Self-injury is, to the common person, unfathomable. Why would someone want to hurt themselves? One of the first times I encountered a child that hurt themselves; I observed a young boy banging his head against a concrete floor. Caregivers immediately intervened and stopped him but with just one hit he had opened up a large gash and was bleeding profusely. One's instincts are to protect the child and prevent harm but is this in their best interest in the long run? Lovaas and Simmons (1969) discuss a case in which a child with autism engaged in self-injury and noted that it occurred most consistently when the child was provided attention by an adult following self-injury. They assumed that his hurting himself was maintained by the things people did for him when he emitted this behavior. Their solution, at least in the initial stage of treatment, was to give him constant access to an adult's attention and this resulted in a much lower frequency of self-injury.
Another pioneer in the development of treatment for problem behavior in children with ASDs was Ted Carr (e.g., Carr, 1977). It was around this time when behavior analysts started to refer to problem behavior as communicative. In some cases problem behavior seemed to suggest that the person was asking for attention or access to a preferred activity or escape from some activity they found unpleasant. It was also suggested that sometimes self-injury might be related the sensory consequences produced by the behavior. That is, the person might like the sensation or perhaps it attenuated pain the person was experiencing. Though a number of hypotheses about the causes of self-injury began to emerge, one thing that was starting to become clear was that the self-injury of different people likely had different causes.
Brian Iwata and his colleagues (1982/1994) at the Kennedy Krieger Institute at Johns Hopkins revolutionized the treatment of self-injury by developing an assessment procedure, referred to as functional analysis, that helped clinicians identify the cause of a person's self-injury. They systematically confirmed that self-injury presented differently in different individuals and that over 95% of the time a specific cause could be identified. A summary of the results of the functional analysis of self-injury with over 150 persons showed the most common cause, just fewer than 40% of cases, was that self-injury was maintained by escape from aversive events. The second most common cause, about 26% of cases, was that self-injury produced access to either caregiver attention or preferred activities while just under 26% of cases suggested that the sensory consequences from self-injury were the cause. More than one cause was identified for about 5% of cases. The remaining cases did not produce interpretable results. Over the years, there have been around 200 studies of the functional causes of self-injury.
There were two major implications of this research. First and foremost, identifying the functional cause of self-injury suggested that teaching an adaptive response that produced the same consequence would be an effective treatment. From the mid-1980s on, there has been a keen focus on developing functional communication training techniques. Many studies have shown that teaching alternative communicative responses produce a drastic change in self-injury. Some studies showed it was possible to produce these changes without imposing any changes in the caregivers' response to self-injury. It should, however, be noted that in other research no change in problem behavior occurs until caregivers not only foster communicative alternatives but also stop responding to the problem behavior.
The other major implication was that it is of great importance to functionally assess self-injury because there were several potential causes. Subsequent research has shown that other severe problem behavior, like aggressing towards others and tantrums also vary in the causes that maintain them. The Individuals with Disabilities Education Act in 2004 mentions functional behavioral assessment as an important tool in developing effect treatments for all problem behavior. Prior to the advent of functional assessment tools, there had been a heavy reliance on intrusive procedures as treatment for problem behavior. Pelios, Morren, Tesch, and Axelrod (1999) reviewed the behavioral treatment research on self-injury and aggression and found that prior to the early 1980s treatments did not vary greatly with a preponderance of intrusive interventions. The less intrusive interventions that were reported tended to be less effective. However, with the development of functional assessments, less intrusive interventions became much more prominent and effective. This is due to the clinician's being able to more precisely prescribe how to promote alternative and more adaptive behavior.
Carr, E.G. (1977). The motivation of self-injurious behavior: A review of some hypotheses. Psychological Bulletin, 84, 800-816.
Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E.,& Richman, G. S. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197-209. (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3-20, 1982).
Iwata, B. A. et al. (1994).The functions of self-injurious behavior: An experimental-epidemiological analysis. Journal of Applied Behavior Analysis, 27, 215-240.
Lovaas, O. I., & Simmons, J. Q. (1969). Manipulation of self-destruction in three retarded children. Journal of Applied Behavior Analysis, 2, 143-157.
Pelios, L., Morren, J., Tesch, D., & Axelrod, S. (1999). The impact of functional analysis methodology on treatment choice for self-injurious and aggressive behavior. Journal of Applied Behavior Analysis, 32, 185-195.