing nailed down." He provided some definitions, and then after he provided them said that obviously these are really vague.

He never really got anywhere trying to define it.

So a behavior analyst named Sidman, he said you can't define it.

A more general psychologist, Levitt, he said you can't define it, Macnaughton said you can't define it.

David Barlow, arguably the most prominent anxiety researcher of the 20th century provided a definition, but it was over 100 words long, and it had about nine terms in it that themselves were not definable.

So he didn't get anywhere.

So that conservative crowd called behavior analysts, they're very reluctant to study things you can't define very well.

I've shot for some definitions.

So here's a lay definition.

Fear-based avoidance of objects, activities, or events that are not harmful.

So it's being afraid of stuff that can't harm you.

I'm from Montana, you know, land where men are men and so are the women.

(audience laughing) It's pretty rough country, and we have a species out there called grizzly bear.

And a grizzly bear attacked and killed and ate my next door neighbor in 1975.

So I'm terrified of grizzly bears.

That's not anxiety.

It would be like stupid to not be afraid of grizzly bears.

Being afraid of public speaking is a little on the stupid side, 'cause you can't hurt me.

But being afraid of grizzly bears makes sense, so there's a difference.

So some synonyms are fear, apprehension, uncertainty, uneasiness foreboding, distress, worry, disquiet, dread, jitters, heebie-jeebies, fretfulness sitting on pins and needles, being in a cold sweat, nervousness, and I could go on, lots and lots of synonyms.

Here's my definition.

Negatively reinforced behavior, emitted it in the presence of events that evoke or elicit the biology of stress or fear, but pose minimal risk of harm.

And that's a picture of BF Skinner there, and he's smiling because he loves my definition.

(audience laughing) No, if you don't like my definitions, I found the place that you can get material to devise your own.

Here it is.

Works for lots of people could work for you.

Now another reason that conservative group named behavior analysts are reluctant to study this concept is because it has a better metaphorical basis.

It's a metaphor.

It doesn't sound like a metaphor.

It doesn't sound like a metaphor.

It sounds like something you could actually catch, but it started out as a metaphor.

And it was obviously a metaphor early on, because early on it was in the old English, old French, old German it was.

(speaking foreign language) It's an as if, not an is.

That's what I mean by metaphor, it's as if this was happening, not this is happening.

So the early words meant to choke, to not be able to breathe, or to feel like you were going to die.

So it was as if the person was choking, it was as if they couldn't breathe, it was as if they were going to die.

They weren't choking, they could breathe, and they weren't going to die, but it was as if they were.

That's how we explain things that we can't explain.

You've got this experience you're having, you want to talk to somebody about it.

You don't have a word for it.

So you use words that point to stuff that's similar and you go, "It's like that." And that's what anxiety is, it's like that stuff.

But anxiety doesn't sound like a metaphor, but here here's another example.

So before a performance, I get this fluttery feeling in my stomach, like butterflies.

It's like butterflies are in there.

Now, you kind of get a sense of what I'm talking about, but you know there are no butterflies in there, because butterflies is obviously a metaphor.

Anxiety is a metaphor, just like butterflies, only it doesn't sound like one, so it tricks us into thinking that it actually exists as a phenomenon in the world, rather than just a way of speaking, and behavior analysts don't want to study that kind of stuff.

And I'm sorry, this is a little philosophical, but it involves what are called category errors.

I'm not gonna to force our thinking too much for too long, but I will a little on the front end here.

So anxiety doesn't exist in the world.

It just exists in language.

It's a way of talking about stuff that exists in the world.

That's tricky, and we make category errors all the time.

So when you say that you went to the university, you're making a category error, because you can't go to a university.

Universities do not exist in the world.

They only exist in language.

They're only categories.

Now the math building, that's that exists in the world.

The psychology building, that exists in the world.

the field house, that exists in the world.

The quad, that exists in the world.

But the university is a category that points to that stuff, but itself can't be located in the world.

You can't point to a university.

You can point to the grounds where the university is supposedly located.

And it's almost impossible to talk about universities without making a category error.

But it's that kind of thing, it's that kind of thinking.

And behavior analysts are pretty careful about that kind of stuff.

They want to study stuff in the world, not stuff that just exists in language.

So they've avoided this whole concept called anxiety.

I bring them to task for that, because I say you don't have to study anxiety.

Why not study the stuff that anxiety, the term, points to in the world, because it is a category.

And so there's the stuff in the category, or some of the stuff in the category, and all that stuff is studya-ble.

So one is conditioned suppression, and that's what BF Skinner studied early on, because he studied anxiety early on.

In 1944, he and Estes wrote a paper on condition suppression, they called it anxiety.

It was an interesting, simple, elegant experiment where he just took organisms and established what's called called a free operant in baseline, which just means the amount of stuff the organism does when you don't constrain it.

Then expose them to a condition aversive stimulus, and what he saw was a suppression in that performance, and he said, "That's anxiety." Well, no.

He was wrong about that.

It's a member of the category called anxiety, but it's not the only member, but it does belong in there.

And that's what you get with mammals.

All mammals, not just humans.

When a mammal is confronted by a conditioned or not conditioned, unconditioned, aversive stimulus, the first thing the mammal does is stop what they're doing to look at it.

What is that? So you get a little bit of a freezing in their performance.

That's the suppression, because the limbic system is taking over, appraising the potential threat and deciding whether to attack or run away.

So you get a suppression and performance.

Like there's a really interesting thing going on on the internet today.

You may have noticed it already, it involves a kid that has autism.

He's 19 years old, he's one month on the job.

He's an airport cleanup guy, cleans the bathrooms.

You guys have flown before.

How much appreciation have you extended to the airport cleanup person? Can you imagine the airport bathrooms if they didn't work there? And these people get no appreciation whatsoever from anybody, they're just in the way.

Anyway, there's this 19 year old, he has autism, and this is his first job.

He's been on the job for a month.

And he runs into a rapper named 50 Cent, you know who I'm talking about.

And 50 cent doesn't like the look of this kid.

And so he starts filming him with his camera and insulting him, and then talking to the camera about the kid being on drugs.

Look at this kid, look at his eyes.

He's obviously on something.

Then he talks about kids today.

Well, no.

The kid was freezing.

He was afraid.

Here's this big hulking rapper pointing a camera at him.

He's one month on the job, the guy is complaining about his performance, and he just kind of froze.

And he didn't say anything, he just kind of walked on.

Hopefully this will result in a little negative publicity for 50 Cent and some positive publicity for kids on the spectrum that are getting a job, like the bathroom cleanup guy at the airport.

Anyway, when a mammal is confronted by an aversive stimulus, you get a slowing of performance, a little freezing, because the limbic system is taking over and decided whether you need to leave.

Then conditioned activation, that's part of the category.

Then it's like attack or run away.

And the general members are mental stuff, the thoughts that go along with like, "What is that?" Or, "This plane is gonna go down." Or, "What if I freeze up here and forget "what I'm gonna to say?" "What if I have a panic attack on the plane?" Those kinds of thoughts.

What if that spider is poisonous? What if that mouse gets into my bed? Those kinds of thoughts.

What if I'm contaminated by the door handle? And then the physiological events, elevated heart rate, blood pressure, skin conductance increase in cortisol, epinephrine, et cetera.

We'll talk about that a little later when I talk about the threat based stress response.

And then motoric, what do you do with your body in space? And as a function of being in the presence of an aversive stimulus.

All those things are in the category.

All those things are worthy of our scrutiny, all those things are worthy of our study, And that's why I point behavior analysts in that direction.

So what are some signs of clinical anxiety? This is really important for you to know.

There is a distinction.

I mentioned that anxiety is kind of the default state of human beings.

This is a thing.

See, I'm an anxious person.

I'm proud of it.

My mission in the world is to make anxiety sexy, because I've got no other choice.

I don't have cool, calm and collected to work with.

I'm not one of those guys.

But do you really want laid back people, and I apologize to the laid back people, but you know what? The laid back people won this argument.

They have us thinking that being laid back is the way to be.

I say no, anxious is way to be.

You don't want the laid back people in charge.

Who's going to go and check and make sure the garage door's closed? Who's going to make sure the bills are paid? Who's going to return the phone calls? Who's going to express the amount of concern that's necessary in order for stuff to get done that needs to get done? I deliberately hire anxious people.

I don't have to check on them.

They check on themselves.

But you get a laid black person under the tent, you got to go check on them on a regular basis.

'cause they're like, "Oh, whatever.

"I'll get around to it.

"What's the big deal?" That kind of thing.

I don't like that kind of thinking.

So anxiety isn't abnormal, it isn't something to get rid of.

It's something that you can utilize.

But when it becomes clinical, that's when it's important.

When it starts to impair the life of the person who is anxious, then we need to pay attention.

So that's the object of our attention today.

Not anxiety itself, but clinical anxiety, and there are signs of it.

So the key word here, the key word is excessive.

So we have some fear-based avoidance of benign objects and things.

I'm not terrified of spiders, but if I can go around a big barn spider, I will.

My reluctance around spiders, and I've been bitten by a spider a few times.

And I found three black widow spiders living underneath my living room floor when I was in Reno, Nevada, and that spooked me.

I was afraid to go down in there, I didn't know how many more there were.

But my reluctance around spiders is not excessive, it seems like it's adaptive.

But if you won't go into a building because there's a spider in it, that would be excessive.

That's what we're looking for is excessive avoidance.

I have a little emotional reaction to spiders, centipedes for example.

I had a little emotional reaction to a centipede, 'cause I've been to Hawaii.

Anybody been Hawaii? You know what they're most afraid of in Hawaii? Centipedes.

But see, their centipedes aren't like our centipedes, their centipedes are this big and their segments are as big as a quarter.

And when they bite, they leave a swollen limb they can last weeks, and they look hideous and they hide in shoes.

So I was a little freaked out by centipedes in Hawaii, and ever since then through stimulus association, I'm freaked out by centipedes in general.

Even though the ones we have our little tiny, and they're cinnamon, and I don't even know if they bite But I have a little emotional reaction, but it's not excessive, you'd never be able to tell.

I'm having an emotional reaction in front of you now.

I'm still a little afraid, but you can't tell.

Obviously it's not excessive.

If I run out of here and go into the bathroom and throw up, that would be an excessive, emotional reaction.

You follow what I'm saying.

An excessive need for control, we all need a little control.

Sense of control is a natural reinforcer for human beings.

But excessive need for control is emblematic of anxiety.

If you know an anxious person, really anxious person, they're going to be controlling.

If you know a controlling person, they're probably anxious.

Here's the deal.

They can't control their feelings, they can't make the discomfort go away.

So they try to control the world they're in that causes the discomfort, and that way they can control their discomfort.

So they become very controlling.

And they're not with uncertainty.

And so if you're a source of uncertainty in the life of an anxious person, you're gonna find that they try to control you, or they just avoid you.

And then worst case scenario, it does occur to me the plane could go down.

The thought does enter my head.

It does occur to me that there's the listeria scare now with frozen fruit, and some packaged vegetables.

And I eat a lot of frozen fruit, and I eat packaged festivals, and I don't like listeria.

That's a week of diarrhea right there.

So I'm concerned about it, I can see it could happen.

I could see the plane go down.

I could see that I could get talking here, and forget what I have to say, and then have a little moment of blankness.

These thoughts occur to me, but not excessively.

And that's the point I'm making.

We all entertain worst case scenarios from time to time.

But the very, very clinically anxious person entertains them almost all of the time with respect to the situation they want to avoid.

And then I'm responsive to reason, but you can't reason somebody out of something they weren't reasoned into.

You can come at me with statistics about the plane going down, and that probably would make sense to me.

You can come at me with statistics about the probability of getting a listeria-contaminated batch of lettuce, and I'd probably calm down.

But you can not call them a person down that's truly clinically anxious with any kind of reasoning, and it doesn't make sense to even try.

It just makes them mad frankly.

Because you don't understand.

You don't the threat! Like that, they just like you realize you're just not getting it.

And in a high frequency of episodes.

What we're looking at is like clinical anxiety, that's our concern.

There are some select anxiety disorders.

I think some of them, I don't know, you probably know what they are.

Separation anxiety, that's pretty straightforward.

Specific phobia, you know what that is.

That used to be called simple phobia.

Social, no, here's what's interesting about social phobia.

Here's how you can tell.

Most of us are a little socially anxious around people we don't know.

And we're particularly anxious about the possibility of critical or negative attention.

But when a person is socially phobic, any attention, not just negative.

So let's say you got a little girl, she's nine, and she does a recital at the PTA.

You have PTA? Parent teacher association.

At the school, there's an event for parents at our school, she does a recital and she hits it out of the park.

She just kills it.

She sings beautifully, she's got two full octaves.

She remembers all of her lyrics, she dances a little bit and wows the crowd.

And they are on their feet clapping for her at the end.

Parents have tears in their eyes.

And then they go backstage to meet their daughter and extol her success.

And she is sobbing back there and says she'll never do that again, don't ever make her do that again.

And the parents can't understand why this is, because it was a success.

She wowed everybody.

Then that would be a sign of social phobia, because all those positive accolades, all that applause is what she's afraid of.

Any kind of attention, not just critical attention.

That's how you smoke out social phobia.

Agoraphobia, you know one, being afraid of open.

Oh, it's interesting in Boys Town.

I work at Boys Town by the way, it's a residential program for out of home youth.

Best known one in the country, probably the world.

There's a movie out about it that want to get Academy award.

There's seven other movies.

Anyway, so these kids, they come from inner city, New York, inner city, LA, inner city, Chicago, and live at Boys Town.

And my staff does a clinical evaluation of everybody that comes in, and we use this computerized diagnostic interview for a few years.

And we found this epidemic of agoraphobia.

And it was all coming from this diagnostic instrument.

And so I went and interviewed about 20 of the kids who were supposed to be agoraphobic and the chances of finding 20 young people with agoraphobia in a population the size of ours, there's only 400, is astronomically small.

So there were more than 20, but even getting 20.

So I went and interviewed them.

So like agoraphobia is where you fear being out in open spaces.

These kids were afraid of being out in open spaces, but they came from inner city Chicago, inner city LA and inner city, New York, where it was really, really dangerous to be out in open spaces because of all the gunfire.

So it was a legitimate fear, not a psychological fear that was excessive concern Obsessive compulsive disorder.

That's not quite right syndrome.

The world isn't quite right.

And I can't do anything until I make it right, because it's so uncomfortable when the world isn't right.

So the world isn't quite clean enough, I got to clean it.

The world isn't quite ordered enough, I got to order it.

The objects in my world haven't been counted accurately and they need to be counted very, very accurately.

So I need to get on with my bookkeeping, and whatever to them.

There's a whole bunch of manifestations of this, but it's just the person trying to make the world right.

And until it's right, they can't go forward.

So there's a big downside of avoidance, because that's central to anxiety.

Remember it's avoiding or escaping from things that aren't dangerous.

And there's a downside to this.

Have you heard of the concept called negative reinforcement before? It's the most misunderstood concept in all of behavioral psychology.

Skinner wasn't the best at coming up with good terms for his concepts, and negative reinforcement was a bad term, because it's so hard to understand.

The thing that needs to know about negative reinforcement, it is a good thing.

Something good has happened.

The best synonym for it that I can think of is relief.

And so when something is negatively reinforced, that means somebody has done something and it has led to a very pleasant outcome.

So avoidance generates negative reinforcement, which is basically relief from not having to be in the presence of the thing.

So it is strengthening any responses that produce that outcome.

Behavior is a function of its circumstances, and there are two possibilities in those circumstances, pleasant circumstances and unpleasant circumstances.

Avoidance or escape from unpleasant circumstances is pleasant, and people will do more of it.

So avoidance is negatively reinforcing, and therefore it strengthens all the responses that produce it.

And then there's what's called stimulus generalization, human beings generalize.

So anything that looks like, sounds like, feels like, smells like, or what am I missing? Sees? Taste, gustatory yes.

Or tastes like, is related to the thing the person or the event or the situation the person's afraid of.

So that stuff kind of gets sucked into the category and broadens out that way.

And then there's another aspect of this for humans.

And that is, after a certain age, in like Piaget's terms, after the age of concrete operations, or if you're a Catholic, after the age of reason, which is seven, that you can do things with language that you couldn't do before.

And by the way, this age is also the age at which serious anxiety disorders become most prominent.

Like it's really unusual for very young children that haven't been truly traumatized to be really anxious.

But after they can reason well, then they can reason themselves almost into an anxiety state, because he can do stuff with language you never could do before.

I'll give you an example.

I work with little kids all the time, and they can't tell me that two objects that look different or the same.

They can't see any sameness.

They can see that two Number two pencils are the same.

They can't tell me that a typewriter and a pencil are the same, even though you And I know that they both write.

The fact is, you can take any two objects on planet earth and you can find a lot of ways they're the same.

Only if you can use language that way, so like an Eskimo and an acorn.

Couldn't be more different, but they are the same in lots of ways.

They're both nouns.

They're both subject to the laws of gravity.

They're both made of material.

They're both on planet earth.

I could go on and on and on here.

So we can actually use language and pull stuff into the category.

And that category would be stuff we're afraid of.

And we're afraid of it, because it's related in some way to the thing that we ultimately, or were initially afraid of.

In other words, the category can get very, very big, and that's where you get generalized anxiety disorder, where the person is basically afraid of life itself.

So it's shrinks the size of a person's life, and the most dramatic example of this is somebody that is a true agoraphobic.

Which means they don't leave their house.

They have their groceries sent in.

They never leave the door, and that's their world.

Anything else they can't even get near.

Just as an aside, a lot of avoidance in the lives of kids on the spectrum.

Yeah, there's a lot of things that they avoid.

A lot of avoidance in the lives of persons on the spectrum.

And I'm only interested in some of them.

Now you're dealing with lots of avoidance.

This is a conversation about anxiety.

So let me see if I can sketch the difference.

Is it safe to say, I don't know.

I don't come to Canada enough to know your dietary proclivities.

The meals I've had here have been pretty good, but I just don't know.

So is it safe to say that most of you would avoid cold spam? Because see if you're in Hawaii, the answer would be no.

You'd have bacon and eggs.

In Hawaii they have spam and eggs.

You go to a restaurant, you want breakfast, you want ham and eggs and hash browns.

What you get is spam and eggs, and white rice.

That's just not gonna do it for me.

Okay, so it's safe to say that you would avoid cold spam.

Let me add to this.

Let's take the cold spam and put some chocolate sauce on it.

And then on top of that, some whipped cream, and on top of that some mustard.

And then some chocolate sprinkles, and now some ketchup.

And a pickle, and cheese sprinkles, and then some bacon.

Now, would you avoid that? Would you be afraid of it? No, it's just disgusting.

I mean, it's not scary, it's just disgusting.

So I don't know how many of you folks go to this conference that we have every year called the Association for Behavior Analysis International, but it's coming up at the end of this month, and it's going to be at the Hyatt in Chicago.

It's been there before.

The Hyatt, it's like 24 stories straight up.

At the very top of the Hyatt is the presidential suite, which is the whole floor.

And it's where the president stays when visiting Chicago.

And so there's a helicopter pad, because the president doesn't have to go to the check-in desk.

He has a, or she, has a different way of getting into the hotel.

They land a helicopter on the helipad and go that way.

When conferences are held there, and the president isn't staying there, then usually the president of the association that sponsors the conference gets that suite.

And so one year Janet Twyman, I don't know if you know that name or not, She's prominent in that community, was president.

She got the suite, she had a big party in her room.

So we all went up there, and some of us went out to that helicopter pad.

We had a couple of beers and headed on out there.

Late at night pitch, black in the sky and the helicopter pad kind of sways a little bit in the wind.

And it's 24 stories straight down.

So not everybody would go onto the pad, but on the pad you could go to the edge of the pad and look straight down into the city of Chicago, 24 stories.

The wind's blowing.

I'm not afraid of heights, but a lot of people are, and a lot of people on the pad were that afraid of heights, they wouldn't go near that edge.

Because it seems like you would fall.

You can't fall, because there's this mesh, wire mesh, finely meshed that goes out several yards.

And so if you fell, you'd fall into the mesh but it's black and you can't see it.

So you get this experience of standing on the edge with nothing to catch your fall.

And like four people would do that, I was one of them.

So let's imagine you're not one of them.

You wouldn't go near that edge on a bet, and I encourage you to go near the edge.

So I could encourage you to eat the spam, and I can encourage you to go near the edge of the helicopter pad.

Where would I get the most resistance? You know what I'm saying? On one you would fight me tooth and nail, on the other we'd just have a little argument.

I'm only concerned today with the one, you follow what I'm saying? I know they won't put their socks on if there's a little wool in the mix.

I'm not concerned about that.

And I'm not really that terribly concerned today about their, I don't know, reluctance to eat foods that have a texture different than chicken tenders.

That's a problem, no question about it, but that's not the problem that I'm concerned about today.

I'm concerned about one that involves fear.

So it's fear-based avoidance, not that other kinds of avoidance.

Even though I know that you have to address that other kind of avoidance every day with these kids and with these adults.

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