EFFECTS OF INTERMITTENT PUNISHMENT ON SELF-INJURIOUS BEHAVIOR: AN EVALUATION OF SCHEDULE THINNING

Although the use of punishment often raises ethical issues, such procedures may be needed when the reinforcers that maintain behavior cannot be identified or controlled, or when competing reinforcers cannot be found. Results of several studies on the effects of intermittent schedules of punishment suggest that therapists must use fairly rich schedules of punishment to suppress problem behavior. However, residential caretakers, teachers, and parents often have difficulty implementing programs that require constant monitoring of the client's behavior. In this study, we examined the feasibility of gradually thinning the delivery of punishment from a continuous schedule to an intermittent schedule during the course of treatment for self-injurious behavior (SIB). Results of functional analyses for 5 individuals who had been diagnosed with profound mental retardation indicated that their SIB was not maintained by social consequences. Treatment with continuous schedules of time-out (for 1 participant) or contingent restraint (for the other 4 participants) produced substantial reductions in SIB. When they were exposed to intermittent schedules of punishment (fixed-interval [FI] 120 s or FI 300 s), SIB for all but 1 of the participants increased to levels similar to those observed during baseline. For these 4 participants, the schedule of punishment was gradually thinned from continuous to FI 120 s or FI 300 s. For 2 participants, SIB remained low across the schedule changes, demonstrating the utility of thinning from continuous to intermittent schedules of punishment. Results for the other 2 participants showed that intermittent punishment was ineffective, despite repeated attempts to thin the schedule.     

THE FUNCTIONS OF SELF-INJURIOUS BEHAVIOR: AN EXPERIMENTAL-EPIDEMIOLOGICAL ANALYSIS

Data are summarized from 152 single-subject analyses of the reinforcing functions of self-injurious behavior (SIB). Individuals with developmental disabilities referred for assessment and/or treatment over an 11-year period were exposed to a series of conditions in which the effects of antecedent and consequent events on SIB were examined systematically by way of multielement, reversal, or combined designs. Data were collected during approximately 4,000 experimental sessions (1,000 hr), with the length of assessment for individuals ranging from 8 to 66 sessions (M = 26.2) conducted over 2 to 16.5 hr (M = 6.5). Differential or uniformly high responding was observed in 145 (95.4%) of the cases. Social-negative reinforcement (escape from task demands or other sources of aversive stimulation) accounted for 58 cases, which was the largest proportion of the sample (38.1%). Social-positive reinforcement (either attention or access to food or materials) accounted for 40 (26.3%) of the cases, automatic (sensory) reinforcement accounted for 39 (25.7%), and multiple controlling variables accounted for 8 (5.3%). Seven sets of data (4.6%) showed either cyclical or inconsistent patterns of responding that were uninterpretable. Overall results indicated that functional analysis methodologies are extremely effective in identifying the environmental determinants of SIB on an individual basis and, subsequently, in guiding the process of treatment selection. Furthermore, an accumulation of assessment data from such analyses across a large number of individuals provides perhaps the most rigorous approach to an epidemiological study of behavioral function.     

TREATMENT OF SELF-INJURIOUS BEHAVIOR USING A WATER MIST: INITIAL RESPONSE SUPPRESSION AND GENERALIZATION

This study evaluated the effects of a fine mist of water applied to the face contingent upon self-injurious behavior (SIB) exhibited by profoundly retarded persons. In Experiment 1, results of individual reversal designs showed substantial reductions in a variety of SIB's (mouthing, hand biting, skin tearing, and head banging) for seven participants. In Experiment 2, two participants who frequently bit their hands were each observed in two different settings. Following initial baselines in each setting, a series of manipulations was undertaken to compare the effects of mild verbal punishment (“No”) with those of a combined treatment (“No” plus mist procedure). Results in one setting indicated that “No” suppressed SIB only after it was first paired with the water mist. Data also suggested that, once acquired, the punishing properties of “No” could be extended to a second setting in which the mist was never applied, and that these effects could be generalized across therapists. Results of these experiments indicate that the water mist procedure may be an effective alternative to traditional punishment techniques. Although conclusions regarding generalization are limited due to the brevity of the maintenance conditions, the data suggest that treatment gains may be transferred to more acceptable forms of social punishment and reinforcement.     

STIMULUS (INSTRUCTIONAL) FADING DURING EXTINCTION OF SELF-INJURIOUS ESCAPE BEHAVIOR

Three individuals with developmental disabilities were exposed to a series of assessment conditions to identify the source of reinforcement for their self-injurious behavior. In each case, self-injury occurred most often in instructional (demand) situations containing a brief time-out from the task contingent on self-injury, indicating that the behavior was an escape response (i.e., maintained by negative reinforcement). Treatment was implemented in a multiple baseline across subjects design and consisted of extinction (prevention of escape) plus instructional fading (initial elimination of instructions followed by their gradual reintroduction). Results showed that the combined treatment produced immediate and large reductions in self-injury that were maintained as the frequency of instructions was increased across sessions to match the original baseline rate of presentation. Results of a component analysis conducted with 1 subject suggested that stimulus fading accelerated the behavior-reducing effects of extinction.     

PUNISHMENT OF SELF-INJURIOUS BEHAVIOR USING AROMATIC AMMONIA AS THE AVERSIVE STIMULUS

Punishment with aromatic ammonia was used to eliminate self-injurious behavior of an autistic woman during experimental sessions. The effects were reversible but were limited to experimental sessions until staff used the ammonia on the ward at all times.     

USE OF NEGATIVE REINFORCEMENT IN THE TREATMENT OF SELF-INJURIOUS BEHAVIOR

Behavioral assessment procedures were used to determine the maintaining conditions of self-injury exhibited by 2 children with severe multiple handicaps. For both children, negative reinforcement (escape from grooming activities) was determined to be the maintaining reinforcer for self-injury (hand/arm biting) within an alternating treatments design. The treatment packages involved the use of negative reinforcement (brief escape from grooming activities) contingent upon a behavior that was incompatible with self-injury (reaching and pressing a microswitch that activated a prerecorded message of “stop”). Treatment was evaluated with a reversal design for 1 child and with a multiple baseline across grooming activities for the 2nd child. The treatment led to a marked decrease in self-injury for both children. At follow-up, high rates of self-injury were reported for the 1st child, but low rates of self-injury and an increase in task-related appropriate behavior were observed for the 2nd child.     

ON THE RELATIONSHIP BETWEEN SELF-INJURIOUS BEHAVIOR AND SELF-RESTRAINT

Many individuals who exhibit self-injurious behavior (SIB) also exhibit self-restraint. Three hypotheses about the determinants of self-restraint have been suggested: (a) Self-restraint is maintained by escape from or avoidance of aversive aspects of SIB, (b) self-restraint and SIB are members of the same functional class, and (c) self-restraint and SIB are functionally independent. This study examined a method by which the relationship between self-restraint and SIB may be investigated using functional analysis. Data were collected on the self-restraint and SIB exhibited by 5 mentally retarded males, while conditions suspected to maintain SIB were manipulated. Results suggested that self-restraint, like SIB, may be maintained by idiosyncratic contingencies. Implications of an understanding of self-restraint for the analysis and treatment of SIB are discussed, as are some general possibilities for future research.     

ARTIFACTUAL EFFECTS OF SENSORY-INTEGRATIVE THERAPY ON SELF-INJURIOUS BEHAVIOR

Three individuals who exhibited self-injurious behavior (SIB) were exposed to sensory-integrative therapy. Prior to treatment, a functional analysis baseline was conducted to identify the motivational features of their SIB. One subject's SIB appeared to be an attention-getting response (maintained by positive reinforcement), which varied subsequently as a function of attention being either withheld or provided noncontingently during sensory-integration sessions. The 2nd subject displayed a pattern of responding suggestive of stereotypic SIB (maintained by automatic reinforcement), which paradoxically increased during sensory-integration sessions. The 3rd subject's SIB appeared to function as an escape response (maintained by negative reinforcement), and his behavior during sensory-integration sessions was similar to that observed during baseline sessions in which demands were not present. The SIB of all 3 subjects later was reduced when behavioral interventions were applied. The data presented raise questions about the active components of sensory-integrative therapy and the functional types of SIB for which it might be appropriate.     

ASSESSMENT OF STEREOTYPIC AND SELF-INJURIOUS BEHAVIOR AS ADJUNCTIVE RESPONSES

Certain responses of both humans and nonhumans appear to be maintained indirectly by intermittent reinforcement schedules and have been referred to collectively as adjunctive behavior. Although basic research has examined adjunctive behavior extensively, relatively few studies have been conducted with humans, particularly those with developmental disabilities who often engage in frequent and varied stereotypic behavior. This study assessed possible adjunctive characteristics of self-injurious and stereotypic behaviors using a multielement design containing two types of control conditions. Four subjects who engaged in both self-injurious behavior and stereotypy participated after variables maintaining their self-injury were identified via functional analyses. Each day, subjects were exposed to three 15-min sessions in random order: (a) noncontingent presentation of food on a fixed-time schedule (e.g., FT 30 s), (b) a massed-reinforcement (food) control, and (c) a no-reinforcement control. A variety of fixed-time schedules were examined during different experimental phases. Results of this preliminary study suggested that self-injury was not induced by intermittent reinforcement schedules, whereas the stereotypic behavior of some individuals showed characteristics of adjunctive behavior. The importance of research on adjunctive behavior and suggestions for future studies are discussed.     

MOMENTUM VERSUS EXTINCTION EFFECTS IN THE TREATMENT OF SELF-INJURIOUS ESCAPE BEHAVIOR

An individual's self-injurious escape behavior was treated using a high-probability instructional sequence with and without extinction. When presented alone, the high-probability sequence did not reduce self-injurious behavior. When escape extinction was implemented either alone or in combination with the high-probability sequence, self-injury decreased and compliance increased, suggesting that extinction may be a necessary component of the treatment for behavior problems maintained by escape.     

EXPERIMENTAL ANALYSIS AND EXTINCTION OF SELF-INJURIOUS ESCAPE BEHAVIOR

Three studies are presented in which environmental correlates of self-injurious behavior were systematically examined and later used as the basis for treatment. In Study 1, 7 developmentally disabled subjects were exposed to a series of conditions designed to identify factors that maintain self-injurious behavior: attention contingent on self-injurious behavior (positive reinforcement), escape from or avoidance of demands contingent on self-injurious behavior (negative reinforcement), alone (automatic reinforcement), and play (control). Results of a multielement design showed that each subject's self-injurious behavior occurred more frequently in the demand condition, suggesting that the behavior served an avoidance or escape function. Six of the 7 subjects participated in Study 2. During educational sessions, “escape extinction” was applied as treatment for their self-injurious behavior in a multiple baseline across subjects design. Results showed noticeable reduction or elimination of self-injurious behavior for each subject and an increase in compliance with instructions in all subjects for whom compliance data were taken. The 7th subject, whose self-injurious behavior during Study 1 occurred in response to medical demands (i.e., physical examinations), participated in Study 3. Treatment was comprised of extinction, as in Study 2, plus reinforcement for tolerance of the examination procedure, and was evaluated in a multiple baseline across settings design. Results showed that the treatment was successful in eliminating self-injurious behavior and that its effects transferred across eight new therapists and three physicians. General implications for the design, interpretation, and uses of assessment studies are discussed.     

SELF-RESTRAINT AS POSITIVE REINFORCEMENT FOR SELF-INJURIOUS BEHAVIOR

Many individuals who engage in self-injurious behavior (SIB) also exhibit self-restraint. We compared rates of SIB exhibited by a 32-year-old woman diagnosed with profound retardation across conditions in which access to restraint was (a) continuously available, (b) presented as a consequence for SIB, or (c) unavailable. Rates of SIB increased when access to restraint was contingent upon SIB and decreased when restraint was unavailable, suggesting that self-restraint functioned as positive reinforcement for SIB.     

THE ROLE OF ATTENTION IN THE TREATMENT OF ATTENTION-MAINTAINED SELF-INJURIOUS BEHAVIOR: NONCONTINGENT REINFORCEMENT AND DIFFERENTIAL REINFORCEMENT OF OTHER BEHAVIOR

Because there are potentially serious limitations to differential reinforcement of other behavior (DRO) (which is probably the most widely used treatment procedure for behavior problems), we examined an alternative procedure—noncontingent reinforcement (NCR). Three females with developmental disabilities, all of whom engaged in severe self-injurious behavior, participated. During a pretreatment functional analysis, each subject's self-injury was shown to be differentially sensitive to social attention as a maintaining consequence. Next, each subject was exposed to a DRO treatment and an NCR treatment. During DRO, attention was delivered contingent on the absence of self-injury for prespecified intervals. During NCR, attention was delivered on a fixed-time schedule that was not influenced by the subject's behavior. Results showed that both procedures were highly effective in reducing self-injury, probably because the functional reinforcer for self-injury was used during treatment. Furthermore, there was evidence that NCR attenuated several of the limitations of DRO. These results are particularly interesting in light of the long experimental history of NCR as a control rather than as a therapeutic procedure.     

REEMERGENCE AND EXTINCTION OF SELF-INJURIOUS ESCAPE BEHAVIOR DURING STIMULUS (INSTRUCTIONAL) FADING

Based on results of a functional analysis indicating that the self-injurious behavior (SIB) of 3 individuals was maintained by negative reinforcement (escape from instructional situations), the effects of stimulus (instructional) fading were evaluated in a multiple baseline design across subjects. The rate of instructions was reduced to zero at the beginning of treatment and was gradually increased (faded in) across sessions as long as SIB remained low. However, if SIB remained high for 10 consecutive sessions, extinction was implemented until SIB decreased, at which point extinction was withdrawn and fading was resumed. Treatment was completed when the rate of instructions was the same as in baseline (two per minute), and SIB remained below 0.5 responses per minute for two consecutive sessions. Results showed that instructional fading (without extinction) virtually eliminated SIB initially, but these effects were not maintained. All 3 subjects required multiple exposures to extinction and over 150 treatment sessions in order to meet the end-of-treatment criteria. Advantages and limitations of fading procedures without an extinction component, as well as extensions of both interventions to other clinical problems, are discussed.     

ASSESSMENT OF SELF-INJURIOUS BEHAVIOR MAINTAINED BY ACCESS TO SELF-RESTRAINT MATERIALS

This study replicates and extends prior research showing that access to self-restraint materials can reinforce self-injurious behavior (SIB). A functional analysis was conducted showing that SIB occurred at differentially high rates when access to restraint materials (a leather jacket) was made contingent on the behavior. In addition, an alone condition during the functional analysis showed that SIB did not occur in the absence of restraint materials. Finally, a treatment analysis showed that functional communication training was effective using an alternative reinforcer.     

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 uints 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.     

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.     

EFFECTS OF REINFORCEMENT FOR ALTERNATIVE BEHAVIOR DURING PUNISHMENT OF SELF-INJURY

A number of variables influence the effectiveness of punishment and may determine the extent to which less intrusive forms of punishment may be used as alternatives to more intrusive interventions. For example, it has been suggested that response suppression during punishment may be facilitated if reinforcement is concurrently available for an alternative response. However, results of basic research demonstrating this finding have not been replicated with interventions more commonly prescribed as treatments for problem behavior. We evaluated the effects of relatively benign punishment procedures (reprimands or brief manual restraint) on the self-injurious behavior of 4 individuals who had been diagnosed with mental retardation, when access to reinforcement for alternative behavior (manipulation of leisure materials) was and was not available. In all cases, punishment produced greater response suppression when reinforcement for an alternative response was available.     

PLAY VERSUS ALONE CONDITIONS AS CONTROLS DURING FUNCTIONAL ANALYSES OF SELF-INJURIOUS ESCAPE BEHAVIOR

We compared the effects of continuous reinforcement (play) and alone conditions as controls during functional analyses for 66 individuals whose self-injurious behavior (SIB) was maintained by escape. In every case, SIB was lower during both control conditions than it was during the test (demand) condition. However, SIB was lowest during the alone condition more often than it was during the play condition. Circumstances under which the alone condition might serve as an alternative or more suitable control for escape-maintained problem behaviors are discussed.