DIRECT AND COLLATERAL EFFECTS OF RESTRAINTS AND RESTRAINT FADING

Mechanical restraints are commonly used to reduce the risks associated with severe self-injurious behavior (SIB), but may result in movement restriction and adverse side effects (e.g., bone demineralization). Restraint fading may provide a method for decreasing SIB while increasing movement and reducing these side effects. In the current investigation, rigid arm sleeves and restraint fading (gradually reducing the rigidity of the sleeves) were used with 3 clients who engaged in hand-to-head SIB. Restraints and fading reduced the hand-to-head SIB of all clients. However, for 1 client, the addition of a water mist procedure further reduced SIB to near-zero levels. For a 2nd client, another form of SIB developed that was not prevented by the rigid sleeves. For a 3rd client, a topography of SIB that was not physically prevented by the rigid sleeves was also reduced when restraints and fading were introduced.     

Treatment of self‐injury correlated with mechanical restraints

Mechanical arm restraints were used to decrease hand‐to‐head self‐injurious behavior (SIB) exhibited by a 16‐year‐old female with severe mental retardation. Although mechanical restraints reduced hand‐to‐head SIB, they were correlated with an increase in other topographies of SIB (e.g., head banging). These other topographies were not significantly affected by the addition of an environmental enrichment procedure, but were immediately and almost completely suppressed when contingent exercise was added. Copyright © 2001 John Wiley & Sons, Ltd.     

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.     

Functional analysis of self-injurious behavior and its relation to self-restraint

Some individuals who engage in self-injurious behavior (SIB) also exhibit self-restraint. In the present study, a series of three functional analyses were conducted to determine the variables that maintained a participant's SIB, one without restraint items available, one with a preferred and effective form of self-restraint (an airplane pillow) available noncontingently, and one with this item delivered contingent on SIB. Results suggested that SIB was reinforced by escape and by access to self-restraint materials, self-restraint appeared to be maintained by automatic reinforcement, and continuous access to highly preferred restraint materials effectively suppressed SIB.     

Self‐restraint and self‐injury: a demonstration of separate functions and response classes

We evaluated the self‐injurious behavior (SIB) and self‐restraint (SR) of an 11‐year‐old boy with severe mental retardation that were suspected to be functionally unrelated. A functional analysis (consequences provided for SIB) resulted in near‐zero levels of SIB across experimental conditions and did not indicate a specific function of SIB. In contrast, high, undifferentiated levels of SR were observed during the attention, control, alone, and demand conditions. Further analysis of a possible tangible function of SIB using pairwise comparisons resulted in a high rate of SIB during the contingent tangible condition, no SIB in the noncontingent tangible condition, and comparable levels of SR in both conditions. A subsequent analysis using restraint blocking during play and no‐play contexts suggested that SR produced automatic reinforcement under conditions of low ambient stimulation. Thus, SIB and SR were shown to be functionally independent and maintained by distinct consequences. The results are briefly discussed and suggestions for future research are provided. Copyright © 2000 John Wiley & Sons, Ltd.     

Restraint fading and alternate management strategies to treat a man with Lesch–Nyhan syndrome over a 2 year period

In this study the variables maintaining self-injury and the use of wrist restraints in a man with Lesch–Nyhan Syndrome were identified through a pre-treatment functional assessment. In phase I, the client's self-injury and use of wrist restraints were treated by his participation in a relaxation training class and substituting his wrist restraints with a hockey-type head helmet in order to reduce self-injury and dependency on the use of wrist restraints and increase functional use of his hands. In phase II, a restraint fading procedure was implemented. This consisted of removing his restraints twice daily for 20 min and engaging him in hand over hand training. This was done in order to systematically reduce the amount of time the subject spent in restraint. In phase III, generalization was implemented across settings including work and home and across different staff persons. In phase IV, skills shaping was used to train the subject to use his hands to engage in and improve his activities of daily living. The results demonstrate a decrease in restraint use and an increase in adaptive and social experiences and reductions in challenging behaviors over a 26 month period. © 1997 John Wiley & Sons, Ltd.     

DECREASING SELF‐INJURIOUS BEHAVIOR AND FADING SELF‐RESTRAINT IN A STUDENT WITH AUTISM AND TOURETTE SYNDROME

This clinical case study was conducted with a student diagnosed with autism and Tourette syndrome who displayed severe self‐injurious behavior (SIB). Behavioral assessments and observations suggested that the student demonstrated less SIB during a self‐restraint, where he wrapped his hands tightly in a large blanket. We used an ABAB design with fading to reduce the size of the blanket to keep rates of SIB low. In addition, we also used a fixed interval reinforcement schedule and extinction during the intervention/restraint phases. Results indicated that the student maintained near‐zero rates of SIB for 6 months after use of the blanket was eliminated. Results and implications for practice and future research are discussed. Copyright © 2012 John Wiley & Sons, Ltd.     

Combination of extinction and protective measures in the treatment of severely self‐injurious behavior

Two female adolescents with profound mental retardation and physical disabilities residing in a state facility exhibited self‐injurious behavior (SIB). They had been wearing restrictive mechanical restraints for more than two years to prevent injuries from occurring. By using an indirect method of functional analysis, social attention was found to be the factor reinforcing and maintaining their behaviors. Extinction in combination with non‐intrusive protective measures was selected as the intervention strategy to reduce SIB. The outcomes of the treatment were evaluated with an AB probe design. Incidents of SIB decreased quickly and sharply after the treatment began. Once the incidents had reached a level of zero for three consecutive sessions, a six‐month follow‐up was started. No SIB was observed or reported during the follow‐up. The advantages of using extinction, especially in conjunction with the non‐intrusive protective measures to treat SIB, are discussed. Copyright © 2003 John Wiley & Sons, Ltd.     

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.     

Further analysis of subtypes of automatically reinforced SIB: A replication and quantitative analysis of published datasets

Hagopian, Rooker, and Zarcone (2015) evaluated a model for subtyping automatically reinforced self‐injurious behavior (SIB) based on its sensitivity to changes in functional analysis conditions and the presence of self‐restraint. The current study tested the generality of the model by applying it to all datasets of automatically reinforced SIB published from 1982 to 2015. We identified 49 datasets that included sufficient data to permit subtyping. Similar to the original study, Subtype‐1 SIB was generally amenable to treatment using reinforcement alone, whereas Subtype‐2 SIB was not. Conclusions could not be drawn about Subtype‐3 SIB due to the small number of datasets. Nevertheless, the findings support the generality of the model and suggest that sensitivity of SIB to disruption by alternative reinforcement is an important dimension of automatically reinforced SIB. Findings also suggest that automatically reinforced SIB should no longer be considered a single category and that additional research is needed to better understand and treat Subtype‐2 SIB.     

MANIPULATION OF POTENTIAL PUNISHMENT PARAMETERS IN THE TREATMENT OF SELF-INJURY1

The self-injurious behavior (SIB) of a blind, profoundly retarded male was observed within a field setting as multiple forms of punishment were applied. The effects of hair-tug punishment were first systematically examined, then hair-tug and electric shock punishment were administered in varing ratios (of punishment deliveries per SIB response) supplemented by continuous restraint contingencies and made contingent on recurrent antecedents of SIB cycles. Treatments were applied over six months of consecutive daily sessions ranging from 30 min to 8 hr duration. Posttreatment followup observations were taken 12, 24, and 34 months after treatment. Partial suppression was produced as a direct function of hair-tug punishment in the initial phase. A generally progressive decrement was produced on already lowered SIB rates with the succeeding components of the treatment package. Extended periods of total SIB suppression occurred as punishment was rendered contingent on antecedent components of each SIB response cycle. Followup observations of nearly 3 yr duration indicated total suppression generalized over all settings in which the subject functioned. The findings were related to the contrasting limits prevailing in most reports of punishment-based SIB suppression.     

Restraint safety in a residential setting for persons with intellectual disabilities

The primary purpose of this study was to estimate the risks associated with the use of emergency personal restraints at a residential facility for persons with intellectual and developmental disabilities. A secondary purpose was to determine if correlates of restraint‐related injury could be determined. One in three restraints resulted in an injury, but all of the injuries were minor. In terms of prediction, frequency of aggressive behavior use was the best single predictor of restraint‐related injury. Copyright © 2009 John Wiley & Sons, Ltd.     

Evaluation of an arm‐splint belt to reduce self‐injury

After a functional analysis yielded undifferentiated results, a subsequent assessment suggested self‐injury exhibited by a young boy with autism was sensitive to physical restraint. Canvas arm splints with metal stays were initially effective to reduce self‐injury. Although we successfully faded the number of stays in each sleeve to 3, self‐injury reemerged. We then used a withdrawal design to evaluate a behind‐the‐back belt connected to the arm splints. When the belt and splints were on, self‐injury did not occur. When the belt was removed, self‐injury increased, even though the splints remained intact. Finally, we faded the length of the belt to allow increased range of motion, and rates of self‐injury remained low.     

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 USE OF PHYSICAL RESTRAINT IN THE TREATMENT OF SELF-INJURY AND AS POSITIVE REINFORCEMENT

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

EFFECTS OF WRIST WEIGHTS ON SELF-INJURIOUS AND ADAPTIVE BEHAVIORS

The effects of wrist weights on the self-injurious and adaptive behaviors of a young boy with profound mental retardation were evaluated. Application of wrist weights reduced SIB by 92% and was associated with either increases or stable levels of multiple novel and preexisting adaptive behaviors.     

UTILIZING INCREASED RESPONSE EFFORT TO REDUCE CHRONIC HAND MOUTHING

The effects of increased response effort on levels of hand mouthing, leisure engagement, and adaptive elbow flexion were investigated with 2 individuals who had been diagnosed with profound disabilities. Arm restraints designed to alter the amount of physical effort necessary to engage in hand mouthing were used. Results indicated that the treatment strategy reduced levels of hand mouthing but produced only small to moderate reductions in levels of leisure engagement and adaptive elbow flexion. At follow-up, the effects of increased response effort on hand mouthing and leisure engagement were maintained for both participants; however, the restraints were associated with substantial reductions in adaptive elbow flexion for 1 participant.     

Functional analysis of self‐injury maintained by automatic reinforcement: exposing masked social functions

Two functional analyses for self‐injurious behavior (SIB) exhibited by a child diagnosed with mental retardation and autism were conducted. Responding was high and undifferentiated in the first functional analysis, indicating that SIB was maintained by automatic reinforcement. During the second functional analysis, the client wore a padded helmet and all SIB was blocked. SIB decreased in all conditions except attention, suggesting that SIB was multiply controlled (social positive and automatic reinforcement). Copyright © 2001 John Wiley & Sons, Ltd.     

Functional analysis and treatment of self-injurious behavior in young children a summary of 30 cases

The assessment and treatment of self-injurious behavior (SIB) has received much attention in the literature; however, few studies have focused on early intervention for this behavior. In the current study, functional analyses with developmentally appropriate modifications were conducted in an outpatient clinic with 30 children (aged 10 months to 4 years 11 months) to assess SIB and problem behavior in its early stages. The reported mean age of SIB onset was 17 months, and head banging was the most prevalent topography. Functional analyses identified sources of reinforcement for SIB in 62.1% of cases; with the inclusion of all forms of problem behavior, sources of reinforcement were identified for 87.5% of cases. Function-based treatments were developed for 24 cases, with functional communication training prescribed most often (70.8% of cases). Implications of these findings for the development of early intervention programs for SIB are discussed.     

DOES FUNCTIONAL COMMUNICATION TRAINING COMPETE WITH ONGOING CONTINGENCIES OF REINFORCEMENT? AN ANALYSIS DURING RESPONSE ACQUISITION AND MAINTENANCE

We examined the effectiveness of functional communication training (FCT) in reducing self-injurious behavior (SIB) and in shaping an alternative (communicative) response while SIB continued to be reinforced. Following a functional analysis of 3 individuals' SIB, we attempted to teach an alternative response consisting of a manual sign to each individual, using the reinforcer that maintained SIB. When FCT was implemented without extinction, SIB remained at baseline rates for all participants, and none of the participants acquired the alternative response. When extinction was added to the training procedure, SIB decreased and manual signing increased for all participants. To determine if signing, when established, would compete with SIB when both were reinforced, extinction was then withdrawn. Signing was maintained and SIB occurred at low rates for 2 individuals, but SIB returned to baseline rates for the 3rd individual, necessitating the reimplementation of extinction. These results suggest that it may be difficult to establish alternative behaviors if inappropriate behavior continues to be reinforced, but that, when established, alternative behavior might compete successfully with ongoing contingencies of reinforcement for inappropriate behavior.