An extinction procedure for eliminating self-destructive behavior in a 9-year-old autistic girl

Self-Injurious Behavior

Over 60 published studies of treatment for self-injurious behavior were analyzed. The analysis involved 17 methodological factors which were considered important inclusions in research and reports in this area. Some of the factors evaluated were: quality of subject descriptions, inclusion or omission of reliability data, generalization information, and follow-up procedures. A reference table is provided, listing each study and its respective ratings in the various categories. A brief summary and suggestions for future research are included in the accompanying text.

Working with People with Learning Difficulties Who Self-Injure: A Review of the Literature

Self-injurious behaviour in people with learning difficulties has been found to be a common and health-threatening problem. As a consequence, there is an expanding literature addressing a variety of methods of intervention that are either designed to facilitate or to enforce the reduction or extinction of such behaviour. It is not clear, however, the extent to which such interventions are successful in achieving their avowed goal. This paper critically reviews the treatment of self-injurious behaviour, including work which takes psychodynamic, psychopharmacological, developmental, self-stimulation or learned behaviour perspectives, in order to establish the current status of interventions in this area. It is concluded that no single treatment approach has been shown to be effective in facilitating a reduction in the self-injurious behaviour of all clients. Rather, individualized programmes of intervention need to be constructed, using careful causal and functional analyses of behaviour. Moreover, such programmes, which may be multi-modal in nature, need to aim for interventions that are minimally or non-aversive.

Applied behavior management and acquired brain injury: approaches and assessment

Individuals who have acquired brain injury (ABI) may express themselves through the use of challenging behaviors, such as aggression, withdrawal, disinhibition, and self-destructive behaviors. This article describes the effectiveness of behavior interventions derived from the assessment of behavior in a community-based setting. The premise is that behavior, no matter how difficult, has function, purpose, and meaning for the individual. A therapeutic model of behavior assessment is presented that bases its strength on behavior assessment and well-trained staff. A well-formulated behavior management plan is developed, reinforcing alternative behaviors teaching skills, and reducing unwanted behaviors. Through the use of data collection methods, the treatment team identifies variables related to unwanted behavior and outcomes of consequences as they relate to the behavior. Illustrated through a case study, the behavioral treatment model is defined through behavior identification, initial assessments, treatment approaches, and tracking outcomes.

Developing a technology for the use of operant extinction in clinical settings: an examination of basic and applied research

Extinction of operant behavior, which involves terminating the reinforcement contingency that maintains a response, is important to the development, generalization, and reduction of behavior in clinical settings. We review basic and applied research findings on variables that influence the direct and indirect effects of extinction and discuss the potential value of a general technology for the use of extinction. We suggest that current research findings are not sufficient for the development of a comprehensive, applied technology of extinction and provide extensive guidelines for further studies on factors that may affect the course of extinction in clinical settings.

Toward a functional analysis of self-injury

This study describes the use of an operant methodology to assess functional relationships between self-injury and specific environmental events. The self-injurious behaviors of nine developmentally disabled subjects were observed during periods of brief, repeated exposure to a series of analogue conditions. Each condition differed along one or more of the following dimensions: (1) play materials (present vs absent), (2) experimenter demands (high vs low), and (3) social attention (absent vs noncontingent vs contingent). Results showed a great deal of both between and within-subject variability. However, in six of the nine subjects, higher levels of self-injury were consistently associated with a specific stimulus condition, suggesting that within-subject variability was a function of distinct features of the social and/or physical environment. These data are discussed in light of previously suggested hypotheses for the motivation of self-injury, with particular emphasis on their implications for the selection of suitable treatments.

Restraint fading and the development of alternative behaviour in the treatment of self-restraint and self-injury

Restraint fading and differential reinforcement were used to reduce the self-injurious behaviour (SIB) and self-restraint of a profoundly retarded man. The variables maintaining both behaviours could not be identified via pre-treatment functional analysis; however, self-restraint exerted at least some stimulus control over SIB. In Phase 1, the subject's topography of self-restraint (wrapping arms in shirt) was replaced with another topography (wrapping wrists in towel) that could be more easily faded to a headband. However, the subject's restraints could not be completely faded, and any movement was accompanied by SIB; thus, in Phase 2, a compliance training procedure was implemented to reduce his SIB while increasing time out of restraint. In Phase 3, the subject was taught to mand for edibles during training sessions. Results indicated that restraint fading combined with the development of alternative behaviour could be an effective treatment procedure for those who engage in both self-restraint and SIB.

Toward a functional analysis of self-injury

This study describes the use of an operant methodology to assess functional relationships between self-injury and specific environmental events. The self-injurious behaviors of nine developmentally disabled subjects were observed during periods of brief, repeated exposure to a series of analogue conditions. Each condition differed along one or more of the following dimensions: (1) play materials (present vs absent), (2) experimenter demands (high vs low), and (3) social attention (absent vs noncontingent vs contingent). Results showed a great deal of both between and within-subject variability. However, in six of the nine subjects, higher levels of self-injury were consistently associated with a specific stimulus condition, suggesting that within-subject variability was a function of distinct features of the social and/or physical environment. These data are discussed in light of previously suggested hypotheses for the motivation of self-injury, with particular emphasis on their implications for the selection of suitable treatments.

Transfer of behavioral function as a contributing factor in treatment relapse

When relapse occurs following successful treatment to reduce problem behavior, it is often attributed to inconsistent implementation of maintenance programs. Although less likely, another potential cause for relapse is a change in the behavior's maintaining contingency over time. To examine this possibility, additional assessment was conducted with 4 individuals who were rereferred to a day-treatment program due to recurrence of their self-injurious behavior (SIB) 2 months to 2 years following successful treatment. In each case, the original treatment had been developed and implemented based on the outcome of functional analysis assessments. For 1 subject, results of a second functional analysis were consistent with those from the original assessment, indicating that the function of her SIB had remained unchanged. For the other 3 subjects, results of the second assessment suggested that their SIB had acquired new or additional functions. These findings indicate that factors other than program inconsistency can lead to relapse, and that clinical reevaluation for such cases should include a current functional analysis to determine if new treatment components are needed.

The use of aversive stimuli in treatment: the issue of consent

It has been argued that, in the consideration of the use of aversive stimuli in treatment, the issues are ideological and philosophical as well as technical. Adopting Horner's (1990) definition of what is meant by 'aversive' in the ideological debate, it is suggested that the crucial issue is the inability of making clients to give their informed consent. It is proposed that proxy consent might be an alternative, but that this would be unacceptable if aversive procedures could be shown to be never in the best interests of the client, or shown to violate clients' rights or to be against the interests of society because of anticipated harm or injustice to others. It is concluded that it is difficult to be certain that it is ever in the best interests of the client for aversive procedures to be employed, that aversive interventions appear not to violate clients' rights necessarily (except possibly the right to dignity and respect while the intervention is operating, and perhaps the right to choice at the beginning of the intervention), but that the inescapable difficulty in the use of aversive interventions is the likelihood that they will be misused with other clients than the ones for whom they may be initially designed.

Personality disorder and self-wounding

At least 1 in 600 adults wound themselves sufficiently to need hospital treatment. More men than women do it, although more women receive psychological treatment. Many have a history of sexual or physical abuse. Self-wounding differs from other self-harm in being aimed neither at mutilation nor at death. Self-wounding coerces others and relieves personal distress. Repeated self-wounding is one criterion of borderline personality disorder but we prefer to consider it an 'addictive' behaviour rather than an expression of a wider disorder. Psychological management may need to be augmented by drug or social treatment. Carers, including professional carers, usually need help to contain the turbulence that self-wounding produces.

Stimulus fading and transfer in the treatment of self-restraint and self-injurious behavior

We conducted several manipulations of mechanical restraint properties during the course of treatment for two profoundly retarded adolescents who exhibited both self-restraint and self-injurious behavior. In study 1, a combination of prompting, differential reinforcement, and stimulus fading reduced one subject's self-restraint, which consisted of holding rigid tubes on his arms. Subsequently, stimulus control of both self-restraint and self-injurious behavior was transferred to tennis wrist bands. In study 2, a second subject's self-restraint--placing his hands in his pants--was immediately eliminated by the use of air splints. Additionally, differential reinforcement and air-pressure fading resulted in the complete mobility of his arms and a substantial increase in appropriate behaviors. Results of this investigation suggest that stimulus fading and transfer may be valuable components in the elimination of self-restraint.

'Addiction' to a strait jacket: a case report of treatment of self-injurious behaviour in an autistic child

A 14-year-old autistic girl presented with severe, chronic head-banging, some relief being obtained by restraint harnesses. Withdrawal of her straitjacket resulted in extreme SIB. Exhibition of fluphenazine relieved the condition.

Using water mist to reduce self-injurious and stereotypic behavior

A mist of water sprayed in the face was used as a punisher for stereotypic and self-injurious behaviors by a boy diagnosed as severely mentally retarded with autistic-like behaviors. The boy had a long history of mouthing and hand-biting behaviors. The latter behavior was evinced by noticeable scar tissue on the backs of his hands. The study took place in a self-contained public school classroom for autistic children and other children with severe communication disorders and functional mental retardation. An ABAB withdrawal design with no treatment probes demonstrated the rapid and dramatic suppressive effects that the response-contingent water mist had on the target behaviors. This procedure was taught to classroom personnel who were able to maintain the suppression with minimal interruption of educational programming for the subject or his peers. No adverse physical effects were observed nor did the child attempt to escape or struggle against the procedure. The results are discussed in relation to ethical considerations and the use of response-contingent aversive stimulation.

Protective equipment: continuous and contingent application in the treatment of self-injurious behavior

This study evaluated the use of protective equipment in treating self-injurious behavior (SIB) exhibited by three retarded persons. In Experiment 1, the equipment was first applied continuously during 20-min sessions in individual multiple baseline designs across settings. Results showed substantial reductions in head hitting, eye gouging, and hand biting. Brief periods of time-out with the protective equipment were later made contingent on SIB and combined with a differential reinforcement procedure. Reduced levels of SIB was maintained with all subjects. Additionally, the amount of time during which the equipment was applied decreased as the SIB diminished. Experiment 2 evaluated the use of contingent protective equipment (the final condition in Experiment 1) when applied directly in the subjects' living units during the day. During Experiment 2, SIB remained at or below the levels found at the termination of Experiment 1. Finally, in an effort to assess the long-term effectiveness of the procedure, responsibility for implementation was given to the staff who were typically assigned to provide therapy to the subjects. Follow-up probe observations conducted up to 104 days after termination of the final experimental condition showed continued low levels of both SIB and equipment usage. Results of these experiments suggest that contingent protective equipment and differential reinforcement may be effective in reducing chronic self-injury.

The effects of physical restraint on self-injurious behaviour

Two experiments investigated the effects of two durations (one and three minutes) of physical restraint on the rate of self-injurious behaviour of a profoundly retarded girl. In the first experiment, a reversal design was used in which three-minute and one-minute restraint conditions were used sequentially. In the second experiment, an alternating treatments design was used in which the two conditions were alternated within the same experimental phase. Physical restraint was made contingent on each instance of SIB during experimental sessions. In the first experiment, with the introduction of three-minute restraint phase SIB increased to a rate high than baseline. However, it was reduced to near-zero levels during the one-minute restraint phase when it followed the three-minute phase. Although three-minute restraint did reduce the rate of SIB in the second experiments, it was found that one-minute restraint was more effective. In both experiments one-minute restraint was found to be more effective than three-minute restraint in reducing the rate of SIB.

Self-injury in the profoundly retarded: clinically significant versus therapeutic control

Two experiments investigated the effects of behavioural interventions on the self-injurious behaviour of two profoundly retarded girls who had a long history of such behaviour. In the first experiment, response-contingent aromatic ammonia was used as the aversive stimulus to reduce the high frequency of face-slapping and face-hitting in a deaf and blind girl. In the second experiment an overcorrection procedure was used to control jaw-hitting in another girl. In both cases, the treatments resulted in near-zero levels of self-injury. However, complete suppression of self-injury was not achieved. The results are discussed in terms of clinically significant versus therapeutic control of self-injurious behaviour in institutionalised profoundly retarded persons.

Cognitive abilities and disabilities in infantile autism: a review

The literature on various aspects of learning and performance in autistic children is reviewed and interpreted as indicating very little that is specific to autism. Inadequate and inconsistent methodology precludes generalizations concerning the nature of the disorder. It is suggested that future research should be particularly concerned with controlling for developmental influences on performance, and with investigation of the higher functioning autistic children who are less governed by retardation factors. The current evidence is considered to support a hypothesis concerning abnormal hemisphere functioning in this group of children.

The use of physical restraint in the treatment of self-injury and as positive reinforcement

Two experiments investigated the effects of a treatment package on the self-injurious behavior of three profoundly retarded persons who appeared to enjoy the physical restraints used to prevent their self-injury. The treatment package included physically restraining subjects contingent on increasing periods of time during which no self-injury occurred, and providing them with toys and attention during intervals between restraints. A reversal and multiple-baseline analysis documented that the rapid and complete reduction in self-injury by all subjects was due to this treatment package. Because these results suggested that physical restraint might function as a positive reinforcer, in a third experiment physical restraint was applied contingent on a marble placement response with one subject. A reversal design demonstrated that toy play systematically increased when each response resulted in restraint. The experiments have implications for the nonaversive remediation of self-injury in individuals who are restrained, as well as for the development and maintenance of self-injury in natural settings.