Toward a functional analysis of self-injury

This study describes the use of an operant methodology to assess functional relationships between self-injury and specific environmental events. The self-injurious behaviors of nine developmentally disabled subjects were observed during periods of brief, repeated exposure to a series of analogue conditions. Each condition differed along one or more of the following dimensions: (1) play materials (present vs absent), (2) experimenter demands (high vs low), and (3) social attention (absent vs noncontingent vs contingent). Results showed a great deal of both between and within-subject variability. However, in six of the nine subjects, higher levels of self-injury were consistently associated with a specific stimulus condition, suggesting that within-subject variability was a function of distinct features of the social and/or physical environment. These data are discussed in light of previously suggested hypotheses for the motivation of self-injury, with particular emphasis on their implications for the selection of suitable treatments.

Factitious gingival ulceration: as presenting sign of Munchausen's syndrome?

This report describes the case of a 21-year-old female who presented with localized gingival ulceration that over a period of 4 weeks became generalized, affecting all the buccal gingiva as well as the lower lip. A detailed medical history suggested that the patient was generating the lesions herself. She was monitored for 6 months, during which time additional lesions developed on the scalp and face. Conventional therapy failed to resolve the lesions and the patient was ultimately referred for a psychiatric consultation in view of the similarity of this case with previously reported cases of factitious disease.

A mistaken health belief resulting in gingival injury: a case report

This case report describes extensive ulceration of the gingiva caused by harsh and repetitive toothbrushing. The lesions wee localized to several areas of the mouth. Despite considerable pain, the patient had persisted in the causative toothbrushing pattern. He had absorbed an invalid health belief that when pain or bleeding occurred, he should utilize consistent harsh brushing in the affected areas. Following re-education, this brushing behavior was discarded and healing ensued. The origin of his health belief and its relationship to the behavioral principle of self-efficacy 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.

Schedule effects of noncontingent reinforcement on attention-maintained destructive behavior in identical quadruplets

Noncontingent reinforcement (NCR), a response-independent schedule for the delivery of reinforcement, has been found to be effective in reducing behavior when the reinforcer delivered is responsible for behavioral maintenance. In this study, dense and lean schedules of response-independent attention were compared to determine whether it is necessary to begin with a dense schedule before fading to a lean schedule, or whether treatment would be as effective using a lean schedule at the outset. The subjects were 5-year-old identical quadruplets diagnosed with mental retardation and pervasive developmental disorder who displayed destructive behavior that was maintained by social attention. NCR was selected partially because it is not very labor intensive and could be implemented by a single mother simultaneously with all 4 children. Using a combination multielement and multiple baseline design, it was found that (a) a dense schedule of response-independent reinforcement (i.e., fixed-time 10 s) resulted in immediate and dramatic reductions in destructive behavior with no evidence of an extinction burst, and (b) an equivalent reduction in destructive behavior was achieved with a lean schedule of response-independent reinforcement (fixed-time 5 min) only after a systematic fading procedure was implemented. The findings suggest that the effectiveness of NCR may be dependent on the use of a dense schedule initially, and that systematic fading can increase the effectiveness of a lean schedule.

Assessment of stereotypic and self-injurious behavior as adjunctive responses

Certain responses of both humans and nonhumans appear to be maintained indirectly by intermittent reinforcement schedules and have been referred to collectively as adjunctive behavior. Although basic research has examined adjunctive behavior extensively, relatively few studies have been conducted with humans, particularly those with developmental disabilities who often engage in frequent and varied stereotypic behavior. This study assessed possible adjunctive characteristics of self-injurious and stereotypic behaviors using a multielement design containing two types of control conditions. Four subjects who engaged in both self-injurious behavior and stereotypy participated after variables maintaining their self-injury were identified via functional analyses. Each day, subjects were exposed to three 15-min sessions in random order: (a) noncontingent presentation of food on a fixed-time schedule (e.g., FT 30 s), (b) a massed-reinforcement (food) control, and (c) a no-reinforcement control. A variety of fixed-time schedules were examined during different experimental phases. Results of this preliminary study suggested that self-injury was not induced by intermittent reinforcement schedules, whereas the stereotypic behavior of some individuals showed characteristics of adjunctive behavior. The importance of research on adjunctive behavior and suggestions for future studies are discussed.

Toward a functional analysis of self-injury

This study describes the use of an operant methodology to assess functional relationships between self-injury and specific environmental events. The self-injurious behaviors of nine developmentally disabled subjects were observed during periods of brief, repeated exposure to a series of analogue conditions. Each condition differed along one or more of the following dimensions: (1) play materials (present vs absent), (2) experimenter demands (high vs low), and (3) social attention (absent vs noncontingent vs contingent). Results showed a great deal of both between and within-subject variability. However, in six of the nine subjects, higher levels of self-injury were consistently associated with a specific stimulus condition, suggesting that within-subject variability was a function of distinct features of the social and/or physical environment. These data are discussed in light of previously suggested hypotheses for the motivation of self-injury, with particular emphasis on their implications for the selection of suitable treatments.

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.

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.

Naltrexone in autistic children: behavioral symptoms and attentional learning

OBJECTIVE

To assess critically the short-term efficacy and safety of naltrexone in autistic children and its effects on discrimination learning in the laboratory.

METHOD

A parallel group design was employed. After a 2-week placebo baseline period, children were randomly assigned either to naltrexone or to placebo for a period of 3 weeks followed by a one-week posttreatment placebo period. Multiple raters and rating scales were employed in a variety of conditions. Forty-one children, all inpatients, ages 2.9 to 7.8 years, completed the study. Naltrexone reduced hyperactivity and had no effect on discrimination learning in the laboratory. There was a suggestion that it had a beneficial effect on decreasing self-injurious behavior. Untoward effects were mild and transient.

CONCLUSION

In the present study, naltrexone significantly reduced only hyperactivity, and no serious untoward effects were observed. The effectiveness of naltrexone in the treatment of autism and self-injurious behavior requires additional assessment in a sample of children with moderate to severe self-injurious behavior.

Efficacy of psychotropic drugs for reducing self-injurious behavior in the developmental disabilities

Self-injurious behavior (SIB) is a serious and moderately prevalent problem behavior among developmentally disabled persons, and it frequently leads to treatment with psychotropic medication. The empirical literature relating to the efficacy of pharmacological intervention is comprehensively reviewed. The rationales for using some "newer" agents, such as serotonin reuptake blockers, opiate blockers, and beta-adrenergic blockers are described. In general there are insufficient data to draw conclusions about specific agents. Evidence for a possible role in managing SIB is strongest for thioridazine, lithium carbonate, and the opiate antagonists. However, further research is needed to define the specific indications, if any, for each of these. Impediments to past research are discussed, possible refinements are offered for future research, and recommendations for treatment are offered.

The association between psychiatric diagnoses and severe behavior problems in mental retardation

To investigate the relationship between psychiatric disorders and severe behavior problems in mental retardation, statewide client databases from developmental disabilities services in California (N = 89,419) and New York (N = 45,683) were analyzed and juxtaposed. The study focussed on nine major DSM-III-R psychiatric categories (or their equivalents), and severe forms of aggressive behavior, property destruction, self-injurious behavior, and stereotyped behavior in individuals 45 years old and younger with mental retardation of all levels of severity. In California, 3.9% had at least one psychiatric diagnosis; in New York, 5.4%. The rate of specific psychiatric diagnoses was variable across states, suggesting local preferences in diagnostic practices. Severe behavior problems occurred in 22.1% in California and in 41.4% in New York. This difference in rates can be attributed in part to different recording criteria for behavior problems. With regard to the association between psychiatric diagnoses and problem behaviors the results were consistent across databases: No compelling correlations were found. This means that neither aggression, self-injury, destruction, nor stereotypies determine whether a person receives a psychiatric diagnosis or not.

Self-injury by people with mental retardation: a compulsive behavior hypothesis

Self-injury is a significant problem for many individuals with developmental disabilities, particularly those with severe or profound mental retardation. Many hypotheses have been suggested to account for self-injury, but none has been comprehensive. In this paper hypotheses suggesting psychological, behavioral, physiological, or neurochemical factors as causes of self-injury were critically reviewed. A compulsive behavior hypothesis was then introduced, which allows for alternative interpretations of some existing data and suggests several readily testable predictions.

Abnormalities of chromosome 18 in a girl with mental retardation and autistic disorder

Structural autosome defects have rarely been described in autism. In this report, the authors describe the association of autism and mental retardation in a girl with mosaicism for a duplication of the long arm of chromosome 18 and a deletion of the short arm of chromosome 18.

Fluoxetine is an effective treatment for neurotic excoriations: case report

A fifteen-year-old girl with a two-year history of severe neurotic excoriations and an obsessive-compulsive disorder experienced a dramatic improvement of her neurotic excoriations after a six-week course of fluoxetine 20 mg per day. This is in contrast to most previously reported treatments, which typically were only moderately effective. The neurobiological basis for the efficacy of fluoxetine, an antidepressant that is a potent serotonin reuptake inhibitor, in the treatment of neurotic excoriations associated with an obsessive-compulsive disorder, is reviewed.

Repeated insertion of foreign bodies into the tracheobronchial tree via tracheostomy

A case of persistent pneumonia in a depressed adult woman occurring as a complication of the repeated insertion of foreign bodies into the trachea via a tracheostomy is presented. This is an unusual complication of tracheostomy but should be considered in cases of persistent or unusual pulmonary infection in tracheostomy patients.

Neurotic excoriations complicating superficial parotidectomy--a case report

A case is described in which division of the great auricular nerve during parotidectomy was complicated by perichondritis of the ear cartilage following self-inflicted injury. The desirability of preserving the posterior branch of the nerve whenever possible is stressed.

Behavioural techniques to reduce self-injurious behaviour in children with autism

This paper is part of a special section on 'self-injurious behaviour and autism' and concentrates on behavioural treatment techniques available and useful to reduce self-injurious behaviour in children with autism (e.g. extinction, time-out, differential reinforcement, alternative forms of stimulation, sensory deprivation, physical restraint, crisis management, environmental modifications). It has become increasingly evident that the successful treatment of self-injurious behaviour requires, first, a systematic and detailed (functional) analysis of the variables associated with the behaviour and, second, a hypothesis-testing approach on an individual, naturalistic basis to increase the acquisition of alternative skills and self-control.

Dermatitis artefacta. Case reports

Patients who seek care for foot problems may present to the podiatrist with concurrent problems, such as anxiety, depression, phobias, personality disorders, and psychoses. These may or may not have any direct relationship to the pathogenesis of the foot problem. The podiatrist may learn of the presence of an emotional problem directly from the patient or from a family member. In many cases, the patient may be unaware or deny the presence of an emotional problem, leaving the podiatric physician in the dark about the patient's mental health state or its implications for the management of the skin problem. In a review of the psychosomatic aspects of dermatology, Koblenzer offered a working classification of the psychodermatoses. This is helpful to the podiatrist in recognizing those dermatologic disease states in which the various aspects of the individual participate in the disease, signs and symptoms of the disease, and the potential psychological value of the disease for the patient. It is also helpful to the podiatrist for recognizing those dermatoses in which psychiatric consultation may be useful so that recognition, treatment, improvement, and perhaps cure may be effected quickly.

Case report: metallic mercury embolism--deliberate self-injection

The first ever report of self-administration of mercury via both arterial and venous routes is presented. The unique feature of this case is the accidental self-injection of mercury into the ulnar artery.

Intracardiac needle in a man with self-injurious behaviour presenting with only a heart murmur

Symptoms of a heart murmur in a 48-year-old male schizophrenic patient with self-injurious behaviour were investigated. Immediately noticeable were multiple scars on his hands. Clinical evidence of subcutaneous needles and aortic regurgitation was found. Echocardiography revealed a linear metallic foreign body across the interventricular septum. He underwent surgery and via a right atriotomy, a needle from the same location was removed.

The deliberate self-harming behaviour of patients within a British special hospital

Within more conventional discourse amongst health-care professionals, 'deliberate self-harm' is largely conceived in pejorative terms. Unlike other so-called 'pathological' behaviour for which the 'sick' are not held wholly responsible, this particular behavioural mosaic carries within its very conception quite different connotations of 'intentionality'. This project constituted a retrospective survey of the phenomenon amongst patients resident within a British special hospital, over a 6-month period, in 1987, prior to the establishment of a unit for disturbed females in November of that same year. It illustrated that the scale, and nature, of the problem was comparable to any of the other much-publicized accounts that have emerged from other custodial establishments. It is the contention, here, that patient characteristics alone are an insufficient explanation for the level of self-harm that prevails and that significant, alternative considerations are available. It is intended that this paper should contribute to the evaluation of the clients' predicament, and the institutional management of their self-harm, within an environment such as a special hospital in the hope that a clearer understanding, and strategy, may be elaborated.