.I. Behav. Thu. & Exp. Psychrot. Vol. 12, No. 1, pp. 81-85, ,981 Printed in Great Britain.

ooo5.7908/81/010081-05 %02.00/0 ‘i) 1981 Pergamon Press l.td.

A COMPARISON OF TECHNIQUES FOR THE ELIMINATION OF

SELF-INJURIOUS BEHAVIOR IN A MILDLY

RETARDED WOMAN*

ARTHUR FLEMING and DAVID NOLLEY

Oakdale Regional Center for Developmental Disabilities, Lapeer, Michigan

Summary-The self-injurious behavior of an institutionalized, highly social, highly verbal, mildly retarded woman was successfully treated through the use of boxing glove restraints over a 30-week period after unsuccessful, less-intrusive means were attempted. Application of the restraint was conditioned to be an (S-delta), contrasted with an expanding Differential Reinforcement of Incompatible behavior (DRI) during periods of restraint removal. Absence of self-injury was maintained at 18 month follow-up by which time she had been discharged to a community placement.

Most reports of the incidence and treatment of self-injurious behavior (SIB) have described the behavior in severely autistic or quite dis- turbed schizophrenic or severely or profoundly retarded children (Green, 1967; Shodell & Reiter, 1968; Bartak and Rutter, 1976; Bau- meister and Rollings, 1976; Schroeder et al.,

1978). In contrast, clinical case studies of self- injury in more intellectually capable clientele generally take the form of psychiatric treat- ment of attempted suicide (e.g. Menninger, 1938), although there have been exceptions (Roback et al., 1972; Stabler and Warren, 1974). This clinical case study is unique in reporting successful results of treating severe SIB in a highly social, highly verbal, mildly retarded woman, using clinical behavior thera- peutic treatments implemented by direct-care staff in a state institution.

SUBJECT

Lorne, a 47 yr old mildly mentally re- tarded woman (Wechsler Full-Scale Adult

IQ = 51), was returned to the institution due to SIB after 3 years in an otherwise successful community placement. The SIB was described as “continual scratching and picking at her skin” which, according to the dermatologist,

had resulted in “multiple excoriations of the face, arms and legs”. He also reported that she had “. . . multiple punched out excoriated

ulcers scattered all over her body”. The depen- dent variable chosen for study and treatment was any occasion when Lorne’s fingertips were touching any part of her body. Reliable data on the severity of the behavior was elusive because Lorne continued to pick her skin even when she was alone using the bathroom and when she was supposedly sleeping. Therefore her bed was moved out to a lighted area under the direct observation of staff during the night.

No formal measures of reliability were taken. Keeping a count of new lesions was found not to represent reliably the severity of the behavior as Lorne often chose to enlarge lesions she had already made. Physical examinations and labor- atory tests had ruled out parasites, skin disease,

*A preliminary version of this paper was presented at the meeting of the Association of Advancement of Behavior Therapy, San Francisco, California, December, 1979. Requests for reprints should be addressed to Arthur Fleming, M.S.W., Oakdale Regional Center for Developmental Disabilities, Lapeer, Michigan 48446. David Nolley is now at Metropolitan Regional Recipient Rights Office, State of Michigan Plaza, Detroit, Michigan.

81

82 ARTHUR FLEMING and DAVID NOLLEY

renal disease, diabetes, carcinomatosis and hormonal imbalance. Psychiatric evaluation had ruled out psychotic depression. She also received unsuccessful treatment with Tofranil on the hypothesis that she suffered from neurotic depression. After 17 months of unsuccessful treatment by various means (see below) she was proposed by the psychiatrist for treatment of the SIB by means of contingent electric shock, because of severe anemia which had resulted from the SIB. A less intrusive treat- ment, viewed to be the last step before pro- posing contingent shock, was then implemented.

PROCEDURES AND RESULTS

Treatment Five was to be the last attempt at treatment before approval could be sought for use of contingent electric shock. Prior to the implementation of Treatment Five, four different treatment techniques were attempted and shown not completely to suppress the behavior. Each treatment was approved by an interdisciplinary team and her guardian, and the facility’s aversive techniques committee (similar to a Human Rights Committee) which had been constituted in time to review and approve the last four treatments.

Treatment One consisted of a typical in- stitutional control technique, contingent mechan- ical restraint, but used concurrently with a program of omission training utilizing Differ- ential Reinforcement of Other Behavior (DRO)

Treatment Treatment

on a 30-min schedule of social reinforcement. Although a 60% reduction in frequency (from 8.5/day during the first month to 3.3/day during the last month of treatment) was realized, as shown in Fig. 1, the severity of the behavior continued and gross excoriations were still present.

Therefore, after 34 weeks without complete suppression, a shift was made to Treatment Two, a program of Differential Reinforcement of Incompatible behavior (DRI). This program used virtually continuous social reinforcement in the form of praise, and polite one-to-one conversation was provided for fine motor activities geared to hand tasks such as em- broidery, needle-point, writing, puzzles, etc. and this was combined with contingent restraint. Treatment over 19 weeks resulted in a frequency of 2.6/day over the last 3 weeks, which was still regarded to be insufficient suppression because excoriations continued to occur.

Treatment Three consisted of a verbal re- quest to stop at the first observed occurrence of the SIB. If the SIB did not immediately cease, then a camisole jacket was applied for I5 min. Concurrently, a form of overcorrection was tried in which Lorne was required to pre- pare and apply her own dressings and to cover and treat her wounds twice daily. After nine weeks, the frequency of SIB had escalated to 12.3/day and the treatment was therefore terminated.

Treatment Four was DRO on a 60-min schedule using social reinforcement concurrent

Treat- Treatment four ment

three 1

. .

di .

5

Weeks

Treatment five (P)

Follow-up

I 6 15

Months

ELIMINATION OF SELF-INJURIOUS BEHAVIOR IN A MILDLY RETARDED WOMAN 83

with contingent restraint for the first exhibition of SIB, daily fingernail trimming, and the application of Vaseline to her fingernails and fingertips in the hope of reducing friction caused by rubbing and/or digging. After 12 weeks the resulting frequency was 7.0/day including 1 week of complete suppression. Between the seventh and eighth week of this treatment in her living unit Lorne spent almost two months in the institution’s hospital in 24 hr restraints in the hope that all her wounds would be allowed to heal, thus allowing fewer discriminative stimuli for SIB. Upon discharge from the institution’s hospital, rates decreased to O.O/day in the ninth week. From the ninth to the twelfth week, however, rates soared again to 7.0/day.

An additional hospitalization followed for a period of 33 days for the same reasons cited above. Then, a reversal to Treatment One: the use of contingent restraint for the first incident of SIB concurrent with omission training on a thirty minute schedule was re- instated on her living unit while approval was sought for the use of Treatment Five. At no time could a no-treatment baseline or reversal be conducted, since Michigan state law specific- ally provides that self or other injurious be- havior must receive intervention.

Treatment Five consisted of the application of 24-hr boxing glove restraints in order to control SIB. For 15 min every 2 hr (8 times per day) a resident care aid (institution worker) engaged Lorne in fine motor activities on a continuous schedule of social reinforcement for appropriate use of hands (DRI). After the 15 min had elapsed, the boxing gloves were reapplied. For the 105 min between sessions, all of Lorne’s behavior was placed on extinction whether the behavior was appropriate or not. If she tried to engage in appropriate vocal be- havior while wearing the boxing gloves, for example, she was ignored. All other behaviors emitted while wearing boxing gloves were ignored with the intent that wearing the boxing gloves should become a stimulus signaling non-exclusionary time-out (Foxx and Shapiro,

1978). If SIB occurred during the 15 min DRI session, manual restraint was applied for the duration of the session and subsequently the boxing gloves were applied. Criteria were established for the expansion of the DRI sessions based upon a maximum of SIB incidents per day, averaged over the week. When Lorne met the first criterion (no more than an average of three SIB incidents daily over one week, while out of restraints), the DRI sessions were expanded to 20 min out of restraints. When she met the second criterion (no more than an average of two SIB incidents daily over 1 week), the sessions were expanded to 30 min of DRI. When the third criterion was met (no more than an average of one SIB incident daily over one week), the sessions were expanded to 45 min, divided into a 30 min DRI and 15 min of supervised free time in order to re- acquaint her with the more typical density of DRO existing in her program unit. When the fourth criterion was met (no more than three SIB incidents in an entire week), the sessions were expanded to 60 min, divided into a 30 min DRI and 30 min of supervised free time. As shown in Fig. 1, complete suppression of SIB was attained by the thirtieth week of treat- ment and was subsequently maintained in the least restrictive living unit at the facility, with- out the benefit of a specified intervention pro- gram for SIB. One, six and fifteen month follow-ups in the less-restrictive environment found Lorne without incidents of SIB. An 18 month follow-up (in a community place- ment) found Lorne without SIB.

DISCUSSION

Mechanical restraints such as leather cuffs, camisole jackets, and wrist ties are ordinarily conceived to be means only of controlling be- havior, infrequently with treatment implications. Use of such means are ordinarily associated with treatment failure. Federal law (Federal Register, 1974) and private association standards (Joint Commission on Accreditation of Hos- pitals, 1975) suggest that restraints might be

84 ARTHUR FLEMING and DAVID NOLLEY

used as a treatment technique-as a “Time Out device”. However, the weight of literature inadequately supports such an option, as there are few papers which have reported use of the technique (e.g. Hamilton, Stephens and Allen, 1967). In the present study, wearing of the boxing gloves was intended to constitute an SA condition, signaling that reinforcement was unavailable. This was contrasted with the re- moval of the gloves which, we hypothesize, came to be a discriminative stimulus for re- inforcement. Subsequently, the activities which were incompatable with SIB such as letter writing and puzzle making, which were used during the expanding DRI, also came to be associated with reinforcement. Lorne frequently asked for access to these materials in the less-restrictive living unit to which she was transferred after treatment, whereas prior to the conditioning program she never initiated requests for such materials. Subjective estimates of her vocal pro- duction also suggested a several-fold increase after the conclusion of Treatment Five, suggest- ing that conversation also came to be paired with reinforcement. Thus, although DRI and restraint had been attempted previously, the combination of the two procedures to signal reinforcement or non-reinforcement might have been the most important treatment variable. At the least, prior experience with restraint and DRl might have contributed to the success seen during Treatment Five, as a result of “carry- over” or sequence effects. In this case, success- ful treatment results were sought at the expense of research results which a reversal after Treat- ment Five might have yielded.

Alternatively, the literature suggests that me- chanical restraints have been used to control SIB between therapy sessions and that they, over time, as therapy progressed toward success, could be faded out (Bucher and Lovaas, 1968; Corte, Wolfe and Locke, 1971; Lovaas and Simmons, 1969; Tate, 1972; Tate and Baroff, 1966; Thomas and Howard, 1971; Yeaker ef al., 1970). This study possibly evaluated an exten- sion of that literature to a client unique in terms of intellectual capability. This study was also

unique since the essentially behavioral technique used was implemented entirely by relatively untrained workers in a state institution.

As the various regulations and standards sug- gest, and this study confirmed, mechanical re- straints can have a role in remediating severe behavior disorders if they are employed within an overall treatment program. Even in poorly staffed state institutions where professional staffing levels are also thin, treatment through the use of restraints can occur if it is simple, measurable, and as easy to follow as this pro- gram was.

REFERENCES

Bartak L. and Rutter M. (1976) Differences between men- tally retarded and normally intelligent autistic children, J. Aut. & Childhoodkhb. 6, 109-120.

Baumeister A. A. and Rollings .I. P. (1976) Self-injurious behavior. In International Review of Research in Mental Retardation (Ed. by ElIiT N. R.). Academic Press, New York.

Bucher B. and Lovaas 0. 1. (1967) Use of aversive stimu- lation in behavior modification. In Miami Symposium on the Prediction of Behavior (Ed. by Jones M. R.). University of Miami, Coral Gables, Fla.

Corte H. D., Wolf M. M. and Locke B. J. (1971) A comparison of procedures for eliminating self-injurious behavior of retarded adolescents, J. Appt. Behav. Anal. 4.201-213.

Federal Register Department of Health, Education 8i Welfare, Thursday, 17 January, 1974, Vol. 39, No. 12, Part II. Medical Assistance Program, Intermediate Care Facility Service.

Foxx R. M. and Shapiro S. T. (1978) The timeout ribbon: A non-exclusionary timeout procedure, J. Appl. Behav. Anal. 11, 125-136.

Green A. (1967) Self-mutilation in ychirophrenic children, Arch. Gen. Psychlat. 17,234-244.

Hamilton _I., Stephens L. and Allen P. (1967) Controlling aggressive and destructive behavior in reverely warded institutionalized resident?, Am. J. Ment. Defic. 71, 852- 856.

Joint Commission on Accreditation of Hospitals (1975) Slandards for Residenrial Facilities ,for the Mental1.v Retarded. 5th printing.

Lovaas 0. 1. and Simmons J. Q. (1969) Manipulation of self-destruction in three retarded children, J. App/. Behav. Anal. 2, 143-157.

Menninger K. (1938) Man Again.s/ HimselJ: Harcourt, New York.

Roback H., Frayn D., Gunby L. and Tuters K. (1972) A multifactorial approach to the treatment and ward management of a self-mutilating patient, J. Behav. Ther. & Exp. Plrychiat. 3, 189- 193.

ELIMINATION OF SELF-INJURIOUS BEHAVIOR IN A MILDLY RETARDED WOMAN 85

Schroeder S. R., Schroeder C. S., Smith B. and Dalldorf J. (1978) Prevalence of self-injurious behaviors in a large state facility for the retarded: A three-yr follow-up study, J. Aut. & Childhood Schiz. 8,261-269.

Shodell M. and Reiter H. (1968) Self-mutilative behavior in verbal and non-verbal schizophrenic children, Arch. Gen. Psych&t. 19,453-455.

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Yeakel M. H., Salisbury L. L., Greer S. L. and Marcus L. F. (1970) An appliance for autoinduced adverse control of self-injurious behavior, J. Exp. Child Psychol. 10, 159-169.