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.     

Rapid assessment of the effects of restraint on self-injury and adaptive behavior

We evaluated the effects of restraint on occurrences of self-injurious behavior (SIB) and adaptive responses exhibited by 2 individuals across eight response-effort conditions: baseline (no restraints); restraint sleeves without stays; restraints with 5, 10, 15, 20, or 25 thin metal stays; and restraints with five thick metal stays. From this analysis, we identified a restraint level for each participant that reduced SIB but did not inhibit adaptive responding.     

Behavioral intervention to reduce physical restraint of adolescents with developmental disabilities

Physical restraint procedures sometimes are approved for implementation in human service settings for children and adults who have developmental disabilities and seriously challenging behaviors. Although use of restraint may be clinically justified to manage behavior disorders and prevent injury to self and others, procedures should be evaluated to decrease, and possibly eliminate, such methods. This study addressed the effects of restraint‐reduction procedures with two adolescents who had developmental disabilities and displayed severe aggression. Clinically significant reductions in the frequency of physical restraint were achieved through a treatment package that included the behavior‐specific criterion for the application of restraint and antecedent control approaches. The implementation of strategic interventions to decrease physical restraint utilization is discussed. Copyright © 2000 John Wiley & Sons, Ltd.     

Reducing Psychotropic Medications in an Intensive Residential Treatment Center

Medication rates in behaviorally disordered children and youth have greatly increased to current high levels and are very controversial. This study examined changes in psychotropic medication use, levels of behavioral disturbance, and use of personal restraint and seclusion in a population of youth with serious behavioral disorders receiving medically directed cognitive-behavioral treatment in an intensive residential setting. The hypothesis was that there would be significant reductions in medication rates, without the unintended consequences of increased rates of problem behavior or offsetting increases in the use of seclusion or personal restraint. Results showed significant reductions in both the number of youth on medication and the average number of psychotropic medications during the residential stay. There were also significant reductions in behavioral disturbance, seclusions, and personal restraints. These results demonstrate that psychotropic medication can be significantly reduced without increases in problem behavior or the use of seclusions or personal restraints. We conclude that it is possible to significantly reduce psychotropic medication rates to far more conservative levels within the context of a clinically directed cognitive-behavioral treatment milieu.     

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.     

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.     

Motivations for Self‐Injury,Affect, and Impulsivity: A Comparison of Individuals with Current Self‐Injury to Individuals with a History of Self‐Injury

Individuals who report nonsuicidal self‐injury (NSSI) are characterized by the tendency to act rashly while experiencing distress (negative urgency), the tendency to act without thinking, and endorsement of both social and affect regulation motives for the behavior. However, very little research has identified characteristics that distinguish current self‐injurers from those with a history of the behavior. The purpose of this study was to compare individuals with current self‐injury to a history of self‐injury on impulsivity‐related personality traits, motives for self‐injury, and distress. Among a sample of 429 undergraduates, 120 reported self‐injury. Among these 120 individuals, 33 endorsed self‐injury within the past month, with a mean frequency of 4.77 acts of NSSI. Within the self‐injury group, current self‐injurers reported higher endorsement of affect regulation motives for NSSI, and higher levels of current negative affect than individuals with a history of self‐injury. There were no differences between current and former self‐injurers on measures of impulsivity, endorsement of social motives for NSSI, or positive affect. We propose that individuals who use NSSI to regulate negative affect may be more likely to repeatedly engage in this behavior over time.     

Reason and Emotion in the Ethics of Self‐Restraint

In this essay I argue that Reinhold Niebuhr's ethics of self‐restraint, though promising, is based on an incomplete and imprecise moral psychology. Although Niebuhr claims that reason cannot provide a sufficient grounding to motivate self‐restraint, he does not disclose which human capacity might serve this purpose. I suggest that we can address this oversight by strengthening Niebuhr's tentative embrace of David Hume, and by developing a concept of the emotions in order to explain how human beings can cultivate a stable inclination to self‐restraint. This project is informed by and in the service of feminist critiques of Niebuhr and social concerns.     

The aggression-coercion cycle: Use of seclusion and restraint in a child psychiatric hospital

The widespread use of seclusion and restraint in child psychiatric hospitals to manage aggression and noncompliance is based on the assumption that coercive consequences reduce the frequency of undesirable behaviors exhibited by the patients. We report a study of the use of seclusion and restraint in a public child psychiatric hospital during a 3-year period. Twenty-eight percent of the patients had been secluded or restrained a total of 1670 times. About 25% of these patients had been secluded more than five times during their hospitalization, and 32% had been placed in restraints more than once. Behaviors that typically resulted in repeated seclusion included physical aggression toward staff, verbal aggression toward peers, non-compliant or oppositional behavior, and self-harm. Variables that predicted patients most at risk for repeated seclusion included age, gender, and psychiatric diagnosis. The predictor variables for those most at risk for repeated restraint included age, property destruction, and self-harm. The high rates of use of seclusion and restraint suggest that these methods for controlling the behavior of children and adolescents in this child psychiatric hospital may not have been therapeutic. We suggest that staff in such hospitals engage in a pattern of behavior characterized by an aggression-coercion cycle, in which increasingly aggressive and coercive behaviors are exhibited by both patients and staff.     

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.     

Treatment of self‐injurious behavior using differential punishment of high rates of behavior (DPH)

The purpose of the current investigation was to explore the effectiveness of differential punishment of high rates of behavior (DPH) to treat the severe self‐injury of a 28‐year‐old man with autism in an adult day program setting. DPH procedures involve the use of an established criterion related to a rate of responding within some time interval at which a punisher is delivered. The implementation of DPH in this study resulted in a substantial long‐term reduction of severe self‐injurious behavior. These findings are significant in that they provide a model for the design and implementation of punishment procedures that can be adopted in applied settings where staff resources are limited. The results of this study have implications for the treatment of severe problem behavior among individuals with autism across settings and age groups.     

The detrimental effects of physical restraint as a consequence for inappropriate classroom behavior.

Functional analyses produced inconclusive results regarding variables that maintained problem behavior for 2 students with developmental disabilities. Procedures were modified to include a contingent physical restraint condition based on in‐class observations. Results indicated that under conditions in which physical restraint (i.e., basket‐hold time‐out) was applied contingent on problem behavior, rates of these behaviors increased across sessions for both subjects. Implications for the use of physical restraint in the classroom are discussed.     

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.     

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.     

The Effect of Shame‐Proneness,Guilt‐Proneness,and Internalizing Tendencies on Nonsuicidal Self‐Injury

Nonsuicidal self‐injury is especially common in adolescents and young adults. Self‐injury may be related to shame or guilt—two moral emotions—as these differentially predict other maladaptive behaviors. Using a college sample, we examined not only how shame‐proneness, guilt‐proneness, and internalizing emotional tendencies related to self‐injury, but also whether these moral emotions moderate the relation between internalizing tendencies and self‐injury. High shame‐proneness was associated with higher frequencies of self‐injury. High guilt‐proneness was associated with less self‐injury, although this effect was mitigated at higher levels of internalizing tendencies. These results suggest shame‐proneness is a risk factor for self‐injury, while guilt‐proneness is protective.     

Predictors of Perceived Susceptibility to Sport-Related Injury among Competitive Runners: The Role of Previous Experience, Neuroticism, and Passion for Running

Whether individuals take steps to protect themselves against sport‐related injury may depend on their perceived susceptibility to injury ( Williams‐Avery & MacKinnon, 1996 ). However, little is known about the determinants of perceived susceptibility to sport‐related injury. The purpose of the present study is to identify the relations of previous experiences with injury, neuroticism, and passion with perceived susceptibility to sport‐related injury among competitive runners. One hundred and seventy competitive runners reported the number of injuries sustained during the last year and completed the neuroticism scale of the NEO‐PIR and the Passion Scale. Separate regression analysis revealed that previous experiences with injury, neuroticism, and obsessive passion were significant positive predictors of perceived susceptibility, whereas harmonious passion was significantly and negatively related to perceived susceptibility. When considered simultaneously, previous experiences, neuroticism, and obsessive passion explained unique variance in perceived susceptibility to sport‐related injury. This study revealed that perceived susceptibility to sport‐related injury is dependent on several distinct variables. Thus, to be effective, injury preventive actions aimed at runners’ behaviour modification need to take into account that runners’ perceived susceptibility to sport has multiple predictors. L’adoption par les individus de comportements de prévention de la blessure en sport est liée à leur vulnérabilité perçue à celle‐ci ( Williams‐Avery & MacKinnon, 1996 ). Cependant, aucune étude ne s’est intéressée aux déterminants de cette dimension dans le contexte sportif. L’objectif de cette étude était d’identifier les relations entre les expériences passées avec une ou plusieurs blessures, le névrosisme, et la passion pour l’activité et la vulnérabilité perçue à la blessure chez des coureurs à pied. 170 coureurs compétitifs ont reporté le nombre de blessures contractées lors de la saison précédente, et ont répondu à l’échelle de névrosisme du NEO‐PIR, et à l’échelle de passion en sport. Des analyses de régression séparées révèlent une contribution positive des expériences passées avec la blessure, du névrosisme, et de la passion obsessionnelle sur la vulnérabilité perçue, alors que la passion harmonieuse contribue négativement à cette dimension. Une analyse de régression multiple intégrant l’ensemble des prédicteurs révèle un lien significatif et positif entre les expériences passées, le névrosisme, la passion obsessionnelle et la vulnérabilité perçue à la blessure. Cette étude confirme que la perception de vulnérabilité est dépendante de dimensions variées et distinctes. Les actions de prévention de la blessure axées sur les changements de perception de vulnérabilitéà la blessure à des fins de modification des comportements doivent prendre en considération les prédicteurs de cette dimension afin d’être efficaces.     

The Impact of Cannabis Use Disorder on Suicidal and Nonsuicidal Self‐Injury in Iraq/Afghanistan‐Era Veterans with and without Mental Health Disorders

The objective of this study was to assess the association between cannabis use disorder (CUD ) and self‐injury among veterans. As expected, after adjusting for sex, age, sexual orientation, combat exposure, traumatic life events, traumatic brain injury, posttraumatic stress disorder, depression, alcohol use disorder, and noncannabis drug use disorder, CUD was significantly associated with both suicidal (OR = 3.10, p  = .045) and nonsuicidal (OR = 5.12, p  = .009) self‐injury. CUD was the only variable significantly associated with self‐injury in all three models examined. These findings are consistent with prior research among civilians and suggest that CUD may also increase veterans’ risk for self‐injurious behavior.     

Suicidal Intent and Method of Self‐Harm: A Large‐scale Study of Self‐Harm Patients Presenting to a General Hospital

Data from the Oxford Monitoring System for Attempted Suicide (2004–2011) were used to study hospital presentations for self‐harm in which Suicidal Intent Scale (SIS) scores were obtained (N = 4,840). Regression of medians was used to control for the confounding effect of age and gender. Higher estimated median SIS scores were associated with increasing age, male gender, self‐poisoning versus self‐injury, multiple methods of self‐harm versus self‐injury alone, use of gas (mainly carbon monoxide), dangerous methods of self‐injury (including hanging, gunshot), and use of alcohol as part of the act. For self‐poisoning patients, there was a correlation between the number of tablets taken and the total SIS score. Compared with self‐poisoning with paracetamol and paracetamol‐containing compounds, self‐poisoning with antipsychotics was associated with a lower median SIS score while antidepressants had the same estimated median as paracetamol. Use of alcohol within 6 hours of self‐harm was associated with lower SIS scores. In conclusion, certain methods of self‐harm, particularly dangerous methods of self‐injury and self‐poisoning with gas, were associated with high intent and should alert clinicians to potential higher risk of suicide. However, apart from use of gas, suicidal intent cannot be inferred from type of drugs used for self‐poisoning.     

An observational study of restraint and helmet wearing behaviour in Malaysia

Unrestrained and unhelmeted occupants are at increased risk of severe injury or death in the event of a crash, and there is evidence that children, particularly in low and middle income countries, have low restraint and helmet wearing rates.Roadside observations of occupants of passing vehicles (7247 cars, vans and taxis and 2897 motorcycles) in nearside lanes were made at seven selected road sites located around the Klang Valley (greater Kuala Lumpur) area representing a variety of demographic locations.The findings revealed an overall low rate of seat-belt wearing in vehicles (front seat drivers: 44.6%; front seat adult passengers: 33.8%; front seat child passengers: 11.8%; rear seat adult passengers: 5.2%; and, rear seat child passengers: 5.8%). For motorcyclists, the majority of adult riders and pillions wore helmets (93.4% and 85.8%, respectively), however a substantial proportion (40%) did not fasten their helmet properly. Of children observed on motorcycles, only 30.5% wore helmets.This study shows low seat-belt and helmet wearing rates, despite enactment of legislation that requires all vehicle passengers to be restrained and for all motorcyclists to wear helmets. This was particularly evident for children (front and rear seating positions) and rear seat adult passengers. It is suggested there is a general lack of awareness of safety and the benefits of restraint/helmet use, and lack of adequate and appropriate enforcement. The implications of the findings are discussed in terms of promoting restraint/helmets use, enforcement of legislation and implementation of technologies to increase appropriate restraint/helmet use.     

APPLIED BEHAVIOR ANALYSIS IN ACQUIRED BRAIN INJURY REHABILITATION: A META‐ANALYSIS OF SINGLE‐CASE DESIGN INTERVENTION RESEARCH

The purpose of this meta‐analysis was to complete a systematic evidence‐based review of published behavioral treatment studies employing single‐case designs with both children and adults with acquired brain injury. Peer‐reviewed journals were searched using PsycINFO, Medline, and ERIC databases with combinations of terms such as brain injury, behavior disorder, behavior therapy, behavior modification, behavior analysis, and verbal behavior. A total of 112 acquisition and reduction studies met the established inclusion criteria. The data extracted from each study included specific details about the participants, target responses, intervention characteristics, use of functional assessment, and outcome characteristics. A data extraction software program was also used to extract data from graphs to calculate percentage of nonoverlapping data as an effect size_. The studies were then evaluated along several dimensions from multiple evidence‐based practice frameworks. Collectively, interventions targeted a wide range of behaviors for acquisition and reduction, but only five interventions were classified as well established according to the American Psychological Association Division 12 criteria. Furthermore, methodology of the identified studies was found to be relatively poor. A variety of methodological concerns are discussed. Copyright © 2014 John Wiley & Sons, Ltd.