THE SELF-INJURY TRAUMA (SIT) SCALE: A METHOD FOR QUANTIFYING SURFACE TISSUE DAMAGE CAUSED BY SELF-INJURIOUS BEHAVIOR

A method is described for classifying and quantifying surface tissue damage caused by self-injurious behavior. The Self-Injury Trauma Scale permits differentiation of self-injurious behavior according to topography, location of the injury on the body, type of injury, number of injuries, and estimate of severity. Fifty pairs of independently scored records were subjected to interrater reliability analyses, and the following mean (median) percentage agreement scores were obtained: overall agreement, 97% (98%); location of injury, 99% (100%); type of injury, 96% (100%); number of injuries, 89% (100%); and severity of injury, 94% (100%). Percentage agreement also was calculated for three summary scores: Number Index, 90%; Severity Index, 92%; and Estimate of Current Risk, 100%. Potential applications and limitations of the scale are discussed.     

EFFECTS AND SIDE EFFECTS OF DRO AS TREATMENT FOR SELF-INJURIOUS BEHAVIOR

A three-part controlled case study is presented in which severe and longstanding self-injurious behavior exhibited by a 9-year-old-boy was treated successfully with differential reinforcement of other behavior. In Phase 1, an experimental analysis demonstrated that the boy's scratching was not maintained by environmental contingencies; instead, it appeared that the self-injurious behavior was a stereotypic (automatically reinforced) response. In Phase 2, the effects of an escalating differential-reinforcement-of-other-behavior schedule mediated through token reinforcement (pennies) were evaluated in a reversal design. Results showed that differential-reinforcement-of-other-behavior eliminated self-injurious behavior very quickly and for periods of time as long as 30 min. A noteworthy side effect observed during Phase 2 was the occurrence of crying behavior following the nondelivery of reinforcement. In Phase 3, the token program was gradually extended in 30-min increments throughout the day. Additionally, results of a brief multielement manipulation showed that the effects of token reinforcement were superior to those of a more easily administered differential reinforcement of other behavior based on social reinforcement, which differed little from baseline.     

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.     

PYRAMIDAL STAFF TRAINING IN THE EXTENSION OF TREATMENT FOR SEVERE BEHAVIOR DISORDERS

We implemented a pyramidal training procedure for staff working with individuals who exhibited self-injurious behavior (SIB), aggression, and disruption. Two adults with developmental disabilities and their direct-care staff and supervisors participated. Following successful treatment by the experimenters, two types of baselines were conducted with the clients and their direct-care staff. During an initial baseline, the staff implemented preexisting procedures. Staff members then received instruction on the new treatment procedures using training methods common throughout the institution, and data were collected during this “post-in-service” baseline. Experimenters then taught unit supervisors to implement treatment, collect and interpret data, and provide similar instructions and feedback to the staff members. The supervisor training was implemented in a multiple baseline design across subjects (clients and direct-care staff). Results showed little change following in-service training but noticeable improvements in direct-care staff behaviors and corresponding decreases in the clients' inappropriate behavior following the pyramidal training intervention with supervisors. Six additional clients (along with their direct-care staff and supervisors) participated in pre- and posttreatment replication designs, and their results provided additional support for the efficacy of the supervisor training procedures.     

Functional analysis methodology: Some closing comments

Functional analysis methodologies have emerged as powerful tools in research on the assessment and treatment of severe behavior disorders. Although the defining feature of these approaches is the systematic identification of environmental determinants of behavior, research methodology has varied widely with respect to the arrangements used to demonstrate experimental control as well as the types of variables subject to analysis. This commentary summarizes methodological and conceptual issues that have been raised in current research and offers some suggestions for their resolution.     

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.     

PROTECTIVE EQUIPMENT AS TREATMENT FOR STEREOTYPIC HAND MOUTHING: SENSORY EXTINCTION OR PUNISHMENT EFFECTS?

We examined the effects of noncontingent and contingent protective equipment as treatment for self-injurious hand mouthing exhibited by 2 individuals with profound mental retardation. Results of a functional analysis assessment revealed that neither subject's self-injury was maintained by social reinforcement: One subject's self-injury was cyclical in nature; the other's occurred during all assessment conditions but most frequently when left alone. In the noncontingent-equipment condition, oven mitts were placed on the individual's hands at the beginning of a session and remained on throughout. In the contingent-equipment condition, the mitts were briefly placed on the individual's hands following occurrences of hand mouthing. For 1 subject, noncontingent mitts produced a large decrease in the rate of hand mouthing and contingent mitts produced similar results following a return to baseline. Hand mouthing was also reduced in the 2nd subject, but this individual was exposed only to the contingent-equipment condition (i.e., there was no prior history with the noncontingent-equipment condition). These results suggest either a punishment or a time-out interpretation rather than an extinction interpretation to account for the behavior-reducing effects of contingent protective equipment on self-injury.     

DRO contingencies: an analysis of variable-momentary schedules.

We conducted several comparative analyses to determine the relative effectiveness of variable-momentary differential-reinforcement-of-other-behavior (VM DRO) schedules. Three individuals who had been diagnosed with mental retardation participated. Results of functional analyses indicated that their self-injurious behavior (SIB) was maintained by social-positive reinforcement. Two individuals participated in a two-stage comparative analysis within multielement and multiple baseline designs. Fixed-interval (FI) and variable-interval (VI) DRO were compared in the first stage; VI DRO and VM DRO were compared in the second. All three schedules effectively reduced the participants' SIB. Treatment for the 3rd individual was conducted in a reversal design to examine the effects of VM DRO when it was implemented in isolation, and results indicated that the procedure was effective in reducing SIB. These findings suggest that VM DRO schedules may represent attractive alternatives to traditional FI schedules because momentary schedules do not require continuous monitoring and may result in higher rates of reinforcement.     

Correspondence between outcomes of brief and extended functional analyses.

We compared results obtained from 50 sets of functional analysis data from assessments of self-injurious behavior (SIB), 35 of which showed clear response patterns and 15 of which were undifferentiated, with those obtained from two abbreviated methods of assessment: (a) a brief functional analysis, consisting of the first session of each condition from the full functional analysis, and (b) a within-session analysis, in which data from the brief analysis were regraphed to show minute-by-minute changes in response rates during a session. Results indicated that outcomes of the brief and within-session analyses corresponded with those of the full functional analyses in 66.0% and 68.0% of the cases, respectively. Further examination of results indicated a tendency for the brief analysis to identify a large proportion of positive cases (both true and false positives) and for the within-session analysis to identify a large proportion of negative cases (true and false negatives).     

Side effects of extinction: prevalence of bursting and aggression during the treatment of self-injurious behavior

Findings from basic and applied research suggest that treatment with operant extinction may produce adverse side effects; two of these commonly noted are an increase in the frequency of the target response (extinction burst) and an increase in aggression (extinction-induced aggression). Although extinction is often used to treat problem behavior in clinical settings, few applied studies have examined the prevalence of these side effects or their possible attenuation with other operant procedures. An analysis of 41 data sets for individuals who received treatment for self-injurious behavior indicated that extinction bursts or increases in aggression occurred in nearly one half of the cases. The prevalence of bursting and aggression was substantially lower when extinction was implemented as part of a treatment package rather than as the sole intervention.