Association for Behavior Analysis International

The Association for Behavior Analysis International® (ABAI) is a nonprofit membership organization with the mission to contribute to the well-being of society by developing, enhancing, and supporting the growth and vitality of the science of behavior analysis through research, education, and practice.


50th Annual Convention; Philadelphia, PA; 2024

Event Details

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Symposium #316
CE Offered: BACB
Personalizing Interventions for Treatment-Resistant Automatically Maintained Self-Injurious Behavior (SIB)
Sunday, May 26, 2024
3:00 PM–4:50 PM
Convention Center, 100 Level, 112 AB
Area: DDA/AUT; Domain: Applied Research
Chair: Savannah Tate (Kennedy Krieger Institute)
Discussant: David M. Richman (Texas Tech University)
CE Instructor: Savannah Tate, Ph.D.
Abstract: The disrupting effects of alternative reinforcement and the presence of self-restraint are the basis for defining subtypes of self-injurious behavior, which differ markedly in response to treatment. Assessment and treatment of treatment-resistant subtypes poses many practical and conceptual challenges. Foremost is the challenge of ensuring safety, which is addressed in the first presentation. Informed by practices that have evolved over time and focused research on SIB, the protective procedures assessment (PPA) is a principled approach to identifying procedures that mitigate risks of SIB and enable safe assessment and evaluation of treatment efficacy. The second presentation will describe newly developed criteria for subtyping SIB that should facilitate wider application of the subtyping model in practice and research. The third presentation will describe an approach to treatment development that relies heavily on pre-treatment assessments, training, and pilot testing of component combinations to empirically derive interventions targeting treatment-resistant subtypes. The final presentation will discuss how clinical procedures described in prior presentations are products of an individualized, mechanistic approach to classification and treatment of clinical problems. Also discussed is how this approach aligns with the paradigm of precision medicine, which can advance understanding of clinical problems and inform the design of more personalized interventions.
Instruction Level: Advanced
Keyword(s): Assessment, Automatic, Self-Injurious Behavior, Treatment
Target Audience: Audience members should understand functional analysis methodology and classification of subtypes of self-injurious behavior.
Learning Objectives: At the conclusion of the presentation, participants will be able to: 1. Describe how level of differentiation in the function analysis quantifies sensitivity to disruption by reinforcement 2. Describe the protective procedure assessment and how it can be used to inform safety measures when assessing self-injurious behavior 3. Describe how hypotheses about mechanisms thought to be in operation for each subtype informs treatment design
Simplified Methods for Identifying Subtypes of Automatically Maintained Self-Injury
DREW E. PIERSMA (Kennedy Krieger Institute), Louis P. Hagopian (Kennedy Krieger Institute), John Falligant (Kennedy Krieger Institute/Johns Hopkins University School of Medicine), Michelle A. Frank-Crawford (Kennedy Krieger Institute), Gayane Yenokyan (Johns Hopkins University School of Medicine), Jasmeen Kaur (University of Nebraska Medical Center - MMI)
Abstract: Automatically maintained self-injurious behavior (SIB) can be categorized into three distinct subtypes based on patterns of responding observed during functional analysis. Current best practice for identifying these subtypes involves first applying structured criteria to determine whether SIB is automatically maintained and then applying additional criteria to determine the specific subtype. In this investigation, we conducted a series of studies to both simplify and validate these procedures, such that the subtyping model could be applied more consistently in both research and clinical practice. In Study 1, we use participant subtypes reported in published literature to identify the optimal level of differentiation (LOD) of SIB across the play and no-interaction conditions to distinguish between Subtypes 1 and 2. In Study 2, we validate this LOD cutoff as a reliable method of subtyping SIB through its application to a cohort of clinical cases. In Study 3, we demonstrate how the combination of visual analysis and LOD can be used in practice to accurately identify an automatic function of SIB and classify subtypes without the additional application of standard structured criteria. Implications for both research and clinical practice are discussed.

Initial Outcomes of the Protective Procedures Assessment: Minimizing Risks When Assessing, Treating, and Conducting Research on Self-Injury

MICHELLE A. FRANK-CRAWFORD (Kennedy Krieger Institute), Louis P. Hagopian (Kennedy Krieger Institute), Drew E. Piersma (Kennedy Krieger Institute), Jonathan Dean Schmidt (Kennedy Krieger Institute)

Providing clinical services to individuals with automatically maintained self-injurious behavior (SIB) classified as Subtype 2 and 3 is challenging as they are less responsive to treatment and present with more severe injuries relative to those with socially maintained SIB. Thus, identifying appropriate, effective, and minimally intrusive patient protections is essential. Here, we describe the protective procedures assessment (PPA), a principled approach to selecting the optimal level of protection that is minimally restrictive yet allows the assessment and treatment of SIB. Following semi-structured interviews, and in consideration of caregiver preferences, potential protective procedures are identified based on the mechanics of SIB and the types of injuries that may be produced. An assessment is then conducted comparing responding in a control condition with the combination of procedures most likely to prevent injury relative to responding in test conditions with lower levels of protective procedures. Outcome measures include: rate of SIB, risk level rating, and level of protective procedures (based on a rating scale). The optimal level of protective procedures are employed during assessment and treatment analyses, then systematically faded once treatment produces reductions in SIB. Outcomes of the PPA as applied to individuals with Subtype 2 and 3 SIB will be reviewed.

The Evolutionary Process of Integrating Treatment Components and Tactics for Reducing Self-Injurious Behavior and Self-Restraint
JONATHAN DEAN SCHMIDT (Kennedy Krieger Institute), Michelle A. Frank-Crawford (Kennedy Krieger Institute), Drew E. Piersma (Kennedy Krieger Institute), Louis P. Hagopian (Kennedy Krieger Institute)
Abstract: Individuals with automatically maintained self-injurious behavior (SIB), Subtypes 2 and 3, typically require multiple treatment components including protective equipment and restraint to obtain clinically significant reductions in SIB and self-restraint. In this talk we present initial findings from a sample of participants admitted to an inpatient hospital unit, enrolled in a clinical trial evaluating the efficacy of combination treatment for treatment-resistant subtypes of automatically maintained SIB. These cases are used to illustrate an approach to treatment development that relies heavily on pre-treatment assessments, training procedures, and pilot testing prior to initiating treatment. Specific assessments are conducted to (a) systematically identify effective components to ensure safety (protective procedures) and identify sources of competing reinforcement and responses (competing stimuli, tasks, and self-control items), (b) implement intensive training to establish prerequisite skills to maximize effects, and (c) pilot test various combinations of treatment components to identify optimal arrangements. Next, treatment components are applied in combination treatment and after obtaining low rates of SIB and self-restraint, treatment is generalized; when possible, protective procedures are systematically faded. Outcomes presented for participants are quantified in terms of reductions in SIB, self-restraint, and the level of protective procedures.

Causal and Treatment-Action Pathways and Their Relevance to Understanding and Treating Automatically Maintained Self-Injury

LOUIS P. HAGOPIAN (Kennedy Krieger Institute), Jonathan Dean Schmidt (Kennedy Krieger Institute), Michelle A. Frank-Crawford (Kennedy Krieger Institute), Drew E. Piersma (Kennedy Krieger Institute)

Analysis of the response dynamics of self-injurious behavior (SIB), including the disrupting effects of alternative reinforcement and/or self-restraint, has provided the basis for delineating subtypes that differ markedly in their response to reinforcement-based treatment. These and other findings allow us to make inferences about the distinct mechanisms that may be in operation for each subtype such as the establishing operations that evoke the behavior and the consequences that reinforce it (i.e., the causal pathways of SIB and self-restraint). This knowledge, in combination with our understanding of the mechanisms by which various treatment components engender behavior change (i.e., the treatment-action pathways), provides the basis for developing interventions directly targeting the causal pathways of SIB. This approach to the classification of clinical problems and treatment is the hallmark of both applied behavior analysis and precision medicine – and differentiates them from non-mechanistically based approaches that focus on management of presenting concerns. The current discussion will illustrate how knowledge of causal and treatment-action pathways has informed the ongoing development of more efficacious behavioral interventions targeting the most treatment-resistant subtypes of automatically maintained SIB.




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