|Tactics and Interventions for Treatment-Resistant Automatically Maintained Self-Injury: Preliminary Findings from a Clinical Trial
|Monday, May 30, 2022
|8:00 AM–9:50 AM
|Meeting Level 2; Room 251
|Area: DDA/AUT; Domain: Applied Research
|Chair: Louis P. Hagopian (Kennedy Krieger Institute)
|Discussant: William H. Ahearn (New England Center for Children)
|CE Instructor: Louis P. Hagopian, Ph.D.
|Abstract: Research has identified subtypes of automatically maintained self-injurious behavior based on its level of differentiation across play and ignore conditions of functional analyses and the presence of self-restraint. Subtype 1 varies inversely with the level of stimulation across conditions; Subtype 2 is invariant; and Subtype 3 is characterized by self-restraint, a self-limiting behavior that impairs functioning. Treatments using noncontingent reinforcement (NCR) are effective for Subtype 1, but significantly less so for Subtypes 2 or 3. This symposium will discuss tactics and interventions for the treatment-resistant subtypes. The first presenter will discuss a principled approach to identifying protective procedures to prevent injury while assessing and evaluating treatments for severe SIB. The second presenter will describe a competing task assessment to identify and establish competing tasks associated with reductions in SIB. The third presenter will discuss findings from a self-control equipment assessment designed to identify equipment to promote self-control that competes with self-restraint. The fourth presenter will review initial findings from a randomized controlled trial comparing combination treatment, which employs methods to increase the amount and vary the sources of competing reinforcement for SIB and self-restraint to NCR with competing stimuli. The discussant will comment on the implications of these findings.
|Instruction Level: Intermediate
|Target Audience: Attendees should be familiar with function-based treatment, automatically-maintained self-injury, and assessment and treatment of severe self-injury.
|Learning Objectives: At the conclusion of the presentation, participants will be able to:
1. describe assessment findings that characterize treatment-resistant automatically-maintained self-injury
2. describe methods that can be used to minimize risks while assessing and treating severe self-injury
3. describe pre-treatment assessments to identify stimuli and tasks that can potentially be used to compete with reinforcement maintaining self-injury
4. describe the principle of reinforcer competition and its use in treatment for automatically-maintained problem behavior
A Protective Procedures Assessment to Minimize Risks When Assessing, Treating, and Conducting Research on Self-Injury
|MICHELLE A. FRANK-CRAWFORD (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Jasmeen Kaur (Kennedy Krieger institute ), Drew E. Piersma (Kennedy Krieger Institute), Jonathan Dean Schmidt (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Louis P. Hagopian (Kennedy Krieger Institute)
Automatically maintained self-injurious behavior is associated with more severe injuries relative to socially maintained self-injurious behavior (SIB). Assessing, treating, and conducting research on severe SIB poses many practical and ethical challenges; chief among them is minimizing risk. Protective procedures often used include mechanical devices that limit the occurrence of the behavior, protective equipment that protect areas of the body from injury, response blocking to prevent the completion of the response, and abbreviated sessions to limit exposure to situations in which the behavior is occurring. We describe a principled approach to guide the application of these and other tactics that balance the need to allow the occurrence of SIB to the extent that it can be assessed and treatments can be evaluated, while also minimizing risks of injury. The general principles include 1) matching the protective procedures based on the form of and injuries produced by SIB, 2) selecting the optimal combination of procedures, starting with the combination most likely to prevent injury, then 3) carefully reducing the use of procedures so that the optimal level of protection that is minimally restrictive is identified. Outcomes of the application of this approach will be discussed.
|Initial Outcomes of a Competing Task Assessment for Automatically-Maintained Self-Injurious Behavior
|JASMEEN KAUR (Kennedy Krieger institute ), Jonathan Dean Schmidt (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Michelle A. Frank-Crawford (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Drew E. Piersma (Kennedy Krieger Institute), Lauren Veirs (Kennedy Krieger Institute), Griffin Rooker (Mount St. Mary's University), Louis P. Hagopian (Kennedy Krieger Institute)
|Abstract: Competing stimulus assessments are used to identify stimuli (usually leisure items) to compete with reinforcement produced by automatically-maintained self-injurious behavior (ASIB). Recent research has highlighted the utility of augmenting these procedures by employing tactics to actively promote engagement with stimuli while disrupting ASIB. There is also preliminary evidence that engagement with tasks may be effective at reducing rates of treatment-resistant ASIB. In the current study, we brought these findings together to develop and evaluate a competing task assessment (CTA) with six participants enrolled in a clinical trial for treatment-resistant ASIB. In contrast to competing stimuli, with which the individual can engage in many ways, competing tasks require a discrete response or chain of responses (i.e., sorting objects). If noncontingent access to tasks did not produce reductions in SIB, we systematically included response promotion (e.g., prompting task engagement and food reinforcement), reductive components (e.g., response blocking SIB), and combinations of these procedures to reduce ASIB. Using this approach, multiple competing tasks were identified to reduce ASIB for all participants, but only after the inclusion of response promotion and reductive components.
|Self-Control Equipment Assessment: Identification of Appropriate Forms of
Self-Control via the Use of Competing Equipment
|DREW E. PIERSMA (Kennedy Krieger Institute), Louis P. Hagopian (Kennedy Krieger Institute), Griffin Rooker (Mount St. Mary's University), Michelle A. Frank-Crawford (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Jonathan Dean Schmidt (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Courtney Hanlin (UMBC)
|Abstract: Some individuals who engage in self-injurious behavior (SIB) also engage in self-restraint (SR), generally defined as behaviors that interfere with the occurrence of SIB (including holding onto objects or others, wrapping hands in clothing, sitting on hands). Although SR can reduce the occurrence of SIB, it can be maladaptive when it limits hand use or has other detrimental consequences (e.g., decreased circulation, skin breakdown). Self-restraint appears to be maintained by the avoidance of SIB, thereby suggesting it can be characterized as topographically maladaptive form of self-control. It is possible that alterations to the topography of SR can mitigate these detrimental consequences while maintaining low levels of SIB. As part of a clinical trial investigating an intervention for treatment-resistant subtypes of SIB, five participants completed a self-control equipment assessment (SCEA) in order to identify equipment that would compete with SR. The assessment examined the effects of the equipment when it was freely available, when its use was prompted, and when its use was prompted while SR was blocked. Preliminary results suggest that empirical identification of equipment that competes with SR is possible in the context of brief sessions. Implications for the extended use of these procedures are described.
Targeting Treatment-Resistant Subtypes of Automatically Maintained Self-Injury With Combination Treatment
|JONATHAN DEAN SCHMIDT (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Louis P. Hagopian (Kennedy Krieger Institute), Michelle A. Frank-Crawford (Kennedy Krieger Institute; Johns Hopkins University School of Medicine), Drew E. Piersma (Kennedy Krieger Institute), Jasmeen Kaur (Kennedy Krieger institute )
The identification of treatment-resistant subtypes of automatically maintained self-injurious behavior (ASIB) created an imperative to develop more efficacious interventions. Increased understanding of the mechanisms involved in the maintenance of these behaviors, and the development of new technologies provide a conceptual and empirical basis for developing an intervention targeting these treatment-resistant subtypes. Combination treatment is based on the same principle of reinforcer competition as the current standard of care treatment, noncontingent reinforcement (NCR) with competing stimuli, but also employs novel methods to greatly increase the amount and vary the sources of competing reinforcement to target both self-injury and self-restraint. Combination treatment includes three phases: 1) Pre-Treatment Assessments to identify competing stimuli, competing tasks, and self-control equipment to reduce self-injury and self-restraint; 2) Intensive Training to strengthen skills needed to fully access available competing reinforcement, and replace debilitating self-restraint with self-control; and 3) Combination Treatment where competing stimuli, competing tasks, and alternative self-control equipment are combined to maximize their effects. The conceptual and empirical basis for this treatment are discussed, and preliminary findings from a randomized crossover design comparing the efficacy of Combination Treatment to NCR with competing stimuli are summarized.