Studio III Research

Preventing and managing self injurious behaviour in childrens services

Andrew McDonnell

Clinical Psychologist,

Director

Studio3 Training Systems

WWW.Studio3.org

Tel 01225 334111

May 2003

Background

SIB sometimes has a communicative function (see Bird, et al, 1989).

SIB evoke strong emotional responses among care staff (Oliver, 1993).

SIB is a little misleading as an expression as the function(s) of such behaviours will vary hugely from one individual to another.

There appears to be a relationship between SIB and stereotypic behaviours. Clinically, the reduction of one behaviour can lead to an increase in the other.

Significant advances have been made in our understanding of the causes and function(s) of SIB (See Iwata, et al, 1982). We are also beginning to understand the early aetiology of SIB.

‘Extinction bursts’ and ‘elicited aggression’ are known side effects of behavioural interventions. (Iwata & Lerman, 1995)

Much of the published literature has focused on behavioural interventions that are based on change rather than management.

Researchers tend to publish positive outcomes.

Behaviour management strategies are relatively poorly understood.

Electric Shock

SIB has attracted some extreme interventions. The most controversial is the use of electric shock. (There are still places in the US and Europe where programmes still exist).

The evidence for shock interventions is at ‘best mixed’. There are obvious ethical questions raised by the use of such methods.

· Some authors have reported high relapse rates (William et al, 1994).

· Others claim maintenance for up to 5 years. (Hartel & Cooley, 1993).

· The most controversial Dutch study (Duker & Seys, 1996) claimed significant reductions in the use of physical (and presumably mechanical restraints) for 7 out of 12 individuals.

Opinion

A) These studies suggest strongly that we are lucky that such procedures are not used in the UK.

B) I find it difficult to justify the use of such a procedure in any circumstances.

C) Why would such a method work ? The most obvious factor is pain. Even though researchers often claim that they used low voltages. The shock may be magnified among people with ‘abnormal and erratic sensory processing.

Sensory Factors

Although there is ample evidence that SIB can be maintained by environmental events such as the need or avoidance of social interaction (Iwata, et al, 1982). There are times when SIB is maintained by INTERNAL EVENTS.

Sensory stimulatory approaches may help to distract people in times of crisis. There is a considerable degree of anecdotal clinical evidence.

· Temple Grandin reported that at times she felt the need for ‘deep pressure contact’. Which appeared to have a calming effect on her. At other times physical contact was almost painful (Grandin, 1989).

· There are at times when people appear to engage in SIB for environmental reasons but, they literally appear to be ‘unable to stop once they start’. (In behavioural psychology it has long been accepted that whatever reinforces a behaviour initially, does not necessarily maintain that behaviour).

· It is not unusual for individuals to ‘self restrain’ I would argue that a person who engages in such a behaviour is probably attempting to prevent themselves from self injuring. (They are aware of what they are doing and have developed their own reactive strategy. For some individuals stereotyped behaviours appear to be inversely relate to SIB.

Example 1

Presenting difficulty

A young man engaged in SIB (tugging at his lip until he practically detached it).

Reactive plan

It was decided to hold him (wrapping their arms around him) when he engaged in this behaviour.

Holding him did not appear to be an aversive event. (Although his behaviour did decrease rapidly so technically it could be viewed as a form of punishment).

To avoid the problem that they were reinforcing holding the workers introduced a number of strategies. First, holding him when not engaging in SIB and secondly providing him with intense physical contact in other ways. 5 minutes every half hour the person was offered deep muscle massage.

(Reported in Willis & LaVigna, 2002)

Opinion

A) Sensory reinforcement was clearly a factor in this case.

B) The strategy is quite labour intensive

Presenting Difficulty

A 25 year old man engaged in eye poking, head banging, head punching and scratching

Reactive Plan

TENS electrodes were placed on his ears

It was found that TENs appeared to decrease his SIB for short duration periods (10 minutes)

The effect seemed to wear off after the period was increased (20 to 30 minutes).

(Fisher et al, 1998)

Opinion

There is clearly a short term effect.

A) TENS may increase the release of endogenous opiates.

B) TENS may provide only short term distraction.

C) TENS may be an excellent short term behaviour management tool when individuals go through distressing periods of self injury.

D) May work better for minor SIB.

Example 3

Presenting Difficulty

A 6 year old boy with learning disabilities with high levels of hand to head hitting. He also suffered from cortical blindness which led to eating difficulties.

Reactive Plan

Wrist weights (2lb per arm) were placed on him.

A vibrating microswitch which he could operate independently was introduced into the sessions.

Levels of SIB practically reduced to zero if weights and an electronic toy were used.

(Hanley et al, 1998)

Opinion

A) The results appear impressive although the evidence is short term.

B) There are a number of reasons why weights may have an effect on SIB.

C) Weights could be a useful short term management tool

Teaching Incompatible Movements

It has been the experience of a number of trainers and clinicians who work for Studio3 that there are alternative’s to the use of blocking and immobilization methods when people experience extreme bouts of self injury. Using movement is another crisis management tool to consider. There are some basic principles:

a) Use natural movements which compete with the SIB.

b) Circular movements often interrupt motor routines.

c) Walking individuals who engage in hand to head banging.

d) Consider using ‘deep pressure’ contact when using movement.

There are huge individual differences which effect peoples susceptibility to specific movement.

It is important to remember that the use of movement is a crisis management tool.

The social acceptability of protective equipment requires further investigations (See Tarnowski, et al, 1989: Wolf, 1978).

NB. Many individuals are particularly sensitive to physical contact

The Role of Protective Equipment

The use of protective headgear is always a controversial area. Most SIB appears to be episodic in nature. However, many individuals who placed in protective headgear and arm splints are often left in them for much longer than the crisis periods.

It is useful to make any use of such protective materials to be made intermittent in times of crisis.

Mechanical and physical restraint can become positively reinforcing with people requesting to placed in them by either requesting mechanical restraint or seeking to be held. (See Favell, et al, 1978; Singh, et al, 1981).

Some types of headgear may provide a form of deep pressure contact.

Age appropriate protective headgear can be used. One of the most unusual is a form of protective ‘bandana’

Some Clinical Suggestions

Recording is essential !

Always attempt to conduct an analysis of function(s) of SIB.

Remember SIB is complicated; and threrefore so should be the analysis. Try to avoid one word functions like ‘Its attention’ or ‘demand related’. Examine the interactions between such function(s), (see Samson & McDonnell, 1990).

Develop an understanding of the episodic nature of the SIB.

Develop a list of crisis management strategies. However, you must bear in mind that people will eventually habituate to such strategies over time.

Strategies which provide short bursts of respite should not be ruled out because their effects are short term.

Useful References

Bird, F., Dores, P.A., Moniz, D., & Robinson, J. (1989). Reducing severe aggressive

and self injurious behaviours with functional communication training. American Journal on Mental Retardation, 94, 37-48.

Duker, P & Seys, D.M. (1996). Long term use of electrical aversion treatment with self injurious

behavior. Research in Developmental Disabilities, 17, 293-301

Favell, J. E., McGimsey, J. F. & Jones, M. L. (1978). The use of physical restraint in the

treatment of self injury and as positive reinforcement. Journal of Applied Behavior Analysis, 11, 225-241.

Fisher, W.W., Bowman, L.G., Thompson, R.H. & Contrucci, S.A. (1998) Reductions in self injury

reduced by Transcuteaneous electrical nerve stimulation. Journal of Applied Behavior

Analysis 31, 493-496

Grandin, T (1989). An autistic persons view of holding therapy. Journal of the National

Autistic Society

Hanley, G.P, Piazza, P.C. Keeney, K.M. ., Bakely-Smith, A.B. & Worsdell, A.F. (1998). Effects of

wrist weights on self injurious and adaptive behaviors. Journal of Applied Behavior

Analysis, 31, 307-310.

Iwata, B.A., Dorsey, M.F., Slifer, K.J., Bauman, K.E., & Richman, G.S. (1982). Toward a

functional analysis of self injury. Analysis and Intervention in Developmental Disabilities, 2, 1-20.

Lerman, D.C & Iwata, B.A. (1995). Prevelance of extinction bursts attenuation during treatment.

Journal of Applied Behavior Analysis, 28, 93-94.

LaVigna, G & Willis, T. (2002) Counter intuitive strategies in crisis management within a non

aversive framework. In D Allen (Ed). Ethical approaches to physical interventions:

Responding to challenging behaviour in people with intellectual disabilities. Plymouth: BILD.

Oliver, C. (1993). Self injurious behaviour: From response to strategy. In C Kiernan (Ed.),

Challenging behaviour and learning disabilities: Research to practice? Implications of research on the challenging behaviour of people with learning disabilites. Clevedon: BILD Publications.

Samson, D.M & McDonnell, A.A. (1990). Functional analysis and challenging

behaviours. Behavioural Psychotherapy, 18, 259-271.

Singh, N. N., Dawson, M. J., Manning, P. J. (1981). The effects of physical restraint on self

injurious behavior. Journal of Mental Deficiency Research, 25, 207-216.

Tarnowski, K.J., Rasnake, L.K., Mulick, J.A. & Kelly, P.A. (1989) Acceptability of

behavioral interventions for self-injurious behaviour. American Journal on Mental Retardation, 93, 575-580.

Williams, D.E., Kirkpatrick-Sanchez, S & Crocker, W.T. (1994). Long term follow up of treatment

for severe self injury. Research in Developmental Disabilities, 15, 487-501

Wolf, M.M. (1978). Social validity: The case for subjective measurement or how

applied behavior analysis if finding its heart. Journal of Applied Behavior Analysis, 11 203-214.


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		Preventing and managing self injurious behaviour in childrens services Andrew McDonnell Clinical Psychologist, Director Studio3 Training Systems *WWW.Studio3.org* *Tel 01225 334111* May 2003 Background SIB sometimes has a communicative function (see Bird, et al, 1989). SIB evoke strong emotional responses among care staff (Oliver, 1993). SIB is a little misleading as an expression as the function(s) of such behaviours will vary hugely from one individual to another. There appears to be a relationship between SIB and stereotypic behaviours. Clinically, the reduction of one behaviour can lead to an increase in the other. Significant advances have been made in our understanding of the causes and function(s) of SIB (See Iwata, et al, 1982). We are also beginning to understand the early aetiology of SIB. ‘Extinction bursts’ and ‘elicited aggression’ are known side effects of behavioural interventions. (Iwata & Lerman, 1995) Much of the published literature has focused on behavioural interventions that are based on change rather than management. Researchers tend to publish positive outcomes. Behaviour management strategies are relatively poorly understood. Electric Shock SIB has attracted some extreme interventions. The most controversial is the use of electric shock. (There are still places in the US and Europe where programmes still exist). The evidence for shock interventions is at ‘best mixed’. There are obvious ethical questions raised by the use of such methods. · Some authors have reported high relapse rates (William et al, 1994). · Others claim maintenance for up to 5 years. (Hartel & Cooley, 1993). · The most controversial Dutch study (Duker & Seys, 1996) claimed significant reductions in the use of physical (and presumably mechanical restraints) for 7 out of 12 individuals. Opinion A) These studies suggest strongly that we are lucky that such procedures are not used in the UK. B) I find it difficult to justify the use of such a procedure in any circumstances. C) Why would such a method work ? The most obvious factor is pain. Even though researchers often claim that they used low voltages. The shock may be magnified among people with ‘abnormal and erratic sensory processing. Sensory Factors Although there is ample evidence that SIB can be maintained by environmental events such as the need or avoidance of social interaction (Iwata, et al, 1982). There are times when SIB is maintained by INTERNAL EVENTS. Sensory stimulatory approaches may help to distract people in times of crisis. There is a considerable degree of anecdotal clinical evidence. · Temple Grandin reported that at times she felt the need for ‘deep pressure contact’. Which appeared to have a calming effect on her. At other times physical contact was almost painful (Grandin, 1989). · There are at times when people appear to engage in SIB for environmental reasons but, they literally appear to be ‘unable to stop once they start’. (In behavioural psychology it has long been accepted that whatever reinforces a behaviour initially, does not necessarily maintain that behaviour). · It is not unusual for individuals to ‘self restrain’ I would argue that a person who engages in such a behaviour is probably attempting to prevent themselves from self injuring. (They are aware of what they are doing and have developed their own reactive strategy. For some individuals stereotyped behaviours appear to be inversely relate to SIB. Example 1 Presenting difficulty A young man engaged in SIB (tugging at his lip until he practically detached it). Reactive plan It was decided to hold him (wrapping their arms around him) when he engaged in this behaviour. Holding him did not appear to be an aversive event. (Although his behaviour did decrease rapidly so technically it could be viewed as a form of punishment). To avoid the problem that they were reinforcing holding the workers introduced a number of strategies. First, holding him when not engaging in SIB and secondly providing him with intense physical contact in other ways. 5 minutes every half hour the person was offered deep muscle massage. (Reported in Willis & LaVigna, 2002) Opinion A) Sensory reinforcement was clearly a factor in this case. B) The strategy is quite labour intensive Presenting Difficulty A 25 year old man engaged in eye poking, head banging, head punching and scratching Reactive Plan TENS electrodes were placed on his ears It was found that TENs appeared to decrease his SIB for short duration periods (10 minutes) The effect seemed to wear off after the period was increased (20 to 30 minutes). (Fisher et al, 1998) Opinion There is clearly a short term effect. A) TENS may increase the release of endogenous opiates. B) TENS may provide only short term distraction. C) TENS may be an excellent short term behaviour management tool when individuals go through distressing periods of self injury. D) May work better for minor SIB. Example 3 Presenting Difficulty A 6 year old boy with learning disabilities with high levels of hand to head hitting. He also suffered from cortical blindness which led to eating difficulties. Reactive Plan Wrist weights (2lb per arm) were placed on him. A vibrating microswitch which he could operate independently was introduced into the sessions. Levels of SIB practically reduced to zero if weights and an electronic toy were used. (Hanley et al, 1998) Opinion A) The results appear impressive although the evidence is short term. B) There are a number of reasons why weights may have an effect on SIB. C) Weights could be a useful short term management tool Teaching Incompatible Movements It has been the experience of a number of trainers and clinicians who work for Studio3 that there are alternative’s to the use of blocking and immobilization methods when people experience extreme bouts of self injury. Using movement is another crisis management tool to consider. There are some basic principles: a) Use natural movements which compete with the SIB. b) Circular movements often interrupt motor routines. c) Walking individuals who engage in hand to head banging. d) Consider using ‘deep pressure’ contact when using movement. There are huge individual differences which effect peoples susceptibility to specific movement. It is important to remember that the use of movement is a crisis management tool. The social acceptability of protective equipment requires further investigations (See Tarnowski, et al, 1989: Wolf, 1978). NB. Many individuals are particularly sensitive to physical contact The Role of Protective Equipment The use of protective headgear is always a controversial area. Most SIB appears to be episodic in nature. However, many individuals who placed in protective headgear and arm splints are often left in them for much longer than the crisis periods. It is useful to make any use of such protective materials to be made intermittent in times of crisis. Mechanical and physical restraint can become positively reinforcing with people requesting to placed in them by either requesting mechanical restraint or seeking to be held. (See Favell, et al, 1978; Singh, et al, 1981). Some types of headgear may provide a form of deep pressure contact. Age appropriate protective headgear can be used. One of the most unusual is a form of protective ‘bandana’ Some Clinical Suggestions Recording is essential ! Always attempt to conduct an analysis of function(s) of SIB. Remember SIB is complicated; and threrefore so should be the analysis. Try to avoid one word functions like ‘Its attention’ or ‘demand related’. Examine the interactions between such function(s), (see Samson & McDonnell, 1990). Develop an understanding of the episodic nature of the SIB. Develop a list of crisis management strategies. However, you must bear in mind that people will eventually habituate to such strategies over time. Strategies which provide short bursts of respite should not be ruled out because their effects are short term. Useful References Bird, F., Dores, P.A., Moniz, D., & Robinson, J. (1989). Reducing severe aggressive and self injurious behaviours with functional communication training. American Journal on Mental Retardation, 94, 37-48. Duker, P & Seys, D.M. (1996). Long term use of electrical aversion treatment with self injurious behavior. Research in Developmental Disabilities, 17, 293-301 Favell, J. E., McGimsey, J. F. & Jones, M. L. (1978). The use of physical restraint in the treatment of self injury and as positive reinforcement. Journal of Applied Behavior Analysis, 11, 225-241. Fisher, W.W., Bowman, L.G., Thompson, R.H. & Contrucci, S.A. (1998) Reductions in self injury reduced by Transcuteaneous electrical nerve stimulation. Journal of Applied Behavior Analysis 31, 493-496 Grandin, T (1989). An autistic persons view of holding therapy. Journal of the National Autistic Society Hanley, G.P, Piazza, P.C. Keeney, K.M. ., Bakely-Smith, A.B. & Worsdell, A.F. (1998). Effects of wrist weights on self injurious and adaptive behaviors. Journal of Applied Behavior Analysis, 31, 307-310. Iwata, B.A., Dorsey, M.F., Slifer, K.J., Bauman, K.E., & Richman, G.S. (1982). Toward a functional analysis of self injury. Analysis and Intervention in Developmental Disabilities, 2, 1-20. Lerman, D.C & Iwata, B.A. (1995). Prevelance of extinction bursts attenuation during treatment. Journal of Applied Behavior Analysis, 28, 93-94. LaVigna, G & Willis, T. (2002) Counter intuitive strategies in crisis management within a non aversive framework. In D Allen (Ed). Ethical approaches to physical interventions: Responding to challenging behaviour in people with intellectual disabilities. Plymouth: BILD. Oliver, C. (1993). Self injurious behaviour: From response to strategy. In C Kiernan (Ed.), Challenging behaviour and learning disabilities: Research to practice? Implications of research on the challenging behaviour of people with learning disabilites. Clevedon: BILD Publications. Samson, D.M & McDonnell, A.A. (1990). Functional analysis and challenging behaviours. Behavioural Psychotherapy, 18, 259-271. Singh, N. N., Dawson, M. J., Manning, P. J. (1981). The effects of physical restraint on self injurious behavior. Journal of Mental Deficiency Research, 25, 207-216. Tarnowski, K.J., Rasnake, L.K., Mulick, J.A. & Kelly, P.A. (1989) Acceptability of behavioral interventions for self-injurious behaviour. American Journal on Mental Retardation, 93, 575-580. Williams, D.E., Kirkpatrick-Sanchez, S & Crocker, W.T. (1994). Long term follow up of treatment for severe self injury. Research in Developmental Disabilities, 15, 487-501 Wolf, M.M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis if finding its heart. Journal of Applied Behavior Analysis, 11 203-214.