Self-injurious behavior: a behavioral analysis

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.

Alternative Strategies and Multiple Outcomes in the Remediation of Severe Self-Injury: Going “All Out” Nonaversively

This case study report describes the various treatments implemented over a 3-year period in an effort to reduce and eliminate multiple and severe self-injurious behaviors in a 45-year-old man who had been institutionalized and had exhibited these behaviors for the majority of his life. After baseline, an aversive procedure (contingent mechanical restraint) had been implemented and judged a failure by institution personnel. Subsequent intervention phases introducing community involvement and performance goals that emphasized functional activities in criterion environments and situations were associated with increasingly positive behaviors. Multiple outcome data are reported, including meaningful changes in targeted self-injurious behaviors, maintenance and generalization of those changes to integrated community environments at follow-up using available staff and resources, acquisition of new alternative skills, and placement in a supported apartment in the community with full-time work in a community job site. The procedures and the results demonstrate possible outcomes when nonaversive intervention procedures and community resources are utilized comprehensively as alternatives to aversive procedures focused upon only the immediate reduction of a single target behavior.

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.

Overcoming the oral aspects of -self-mutilation: description of a method

BACKGROUND/AIM

Self-injurious behavior (SIB) is a serious and chronic condition frequently seen in special needs populations, affecting 10% to 17% of individuals diagnosed with intellectual and/or developmental disabilities. A 2.5-year-old infant with SIB, whose presenting symptoms were severe tongue and lip lacerations accompanied by much hemorrhage, is presented here to illustrate the problem and to show how this may be prevented.

MATERIALS AND METHODS

An appliance is described which effectively limits the damage caused by SIB and permits rapid healing of existing injuries.

RESULTS

The method provides for a stable, retentive, and comfortable device on the infant's undererupted and largely nonretentive crowns of the deciduous teeth as well as for all permanent teeth in children, adolescents, and adults.

CONCLUSIONS

The appliance has been successfully employed for the past 10 years in patients with SIB who have attended for treatment in the Special Needs Clinic in our Department.

Management of Self-Harm Injuries in the Maxillofacial Region: A Report of 2 Cases and Review of the Literature

Clinicians face numerous challenges when managing psychiatric patients who self-inflict injuries within the maxillofacial region. In addition to a complex clinical examination, there are both surgical and psychiatric factors to consider, such as the risk of damaging vital structures, the exacerbation of the patient's psychiatric status, and the long-term psychosocial and esthetic sequelae. We present 2 cases of adolescents who repeatedly self-inflicted wounds and/or inserted foreign bodies (FBs) into the face, scalp, and neck. The different treatment modalities were based on full evaluation of the patient's clinical, medical, and diagnostic test findings coupled with a psychiatric assessment. The decision for conservative management or surgical intervention was made according to the presence and location of the FBs, degree of hemorrhage, signs and symptoms of infection, and unpleasant scars that could lead to long-term psychological impairment. In most cases, the FBs were removed and the wounds were toileted and closed under local or general anesthesia. We advocate a holistic approach via a multidisciplinary team, which is deemed essential to provide the highest quality of care for patients to reduce the risk of further relapses. Lastly, a satisfactory esthetic outcome is always paramount to achieve long-term psychological and physical welfare.

Self-injurious behaviour and the serotonin link: two case illustrations and theoretical overview

Self-injurious behaviour (SIB) is one of the challenging behaviours that is exhibited by people with severe learning disabilities. Various current aetiological theories of SIB have failed to provide a feasible model of care for this complex clinical problem. Recent advances in the understanding of serotonin neurotransmitter function may provide a way forward in the management of SIB. Case histories of two people whose SIB responded to antidepressant medication are described. Possible implication of serotonin neurotransmitter function in the causation of SIB is explored and relevant recent literature is reviewed.

Identification of Emerging Self-Injurious Behavior in Young Children: A Preliminary Study

Self-injurious behavior (SIB) is a chronic disorder that often begins in early childhood; however, few studies have examined the onset of SIB in young children. This preliminary study reports on the identification, assessment and observation of SIB in 32 children who had begun to engage in SIB within the previous 6 months. Participants were ages birth to 5 years and presented with or were at risk for intellectual and/or developmental disabilities. Assessment measures included parental interviews, developmental and language measures, standardized measures of problem behavior, and direct observations conducted in the home. Results indicated that for most children, SIB emerged prior to age 1 year, and multiple topographies of SIB and other problem behaviors developed in most children. Multiple measures were useful in identifying SIB and in characterizing the behavior by topography, frequency, and severity. Findings from the examination of child communication in relation to SIB were inconclusive. Results are discussed in relation to theories of SIB emergence, and previous observational studies of young children with SIB.

Human suicide: a biological perspective

Human suicide presents a fundamental problem for the scientific analysis of behavior. This problem has been neither appreciated nor confronted by research and theory. Almost all other behavior exhibited by humans and nonhumans can be viewed as supporting the behaving organism's biological fitness and advancing the welfare of its genes. Yet suicide acts against these ends, and does so more directly and unequivocally than any other form of maladaptive behavior. Four heuristic models are presented here to account for suicide in an evolutionary and sociobiological framework. The first model attributes suicide to the extraordinary development of learning and cultural evolution in the human species. Learning may make human behavior so independent of biological constraints that it can occasionally assume a form entirely contrary to the principles of biological evolution. The second model attributes suicide to a breakdown of adaptive mechanisms in extremely stressful novel environments. The third model involves kin and group selection, arguing that in limited circumstances suicide may occur because of beneficial effects it has on other, surviving individuals who share the suicidal individual's genes. The last model suggests that suicide should be tolerated by evolution when it has no effect on the gene pool. This model holds particular promise in accounting for aspects of suicide not attributable to culture. The evidence indicates that suicide is most common in individuals who are unlikely to reproduce and unable to engage in productive activity; such individuals are least capable of promoting their genes. A complete explanation of suicide may derive only from an analysis of its biological significance.

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.

A review of behavioral treatments for self-injurious behaviors of persons with autism spectrum disorders

Autism spectrum disorders (ASD) are considered to be among the most serious of the mental health conditions. Concomitant with many cases of ASD is intellectual disability. Further compounding the disability is the fact that both conditions are known risk factors for self-injurious behavior (SIB). To date, the most effective intervention methods, based on the available data, appear to be variants of behavior modification. This article provides an overview of the current status of learning-based interventions for SIB in ASD and provides a review of specific studies. Although most studies describe some combination of reinforcement and punishment procedures, efforts are under way to develop more positively oriented strategies, such as functional assessment, to decrease the use of punishment. However, almost all the treatment studies employ single case designs, thus preventing a comparison of treatment efficacy. These issues are discussed along with other strengths, weaknesses, and future directions for clinical practice and treatment.

Combination therapy reduces self-injurious behavior in a chimpanzee (Pan Troglodytes Troglodytes): a case report

Self-injurious behavior (SIB) remains a severe and intractable abnormal behavior for nonhuman primates in diverse settings and is a significant concern for veterinarians and behavioral scientists. To date, no single pharmacological, behavioral, social, or environmental intervention method has emerged as a reliable permanent cure for treating SIB in all, or even most, individuals. Implementation and evaluation of a combination therapeutic approach to treating SIB for nonhuman primates is rare. In May 2004, a 25-year-old male chimpanzee with severe SIB (M = 2.09 episodes/day, range = 1-4 episodes/day) underwent intensive behavioral intervention that utilized a combination of techniques. The combination therapy approach entailed the following: (a) pharmacological intervention with a gamma-aminobutyric acid (GABA) analogue to treat suspected HIV-related sensory neuropathic pain, (b) positive reinforcement training, and (c) environmental enrichment, as well as social and environmental modification. The severity of SIB warranted immediate implementation of intensive combination therapy rather than a systematic evaluation of the individual treatment options. The individually tailored, multifaceted combination therapy resulted in the virtual elimination of SIB in this chimpanzee over a 2-year period.

The development and factor structure of the Functional Assessment for multiple causaliTy (FACT)

Since behavioral intervention is linked to the findings of a functional assessment, the reality of behaviors maintained by multiple functions is a frequent and troublesome issue for clinicians and researchers. Current methods of functional assessment provide little help in the way of providing information useful for prioritizing intervention strategies for problematic behaviors maintained by multiple functions. In an effort to account for this deficiency, we developed the Functional Assessment for multiple CausaliTy (FACT). The FACT is an informant-based, forced-choice measure designed to identify the most prominent function associated with the occurrence of problem behaviors. In the present study, we describe the factor structure and internal consistency of the FACT. Suggestions are provided for future validation strategies.

Functional analysis of problem behavior: a review

Functional analysis methodology focuses on the identification of variables that influence the occurrence of problem behavior and has become a hallmark of contemporary approaches to behavioral assessment. In light of the widespread use of pretreatment functional analyses in articles published in this and other journals, we reviewed the literature in an attempt to identify best practices and directions for future research. Studies included in the present review were those in which (a) a pretreatment assessment based on (b) direct observation and measurement of (c) problem behavior was conducted under (d) at least two conditions involving manipulation of an environmental variable in an attempt (e) to demonstrate a relation between the environmental event and behavior. Studies that met the criteria for inclusion were quantified and critically evaluated along a number of dimensions related to subject and setting characteristics, parametric and qualitative characteristics of the methodology, types of assessment conditions, experimental designs, topographies of problem behaviors, and the manner in which data were displayed and analyzed.

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.

Orthognathic surgery for the treatment of chronic self-mutilation of the lips

Self-mutilation by lip chewing is an uncommon problem, but may result in severe mutilation, infection and loss of tissue, with associated scarring. Many modalities of treatment have been proposed in the literature with variable success and morbidity to the patient. Alternative techniques involving orthognathic surgery to create an anterior open bite are described which may result in cessation of self-mutilation. A case is presented with a 13-year follow-up, the anterior open bite is still present, and no recurrence of self-mutilation.

Self-injury concept formation: nursing diagnosis development

Self-inflicted injury, an increasingly common phenomenon in psychiatric settings, often is seen in borderline clients who scratch or burn themselves repeatedly. Their dysfunctional behavioral patterns present special challenges to the psychiatric/mental health nurse who seeks to interrupt such destructive means of coping. Aside from the difficult task of assisting these individuals to deal with their feelings in a constructive way, the psychiatric nurse often struggles with difficult countertransference feelings. The authors review a historical perspective of self-injury behaviors, define the phenomenon through the procedure of concept analysis, propose the creation of a new nursing diagnosis, and outline interventions appropriate for these clients.

A reciprocal control approach to the treatment of repeated parasuicide

Patterson and Reid's formulation of coercive versus reciprocal control offers a theoretical model for understanding both parasuicide and nontherapeutic exchanges between treatment staff and repeat suicide attempters. An interpersonal treatment program, derived from the Patterson and Reid formulation, which has been consistently associated with positive changes in the course of hospitalization for moderate-risk inpatients, is outlined, followed by a case illustration and discussion of the treatment strategy. The article stresses the importance of targeting the interpersonal environment as well as parasuicidal acts in the treatment program for repeat suicide attempters.

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.

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.

The definition, taxonomy, epidemiology, and ecology of self-injurious behavior

The paper is a theoretical analysis of the evolution of the concepts related primarily to the definition and to the antecedents of self-injurious behavior (SIB). It was found that the definition of SIB as currently used contains surplus meanings unrelated to its scientific utility. At present, a restricted definition of SIB is not warranted because its basic parameters have not been studied adequately. Analysis of SIB taxonomies suggests two subclasses of SIB: social and nonsocial. Epidemiological studies of SIB suggest chronic and acute subsamples that differ in organicity, chronicity, and length of institutionalization. Ecological analysis suggests that a variety of antecedent conditions affect rates and topographies of SIB, e.g., ambient environmental conditions, background settings, situational demands, self-restraint, and type of daily routine activity. Implications were drawn for the organization of therapeutic environments, the study of covariation among collateral topographies, the dynamics of SIB responding, and sequential dependencies among SIB and related topographies.