Treatment of self-restraint associated with the application of protective equipment

Acknowledging caregivers' vulnerability in the managment of challenging behaviours to reduce control measures in psychiatry

BACKGROUND

The management of challenging behaviours in inpatient with intellectual disability and/or autism spectrum disorders can lead to an escalation of control measures. In these complex situations where patients have an intellectual disability/autism spectrum disorder accompanied by a psychiatric comorbidity, the experiences of caregivers related to the crisis management have rarely been studied.

PURPOSE

This study examined the moral experiences of caregivers related to challenging behaviours' management and alternatives to control measures.

RESEARCH DESIGN

Using Charles Taylor's hermeneutic framework, a 2-month focused ethnography with a participatory approach was used.

PARTICIPANTS AND RESEARCH CONTEXT

Sixteen caregivers were interviewed in a Canadian mental health setting for adults with intellectual disability/autism spectrum disorder and psychiatric comorbidity.

ETHICAL CONSIDERATIONS

The research was conducted in compliance with the Declaration of Helsinki and local Research Ethics Board approval. Written informed consent was collected systematically from participants.

FINDINGS

By accounting for caregivers' moral experiences, this study sheds light on a neglected dimension of the care relationship: the vulnerability of the caregiver. We highlight the main barriers and facilitators to alternatives to control measures. First, a caregiver's vulnerability was characterised by the overall impact of challenging behaviours and the moral distress associated with the use of control measures and exclusion mechanisms of intellectual disability/autism spectrum disorder patients. Second, a strong ambiguity between care and control measures and a lack of inclusive approaches were identified as the two main barriers to challenging behaviour management. Third, the involvement, both professional and personal, of caregivers was deemed necessary to implement alternatives to control measures.

DISCUSSION

A conflict of values opposes two conceptions of autonomy: a rational autonomy, which is counterproductive to the reduction of control measures, versus a relational autonomy based on shared vulnerability.

CONCLUSION

The recognition of caregiver's vulnerability is a benchmark to create alternative approaches, which defuse the logic of control and promote an ethics of care within which caregivers' self-concern can be understood as fostering mutual respect.

Treatment Burst Data Points and Single Case Design Studies: A Bayesian N-of-1 Analysis for Estimating Treatment Effect Size

Single-case experimental designs (SCED) evaluate treatment effects for each participant, but it is difficult to aggregate and quantify treatment effects across SCED participants receiving the same type of treatment. We applied Bayesian analytic procedures to SCED data aggregated across participants that have previously only been applied to large-N and group design studies of treatment effect sizes. For the current study, we defined transient elevated treatment data points as (1) above the range of the last five baseline sessions during the first three sessions of treatment (i.e., extinction burst); (2) within or above the range of baseline after the first three treatment sessions (i.e., recurrence burst); or (3) thinning phase data points above the last three prethinning treatment data points (i.e., thinning burst). Results indicated that the treatment effect sizes remained large regardless of controlling for transient elevated treatment data points. Finally, we examined the effects of reinforcer schedule thinning on estimates of treatment effect size. Results indicated a moderate negative impact of schedule thinning on treatment effect size with a 16% decrease in effect size. Recommendations for research and practice are provided, and the utility of using Bayesian analysis in single-case experimental designs is discussed.

A review of environmental enrichment as treatment for problem behavior maintained by automatic reinforcement

We reviewed studies that used environmental enrichment as treatment for problem behavior maintained by automatic reinforcement. A search of behavior analytic journals produced 71 publications with a total of 265 applications of environmental enrichment used alone or in conjunction with alternative behavior manipulations (e.g., prompting, reinforcement) and problem behavior manipulations (e.g., blocking, restraint). Environmental enrichment, as a sole intervention, was efficacious in 41% of the sample. Alternative behavior manipulations, problem behavior manipulations, and a combination of both improved the overall efficacy of environmental enrichment. We discuss factors that may influence the efficacy of environmental enrichment, current trends in research on this topic, and implications for both practitioners and researchers.

Practitioner Review: Self-injurious behaviour in children with developmental delay

BACKGROUND

Self-injurious behaviour is shown by a significant minority of children with developmental delay and has a substantial impact on child and carer wellbeing. Characteristics such as a greater degree of intellectual disability, autism spectrum disorder, some genetic syndromes and repetitive and impulsive behaviours are positively associated with self-injury. Prevalence generally increases with age into midadulthood and the behaviour is notably persistent.

SCOPE

In this review, we discuss the dominant causal theory of self-injury which draws on the principles of operant learning. We evaluate the utility of this theory to account for all empirical observations of self-injury.

FINDINGS

A model of self-injury is presented that extends a previous model described by Guess and Carr. The new model integrates child characteristics and operant learning principles in a phenotype × environment paradigm to explain the variance in developmental trajectory of the severity of self-injury.

CONCLUSIONS

Behaviour dysregulation, as evidenced by the associations between self-injury, self-restraint, repetitive and impulsive behaviours, is identified as potentially influencing the severity and persistence of self-injury. Risk markers for self-injury are identified and the extended model indicates points of intervention and highlights the possibility of risk-related, targeted early intervention. The need for increased training of practitioners in the delivery of demonstrably effective interventions for self-injury is identified.

Effects of arm-splint rigidity on self-injury and adaptive behavior

The current study replicated and extended previous research on the use of a rapid assessment to identify effective arm-splint rigidity with 2 participants who had been diagnosed with autism and who engaged in self-injurious behavior (SIB). We varied rigidity levels within a multielement design across several adaptive tasks and identified the most effective rigidity level in terms of reductions in SIB and levels of compliance.

The association for behavior analysis international position statement on restraint and seclusion

A task force authorized by the Executive Council of the Association for Behavior Analysis International (ABAI) generated the statement below concerning the techniques called restraint and seclusion. Members of the task force independently reviewed the scientific literature concerning restraint and seclusion and agreed unanimously to the content of the statement. The Executive Council accepted the statement, and it was subsequently approved by a two-thirds majority vote of the general membership. It now constitutes official ABAI policy. The position statement is posted on the ABAI Web site (www.abainternational.org/ABA/statements/RestraintSeclusion.asp). The purpose of the position statement is to provide guidance to behavior analysts and other professionals interested in the position of ABAI on these controversial topics. In extreme cases, abuses of procedures erroneously used in the name of behavior analysis are not defensible. On the other hand, behavior analysts acting ethically and in good faith are provided with guidelines for sound and acceptably safe practice. To the extent that behavior-analytic positions influence public policy and law, this statement can be presented to officials and lawmakers to guide informed decision making. At the conclusion of the document, a bibliography is provided of articles and presentations considered by one or more task force members in developing the position statement.

Analysis of social variables when an initial functional analysis indicates automatic reinforcement as the maintaining variable for self-injurious behavior

Self-injurious behavior (SIB) that occurs at high rates across all conditions of a functional analysis can suggest automatic or multiple functions. In the current study, we conducted a functional analysis for 1 individual with SIB. Results indicated that SIB was, at least in part, maintained by automatic reinforcement. Further analyses using protective equipment (i.e., a helmet with face shield) revealed an attention function for the SIB.