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15-10-2008, 11:13 PM
Studio3 position statement on the management of severe
Self Injurious Behaviour (SIB) - pdf at end
Background
To illustrate the issues and concerns the following represents a highly selective view of the academic literature with regard to the management of SIB. There is no single universal theory that significantly explains and defines the aetiology of self-injurious behaviour in all people. Significant advances have been made in our understanding of the causes and function(s) of SIB (See Iwata, et al, 1982). Researchers are only beginning to understand the early onset of SIB. Behavioural models would suggest that behaviour may be reinforced by extrinsic sources of positive reinforcement such as attention, negative reinforcement, such as escape from demands, or that the behaviour may produce intrinsic reinforcement such as sensory stimulation or pain reduction (Hammock et al, 1995).
Individuals with a severe/profound degree of ID were significantly more likely to show self-injury and stereotypy than individuals with a mild/moderate degree of ID. (McClintock, et al, 2003).
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.
Individuals with deficits in receptive and expressive communication were significantly more likely to show self-injury (McClintock, et al, 2003; Bird et al, 1989).
Higher incidence rates of SIB are reported in people with a diagnosis of ASD.
SIB can evoke strong emotional responses among care staff (Oliver, 1993).
The management of these behaviours is a paramount concern of service providers. Physical restraint is used with SIB (Favell, et al, 1978; Singh et al, 1978).
There have been a number of behaviour management approaches which include sensory components. The use of contingent massage has had some reported success (Willis & LaVigna, 2002); wrist weights (Haney et al, 1998) and even TENs devices (Fisher et al, 1998).
These behaviours have been the subject of controversial approaches
such as the use of contingent electric shock (Duker & Seys, 1996; Williams, Kirkpatrick-Sanchez, S & Crocker, 1994). Recently, the Judge Rotenberg Centre in Boston has been the subject of extreme controversy by admitting to using electric shocks on a significant number of pupils with ASD and SIB. Sensory issues are involved in the maintenance of some of the challenging behaviours. The avoidance of these extreme intervention methods is a major focus of Studio3 philosophy.
SIB behaviour management is still in its infancy. Methods which rate in social validity (Wolf, 1978) and are effective and safe are a desirable goal. For this both crisis response and longer term behavioural strategies are required (Oliver, 1993)
Definition
1) Measurement of SIB should contain a clearly defined severity protocol which uses behavioural injury data, this will assist the risk management process. I would suggest the following rating scale for severity of SIB.
- No apparent external injuries after SIB.
- Minor: External injuries such as reddening skin, swelling, bruising, which is not visible after 24 hours.
- Moderate: External injuries such as bruising and minor lacerations, which may require immediate first aid.
- Severe: External injuries which breaking of bones, external tissue damage requiring emergency medical treatment including damage to retina and major lacerations requiring multiple sutures.
2) Consistent language for frequency of behaviours should also be adopted. SIB should be rated as very high frequency (occurs at least hourly), high frequency (daily), medium frequency (weekly), low frequency (monthly), very low frequency (every 3 months).
3) Using the above definitions SIB which is rated as moderate and above in severity and is rated as high frequency should require a clear crisis support/reactive plan; these individuals should be rated as ‘high risk’.
The management of severe SIB: Best practice guidance.
We recommend that if an individual shows moderate/severe SIB the following best practice guidelines developed by staff at Studio3 may be of use to carers and practioners. Given the obvious complexities of SIB a multidisciplinary approach to its management is a necessity. Both external and internal stimuli may maintain SIB. The following approach represents a systematic strategy for the management of intense episodic SIB.
STAGE 1: Medical screening
Medical screening of people with intellectual disabilities can be relatively limited (Hatton, Elliott & Emerson, 2002). The recent best practice advice on challenging behaviour (Royal College of Psychiatrists, 2007) identified several medical factors which may require screening: Cerebrovascular and epilepsy-related events, earache and toothache, eyesight disorders, gut-related pain such as gastro-oesophageal reflux, colic, peptic ulcers, constipation, urinary tract infections, prostatism bone and joint pain, neoplasms, wounds and fractures.
In the case of recent onset moderate/severe SIB the following categories should not be viewed as exhaustive. In our experience intense episodes often have causes related to internal pain and distress.
Dehydration: This can occur for a variety of reasons. It has been our experience that a number of individuals appear to require increased fluid intake to manage their behaviour in the short term.
Pain: The use of over the counter pain relief on a systematic basis for two to three weeks can establish a link to pain. In some cases a systematic test of higher dosage pain relief should be sought on consultation with a medical practitioner. It is important to note that the reduction of the frequency and intensity of SIB after the administration of pain relief cannot identify the specific causes of the pain.
Bowels/gastric problems: Many gastric difficulties such as helicobacter Pylori can cause extreme discomfort and exacerbate SIB.
An MRI scan for tissue damage: This acts as a baseline to determine if there is surface damage to the cortex and should be repeated at least biannually.
Heart rate: Physiological arousal is associated with SIB. The measurement of physiological arousal using simple heart rate monitors, usually attached to an individual’s wrist, is recommended especially for service users rated as high risk. For some individuals internal elevation of arousal may be a risk indicator of episodes of moderate or severe SIB.
STAGE 2: A functional assessment
A thorough Functional Assessment should be conducted. This should include an investigation of environmental factors including the behaviour of carers.
SIB can serve a communicative function including escape from demands or requests. Individuals in crisis should have a mechanism for avoiding situations which they find distressing.
A Sensory profile should be a component of any good functional assessment. Sensory triggers can often maintain SIB. Smells, tastes, sounds, particular movements should be examined carefully. In our experience individuals may try to avoid sensory stimuli which they find unpleasant. Positive sensory experiences can often be used to distract individuals.
STAGE 3: A Low Arousal environment
Medical and functional assessments as described in stages 1 and 2 can require a considerable amount of time. The short term management, especially of severe SIB, often requires more immediate action.
The creation of Low Arousal environments requires the placement of the person in a low stimulation environment.
Multisensory rooms can be useful safe areas for some individuals. It is really important that people are closely monitored.
Some individuals often require more space and therefore increasing schedules of walking or other outside activities is very important.
In communal settings individuals should not necessarily be isolated from others, however a number of people do benefit from changes in their routine such as eating meals on their own and avoiding communal lounges.
STAGE 4: Reactive strategies
As clinicians we have found that the reduction of demands and the avoidance of non preferred activities for a period of 2 – 3 weeks can lead to reductions in SIB. Low Arousal Approaches often include the creation of environments that reduce external arousal (especially noise).
In developing reactive strategies that reduce physiological arousal the use of exercise to stabilise cardiac rhythm can be useful in some cases.
Stereotyped behaviours often increase in cases of severe SIB. These behaviours should not be responded to by staff as for some individuals they appear to help reduce SIB in the short term.
The use of preferred objects or sensory reinforcers should be increased. It is important that the reduction of the intensity of the behaviour is a major focus of crisis management. Staff should not be concerned about reinforcing behaviour in the short term; especially if these reinforcers serve to distract the person.
STAGE 5: Physical interventions
In extreme circumstances an individual may require some form of physical intervention. This poses obvious ethical and practical questions for service providers.
Restraint may become positively reinforcing in itself.
In many cases individual can literally lose control of their bodies and be stuck in repetitive and damaging SIB. Some individuals may require intermittent holding. In this case holding should take place for no more than a matter of a few minutes. Staff should then ease off holds.
The use of methods which allow movement are often preferred by Studio3 staff.
Where possible encourage an individual who is being held to walk as it is sometimes difficult for individuals to engage in SIB and walk at the same time.
Mechanical restraint should not be considered in isolation. Mechanical restraints such as armsplints and protective headgear may be employed in extreme circumstances where an individual’s self injury is rated as severe. Intuitively, protective helmets may appear to reduce external damage to the cranium. However, we have also come across individuals who have quite literally banged harder after headgear has been used. The measurement of intensity of these behaviours is really important in these circumstances to help determine the impact of such devices. Individuals who may be receiving mechanical restraints on a regular basis should have a restraint reduction plan in place.
If restraint (either mechanical or physical) is used on a daily basis a restraint reduction plan should then be put in place.
Andrew McDonnell, PhD,
Regine Anker.
July 2008.
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
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.
Hatton, C., Elliott, J. & Emerson, E. (2002) ‘Key Highlights’ Of Research Evidence On The Health Of People With Learning Disabilities. Institute for Health Research, LancasterUniversity (commissioned by the Valuing People Support Team, Department of Health).
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.
McClintock, K Hall, S. Oliver, C. (2003) Risk markers associated withchallenging behaviours in people with intellectual disabilities: a meta-analytic study
Journal of Intellectual Disability Research 47 (6), 405–416.
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.
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.
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.
PDF - Studio3 position statement on the management of severe
Self Injurious Behaviour (SIB) (http://studio3.org/data/s3position/Studio3PositionStatementontheManagementofSevereSIB .pdf)
Self Injurious Behaviour (SIB) - pdf at end
Background
To illustrate the issues and concerns the following represents a highly selective view of the academic literature with regard to the management of SIB. There is no single universal theory that significantly explains and defines the aetiology of self-injurious behaviour in all people. Significant advances have been made in our understanding of the causes and function(s) of SIB (See Iwata, et al, 1982). Researchers are only beginning to understand the early onset of SIB. Behavioural models would suggest that behaviour may be reinforced by extrinsic sources of positive reinforcement such as attention, negative reinforcement, such as escape from demands, or that the behaviour may produce intrinsic reinforcement such as sensory stimulation or pain reduction (Hammock et al, 1995).
Individuals with a severe/profound degree of ID were significantly more likely to show self-injury and stereotypy than individuals with a mild/moderate degree of ID. (McClintock, et al, 2003).
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.
Individuals with deficits in receptive and expressive communication were significantly more likely to show self-injury (McClintock, et al, 2003; Bird et al, 1989).
Higher incidence rates of SIB are reported in people with a diagnosis of ASD.
SIB can evoke strong emotional responses among care staff (Oliver, 1993).
The management of these behaviours is a paramount concern of service providers. Physical restraint is used with SIB (Favell, et al, 1978; Singh et al, 1978).
There have been a number of behaviour management approaches which include sensory components. The use of contingent massage has had some reported success (Willis & LaVigna, 2002); wrist weights (Haney et al, 1998) and even TENs devices (Fisher et al, 1998).
These behaviours have been the subject of controversial approaches
such as the use of contingent electric shock (Duker & Seys, 1996; Williams, Kirkpatrick-Sanchez, S & Crocker, 1994). Recently, the Judge Rotenberg Centre in Boston has been the subject of extreme controversy by admitting to using electric shocks on a significant number of pupils with ASD and SIB. Sensory issues are involved in the maintenance of some of the challenging behaviours. The avoidance of these extreme intervention methods is a major focus of Studio3 philosophy.
SIB behaviour management is still in its infancy. Methods which rate in social validity (Wolf, 1978) and are effective and safe are a desirable goal. For this both crisis response and longer term behavioural strategies are required (Oliver, 1993)
Definition
1) Measurement of SIB should contain a clearly defined severity protocol which uses behavioural injury data, this will assist the risk management process. I would suggest the following rating scale for severity of SIB.
- No apparent external injuries after SIB.
- Minor: External injuries such as reddening skin, swelling, bruising, which is not visible after 24 hours.
- Moderate: External injuries such as bruising and minor lacerations, which may require immediate first aid.
- Severe: External injuries which breaking of bones, external tissue damage requiring emergency medical treatment including damage to retina and major lacerations requiring multiple sutures.
2) Consistent language for frequency of behaviours should also be adopted. SIB should be rated as very high frequency (occurs at least hourly), high frequency (daily), medium frequency (weekly), low frequency (monthly), very low frequency (every 3 months).
3) Using the above definitions SIB which is rated as moderate and above in severity and is rated as high frequency should require a clear crisis support/reactive plan; these individuals should be rated as ‘high risk’.
The management of severe SIB: Best practice guidance.
We recommend that if an individual shows moderate/severe SIB the following best practice guidelines developed by staff at Studio3 may be of use to carers and practioners. Given the obvious complexities of SIB a multidisciplinary approach to its management is a necessity. Both external and internal stimuli may maintain SIB. The following approach represents a systematic strategy for the management of intense episodic SIB.
STAGE 1: Medical screening
Medical screening of people with intellectual disabilities can be relatively limited (Hatton, Elliott & Emerson, 2002). The recent best practice advice on challenging behaviour (Royal College of Psychiatrists, 2007) identified several medical factors which may require screening: Cerebrovascular and epilepsy-related events, earache and toothache, eyesight disorders, gut-related pain such as gastro-oesophageal reflux, colic, peptic ulcers, constipation, urinary tract infections, prostatism bone and joint pain, neoplasms, wounds and fractures.
In the case of recent onset moderate/severe SIB the following categories should not be viewed as exhaustive. In our experience intense episodes often have causes related to internal pain and distress.
Dehydration: This can occur for a variety of reasons. It has been our experience that a number of individuals appear to require increased fluid intake to manage their behaviour in the short term.
Pain: The use of over the counter pain relief on a systematic basis for two to three weeks can establish a link to pain. In some cases a systematic test of higher dosage pain relief should be sought on consultation with a medical practitioner. It is important to note that the reduction of the frequency and intensity of SIB after the administration of pain relief cannot identify the specific causes of the pain.
Bowels/gastric problems: Many gastric difficulties such as helicobacter Pylori can cause extreme discomfort and exacerbate SIB.
An MRI scan for tissue damage: This acts as a baseline to determine if there is surface damage to the cortex and should be repeated at least biannually.
Heart rate: Physiological arousal is associated with SIB. The measurement of physiological arousal using simple heart rate monitors, usually attached to an individual’s wrist, is recommended especially for service users rated as high risk. For some individuals internal elevation of arousal may be a risk indicator of episodes of moderate or severe SIB.
STAGE 2: A functional assessment
A thorough Functional Assessment should be conducted. This should include an investigation of environmental factors including the behaviour of carers.
SIB can serve a communicative function including escape from demands or requests. Individuals in crisis should have a mechanism for avoiding situations which they find distressing.
A Sensory profile should be a component of any good functional assessment. Sensory triggers can often maintain SIB. Smells, tastes, sounds, particular movements should be examined carefully. In our experience individuals may try to avoid sensory stimuli which they find unpleasant. Positive sensory experiences can often be used to distract individuals.
STAGE 3: A Low Arousal environment
Medical and functional assessments as described in stages 1 and 2 can require a considerable amount of time. The short term management, especially of severe SIB, often requires more immediate action.
The creation of Low Arousal environments requires the placement of the person in a low stimulation environment.
Multisensory rooms can be useful safe areas for some individuals. It is really important that people are closely monitored.
Some individuals often require more space and therefore increasing schedules of walking or other outside activities is very important.
In communal settings individuals should not necessarily be isolated from others, however a number of people do benefit from changes in their routine such as eating meals on their own and avoiding communal lounges.
STAGE 4: Reactive strategies
As clinicians we have found that the reduction of demands and the avoidance of non preferred activities for a period of 2 – 3 weeks can lead to reductions in SIB. Low Arousal Approaches often include the creation of environments that reduce external arousal (especially noise).
In developing reactive strategies that reduce physiological arousal the use of exercise to stabilise cardiac rhythm can be useful in some cases.
Stereotyped behaviours often increase in cases of severe SIB. These behaviours should not be responded to by staff as for some individuals they appear to help reduce SIB in the short term.
The use of preferred objects or sensory reinforcers should be increased. It is important that the reduction of the intensity of the behaviour is a major focus of crisis management. Staff should not be concerned about reinforcing behaviour in the short term; especially if these reinforcers serve to distract the person.
STAGE 5: Physical interventions
In extreme circumstances an individual may require some form of physical intervention. This poses obvious ethical and practical questions for service providers.
Restraint may become positively reinforcing in itself.
In many cases individual can literally lose control of their bodies and be stuck in repetitive and damaging SIB. Some individuals may require intermittent holding. In this case holding should take place for no more than a matter of a few minutes. Staff should then ease off holds.
The use of methods which allow movement are often preferred by Studio3 staff.
Where possible encourage an individual who is being held to walk as it is sometimes difficult for individuals to engage in SIB and walk at the same time.
Mechanical restraint should not be considered in isolation. Mechanical restraints such as armsplints and protective headgear may be employed in extreme circumstances where an individual’s self injury is rated as severe. Intuitively, protective helmets may appear to reduce external damage to the cranium. However, we have also come across individuals who have quite literally banged harder after headgear has been used. The measurement of intensity of these behaviours is really important in these circumstances to help determine the impact of such devices. Individuals who may be receiving mechanical restraints on a regular basis should have a restraint reduction plan in place.
If restraint (either mechanical or physical) is used on a daily basis a restraint reduction plan should then be put in place.
Andrew McDonnell, PhD,
Regine Anker.
July 2008.
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
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.
Hatton, C., Elliott, J. & Emerson, E. (2002) ‘Key Highlights’ Of Research Evidence On The Health Of People With Learning Disabilities. Institute for Health Research, LancasterUniversity (commissioned by the Valuing People Support Team, Department of Health).
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.
McClintock, K Hall, S. Oliver, C. (2003) Risk markers associated withchallenging behaviours in people with intellectual disabilities: a meta-analytic study
Journal of Intellectual Disability Research 47 (6), 405–416.
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.
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.
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.
PDF - Studio3 position statement on the management of severe
Self Injurious Behaviour (SIB) (http://studio3.org/data/s3position/Studio3PositionStatementontheManagementofSevereSIB .pdf)