Eliminating self-injurious behavior by educative procedures

Nathan H. Azrin: A Case Study in Research Translation in Behavior Science

Nathan H. Azrin (1930-2013) contributed extensively to the fields of experimental and applied behavior analysis. His creative and prolific research programs covered a wide range of experimental and applied areas that resulted in 160 articles and several books published over a period of almost 6 decades. As a result, his career illustrates an unparalleled example of translational work in behavior analysis, which has had a major impact not only within our field, but across disciplines and outside academia. In the current article we present a summary of Azrin's wide ranging contributions in the areas of punishment, behavioral engineering, conditioned reinforcement and token economies, feeding disorders, toilet training, overcorrection, habit disorders, in-class behavior, job finding, marital therapy, and substance abuse. In addition, we use scientometric evidence to gain an insight on Azrin's general approach to treatment evaluation and programmatic research. The analysis of Azrin's approach to research, we believe, holds important lessons to behavior analysts today with an interest in the applied and translational sectors of our science.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-020-00278-4.

Reducing Self-Injurious and Aggressive Behavior in Deaf-Blind Persons through Overcorrection

The self-injurious or aggressive behaviors of three deaf-blind individuals (ages 5, 9, and 21) were reduced through application of overcorrection procedures by both professional and paraprofessional staff. When applied to the 21-year-old's aggressive behavior, her episodes of aggression declined immediately and dramatically, and her self-injurious behavior also declined. During 14 weeks of follow-up, the procedure continued to exert a controlling influence over both behaviors. Overcorrection was equally effective in controlling the self-injurious behavior of the two children.

Animal Models of Self-Injurious Behavior: An Update

Although self-injurious behavior is a common comorbid behavior problem among individuals with neurodevelopmental disorders, little is known about its etiology and underlying neurobiology. Interestingly, it shows up in various forms across patient groups with distinct genetic errors and diagnostic categories. This suggests that there may be shared neuropathology that confers vulnerability in these disparate groups. Convergent evidence from clinical pharmacotherapy, brain imaging studies, postmortem neurochemical analyses, and animal models indicates that dopaminergic insufficiency is a key contributing factor. This chapter provides an overview of studies in which animal models have been used to investigate the biochemical basis of self-injury and highlights the convergence in findings between these models and expression of self-injury in humans.

Educational Validity Revisited

In 1983, Voeltz and Evans introduced a set of criteria for establishing educational validity. Their intent was to improve the documentation of quality educational programs for learners with severe disabilities. Although the concept of educational validity is sound, we feel that Voeltz and Evans were not justified in rejecting single-subject research methodology as a vehicle for assessing educational validity. The present paper (a) provides a summary of the arguments of Voeltz and Evans against the use of single-subject research designs in establishing educational validity, (b) addresses each of the major concerns of Voeltz and Evans with single-subject research methodology, and (c) demonstrates how single-subject research methodology can be used to demonstrate educational validity.

Behavioral Training Strategies in Sheltered Workshops for the Severely Developmentally Disabled

This paper is a behavioral analysis of learning and behavior problems which may be expected of severely developmentally disabled persons in vocational settings. The behavioral analysis includes three major sections: (1) a categorization and description of primary problems encountered by a severely handicapped population, (2) a logically arranged hierarchy of behavioral procedures which can be used to treat different types of problems, and (3) a general set of management strategies. It is recommended that the hierarchy of behavioral procedures be empirically validated.

The Use of Mild Punishment in Combination with Reinforcement of Alternate Behaviors to Reduce the Self-Injurious Behavior of a Profoundly Retarded Individual

A procedure involving the response-contingent presentation of a mild aversive stimulus, reinforcement of alternative behaviors, and training for stimulus control was used to suppress self-injurious behavior of a profoundly retarded individual. This procedure, implemented by several people in varied settings throughout the entire school day, produced an immediate and substantial suppression effect in the training environments. Examination of school records and extensive staff interviewing indicates that the suppression effect generalized from the training environments to the hospital living area. In addition, it was durable in both the training and nontraining settings over an 8-month interval, although 20 months after treatment termination, a large portion of the generalized suppression effect in the nontraining environment was reversed. Possible explanations for this phenomenon are presented. These records and interviews also indicate that the inhibition factor of self-injurious responding was not associated with increases in existing stereotypic behavior or the development of new stereotypic behaviors. The public school personnel who conducted the program were completely trained in one school day without disruption to their normal activities.

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.

Decreasing Self-Injurious Behavior

A profoundly mentally retarded adolescent received contingent citric acid applied to his mouth for engaging in self-injurious behvior (SIB) and tantrum screaming. A combination multiple baseline across behaviors and reversal design was used. Citric acid was first introduced for screaming and then for SIB. When the solution was delivered for screaming, this behavior decreased while SIB remained high. Presentation of citric acid for SIB was also associated with a decrease in that behavior. Withdrawal of punishment for the SIB was associated with an increase in the behavior, while reintroduction of the citric acid resulted in a decrease in the behavior. Following this condition, proximity to and orientation toward the trainer was positively reinforced in addition to the punishment contingency. Reinforcement for these behaviors was then withdrawn and reintroduced. Those conditions in which positive reinforcement was presented and SIB was punished were associated with the most consistently low levels of self-injurious behavior. The data suggest that citric acid may be an effective punisher in decreasing a variety of behaviors.

Elimination of Self-Injurious Behaviour in an Autistic Child by use of Overcorrection

Mild punishment, overcorrection and reinforcement of an alternative behaviour were used to reduce and eliminate the incidence of severe self-injurious behaviour in an autistic 12-year-old boy who had sustained major damage to his wrists and fingers. Data were collected over 10 × 30-minute periods per day and showed that banging and touching of a protective cast and later the injured hand itself were reduced to zero in approximately three weeks. The injury had healed and self-injurious behaviour was still extinguished at 10-month follow-up.

Overcorrection: A review and critical analysis

This paper reviews the overcorrection literature with a focus on the subject populations, dependent variables, procedural variations and research methodology reflected in overcorrection research. It analyzes overcorrection in terms of its punishment characteristics, and based on this, offers suggestions for the effective use of overcorrection. It raises issues regarding generalization and maintenance and the lack of data supporting claims for an educative value of overcorrection. We conclude that overcorrection can be an effective response suppressing procedure with greater social acceptability than other forms of punishment, but that the staff time involved in its use constitutes a possible drawback. We suggest the need for analytic research to identify overcorrection's critical components and minimal effective duration. Finally, we offer a suggestion for the use of more descriptive and precise terminology with respect to overcorrection procedures.

Animal models of self-injurious behaviour: an overview

Self-injurious behaviour is highly prevalent in neurodevelopmental disorders. Interestingly, it is not restricted to any individual diagnostic group. Rather, it is exhibited in various forms across patient groups with distinct genetic defects and classifications of disorders. This suggests that there may be shared neuropathology that confers vulnerability. Convergent evidence from clinical pharmacotherapy, brain imaging studies, postmortem neurochemical analyses, and animal models indicates that dopaminergic insufficiency is a key culprit. This chapter provides an overview of studies in which animal models have been used to investigate the biochemical basis of self-injury, and highlights the convergence in findings between these models and expression of self-injury in humans.

The Effectiveness of Abbreviated Overcorrection-based Treatments

Treatment programmes involving a very brief period of Restitution and/or Positive Practice as derived from the overcorrection rationale, coupled with differential reinforcement of other behaviours, were successfully implemented with six severely mentally handicapped children who displayed either self-injurious or self-stimulatory behaviours. The reduction in the period of time devoted to Restitution and/or Positive Practice from the 20 min traditionally used to approximately 1 min is seen as beneficial in that it reduces demands on direct care-givers' time and stamina, while concurrently allowing an increase in the number of times the child associates the undesirable behaviour with its aversive consequences. The importance of positive reinforcement, the care necessary when using punishment procedures, however brief, in an institutional setting and the attitudes of direct care-givers are discussed.

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.

Using obsessions as reinforcers with and without mild reductive procedures to decrease inappropriate behaviors of children with autism

We assessed the effectiveness of using the obsessions of children with autism to reduce their inappropriate behaviors. Baseline consisted of a traditional differential reinforcement of other behaviors (DRO) in which food reinforcers were provided contingent upon a period of nonoccurrence of the inappropriate behaviors. Then, three treatment conditions were assessed using a multielement design. One condition provided objects of obsession as reinforcers for periods of nonoccurrence of the inappropriate behaviors. A second condition also provided the obsessions as reinforcers, but in conjunction with mild reductive procedures (verbal "no", time-out). A final condition used the food reinforcers of baseline, but with mild reductive procedures. Results indicated that all three treatment conditions were more effective than the traditional food DRO of baseline. The most effective condition was the obsessions plus mild reductive procedures. Results are discussed in terms of recommendations for effective treatment planning.

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.

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.

Behavioral interventions to reduce maladaptive responding in youth with dual sensory impairment. An analysis of direct and concurrent effects

Many persons who have multiple sensory, physical, and developmental disabilities display behaviors that interfere significantly with adaptive functioning and social acceptance. In this investigation, the efficacy of multiple component behavioral interventions for reducing maladaptive responding exhibited by two individuals with dual sensory impairment and profound mental retardation was evaluated. Results indicated that differential reinforcement of other behavior (DRO) approaches were not effective in either case. However, when deceleration procedures (overcorrection or brief physical restraint) were added, target behaviors decreased quickly. Also, interventions were faded in such a way that gains were maintained for 6 months with only minimal effort by staff. Ongoing assessment of concurrent effects of behavior reduction strategies revealed increases in time on task or amount of work completed, even though these responses were not targeted specifically. Yet negative side effects (e.g., increases in self-stimulation) also were documented, highlighting the importance of evaluating multiple behaviors during intervention. Finally, despite the fact that objective assessments led to positive conclusions regarding treatment efficacy, ratings of baseline and treatment behavior samples by independent judges showed overall improvement in only one case. These findings suggest the need for multifaceted evaluation to determine the utility of interventions in applied settings.

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.

Treating high-rate stereotyped behaviours in children

High-rate stereotyped behaviour is typically displayed by children who present with some form of sensory or intellectual handicap. This paper reviews the available knowledge on the treatment of the disorder and suggests specific intervention guidelines.

The reinforcement of calm sitting behavior: a method used to reduce the self-injurious behavior of a profoundly retarded boy

The frequency and intensity of a 14-year-old profoundly retarded male's self-injurious behavior was significantly reduced by the reinforcement of calm sitting behavior. Social validation ratings confirmed the effectiveness of treatment, and showed that gains generalized across treatment and non-treatment settings and across people associated or not with treatment. Treatment gains were maintained at 6- and 12-month follow-ups.

The immediate and long-term effectiveness of overcorrection in treating self-injurious behavior in a mentally retarded adult

A brief positive practice overcorrection procedure was used as a method of eliminating head-banging in a profoundly mentally retarded adult. Treatment produced an immediate reduction in head-banging episodes, with near zero occurrence of behavior during the third phase of treatment. One year later data collection was resumed on the subject for an 11-week period. Data from the long-term follow-up revealed that head-banging continued to occur, but mean weekly levels of episodes (M = 5.8) were still well below those recorded during the baseline period (M = 18.8). The overcorrection procedure produced immediate short-term effects and, in this case, was also effective in the long-term. Variables related to the maintenance of response suppression are discussed with respect to this intervention's success.

Parental ratings of treatments of self-injurious behavior

This study examined (a) how parents of autistic children, parents of other handicapped children, and parents of nonhandicapped children rate, as a whole, acceptability of time-out, differential reinforcement, overcorrection, and shock as treatments for self-injurious behavior, and (b) whether these parents show differences, as groups, in ratings of these treatments. On the Treatment Evaluation Inventory, all groups consistently rated differential reinforcement, time-out, and overcorrection as acceptable and shock as unacceptable. Differential reinforcement was consistently rated as the most acceptable, but the groups differed in ratings of acceptability of other treatments. On the Semantic Differential, ratings of differential reinforcement, overcorrection, and time-out did not differ. However, shock was consistently rated as the most potent and active of treatments as well as the most unacceptable. The implications of these findings for treatment of autistic and other handicapped children are discussed.

Treatment of severe self-injurious and aggressive biting

The treatment of a 16-year-old severely mentally retarded and blind female client exhibiting severe biting of self and others consisted of the contingent application of an aversive gustatory stimulus (Tabasco Sauce), brief timeout, DRO, and contingent restraint against biting while in time-out. This is the first use of Tabasco as the aversive stimulus against biting. Deceleration of biting was rapid and maintained for 20 months after initiation of treatment.

Treatment of self-injurious behavior. Contingent versus noncontingent positive practice overcorrection

Positive practice has several components that may function within the procedure including the following: (1) the contingency aspect of the procedure, (2) the extensive reeducative practice of alternate, correct responses, and (3) the period of timeout from positive reinforcement. A single case reversal design was used to determine if the contingency component of positive practice was necessary to reduce the frequency of SIB. The results showed that positive practice was not effective when applied noncontingently but highly effective when administered contingently. Because practice alone was not sufficient to reduce the frequency of SIB, positive practice appears to be a punishment procedure. Also, because timeout is a component of contingent positive practice, it is still unclear whether or not time-out is a necessary component of positive practice.

Reduction of eye gouging using a response interruption procedure

A profoundly retarded male with severe congenital impairment of vision and hearing was treated for self-inflicted eye gouging. Prior to intervention, continuous mechanical restraint was required to prevent the response, precluding participation in educational and play activities. The response topography, the nature of the client's deficits, and a preliminary behavioral and medical assessment suggested that the response functioned as a source of sensory self-stimulation. Presentation of toys plus differential reinforcement of other behavior (DRO) as alternate sources of stimulation during baseline had no impact on eye gouging. The introduction of a contingent response interruption procedure reduced eye gouging and decreased the amount of time spent in restraints. Treatment effects were replicated in a group setting, and in the natural environment. Parents and school personnel were trained to use the treatment, and eye gouging remained infrequent at a 9-month follow-up.

Psychological models of self-mutilation

The descriptive models of self-mutilation fall into three broad categories. The psychodynamic formulation; the second category includes the anxiety reduction model, the hostility model, the behavioral learning model and the appeal model; the third social learning category includes the group-epidemic model and aspects of the violence and punishment model. The three models support the view that there is no single cause or motive responsible for self-mutilating behavior. Having a number of factors in mind allows for flexibility and enables clinicians to test particular hypotheses during management and gives them the opportunity to alter intervention accordingly. The problems faced by self-mutilating patients are so varied that no single form of treatment is likely to be universally appropriate.

Effects of gross motor activities on the severe self-injurious tantrums of multihandicapped individuals

The present study assessed the effects of gross motor activities on the self-injurious tantrums of three multihandicapped subjects. The tantrums did not seem related to specific environmental events and were rather infrequent, yet very severe. The study was carried out according to a withdrawal (ABAB) design. During baseline, the subjects executed routine activities that required minimal physical effort. During treatment, they performed gross motor activities that required considerable physical effort. These activities were designed to provide a wide variety of sensory (e.g., tactile, proprioceptive) input, but without tiring the subjects excessively. They were implemented when the subjects were in a quiet state. The results showed that concomitant with treatment, all subjects had a definite decline in the rate of self-injurious tantrums. Two subjects also exhibited a reduction in the duration of the tantrums.

A brief correction procedure for the management of high rate spitting in a profoundly retarded girl

This study demonstrates the effectiveness of a brief correction procedure in decelerating a high rate anti-social behaviour (spitting) in a profoundly retarded girl. A simple correction procedure seemed as effective as a more elaborate procedure incorporating positive practice elements, and gains were sustained with some variability over an extended period of time. No reliable increases in collateral behaviours were noted to result from the deceleration in spitting.

In vivo desensitization in the management of self-injurious behavior

In vivo desensitization procedures were used successfully to manage self-injurious face slapping in a 10 yr old retarded boy. Face slapping had increased and persisted at self-injurious intensity following a surgical dental evaluation and had initially been prevented by the use of a hockey helmet. Parent's efforts to remove the helmet resulted in increased agitation, severe self-injurious behavior, and repeated efforts by the child to replace the helmet to restrain himself, or prompt adult restraint. An in vivo desensitization procedure involving increasingly extended periods without the helmet was introduced by the parents into a hierarchy of situations at home. Progress was monitored across four situations using a multiple baseline design with 6, 9, 12 and 15 month follow-up on each baseline. During treatment, self-injurious behavior was eliminated and the child developed a self-control response of wearing the helmet when agitated and spontaneously removing it when relaxed. Continued improvement was noted at 6, 9 and 12 month follow-ups. At the 15 month follow-up, no self-injurious behavior was observed and the use of the helmet was discontinued.

Identifying the educative and suppressive effects of positive practice and restitutional overcorrection

Two major features of the overcorrection procedure, restitution and positive practice, were analyzed for their educative and suppressive properties in the treatment of profoundly retarded adults. Positive practice techniques that were topographically similar and dissimilar to the target behavior were studied. Eating behavior and puzzle performance were observed. Restitutional overcorrection and both forms of positive practice were effective for suppressing inappropriate behaviors. Even when appropriate behaviors had been acquired by positive practice, restitution and dissimilar positive practice were generally ineffective for increasing their rate of occurrence. However, topographically similar positive practice was successful as a means of teaching new appropriate behaviors.

Task difficulty and aberrant behavior in severely handicapped students

The influence of task difficulty on aberrant behavior was investigated with three severely handicapped students. Noticeably higher rates of problem behavior occurred in demand compared to no-demand conditions. In addition, there were higher rates of problem behaviors on difficult versus easy tasks. Both these findings were validated with visual discrimination and perceptual motor tasks. An errorless learning procedure effectively minimized errors and aberrant behavior in visual discrimination tasks but not in perceptual motor tasks. It was conceptualized that aberrant behavior was maintained by negative reinforcement contingencies. Difficult tasks were aversive to the children, who emitted aberrant responses to escape or avoid such tasks. By contrast, conditions in which no demands were made, easy tasks, and, in visual discrimination learning, errorless tasks, were less aversive and resulted in little or no problem behavior. Implications for reducing maladaptive behaviors through curricular modifications are discussed and contrasted to more traditional consequence manipulation approaches.

Stereotyped behaviour, alternative behaviour and collateral effects: a comparison of four intervention procedures

The effects of four procedures (i.e. a mild slap to the forearm, differential reinforcement of an alternative behaviour (DRA), overcorrection plus DRA, and a mild slap plus DRA), on a sterotyped behaviour, an alternative behaviour, and collateral self-injurious behaviours of a profoundly retarded five-year-old girl were assessed in a modified multiple baseline, reversal design. A mild slap resulted in rapid suppression of target and nontarget behaviours. During DRA, a slight increase was achieved in the target behaviour. However, no suppression of the other behaviours were evidenced. Overcorrection plus DRA proved relatively ineffective both in suppressing the target stereotyped behaviours and in accelerating the alternative behaviour. The most effective procedure was mild slap plus DRA. Near zero suppression of the stereotyped behaviour was attained on the first day of implementation, collateral self-injurious behaviours were virtually eliminated, and alternative behaviour increased dramatically. There was some evidence for generalisation across trainers, settings, and time.

Suppression of self-injurious behaviour: determining the least restrictive alternative

In keeping with recent ethical and legal guidelines regarding the use of aversive treatment procedures, a number of alternatives for the treatment of self-injury have been suggested. The present study provides an example of the determination of the least restrictive but most effective treatment with a case of self-injury. Employing a combination of multiple baseline and reversal designs, the effects of DRO, overcorrection, lemon juice, and aromatic ammonia on the rate of self-poking in a profoundly retarded child were examined. DRO and overcorrection were both ineffective. Although lemon juice suppressed and stabilised the rate of poking, aromatic ammonia produced greater suppression. Implications for the testing of treatments for SIB are discussed.

Problems in the behavioural treatment of self-injury in the Lesch-Nyhan syndrome

The results are described of a behavioural programme designed to modify self-injurious behaviour of a child with Lesch-Nyhan syndrome. The treatment combined extinction of the injurious behaviour and reinforcement of alternative behaviour, and was successful in the controlled hospital environment. However, an attempt to teach the parents to continue the treatment at home failed. The results are discussed in terms of the possible relationship between organic and environmental factors in maintaining the injurious behaviour, and the importance of analysing both the behaviour itself and the factors (including familial) maintaining it. It is suggested that parents should be advised about management of behavioural problems at an early age.