SelfInjurious Behavior: A Functional Approach to Assessment and Treatment

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Self-Injurious Behavior A Functional Approach to
Assessment and Treatment

• Kyle Bennett, MS, BCBA
• Florida Atlantic University
• Center for Autism and Related Disabilities
• Toby Honsberger, M.Ed., BCBA
• Renaissance Learning Center
• FAU-CARD is Funded by the Florida Department of
  Education

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Overview of Session

• Description of Self-Injurious Behavior (SIB)
• Research on SIB
• Purposes of SIB
• Assessment strategies overview
• Case studies
• Assessment strategies
• Treatment issues
• Ethical Issues

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What is SIB?

• A disorder that involves repeated
  self-infliction of physical damage Iwata
• A response that produces physical injury to the
  individuals own body. Tate Baroff

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Some Examples

• Head banging
• Face slapping
• Biting self
• Eye poking/gauging
• Pull own hair
• Scratching self

• Pica (ingestion of inedible items)
• Aerophasia (chronic swallowing of air)

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Prevalence

• No profile that may predict SIB
• Seen in infants, children, adolescents, and
  adults
• 10 14 of individuals who are intellectually
  disabled engage in SIB
• Severe-profound 71.2
• Moderate 8.5
• Mild 2.1

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Prevalence

• Among secondary diagnosis
• Autism 10.1
• Rett Syndrome - .7
• Sensory impairments (visual auditory separate
  diagnosis) 20
• Remember, these diagnoses were secondary to
  intellectual disabilities

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Prevalence

• Types of SIB
• Head banging/hitting 49
• Biting self 30
• Hand mouthing 13.9
• Body hitting 11.2
• Pica 7.8
• Scratching 5.7
• Eye poking 5.2
• There are other types of SIB that are not included

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Why Does SIB Occur?

• Most research indicates that it is a learned
  behavior(s)
• Although there are medical reasons, as well.
• Sensitive to reinforcement (positive and
  negative)
• Thus, it is taught!
• If it is occurring, it is being reinforced
  somewhere.

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Positive Reinforcement

• Positive reinforcement is the addition of
  anything following a behavior that increases the
  likelihood of that behavior happening again in
  the future

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Negative Reinforcement

• Negative reinforcement is the removal, delay, or
  decrease of anything following a behavior that
  increases the likelihood of that behavior
  happening again in the future

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Classifying Behavior

• Socially-mediated positive reinforcement
• Socially-mediated negative reinforcement
• Automatic positive reinforcement
• Automatic negative reinforcement

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Socially-Mediated Positive Reinforcement

• Reinforcement delivery involves other people
• Some stimulus is added following a behavior
• Behavior likely to increase in the future

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Broad Category of Socially-Mediated Positive
Reinforcement

• Attention I need/ want someone.

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Specific Examples of Attention

• Talking to the person
• Reprimands
• Eye contact
• Prompting the person
• Smiling at them
• Pointing at them
• Helping them
• Physical restraint
• Blocking/physically interrupting behavior
• Applying protective equipment
• Etc.

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Broad Category of Socially-Mediated Positive
Reinforcement

• Tangible I need/want something.

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Specific Examples of Tangible

• Food
• Drink
• Toys
• Games
• Activities
• Protective equipment
• Etc.

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Socially-Mediated Negative Reinforcement

• Reinforcement involves other people
• Some stimulus is removed, delayed, or diminished
  following a behavior
• Behavior likely to increase in the future

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Broad Categories of Socially-Mediated Negative
Reinforcement

• Escape Get me outta here!
• Avoidance Dont even think about it.

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Specific Examples of Escape/Avoidance

• Terminate work
• Delay work
• Give easier work
• Protective equipment
• Terminate, delay, diminish social contact
• Termination of sounds/noises
• Reduction of crowds
• Etc.

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Role of Communication

• Thus far, we have covered the majority of the
  broad categories of behavioral function
• Critical Questions
• What would this mean if he/she was speaking
  English?
• How might I translate for him/her?

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Automatic Positive Reinforcement

• The delivery of reinforcement does not involve
  other people
• Stimulus is added following a behavior
• The behavior produces its own reinforcement
• Keeps itself going
• Behavior is likely to increase in the future

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Broad Category of Automatic Positive Reinforcement

• Sensory stimulation
• This is cool, I like this, This feels good

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Automatic Negative Reinforcement

• Reinforcement does not involve other people
• Stimulus is removed, diminished, etc. following a
  behavior
• The behavior produces its own reinforcement
• Keeps itself going
• Behavior is likely to increase in the future

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Broad Category of Automatic Negative Reinforcement

• Reduction of pain/discomfort
• This helps

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Medical/Health Issues and SIB

• Illness, injury, and discomfort can make SIB more
  likely or set the occasion for it to occur.
• Thus, must be ruled out.
• Examples
• Ear infection
• Dental problems
• Peanut in the nose
• Allergies
• Dermatitis, etc.

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Medical/Health Issues and SIB (cont.)

• Some things that I look for
• Episodic
• Occurring throughout the day no matter what is
  going on
• Temporary improvement following medicine (i.e.,
  Motrin, Tylenol, Advil, etc.)
• No history of SIB
• Including minor, sporadic occurrences of SIB and
  now the rate is high

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Medical/Health Issues and SIB (cont.)

• Medical v. Behavior
• Behavioral persistence after medical issues
  resolved.
• Transferring functions

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Prevalence of SIB Purposes

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Determining Function

• Medical evaluation
• Review relevant records
• Interview caregivers/significant others
• Direct observation
• Determine dimension of the behavior
• Determine severity
• Baseline
• ABC data
• Functional Analysis/Systematic Manipulations
• Preference Assessments

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Multi-Function SIB

• Same or similar behavior that occurs for more
  than one purpose
• Often, SIB can serve several purposes
• Escape and attention
• Attention and tangible
• Automatic positive reinforcement and escape
• Usually occurs in individuals with
  ineffective/inefficient communication
  repertoiresalthough can occur with individuals
  who communicate quite well.
• Even greater care is needed in determining
  multi-function SIB
• Need to know different events that may occasion
  the SIB

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Multi-Function SIB

• Knowing what maintains or reinforces the behavior
  is critical
• Different strategies will be needed depending on
  the current function or purpose
• Particular focus needs to be placed on the
  antecedent portion of the contingency
• What sets the behavior into action?
• This will usually be your guide as to what
  intervention steps to take

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Multiple-Topographies

• There may also be multiple topographies of SIB
• These can serve the same function or different
  functions

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Multiple-Topographies (cont.)

• If different forms of SIB are occurring for the
  same function or purpose, then similar
  intervention steps can be taken
• If, however, different forms of SIB are occurring
  for different functions or reasons, then each
  intervention step taken must be specific to that
  function

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Case Study - Alex

• Target Behavior
• Bites both wrists (bruising and bleeding)
• Throw furniture
• Hit staff with open or closed hands
• Kick staff
• Biting wrists occurred appx. 10-12 times per hour

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Case Study Alex (cont.)

• Situation
• History of a 11 aide 24/7.
• History of verbal and physical abuse
• Moderately vocal with prompting, difficulty
  initiating.
• Minimal leisure/recreation skills.
• Typical antecedents included adult attention
  diverted (briefly), adult with him but not
  looking at him, adult not talking to him, adult
  not in physical contact with him, negative
  comments
• Typical consequences looks, warnings,
  reprimands, physical blocking, restraining,
  physical guidance to work, restore the
  environment, sometimes ignoring

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Case Study Alex (cont.)

• Likely function
• To obtain attention
• Specifically, obtain negative attention
• Reprimands
• Restraint
• Etc.
• Additional Issue(s)?

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Case Study - Brian

• Target Behavior
• Punch either or both sides of his cheek bones ½
  inch away from his eyes
• Caused severe bruising bleeding.
• Occurred has high a 10 - 15 times per minute

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Case Study Brian (cont.)

• Situation
• 15 year () history of engaging in this form of
  SIB
• Differing forms of SIB occurred in the past
• High school class in a center program
• Ratio in the room was 31
• Non-verbal
• Adequate use of PECS (he could make his needs
  known by hand leading)
• Excellent leisure/recreation skills

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Case Study Brian (cont.)

• Situation
• Typical antecedents included denying access to a
  preferred item or activity, removal or
  termination of a preferred item or activity
  (especially when paired with a work demand)
• Typical consequences included allowing access to
  the materials, blocking the behaviors and prevent
  access, and sometimes requiring work or demand
  completion before getting the material back
• Smells like an intermittent reinforcement
  schedule!

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Case Study Brian (cont.)

• Function
• Access to materials
• Specifically, to obtain
• Music headphones
• Radios
• Computer games
• Also,
• Escape/avoid work if removal of a preferred
  activity preceded it.
• A FA was conducted to confirm these functions

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Case Study - Melissa

• Target Behavior
• Bite either hand above the thumb
• Caused bleeding, bruising, and permanent scaring
• Occurred up to 20-30 times per hour

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Case Study Melissa (cont.)

• Situation
• She was 5-years old with a 3.5 year history of
  emitting this behavior
• Came to us with protective equipment
• Bilateral hand/wrist splints
• No appropriate communication skills
• No functional or appropriate play skills
• No hand-object manipulation skills
• Typically, the problem behaviors occurred during
  down time but would also occur while engaged when
  the opportunity presented itself

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Case Study Melissa (cont.)

• Likely function
• Obtain sensory reinforcement
• Many times a social consequence did not follow
  the occurrence of SIB
• Would occur across people, activities, and
  settings
• Would occur during preferred activities
• Typically, Melissa would giggle or smile during
  episodes.
• A FA confirmed this

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Intervention Overview

• Must be based on the function or purpose
• Based on assessment results
• Linking intervention to assessment
• Focus on prevention strategies
• Heavy emphasis on teaching replacement behaviors
• Teaching backup behavior (supports the
  replacement behaviors)
• Although, may not always be necessary or
  warranted
• Managing consequences
• Emergency procedures
• Protective equipment

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Prevalence of Treatment1964-2000
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Sample of Tx Options Positive Reinf.
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Case Study Alexs Intervention

• Prevention
• Kept 11 aide, but rotated among
  paraprofessionals.
• No distractions for the aide working with him.
• Note Intention is to eventually fade the aide.
• Provided plenty of positive attention
• Absolutely no negative comments in the classroom
• Kept engaged often

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Case Study Alexs Intervention

• Replacement Behaviors/Skills
• Requesting attention
• Taught him to raise his hand and ask for
  attention.
• Built self-initiation with asking for attention.
• Supporting behaviors
• Taught him to request several times (persistence)
• Taught him to tap the teacher
• Taught him to make positive comments
• Taught leisure/recreation skills
• First step was to teach him how to manipulate the
  items
• The next step was to increase his engagement time

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Case Study Alexs Intervention

• Consequences
• Reinforced each replacement behavior
• 11 ratio at first and then thinned to natural
  delivery
• Minimal response block with no verbal
  interaction, no display of emotion, and minimal
  to no eye contact
• After 5-10 seconds with no attempts to engage in
  px, Alex was prompted to request
• No physical restraintterminal reinforcer for
  problem behaviors

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Sample of Tx Options-Negative Rein.
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Case Study Brians Intervention

• Prevention
• Made sure he had plenty of free access to the
  preferred items
• Gave warnings that preferred activity was about
  to end
• Used a visual first/then system
• Work was made shorter in duration
• Length of work was defined by pieces completed
  and not time
• Allowed him to choose what he would work for

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Case Study Brians Intervention

• Replacement Behaviors/Skills
• Request items/activities using PECS
• Supporting Behaviors
• Taught him to work for extended periods by slowly
  increasing the amount of pieces of work
• Taught him to give up the preferred item by
  having him turn off the music or computer or by
  giving the item to the staff.

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Case Study Brians Intervention

• Consequences
• Reinforcement for appropriate use of PECS to
  request (11 at first and then thinned)
• Unless during a work demand
• Showed visual first/then
• Blocked SIB (not restraint)
• See demonstration
• Redirected to work
• Had to finish work without SIB occurring for
  10-15 sec.
• Adjusted work requirement depending on EO/Setting
  Event (for next sessionNOT during current
  session)

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Sample of Tx Options Auto. Reinf.
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Case Study Melissas Intervention

• Prevention
• Increase active engagement with adults and
  activities
• Faded the splints once toy play was established
  with several toys
• If splints were on, minimal occurrences of SIB
• When splints were off, high rates of SIB
• Cut pieces of the splints away over time

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Case Study Melissas Intervention

• Replacement Behavior
• Taught to play with 8-10 toys
• Means-end toys at first
• Taught her to operate the toy
• Then, taught her to play with it for extended
  periods
• Supporting Behavior
• Taught her to request toys and adult attention
• Voice output devices and pictures

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Case Study Melissas Intervention

• Consequence
• Reinforcement with attention for toy play and
  requesting attention (nearly 11 ratio and then
  thinned)
• Problem behaviors were blocked (hands were not
  restrained)
• See demonstration
• Did not put the splints contingent on the
  occurrence of problem behaviorevidence of
  self-restraint

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Some Ethical and Practical Considerations
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Specific Consequent Strategy Issues

• Extinction decreasing the rate of a previously
  reinforced behavior by no longer providing
  reinforcement
• Example
• A functional assessment suggests a 5 y.o. boy
  hits head to get attention from his Mom (she
  picks him up).
• Head hitting is put on extinction and Mom no
  longer reinforces the behavior by providing
  attention.
• Frequency of head hitting decreases

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Specific Consequent Strategy Issues

• Extinction (cont.)
• Extinction Burst a brief increase in frequency,
  duration, or intensity of the behavior
• Things get worse before they get better

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Extinction Burst
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Specific Consequent Strategy Issues

• Extinction (cont.)
• Can the staff or family manage the burst?
• Is it safe to allow the behavior to burst?
• Moral, ethical, policy, and legal considerations?
• Example of extinction and blindness case

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Specific Consequent Strategy Issues

• Punishment
• Aversive control
• Legal and ethical issues
• Punishment-induced aggression
• Counter-control
• Modeling of punishment
• Avoidance of situation that are associated with
  punishment
• People
• Places
• Material
• Etc.
• Habituation
• Negative reinforcement for punisher

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Managing Emergencies

• A system for working with emergencies must be
  (extremely carefully) considered
• Best to be proactive
• This may be
• Implementing contingencies
• Manual restraint
• PRN
• Involving medical personnel or mental health
  providers
• Involving authorities
• Etc.

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Managing Emergencies

• Physical/Manual Restraint
• Must be part of a behavior intervention plan
• Only in emergencies
• Informed consent
• Involvement of qualified practitioners
• Certifying agencies
• CPI
• PCMA
• Etc.

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Protective Equipment

• Why its used
• Issues
• Restraint
• Tendon, muscle, bone problems
• Self-restraint

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Protective Equipment (cont.)

• Issues
• Legal
• Florida Statute 393.13
• (g)  Persons with developmental disabilities
  shall have a right to be free from harm,
  including unnecessary physical, chemical, or
  mechanical restraint, isolation, excessive
  medication, abuse, or neglect.
• (h)  Clients shall have the right to be free from
  the unnecessary use of restraint or seclusion.
  Restraints shall be employed only in emergencies
  or to protect the client or others from imminent
  injury. Restraints may not be employed as
  punishment, for the convenience of staff, or as a
  substitute for a support plan. Restraints shall
  impose the least possible restrictions consistent
  with their purpose and shall be removed when the
  emergency ends. Restraints shall not cause
  physical injury to the client and shall be
  designed to allow the greatest possible comfort.

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Protective Equipment (cont.)
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Protective Equipment (cont.)
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Protective Equipment (cont.)
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Summary

• SIB
• Variety of topographies
• Purposeful
• Effective assessment methods
• Treatable
• Reinforcement procedures
• Issues
• Multi-element plans
• Issues
• Role of extinction and punishment
• Issues
• Emergencies, Manual Restraint, Protective
  equipment