At least one quarter of the 18 million persons in the US with intellectual and developmental disabilities engage in self-injurious behavior (SIB), which can result in injuries, disfigurement, and loss of function (e.g., blindness). In most cases, SIB is maintained by social reinforcement (e.g., attention). SIB that persists in the absence of social reinforcement has been referred to as automatically reinforced SIB (ASIB), based on the supposition that the behavior itself produces some type of biological reinforcement. The current standard of care approach to treatment for ASIB includes two phases: a Pre-Treatment Assessment (a Competing Stimulus Assessment to identify stimuli associated with reductions in ASIB), followed by treatment where competing stimuli are delivered on a noncontingent reinforcement (NCR) schedule. Our NICHD- supported research to date has identified subtypes of ASIB that vary greatly in terms of their responsiveness to these treatments. Subtypes are based on results of standardized assessment conditions: 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 occurs to avoid ASIB, but also impairs adaptive functioning. Treatments using NCR with competing stimuli alone are effective in over 82% of cases with Subtype 1, but in only 7% of cases with Subtype 2 or 3, necessitating restraint or protective equipment to sufficiently reduce ASIB. The identification of subtypes has revealed the urgent need for more effective interventions for the treatment-resistant subtypes. Fortunately, our research (R01 HD076653) has also led to several recent discoveries that provide the conceptual and empirical basis for a new Intensified Approach to treatment targeting the most treatment-resistant subtypes (Subtype 2 and 3 ASIB). The proposed treatment approach is based on the same principles as the current Standard of Care Approach (Matching Law and reinforcer competition), but employs novel methods to more effectively compete with reinforcement maintaining Subtype 2 and 3 ASIB, and to address self-restraint for Subtype 3. The proposed Intensified Approach to treatment includes three phases: 1) Pre-Treatment Assessments will identify competing stimuli, tasks, and self-control devices that reduce ASIB; 2) Intensive Training to strengthen skills needed to fully access available reinforcement, and replace debilitating self-restraint; and 3) Combination Treatment using NCR to deliver, and differential reinforcement for engagement with: multiple competing stimuli, competing tasks, and alternative self-control devices (for Subtype 3). Combination Treatment is designed to greatly increase the amount and vary the sources of alternative reinforcement.
Aim 1 is to identify and establish competing stimuli, competing tasks, and self-control devices (Subtype 3 ASIB).
Aim 2 is to employ a randomized crossover design to demonstrate the effectiveness of Combination Treatment (developed using the Intensified Approach), relative to NCR with competing stimuli alone (developed using the current Standard of Care Approach) for reducing ASIB and self-restraint.

Public Health Relevance

Some individuals with intellectual and developmental disabilities engage in self-injurious behavior (SIB), which can result in injuries, disfigurement, and loss of function (e.g., blindness). Our research on the least understood type of SIB showed it was actually comprised of subtypes, including some that did not respond well to currently available treatments. With further study, we gained insight into how the subtypes differed, pilot tested novel-treatment procedures, and are now positioned to conduct a clinical trial evaluating an intensive treatment approach targeting the most treatment- resistant subtypes.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
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Child Psychopathology and Developmental Disabilities Study Section (CPDD)
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King, Tracy
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Hugo W. Moser Research Institute Kennedy Krieger
United States
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Newcomb, Eli T; Hagopian, Louis P (2018) Treatment of severe problem behaviour in children with autism spectrum disorder and intellectual disabilities. Int Rev Psychiatry 30:96-109
Hagopian, L P; Frank-Crawford, M A (2018) Classification of self-injurious behaviour across the continuum of relative environmental-biological influence. J Intellect Disabil Res 62:1108-1113
Hagopian, Louis P; Rooker, Griffin W; Zarcone, Jennifer R et al. (2017) Further analysis of subtypes of automatically reinforced SIB: A replication and quantitative analysis of published datasets. J Appl Behav Anal 50:48-66
Zarcone, Jennifer; Hagopian, Louis; Ninci, Jennifer et al. (2016) Measuring the Complexity of Treatment for Challenging Behavior using the Treatment Intensity Rating Form. Int J Dev Disabil 62:183-191
Hagopian, Louis P; Rooker, Griffin W; Zarcone, Jennifer R (2015) Delineating subtypes of self-injurious behavior maintained by automatic reinforcement. J Appl Behav Anal 48:523-43
Bushnell, Cheryl; Bettger, Janet Prvu; Cockroft, Kevin M et al. (2015) Chronic Stroke Outcome Measures for Motor Function Intervention Trials: Expert Panel Recommendations. Circ Cardiovasc Qual Outcomes 8:S163-9