Case study: Effects of naltrexone and sibis on self-injury

The present case study was an effort to determine the relative effectiveness of two variant treatment modalities, and to provide an exploratory study of the hypothesis that therapy with naltrexone might increase the effectiveness of an aversive stimulus in controlling self-injury. Data are presented for a man who was treated for severe self-injury with the Self-Injurious Behavior Inhibiting System (SIBIS) and naltrexone, conducted under open-trial conditions utilizing fixed doses of 50 mg, 75 mg, and 100 mg per day. The effects of naltrexone on SIB were evaluated alone and paired with SIBIS. When used alone, lower dosages of naltrexone produced moderate decrements in self-injury. However, the rate of SIB increased in a dose-dependent manner when naltrexone was paired with SIBIS. The data also suggested that naltrexone may have caused a generalized blunting of both positive and negative affect.     

ANALYSIS OF THE REINFORCEMENT AND EXTINCTION COMPONENTS IN DRO CONTINGENCIES WITH SELF-INJURY

Previous research has shown that self-injurious behavior (SIB) maintained by positive reinforcement may be reduced under differential-reinforcement-of-other-behavior (DRO) contingencies. In this study, we conducted an analysis of the reinforcement and extinction components of DRO while treating the self-injury of 3 women with developmental disabilities. A functional analysis revealed that each subject's SIB was maintained by positive reinforcement in the form of attention. Subsequent reinforcer assessments identified preferred and nonpreferred stimuli for later use in conjunction with DRO. Results showed high rates of SIB for all 3 subjects during baseline, which persisted when DRO was implemented without the relevant extinction component (withholding of attention for SIB) for 2 of the subjects. Low rates of SIB were observed for all subjects when DRO plus extinction was implemented or when extinction was implemented alone, suggesting that extinction may be a critical component of DRO schedules.     

EXPERIMENTAL ANALYSIS AND TREATMENT OF MULTIPLY CONTROLLED SELF-INJURY

A functional analysis of the self-injurious behavior (SIB) of 3 adults with profound developmental disabilities showed that each engaged in SIB in more than one assessment condition. Such outcomes may result from a failure to isolate the variable maintaining SIB, or they may reflect multiple sources of control over SIB. In order to identify more clearly the determinants of SIB, each subject was exposed to a series of treatments appropriate to one or both of the apparent functions of SIB. These treatments, applied sequentially on baselines appropriate to each behavioral function, identified the maintaining variables for SIB through differential outcomes across baselines. Results indicated that the SIB of 2 subjects was multiply controlled, confirming the outcomes of the functional analysis. However, the SIB of the 3rd subject was eliminated using a treatment designed for a single function, suggesting spurious results of the original assessment. Alternative interpretations of undifferentiated assessment data are discussed, as are analysis and treatment issues related to multiply determined behavior disorders.     

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.     

Acceptability bias: The effects of treatment acceptability on visual analysis of graphed data

Vignettes depicting a mildly or severely self-abusive child with profound mental retardation who received either a differential reinforcement of other behavior or a contingent electric shock treatment were presented to 161 undergraduates. After subjects rated the acceptability of the given treatment on the Treatment Evaluation Inventory (TEI), they evaluated the efficacy of the given treatment based upon six AB data graphs. Visual analytic judgments were not significantly effected by type of treatment, severity of self-injurious behavior (SIB), or the treatment × SIB interaction. TEI scores differed significantly according to type of treatment. Simple and multiple correlations computed between TEI scores and graph evaluations provided evidence ofacceptability bias, such that more favorable appraisals of treatment acceptability were related to perceptions of greater treatment effectiveness.     

EFFECTS OF WARNING STIMULI FOR REINFORCER WITHDRAWAL AND TASK ONSET ON SELF-INJURY

Results of a functional analysis of self-injurious behavior (SIB) in a child with autism showed that her SIB was maintained by access to preferred objects and escape or avoidance of task demands. Extinction and noncontingent reinforcement treatments were supplemented by presenting a statement combined with a picture cue at 30-s intervals indicating that a preferred object would be removed or a task would be presented. Warning stimuli in combination with extinction and noncontingent reinforcement reduced SIB to acceptable levels. SIB rates remained comparatively high in a control condition consisting of a 2-min delay to onset of reinforcer removal or task demands.     

EXTINCTION OF SELF-INJURIOUS ESCAPE BEHAVIOR WITH AND WITHOUT INSTRUCTIONAL FADING

Three individuals with developmental disabilities participated in a study of the treatment of self-injurious behavior (SIB) maintained by negative reinforcement (escape from educational tasks). Treatment was implemented in a multiple baseline design across subjects, in which two treatments were compared in a multielement format. Both treatment conditions included an escape-extinction component in which SIB no longer produced escape. One of the conditions also included a fading component in which the frequency of instructions was initially reduced to zero and then was gradually faded back in across sessions until the instructional rate matched that of the original baseline. Results indicated that extinction alone reduced SIB to the end-of-treatment criterion in fewer sessions than did extinction plus fading for all 3 subjects. For 2 of the 3 subjects, however, there was an initial increase in the frequency of SIB at the outset of treatment with extinction (an extinction burst) that was not observed when extinction was combined with the fading component.     

Decreasing self‐injurious behavior associated with awakening in a child with autism and developmental delays

Direct observation data revealed that self‐injurious behavior (SIB) emitted by a young boy with autism occurred primarily within one hour after waking versus all other times of the day. Experimentally manipulated scheduled awakenings supported the hypothesized relation between waking and SIB. A faded‐bedtime procedure was then implemented to stabilize his sleep patterns, which reduced awakenings by 81% and post‐waking SIB by 82%. Copyright © 2004 John Wiley & Sons, Ltd.     

Decreasing Self-Injurious Behavior in a Student with Autism and Tourette Syndrome through Positive Attention and Extinction

This case study was conducted with a student diagnosed with autism and Tourette syndrome who displayed severe self-injurious behavior (SIB). We conducted a functional behavioral assessment which indicated that SIB was maintained by multiple functions using an ABAC design to determine the effect of positive social attention and extinction. Results show a considerable decrease in SIB incidents, particularly when session duration was reduced from 10 minutes to 5 minutes during the second intervention phase. Thus, the combination of contingent social attention formulated from the functional assessment and extinction was successful in bringing about significant decreases in SIB. This combination holds great promise as a nonintrusive positive strategy for SIB.     

Predicting self-injury in BPD: an investigation of the experiential avoidance model

This study investigated the contribution of indices of experiential avoidance to prediction of frequency and lethality of self-injurious behaviour (SIB) in a female BPD sample (N = 71) with high levels of SIB and histories of poor treatment outcomes. The experiential avoidance model (EAM) tested included motivations for SIB, coping style and DSM-IV Avoidant PD criteria. Distinct findings for suicidal and non-suicidal SIB were noted. In partial support of the model, motivations related to relief from negative emotions positively predicted frequency of non-suicidal, but not suicidal, SIB. Avoidant PD traits predicted a pattern of more frequent, less risky non-suicidal SIB. However, reliance on avoidant coping strategies predicted lethality but not frequency of SIB, while self-blaming coping and SIB motivations related to a desire to influence others predicted frequency of non-suicidal SIB. Results suggest the need for investigation of a more complex model of the antecedents and functions of SIB that includes the contribution of Avoidant PD traits.     

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.     

Examining the Efficacy of Parent–Child Interaction Therapy with Children on the Autism Spectrum

Externalizing behaviors are a common component of the clinical presentation of autism spectrum disorders. Although traditionally used with typically-developing children, parent–child interaction therapy (PCIT) is one behaviorally-based parent training program that has demonstrated success in increasing child compliance, reducing problem behavior, and improving parent–child communication. The study examined the efficacy of PCIT as a treatment for children with autism spectrum disorders by employing a single subject, non-concurrent multiple baseline design across three subjects. Primary findings revealed increases in child compliance, reductions in child disruptive behavior, and improved parenting skills across participants. In addition, each caregiver reported high levels of satisfaction with the intervention. Results suggested that PCIT may be a treatment option for children on the autism spectrum with co-occurring behavioral difficulties. Although the non-concurrent nature of the multiple baseline design is a limitation, this study replicates and extends previous research investigating the efficacy of PCIT with children with autism and their parents.     

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.     

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.     

Continuous Access to Competing Stimulation as Intervention for Self-Injurious Skin Picking in a Child with Autism

Children with autism frequently display self-injurious behavior (SIB), but skin picking—a less severe topography of SIB—has not been the focus of much clinical research. The present study evaluated a home-based intervention that was implemented with a 9-year-old girl who had autism and picked her fingers with resulting tissue damage. The intervention allowed the girl to hold and manipulate preferred objects during play and leisure activities. Evaluated in an ABAB reversal design, intervention essentially eliminated skin picking. Clinical and research implications are discussed.     

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.     

COMPUTER‐ASSISTED MEASUREMENT OF WOUND SIZE ASSOCIATED WITH SELF‐INJURIOUS BEHAVIOR

We evaluated an inexpensive, efficient, and noninvasive technique for measuring tissue damage produced by self‐injurious behavior (SIB). The technique involved computerized measurement of wound surface area (WSA) based on digital photographs. In Study 1, we compared photographic measurement to a more commonly used procedure, transparency measurement, in estimating WSA of 20 wound models. Results showed that both methods were reliable and that there was a high degree of correspondence between the 2 sets of measures. In Study 2, we compared photographic WSA measures to direct‐observation measures in documenting changes over time in the SIB exhibited by a woman with Prader‐Willi syndrome. Results showed that increases and decreases in observed SIB during baseline and treatment conditions corresponded with changes in WSA measures, indicating that the computer‐assisted photographic technique may be useful as a corroborative measure or as a primary measure when direct observation of SIB is not feasible.     

Callous-unemotional traits,borderline personality,and self-injury in gothic subculture

The present study investigates individual characteristics of a sample of young adults from gothic subculture, in terms of personality traits (i.e., borderline personality and callous-unemotional traits), prevalence and functions of non-suicidal self-injury behaviours (i.e., internal emotion regulation, external emotion regulation, social influence, and sensation seeking). Fifty-one young adults (28 girls and 23 boys, mean age = 26.20, SD = 4.61) were recruited at a gothic meeting in Italy. They completed self-report questionnaires related to self-injury behaviours and self-injury functions, along with measures of borderline personality disorder and callous-unemotional traits. The results indicated that nearly 65% of the participants reported having committed self-injury at least once. Moreover, both bivariate and multivariate analyses indicated that self-injury behaviours were related to borderline personality and internal emotion regulation function. Lastly, association between considered personality traits and self-injury functions were investigated. Overall, results indicated that in gothic subculture self-injury has the function of regulating emotion to maintain the integrity of the Self and is related to the perception of a traumatic reality in which derealization coexists with extreme self-directed aggression.