Khan, 2015 ONTABA. Using a Biopsychosocial Approach To Decrease Aggression, Rectal Picking, and Obsessive Compulsive Behaviour
Using a Biopsychosical Approach to Reduce Physical Aggression, Rectal Picking, and Obsessive Compulsive Behaviours
Engel (1977) described the need for a new approach to treating issues related
to disability and disease . This approach was described as a biopsychosocial
Borrell-Carrió, Suchman, & Epstein (2004) described the biopsychosocial
model as a refutation of the perception of illness as purely biochemical.
The biopsychosocial model asserts that illness is not associated purely with
biochemical alterations; but rather, results from the interaction of diverse,
These factors can include molecular, individual, and social levels of
functioning. Health and well-being are determined by the collective
interaction of the cited factors.
Social service agencies often use this model to assess and treat harmful
behaviours for people they support. This poster will present three cases of
individuals with Autism that are being supported in residential treatment
All 3 subjects currently reside in residential treatment homes in a rural setting in
52 year old male with a diagnosis of Autism.
Institutionalized from the age of 9 until the age of 44.
Moved into residential treatment setting after the closure of the institution where
he had been living.
Subject has a very strong history of physical aggression and self-injurious
Maintained on antipsychotic medication for most of his life.
Limited verbal communication skills.
Target behaviour: Physical Aggression (In the form of striking other people with
his hands and feet)
Function of Physical Aggression: Escape
44 year old male with a diagnosis of Autism.
Presence of seizure disorder and possible early stage dementia.
Resided in an institution for at least 10 years after several unsuccessful efforts to
support him in community settings (prior to moving into current residence).
Historically, this person had a very significant presentation of physical aggression
and self-injurious behaviour (often required mechanical restraint) in the institution
where he was living.
Subject 2 almost died as a result of medication toxicity 8 months prior beginning
these documented interventions.
Presence of hemmorhoids noted by Doctors.
Uses sign language to communicate wants and needs; however he has
overgeneralized several signs.
Target behaviour: Rectal Picking (Subject uses his own hands or objects in the
environment to poke and scratch in and around his anal region)
Function of Rectal Picking: Automatic Reinforcement
26 year old female with a diagnosis of Autism.
Limited verbal repertoire used to communicate.
Strong history of obsessive compulsive behaviour in the form of grabbing cups of
hot beverages from other people and dumping them on the ground and on herself
(at times resulting in burns).
Several unsuccessful treatments attempted historically to treat obsessive
compulsive behaviour (including satiation-based procedures, and strict
environmental and community restrictions).
Target Behaviour: Obsessive-Compulsive Behavior (In the form of grabbing and
dumping beverages and attempting to enter rooms to search for beverages)
Function of Obsessive-Compulsive Behaviours: Automatic Reinforcement &
A biopsycholsocial approach can help people with developmental disabilities
reduce harmful behaviour.
Findings suggest that one treatment approach (medical, or behavioural) may
be insufficient for persons with complex needs.
Data collection and analysis are essential to determining if treatments of all
kinds are working, need to be discontinued, etc. These include medical and
behavioural interventions, as well as environmental and social variables.
Use of the biopsychosocial model to treat harmful behaviour can be
Borrell-Carrió, F., Suchman, A.L., & Epstein, R.M. (2004). The biopsychosocial model 25
years later: Principles, practice, and scientific inquiry. Annals of Family Medicine,
Bijou, S.W., Peterson, R.F., & Ault, M.H. (1968). A method to integrate descriptive and
experimental field studies at the level of data and empirical concepts. Journal of
Applied Behavior Analysis, 1(2), 175-191.
Carr, E.G., & Durand, V.M. (1985). Reducing behavior problems through functional
communication. Journal of Applied Behavior Analysis, 18(2), 111-126.
Catania, C.N., Almeida, D., Liu-Constant, B., & Digennaro Reed, F.D. (2009). Video
modelling to train staff to implement discrete-trial instruction. Journal of Applied
Behavior Analysis, 42(2), 387-392.
Donnely, D.R. & Olczak. (1990). The effect of differential reinforcement of incompatible
behaviors (DRI) on pica for cigarettes in persons with intellectual disability.
Behavior Modification, 14(1), 81-96.
Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine.
Science, 196, 129-135.
Fisher, W.W., O’Connor, J.T., Kurtz, P.F., DeLeon, I.G., & Gotjen, D.L. (2000). The effects of
noncontingent delivery of high and low-preference stimuli on attention-
maintained destructive behaviour. Journal of Applied Behavior Analysis, 33(1), 79-
Grey, I.M., & Hastings, R.P. (2005). Evidence-based practices in intellectual disability and
behaviour disorders. Current Opinion in Psychiatry, 18, 469-475.
Hegel, M.T., & Ferguson, R.J. (2000). Differential reinforcement of other behavior (DRO)
to reduce aggressive behavior following traumatic brain injury. Behavior
Modification, 24(1), 94-101.
Sarakoff, R.A., & Sturmey, P. (2004). The effects of behavioral skills training on staff
implementation of discrete-trial teaching. Journal of Applied Behavior Analysis,
Schwartz, G.E. (1982). Testing the biopsychosocial model: The ultimate challenge facing
behavioral medicine? Journal of Consulting and Clinical Psychology, 50(6), 1040-
Stokes, J.V., Luiselli, J.K. (2008). Applied behaviour analysis assessment and intervention
for health threatening self injury (rectal picking) in an adult with prader-willi
syndrome. Clinical Case Studies. 1-10. doi: 10.1177/1534850-108327011
Treatment Modalities (Biopsychosocial Methodology)
1. Ongoing psychiatric care and use of medications (these included
Risperidone, Chlorpromazine, and in the case of subject 3 birth control
2. Ongoing collaboration between psychiatrist and family physicians to
determine when to start and stop medical interventions (i.e. medication
dosage changes) supported by data supplied by staff and behaviour
1. Noncontingent attention (Fisher, O’Connor, Kurtz, DeLeon, & Gotjen (2000)
utilized in the case of Subject 3.
2. DRI procedures (Donnely & Olczak, 1990), (Stokes & Luisellii, 2008) used
with subjects 2 and 3.
3. DRO procedures (Hegel & Ferguson, 2000) used with subject 3
4. Functional communication training (Carr & Durand, 1985) was a
component of all treatment approaches for all participants.
1. Adjustments to the environment (i.e. subject 1 moved to a quieter
environment in the final treatment phase) occurred.
2. All three subjects had increased opportunities to access their community.
3. Increased community access involved the use of behavioural interventions
being generalized to these new environments.
Medical treatments prescribed by Psychiatrist and family physicans and
implemented by staff.
For all three subjects, behavioural skills training (Sarakoff & Sturmey, 2004)
was utilized to facilitate behavioural interventions designed by a behaviour
For Subject 2, video models (Catania, Almeida, Liu-Constant, & Degennaro
Reed, 2009) were utilized to demonstrate differential reinforcement of
incompatible behaviour procedures.
All behavioural treatments were documented for support staff in individual
behaviour support plans.
Standard Antecedent, Behaviour, & Consequence (ABC) data tracking (Bijou,
Peterson, & Ault, 1968) is consistently used in the residential treatment centres
where all three subjects reside.
Functions for all three target behaviours were determined based on the results of
analysis of over 1 years worth of daily ABC charting for all three individuals.
Alternating Treatment Design used for all 3 Subjects
Subject 1: ABCD Design
Subject 2: ABCDE Design
Subject 3: ABCD Design
PURPOSE & HYPOTHESES
Grey & Hastings (2005) outlined the effectiveness of using a combination of
antipsychotic medications (Risperidone) and applied behaviour analysis (ABA)
to help people with developmental disabilities decrease harmful behaviour.
The findings of Grey & Hastings (2005) support a hypothesis that a
biopsychosocial approach can be effective in helping people with
developmental disabilities reduce harmful behaviour.
Of special note in this poster will be a response to the issue of being able to
measure the use and effectiveness of this model of treatment (Schwartz,
27 instances of physical aggression in one month prior to second treatment
1 instance of physical aggression in the last month of the final treatment
phase (antipsychotic medication dose adjusted, combined with DRO and
increased community access).
81 instances of rectal picking in the 4th month of tracking behaviour.
2 instances of rectal picking in the 9th month in the third phase.
Behaviour re-emerged at a high frequency (89) in the 11th month.
After addressing issues with treatment fidelity, behaviour had been reduced
to a frequency of 16 as of the 14th month.
Subject 3 was engaging in OCD behaviour across almost 53% of her waking
hours during initial measurment.
During the final treatment phase, subject 3 reduced her OCD behaviour to
occurring across 27% of her waking hours.
The behaviour was reduced by 26% in month 7 at it’s lowest point.