Self-injurious behavior (SIB) is a serious problem behavior that can have a negative impact on both a child’s health and overall quality of life (Symons, Thompson, & Rodriquez, 2004). Common forms of SIB include face-slapping, head-banging, self-biting, severe scratching or rubbing. Although SIB is not present in all individuals with autism spectrum disorder (ASD), SIB is significantly more present in those with ASD than the general population and even more common in individuals with ASD and an intellectual disability (Matson & LoVullo, 2008). There are many reasons why an individual may engage in SIB, ranging from physiological to social causes. In the current article, we will explore how the social environment can impact a child’s SIB as well as treatment for socially-maintained SIB.
In some cases, SIB has been shown to be the result of a response to the interactions of other people (Durand & Moskowitz, 2016). For example, a child with autism may be sitting at the dinner table when he tips over and hits his head on the wall behind him. Mom and dad rush over to see if he is okay and they provide a lot of hugs and reassurance. While these parents were doing something very natural, this child may now make the connection that hitting his head on the wall brings about high amounts of attention. Whereas a typical child may never use SIB again to gain attention, a child with ASD who has limited verbal or social skills, may find that SIB is the best way to gain attention. This becomes a serious issue when the child continues to engage in SIB and those around him will hug and tell him not to hurt himself. Although this seems like a caring thing to do, it is inadvertently reinforcing the behavior and making it more resistant to change.
This example of the child engaging in head hitting for attention is one of the four functions that can reinforce SIB. The other three functions are escape or avoidance of difficult tasks or undesirable stimuli, access to desirable items or activities (also known as access to tangibles), and access or avoidance of sensory stimulation. By being aware of the possible functions that may reinforce SIB, we can prevent reinforcing these behaviors and also teach the child an appropriate way to gain access or avoid stimuli within their environment.
Considering SIB can be viewed as a communicative act the person uses to express their wants and needs from the environment, the logical replacement behavior to teach is communication. An intervention that has been widely used to reduce SIB is Functional Communication Training (Durand & Moskowitz, 2016). Functional Communication Training, commonly known as FCT, was developed by Carr and Durand in the mid-1980s, has been proven to be effective in numerous studies and is one of the 27 focus interventions identified by the National Professional Development Center on Autism Spectrum Disorders (Carr & Durand, 1985). Find more information on FCT and the other evidence-based practices here, https://autismpdc.fpg.unc.edu/evidence-based-practices.
Steps to Implementing Functional Communication Training (FCT)
1. Assess the Function of the Behavior: This is the most important step! Without conducting a functional behavioral assessment or incorrectly identifying the function of the behavior, it may lead to an unsuccessful intervention. Thus, functional behavioral assessments should include multiple components in order to identify the antecedents that trigger the behavior and the consequences that maintain the behavior. Types of assessment to include are informal measures like the Motivation Assessment Scale, direct observations collecting ABC data, and scatterplot forms that allow you to pinpoint what part of the child’s day the behavior occurs most often. For more information, check out the IRCA’s article on Observing Behavior Using A-B-C Data (Observing-Behavior-Using-A-B-C-Data) or the National Professional Development Center has a module on Functional Behavior Assessment (https://afirm.fpg.unc.edu/node/783).
2. Select Communication Modality: Once the function is identified (escape/avoidance, access to attention/tangible, sensory stimulation), the goal is to teach a form of communication that allows the child to gain access or avoid the same function as the SIB. It is important to note that in the beginning, only one communicative response should be taught. For example, if a child engages in hand-biting to escape circle time, the teacher will want to teach the communicative response “I want a break.” If we try teaching too many communicative responses all at once, the child may not make the connection between the new response and being able to access the preferred consequence. For more examples of functions of behavior and possible communicative responses, see the chart below. The next step is to choose the mode of communication the child can easily use. Children who have difficulty with verbal communication or have no verbal communication, may use an alternative mode of communication. This may include a picture symbol that the student hands to their communication partner (e.g., picture of favorite food in order to request it), voice-output communication aides that can produce a phrase when you press the button (e.g., Big-Mac switch), or a speech-generating device that displays pictures or a keyboard on the computer screen that can produce an auditory response (e.g., Tobii, Dynavox, or iPad communication apps like Proloquo2Go, TouchChat HD, or TapSpeak Choice). Whichever mode of communication is chosen, it should be easier and more efficient for the child to use than the SIB. Otherwise, the child will resort to using SIB to communicate.
3. Creating Teaching Situations: In order to teach new communication, teachers should arrange the classroom to create opportunities for teaching communication. A teacher may think about the school-day and where the child is most likely to engage in SIB. The teacher may then present an antecedent that would trigger the behavior, such as having a favorite toy out of reach, presenting a difficult assignment, having another student make a lot of noise, or giving the child’s peer a lot of attention.
4. Prompt Communication: When first teaching the new communication, the teacher should have a plan for how the child will be prompted to use the alternative communication instead of engaging in SIB. The least to most intrusive prompts are gestural, verbal, visual, model, partial physical, and full physical. For the first couple of teaching situations, a teacher or teacher’s assistant may stand behind the child and provide a full physical, hand-over-hand, prompt to pick up a picture symbol and hand it the communication partner. The communication partner will then reinforce the response by providing the desired consequence.
5. Fade Prompts: After multiple trials, the prompting should fade by using less intrusive prompts until the child reaches independence. The teaching assistant who started with full physical prompts may fade prompts by moving the arm towards the picture and later just pointing to the picture. The goal is to quickly fade to avoid prompt dependency. For more information on prompting, check out the National Professional Development Center’s module on prompting at http://afirm.fpg.unc.edu/prompting.
6. Generalization: Once the child is independently using the communication instead of SIB in the specific teaching situation, the communicative response should be taught within new settings, people, and materials.
7. Teach New Forms of Communication: When initially teaching the new response, we want to eliminate confusion by only teaching one thing. However, once the child has mastered using the communication to gain their preferred reinforcer, teachers and speech pathologists should introduce new language (verbal or alternative communication) to the child. The more language the child has, the less likely they will resort to using SIB. For more information on teaching communication, check out IRCA’s website at articles-communication.
| Functions of Behavior | Possible Situation | Examples of Communicative Responses to Teach |
|---|---|---|
| Escape/Avoidance | Student engages in SIB when sitting in direct instruction for too long. | "I want a break". |
Student engages in SIB when in independent work and it is too difficult | "I need help." | |
Student engages in SIB when social situations become too overwhelming. | "I need to leave." | |
| Attention | Student engages in SIB to get peer's attention | "Can you play with me?" |
Student engages in SIB when teachers are faw away from them. | "Can you come here?" | |
Student engages in SIB when sitting at desk doing independent work | "Am I doing good work?" | |
| Sensory Stimulation | Students engages in SIB to get teachers to hug him to access deep pressure. | “I want to be squeezed.” |
Student engages in SIB when it is too loud in the classroom. | “I need my headphones.” | |
Student engages in SIB when there is too much stimulation (noise, lights, crowded spaces). | “I need to get out of here.” | |
| Access to Tangible | Student engages in SIB when toy is out of reach or they would like to engage in a preferred activity. | “I want [name of desired toy, food, or activity].” |
*** All of the above communicative phrases can be taught with verbal communication or an alternative means like a picture symbol.
Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18(2), 111-126.
Durand, V. M., & Moskowitz, L.J. (2016). Understanding functional communication to treat self-injurious behavior. In S.M. Edelson & J.B. Johnson (Eds.), Understanding and treating self-injurious behavior in autism: A multi-disciplinary perspective (186-197). London & Philadelphia: Jessica Kingsley Publishers.
Matson, J. L., & LoVullo, S. V. (2008). A review of behavioral treatments for self-injurious behaviors of persons with autism spectrum disorders. Behavior Modification, 32(1), 61-76.
Symons, F. J., Thompson, A., & Rodriguez, M. C. (2004). Self-injurious behavior and the efficacy of naltrexone treatment: A quantitative synthesis. Mental Retardation and Developmental Disabilities Research Reviews, 10(3), 193-200.
Quest, K. (2016). Using functional communication training to reduce self-injurious behavior. The Reporter, 21(14). Retrieved from using-functional-communication-training-to-reduce-self-injurious-behavior