Ep. 54: ABA Tools for Tolerance – Haircuts, Doctor Visits & More

This week, we’re diving into ABA strategies for building tolerance in real-life situations like haircuts, doctor visits, and dental appointments. Many learners with autism and anxiety struggle with these experiences, and traditional approaches like social stories aren’t always enough. We’ll break down how to desensitize fears, use reinforcement effectively, and teach coping skills to make these essential life skills more manageable.

🔑 Key Takeaways
✅ Meet learners where they are – Start with the smallest step they can tolerate and build up gradually.
✅ Break it down like a task analysis – Even sitting near a hair clipper or stepping into a waiting room is progress.
✅ Use real-life visuals & practice visits – Take pictures, arrange preview visits, and mimic the experience as closely as possible.
✅ Find powerful reinforcers – Whether it’s a favorite toy or a coping strategy, reinforcement helps learners push through discomfort.
✅ Teach coping skills proactively – Don’t just rely on external rewards—help learners self-regulate with breathing techniques, fidgets, or preferred items.

📚 Resources and Ideas
📌 Check out Episode 49 on anxiety!
📌 A couple social stories for young learners that might help: https://abainschool.com/wvvp and https://abainschool.com/13ou
📌 Coping Skills visuals

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Transcript

Ep 54 ABA Tools for Tolerance: Navigating Haircuts, Doctor Visits, and More

Caitlin: [00:00:00] when I literally took that out of the bag one day and put it on the table, this was a child who didn't have verbal abilities, but his true like fear and phobia, I mean, he would just flee the classroom. He would attempt to leave. He was never one for self-injury or harm, and he would start engaging in those behaviors. So we were so far from a starting place that we could envision that we had to kind of scrap any kind of preconceived notions we had about like, oh, social story or like a simple reinforcer or something.

Intro: Welcome to the Misfit Behaviorist Podcast. Join your hosts, Audra Jensen and Caitlin Beltran, here to bring you evidence-based strategies with a student-centered focus. Let's get started. 

Caitlin: Hey everybody. Welcome back to the Misfit Behaviorists. I'm Caitlin and joined by Audra. As always, today we are talking about tools for tolerance, and what I mean by that is teaching learners to tolerate outings in the community that are really functional life skills at their core. So talking about doctor's visits, blood work, dental visits, the [00:01:00] dreaded haircut, all those kinds of things. Audra, what kind of experience do you have with this, with your own son?

Audra: Well, actually the one that comes to mind is a little guy that we worked with who had an incredible phobia of dentists. And so it took a long time to get through that one. This was clinical so we could do stuff like this, but walking one step into the door and then the next day was two steps. And then finally we got him to sit in there and then it was counting the teeth. I think it took years for us to finally, that he, I think he goes to the dentist now. He's an adult now.

Caitlin: And it can take that long. And that's kind of what I want to focus on because sometimes we're working with learners, I think, who are afraid of the dentist, afraid of getting a haircut, and yet we can put a social story together, we can pair it with a reinforcer. They're getting a balloon after and a couple of visits later, and we have a solution. But I know it sounds like we've both worked with a lot of learners who it was a really long-term goal. I had a learner who would get a haircut once a year, [00:02:00] and that was when his mom would just shave his entire head in his sleep because she said it was just a nightmare and he was fighting everyone. He had also built up this aversion to it because he never had a proper haircut in so many years. And I mean, he kind of would have a workaround for that because long hair can be trendy too. But there's certain things you can't work around, like you can't work around a doctor's visit or getting blood drawn if you need to or things like that. 

So that's what I wanted to focus on today and I, I was thinking of the initial phase of sort of just starting with our least restrictive interventions as always. So have we tried the visuals, the social stories and things like that? So visual cues and putting together pictures and packets of anytime you can bottle that real life environments. So if they're afraid of the dentist, do I have pictures of that exact dental office? Do I have pictures of that exact person that's gonna be counting or touching their teeth? Can we arrange a visit just for like a priming visit or something like that? 

Audra: We even had one learner who was afraid of going on airplane and they were taking a trip to Disneyland of all [00:03:00] places, which is wonderful, but they arranged with the airport to be able to go on a different day, to take him all the way through the gate. He didn't need a wheelchair, but they got a wheelchair for him so he didn't have to even walk. They practiced going through security. They were able to skirt the line to go directly through security. All the way down to an empty plane to walk onto the plane, they were able to arrange that all so that when the day actually came, he'd been through it once and it was easier. I mean, there was a lot of Benadryl involved, I'm pretty sure. But yeah, I mean, just thinking ahead, I love what you said about getting real pictures of the real situation, it is absolutely the best thing you can do, obviously in lieu of being there physically yourself, but getting pictures of the real people involved in the real setting.

Caitlin: And I think the next thing for me is really just breaking down the skill and seeing where the breakdown is on the part of your learner. Using the haircut example, this is a learner who we volunteered in school and we had partnered with the family to try and target this as a goal. And I remember mom saying like, [00:04:00] you're not gonna believe me until you see it. That like, for example, I'll give you the buzzer kit. It's not like, oh, you can get a few swipes. And not that we were actually gonna cut it, we were just gonna play the noise and mimic the haircut and things like that. But when I literally took that out of the bag one day and put it on the table, this was a child who didn't have verbal abilities, but his true like fear and phobia, I mean, he would just flee the classroom. He would attempt to leave. He was never one for self-injury or harm, and he would start engaging in those behaviors. So we were so far from a starting place that we could envision that we had to kind of scrap any kind of preconceived notions we had about like, oh, social story or like a simple reinforcer or something. And really looking at this skill as you would any other academic skill. We would never teach a child to count day one we're going to 50. Like you start with one. Right? So we had to break up that skill of like getting your haircut into so many prerequisite subskills and kind of looking at it as a task analysis, [00:05:00] but even again, going further back than you normally would. It wasn't teaching the learner to do anything yet just teaching them to tolerate being in the presence of a haircut scissor, or a buzzer for five seconds without, in that elopement, that was it. That was his goal. 

Audra: You just, you meet them where they're at, wherever they're at. 

Caitlin: That's huge because we had to learn and also train staff and train the family that once he was able to do that, that he got his reinforcer. I always see the steepest learning curve is at the beginning and then once we have some semblance of, like, even when he was able to just see the haircut case for five seconds and be okay and then he would earn his iPad, I was like, we gotta, like we, I, it's gonna take a long time, but we're gonna do this, I could tell, and that was probably the longest we were on that one target for, then we did 10 seconds and then we would unzip the case and take out the buzzer. That was all, that was all we did. 

And so sometimes there's that staff training aspect too, where we're reminding [00:06:00] everybody that we're meeting him where he's at, and we are providing a reinforcer for him, literally doing nothing but not engaging in self-injury and not fleeing in the presence of these things that he is such a phobia over.

Audra: How long did it take for you to get to where he could? 

Caitlin: I think it took about a year, but I will say maybe just under, to where I'll never forget the day I walked in and one of the therapists was just holding the buzzer, going like this around his head. The buzzer was on, it didn't have a blade, but mimicking it, like touching his head with their finger. So it actually felt like a haircut and just looking at me going, I never thought this day would come. It was amazing and it took low and steady progress, but he got there. 

Audra: It's kind of like what we talked about last week. There's the impact. I mean, those things when you're working on things for so long or these baby steps that look like baby steps, but they're huge and it's so satisfying, and that's why we do this, is in days like that.

Caitlin: This learner also had an aversion to bandaids. He would [00:07:00] not wear a bandaid and he would not get his haircut and the bandaid a lot of the times you can avoid, but not always. So that was, again, one of those things where we targeted the haircut first because we were like, well he's already gone so long without wearing a bandaid. But rightfully so, mom had valid concerns about like he, it's not like he can always go to the emergency room, get a stitch or something, or get glue or whatever he might need, or have the mom hold pressure if he ever were to become really injured. So then we kind of replicated the same process with the bandaid. However, we'd put the bandaid, rip it off, we'd put the bandaid, rip it off. And that went on. But again, we had like a protocol I would say that was working. We had a powerful reinforcer, which I think brings us to our next thing is that the desensitization paired with what are they getting for that becomes really huge because then you're showing the learner, there's an end in sight. We were able to put it on a simple rule card like haircut scissors equals iPad or something. It would be a little picture of a timer or something like that. And he was able to understand that his preferred reinforcer was coming. [00:08:00] It was a signal to him that there would just be an end in sight to that stimuli that he was so averse to.

Audra: Our little guy who we did with the dentist, it wasn't reinforcer so much, but as a coping, as he liked rocks or fruit snacks in a baggie, and it was a visual stim, but being able to keep that the whole time, no matter what, adding things into it, it helped. It was his way of coping with the stress. Most of the situations, I'm thinking back over the years of this level of phobia has been those who have been non-speaking or profound autism. Those seem to be because you can't talk through anything. So when you think about in the kind of just regular counseling field or you know, CBT, cognitive Behavioral therapy, you learn self-talk. You learn things that you can talk to yourself about to get through these difficult times. These learners can't do that, and so we have to get kind of creative in how we help them desensitize in a different way. 

Caitlin: You just brought up me to my next point, which was just, yay coping skills. And I feel exactly the same. There's been so many times where it just, it's enough to make you cry [00:09:00] because you can see the pure anxiety on their face and you wish so badly that you can explain to them it's gonna be okay. And help them understand, this is for your best interest, this is for hygiene, this is for safety. And then it will be okay. And again, with your analogy of just a person that would entertain the idea of going to therapy and talking about a phobia. They don't even have the ability to do so. They're robbed of that. So teaching them in other ways, but I don't think we can overlook the importance of, again, like you said, just giving them some kind of coping skill, even if they cannot maybe rationally have the conversation with you about why doing that will help them. Whether it's deep breathing, squeezing a ball, using a fidget, headphones, whatever it might be. It's just so important 'cause you're literally just kind of hopefully replacing that thought of going in their mind of just what's probably pure panic at this point with something else. So you're no longer telling them, just don't do anything and grin and bear it and you'll get this reinforcer. But here's something you can do. And we always have more success [00:10:00] teaching learners to do something than just to not do something, if that makes sense. So again, you're going to the doctor's visit and you know there's gonna be blood work, you're gonna walk through the steps. You're gonna desensitize one step at a time, but then giving them something to do. Maybe they can't actually play their I iPad game while that's happening, but maybe they can shake a ball or trace a string or something like that. 

Audra: I would also look at that learner in their most calm, happy times. And what do they look like? What are they doing? And I think about going to bed or something is a wonderful calming place for a lot of kids. And then bring that exact blanket, bring that pillow that they like, bring that stuffed animal that they like, something that gives them comfort or reminds them of a peaceful time in their life. Bring that into a situation so rather than just thinking, oh, you know, you probably like these fruit snacks. You know, really think about that learner and when do they feel the calmest and the happiest? What do they look like? What are they using? And then use that. Get creative. 

Caitlin: Yeah, and practice those coping skills, even when they're not heightened, [00:11:00] I think is so important because hopefully we're taking it from a slice of real life where I see they're calm when they're using this, but also some of our learners don't have that naturally. So thinking about how can I teach them this kind of calming strategy and let's just start with it as like an everyday movement break and not something to give them when they're heightened because if they don't have any strategies to calm down yet, because we've just been removing those aversive settings and stimuli, teaching that might be your actual first step. 

Audra: You also touched on another piece. I don't know if you're gonna talk about role playing, but even those who are non-speaking can do role playing. So like you did with the cutters or whatever they're called clippers, set up a pretend dentist chair and you know, pretend going in practice. Even your non-speaking kiddos can do that stuff. And I think that will help in the real moment. 

Caitlin: I think we can't overestimate the importance of just making it as real as possible. Because my old school had like that mock dental chair, and I had so many learners over time would be like, okay. They'd climb in a little orange chair, they'd be like, [00:12:00] ah, like somebody would pretend to count their teeth. And then their mom was like, no, it went terrible at the dentist, didn't do it. So it just depends on your learner, of course. 

Just working with the family, obviously as much as possible, but see if they're willing, like some of the schools I worked at, we would get opportunities to do, whether it was like a community visit or a visit with the family. Of course, this really just depends on what type of setting you're in, but if the family is able to, like if they had a real need for something like this, the school would pay one of us to do like extra hours, afternoons or weekends or something for like a familiar person to accompany. And that's when I think doing those practice visits is key. Instead of just that once every six month dental visit, can we ask dentist if we can visit them? 

Audra: We did. It was like every day. They were so good about it. Especially in the community today, I think most people are super accepting of that because, they want them to be successful too. They don't want the screaming kid in the dentist chair. That's no fun for them. So yeah, they were very accommodating when we were doing that. 

Have you done like power cards where you take the favorite character of the [00:13:00] learner and create either a story or a strip or something of that favorite character in those situations. So like a dentist or something. So like they're super in a Pokemon and you get Pikachu, Pikachu's in the dentist chair, Pikachu's getting his..., and so that's another strategy to try. 

Caitlin: I haven't thought of that. I think, like you said earlier, a lot of the times with my experience with this, it's been with those learners where they were nonverbal. They weren't interested in certain shows that like another kid might have been. That's where we struggle the most because they already had the cards stacked against them. So just really getting creative in any way you can. 

And I guess I just wanted to close with always asking the family. I feel like when I first started teaching, this wasn't on my radar because I wasn't a mom yet, and unless the family brought it up, and if they did, I was like, great, we can work on that. But it never really occurred to me to go out of my way to say, not just teeth brushing in, hair brushing and deodorant, things we'd work on in the school anyway in a life skills classroom. But like what does it look like for you at the dentist? What does it look like for you at the doctor? What does it look [00:14:00] like for you when you have to wait at the bank? Because we had so many students who'd make great progress in school, they're counting and they're reading and they're teeth brushing and deodorant. I had no idea because the families just never thought to mention it to us that like Sunday mornings are a nightmare because that's when you know they have to run this errand that always goes poorly or something. So in really thinking about how many hours we could have spent working on those things to help that family and to help that student where it really mattered the most. That's one thing I'm really passionate about too. So making that like an open dialogue at IEP meetings and working with all your resources, the school, the community, the family, to make sure you're really hitting those truly functional goals for the learners. 

Audra: And then I'd put an extra plug in there being culturally aware, because sometimes we think in our kind of American culture that something's important or not important. The family and their culture, it may be really important or not important. So making sure you have that really open dialogue of what's important to them. It could be a culture that you're not familiar with at all, but this particular thing is really [00:15:00] important to them and their culture, and that would be important to us then working on too.

Caitlin: Yeah, I've had, in my home cases, one of our techs went to Temple with one of the families and they had just, I mean, naturally the child had to sit for a long time and be quiet and it was always difficult for them. So we would practice sitting of course, but then when we were able to send someone to help and kind of teach the family how to maybe reserve a small bag of treats or something. Nothing mimics just being there in the environment, teaching the skill in that setting. 

Audra: We had a family who didn't wear shoes in the house and getting shoes on and off was really big, and so we focused, even though he was young, being able to put his shoes on and off so that it was independent. So that was important to them, it became important to us. 

Caitlin: And that's the perfect way to say it. What is important to you as a family? Because that's what I want to be important to us for teaching. 

Just guess to recap, just making sure you're prioritizing those skills in the first place. Using those visuals of social stories that we all love, but also just going deeper, looking at it as a true skill [00:16:00] deficit and not like a behavior problem, but something that we can break down, task analyze, go through the nitty gritty of like what is the breaking point. I've had learners who like were really fearful of public restrooms, whether it was like the loud hand dryers or something, and so again, it just made a part of our program and they're only on step one and we only have to go in for one second come out, but each community outing we're able to up the bar.

Really finding those powerful reinforcers and also teaching those coping skills. So hopefully that helps some of us. If you do have more questions on this topic, we'd love to hear about it. Or if you have any ideas for future episodes, drop in with the Facebook group. Find us on Instagram Misfit Behaviors podcast.

Otherwise, I think that's it and we'll see you next week. 

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