Decreasing Self-Injury in a Child with Multiple Disabilities.pptx

SIB

1. Decreasing Self-Injury in a Child with Multiple Disabilities: A Practitioner’s Demonstration Brianna Laureano I Rajen Bajracharya I Emily A. Chesbrough I John Michael Falligant Abdallah Alsaidy B.Sc., Qasp-s

2. What is Self-Injurious Behavior (SIB)? DSM-5: Classified as Stereotypic Movement Disorder with SIB Common in individuals with intellectual & developmental disabilities Risks & Consequences of SIB Direct risks: Concussions, lacerations, body disfigurement Permanent sensory loss (e.g., vision) Death in severe cases Indirect consequences: Restrictive placements (home, school, residential) Use of pharmacological & physical restraints Stress & suffering for caregivers

3. What Maintains SIB? Literature review: ~ 75% of cases maintained by social consequences Attention Escape from demands Access to preferred items Caused by: Primary disability deficits (limited communication & adaptive skills) Reinforcing learning history (e.g., consoling, removing tasks) Why Functional Communication Training (FCT)? 1-Empirically supported treatment for challenging behavior 2-FCT teaches alternative appropriate responses to access the same reinforcer Example : If SIB = to get attention → Teach hand raising, tapping shoulder, vocal request

4. Research Gap & Purpose Limited FCT research for individuals with: Hearing impairments (1 participant) Visual impairments (5 participants) Orthopedic impairments (13 participants) Importance : Requires individualized & modified procedures for multi-disability cases Purpose of study: Demonstrate how to modify behavioral assessment & treatment Reduce SIB & promote independence in individuals with multiple disabilities

5. | METHOD 2.1Participant and setting Participant: Ava, 8-year-old female Diagnoses: Autism Spectrum Disorder Down Syndrome Stereotypic Movement Disorder with Self-Injury Profound Intellectual Disability Medical Conditions: Bilateral retinal detachment → Blindness Mild hearing loss (right ear) Communication & Skills: No vocal speech Limited sign language Very limited receptive & expressive language Physical Support: Full assistance with all daily living activities Complete physical support during transitions Unable to bear weight → Requires stroller/wheelchair Setting : Hospital-based inpatient unit Sessions: 5 days/week in a padded treatment room

6. 2.2 Response Measurement and Interobserver Agreement Primary Dependent Variables: During Functional Analysis & Treatment: Rate of head-directed self-injurious behavior (H-SIB) During FCT: ASL sign for “more” ( verbal prompted or independent) During Backward Chaining: Independent completion of the targeted step after one verbal prompt Interobserver Agreement (IOA): Recorded via BDataPro software Percentage of sessions with IOA: Functional Analysis: 100% FCT: 29.4% Backward Chaining: 18.2% Treatment Evaluation: 34.1% Mean IOA: Pairwise FA: 93.8% (range 0–100%) TBFA trial based functional analysis: 83.3% (range 50–100%) FCT: 98.0% (range 85.7–100%) Backward Chaining: 97.6% (range 83.3–100%)

7. 2.3.1Safety Precautions Reason: Severe H-SIB and head-banging (HB); history of retinal detachment Implemented by: Trained clinicians Progressive Blocking Sequence: Standard Blocking: Therapist places arm between Ava’s hand and head/face Shadowing: Therapist’s hands closely follow Ava’s hand movements Brief Holding: Therapist gently cups Ava’s hand with light pressure to prevent impact Additional Measures: Padded floor mat to prevent injury from HB Session terminated if redness, swelling, bleeding, or bruising occurred Backward Chaining Steps (for later slide) for change songs: Orient to the cube – Turn shoulders, place hand on cube Find the Velcro – Place hand on Velcro Press the button – Compress the right side of the switch

8. 2.3.2Functional Analysis Purpose: To determine if Ava’s head-directed self-injury (H-SIB) was maintained by positive reinforcement (changing music). Setup: Location: Inpatient bedroom with mat, Bluetooth speaker, and therapist nearby. Device: Bluetooth handheld speaker linked to a music playlist on a smartphone. Ava had auditory impairment in right ear → kept speaker close to left ear. Conditions: 1-Control: Music freely available. Therapist provided attention and complied with all requests to change songs. No consequence for H-SIB. 2-Test: Similar to control except: therapist ignored song-change requests. If Ava engaged in H-SIB → therapist said: “Ok, I can change the song for you” and pressed Next.

9. 2.3.3 Treatment Evaluation Design: ABAC Design A = Baseline B = DRA + Blocking C = DRA + Blocking + AbleNet® Switch Session Details: Duration: 5 minutes each Location: Same room as functional analysis Therapist: Within arm’s reach (unless otherwise specified) Phase Objectives: Phase B (DRA + Blocking): Teach Ava to appropriately request music when it was not playing Phase C (DRA + Blocking + AbleNet® Switch): Teach Ava to independently change songs while music was playing Goal: Further reduce problem behavior & increase independence Diagram

10. A horizontal flow diagram with four connected boxes labeled A → B → A → C, with descriptions under each: A (Baseline): 2-min free access to music before session If H-SIB → 30s access to music Therapist provided attention throughout B (DRA + Blocking): Teach Ava to request music when it’s not playing Reinforce alternative behavior Block H-SIB A (Return to Baseline): Same as initial baseline C (DRA + Blocking + AbleNet® Switch): Teach Ava to change songs independently using switch Reduce reliance on therapist

11. Functional Communication Training (FCT) Objective: Teach Ava to request music using the ASL sign for “more” as a Functional Communicative Response (FCR). Why this response? Simple gesture Fits Ava’s limited fine motor skills Teaching Procedure: Prompting Strategy: Physical prompt → Progressive prompt delay Sessions: 5 consecutive trials Reinforcement: Independent or prompted FCR → 1 min of music Blocking: Therapist ignored & blocked all H-SIB Mastery: 2 sessions with ≥ 80% independent FCR Phases: Baseline: Verbal prompt (“Sign more for music”) Guided Exposure: Hand-over-hand guidance after initial prompt Prompt Delay: 5s delay before prompting (least-to-most hierarchy) Generalization: Same as prompt delay with novel therapists

12. DRA + Blocking Intervention 1. Pre-Session Preparation Ava given 2 min free access to music via handheld speaker. Speaker removed at session start with verbal cue: “Time to put the speaker away.” 2. During Session H-SIB blocked by therapist. Functional Communication Response (FCR): If emitted → therapist gives speaker + music for 30 s. Noncontingent Attention (NCA): Delivered on FT 30-s schedule, song changed if Ava handed back the speaker. Thinned over 23 sessions → FT 300-s terminal schedule. 3. Stimulus Control Textured bracelet (right hand): signals alternative reinforcement availability. Compression band (left wrist): signals response-blocking contingency.

13. Backward Chaining to Teach Music Changing 1. Objective: Teach Ava to independently change her music using the AbleNet® Blue2 Bluetooth Switch®. 2. Device Description & Modifications: Wireless device with two compressible buttons, connected to a smartphone. Right button: “Next” to change the song. Modifications for visual and motor impairments: Switch attached to a white portable cube with a rope → easier to locate and pull. Four large medical foam squares on the “Next” side → raised the correct button. Hard Velcro covering → tactile guide to locate the button. Extra weight reduces force needed to press → accommodates motor difficulties. 3. Backward Chaining Steps: Orient to the cube. Locate the Velcro side. Press the button to change music 4. Training Procedure: 1-Sessions start with music playing. 2-Verbal instruction: “Change the music.” 3-Focus initially on final step (press the button). 4-If Ava does not complete within 5 s → least-to-most prompting applied. 5-Once step 3 mastered at ≥80% over 2 consecutive sessions → train steps 2 and 3 together. 6-Continue until Ava masters all three steps.

14. DRA + Blocking + AbleNet® Switch 1. Integration with Skill Training: After backward chaining training, treatment resumed with the AbleNet® switch. Ava had continuous access to independently change her music whenever she wanted. 2. Therapist Redirection: If Ava requested to change music (e.g., handed the speaker to therapist): Therapist guided her hand to the switch on the cube. 3. Proximity Fading: Therapist gradually increased distance over 11 sessions (sessions 57–68). Final setup: Therapist 5 ft away, providing attention on FT 60-s schedule.

15. Functional Analysis & Baseline 1. TBFA Results: H-SIB occurred in 87.5% of test components vs. 25% of control components. Suggests H-SIB was maintained by positive reinforcement (therapist changing the song). 2. Baseline Data: Mean H-SIB: 1.08 responses per minute across baseline phases. 3. Next Step: Functional Communication Training (FCT) implemented after baseline to teach Ava an appropriate way to request music.

16. Treatment evaluation. BL, baseline; DRA, differential reinforcement of alternative behavior; H‐SIB, head‐directed self‐injurious behavior 1. Functional Communication Training (FCT): Ava learned to request access to music appropriately. Independent FCR engagement: Baseline: 44% Training: 45% Generalization: 85% Mastery achieved in 8 sessions 2. DRA + Blocking Phase: Mean H-SIB: 0.28 responses/min 3. Skill Acquisition (Backward Chaining): Three-step chain for independent music changing: Orient to cube Touch Velcro® Press button Independent performance: Step 3: 68.18%, mastery in 11 sessions Step 2: 57.14%, mastery in 14 sessions Step 1: 67.5%, mastery in 4 sessions Total mastery of chain: 29 sessions

17. functional communication T DRA + Blocking + AbleNet® Switch Phase 1. Treatment Evaluation: Phase depicted in Phase 5 of Figure 3. Mean H-SIB: 0.28 responses/min. At final proximity (5 ft) and FT 60-s attention schedule, treatment led to 87.5% reduction in H-SIB relative to last five baseline sessions. 2. Overall Implications: Demonstrates effective integration of skill acquisition and behavior reduction interventions for an individual with multiple disabilities (visual, hearing, and motor impairments). Literature review (Clark-Bischke & Crowley, 2011) noted that interventions for individuals with visual impairments often include some form of punishment procedure, highlighting the relevance of reinforcement-based strategies used here.

18. Discussion and Practical Implications 1. Intervention Without Punishment: Previous studies often used punishment or more intrusive procedures (e.g., non-exclusionary time-out, denied access to preferred stimuli). This study demonstrates the effectiveness of an intervention without punishment for an individual with multiple impairments. In the final treatment package, the therapist could step 5 ft away from Ava and provide attention every 60 seconds, compared to the beginning of treatment when the therapist was within arm’s reach to block H-SIB. Fading distance and attention schedule increased the feasibility of the intervention in her natural environment. 2. Behavioral Outcomes: Ava’s challenging behavior was maintained by access to preferred music, which functioned as a powerful reinforcer for both problem and appropriate behaviors. Similar findings were observed in Desrochers et al., 2014, where noncontingent background music decreased interfering behavior. In this study, preferred music maintained problem behavior and was used as a reinforcer to teach a functionally equivalent alternative response. Clinicians and researchers should consider incorporating auditory stimuli for individuals with visual impairments, as they may serve as high-quality reinforcers for teaching adaptive skills or reducing challenging behavior.

19. 3. Quality of Life: The study contributes to improving quality of life for individuals with disabilities. Quality of life often involves readily available and accessible sources of reinforcement (Bishop-Fitzpatrick et al., 2016; Bukszpan & Streff, 2022). Environmental enrichment is more effective when paired with prompting or reinforcement strategies for alternative behavior (Gover et al., 2019). Teaching Ava to access music dependently via the FCR may have been more preferred and effective than providing music freely. Expanding skill repertoires for independent access to highly preferred reinforcers increases quality of life and reduces reliance on others. 4. Promoting Independence: Ava could change her music independently without therapist assistance once she had access to the device. Reducing challenging behavior and increasing independent communication and adaptive behavior aligns with the habilitative goals of applied behavior analysis (Bannerman et al., 1990). 5. Individualized Modifications: Several adjustments accommodated Ava’s multiple impairments: FCR selected to involve physical responses within her gross motor abilities. Device modified to reduce effort required for independent responding. Contingency-correlated stimuli chosen for tactile properties to aid discrimination.

20. THANKS