Eastern Michigan University[email protected]Masters These

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Master's Theses and Doctoral Dissertations
Master's Theses, and Doctoral Dissertations, and
Graduate Capstone Projects
2014
Study of self-injurious behaviors and the
intervention with visual supports
Karoline Kenville
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Study of Self-Injurious Behaviors and the Intervention with
Visual Supports
by
Karoline Kenville
Thesis

Submitted to the Department of Special Education
Eastern Michigan University
In partial fulfillment of the requirements
For the degree of
Masters of Arts
in
Autism Spectrum Disorders
Thesis Committee:
Gilbert Stiefel, Ph.D, Chair
Derrick Fries, Ph.D
2014
Ypsilanti, Michigan
ii

Acknowledgements
This thesis would not have been possible without the
the involvement my student, his family, and my colleagues.
It is with immense gratitude that I acknowledge the support,
guidance, and help of my professor,
Dr. Gilbert Stiefel.
iii

Abstract
The intent of this research was to investigate the use of visual
supports for individuals who suffer
from Self-Injurious Behaviors (SIB) stemming from
developmental disabilities such as Autism
Spectrum Disorder (ASD). It has been determined that there are
many causes of SIB in
individuals with ASD, and while some theories are no more than
untested assumptions, there is
validated research on behavioral patterns that suggests that
evidence-based practice of visuals
supports may effectively be used as part of an intervention to
modify behaviors. Visual supports
refers to the range of procedures through social stories,
checklists, and video modeling that assist
in creating positive behavioral supports for individuals with
ASD. These supports are tools that
can teach individuals with ASD self-regulation and de-
escalations strategies to manage the SIB.
This study is intended to expand on studies which indicate that
visual supports can teach self-
management skills to aid in an individual becoming more aware
of his/her own actions.

iv
Table of Contents
Literature Review
...............................................................................................
......................... 1
Assessment for SIB Intervention and Antecedents
.................................................................. 2
Intervention with Strengths for Visual Supports
..................................................................... 4
Visual Skills and Visual Supports
........................................................................................... 4
How Visual Supports Work
...............................................................................................
..... 5

Video Modeling
...............................................................................................
...................... 6
Social Stories
...............................................................................................
.......................... 6
Checklists
...............................................................................................
................................ 7
Thesis Introduction
...............................................................................................
...................... 8
Methodology
...............................................................................................
........................... 9
Participant
...............................................................................................
............................. 12
Operational Definitions
...............................................................................................
......... 13
Procedure
...............................................................................................
.............................. 13
Results
...............................................................................................
....................................... 15

Disclaimer
...............................................................................................
............................. 18
References
...............................................................................................
................................. 19
Appendix I
...............................................................................................
................................. 22
Appendix II
...............................................................................................
................................ 23
Literature Review
Individuals with Autism Spectrum Disorders (ASD) are known
to engage in behaviors that result
in physical injury to their body (Self-Injurious Behaviors, SIB).
The most common forms of these
behaviors are head-banging, biting, rubbing, scratching, hitting,
and picking (Richard, Oliver, Nelson &
Moss, 2012). SIB also occurs in connection with other disorders
like alcohol abuse, drug abuse, post -

traumatic stress disorder, eating disorders, personality disorder,
and it rarely occurs in isolation from
other symptoms or disorders (Mueller & Nyhan, 1982).
SIB, are, arguably some of the most distressing behaviors
exhibited by people with
developmental disabilities (Edelson, 2013). The exact cause/s of
self-injurious behaviors are
unknown, but could be related and not limited to chemical
imbalance, sinus problems,
headaches, seizures, ear infection, frustration, sensory input,
sensory overload, or task avoidance
(Edelson, 2013). SIBS are relatively common in individuals
with ASD with 50% of individuals in
one study reported to have engaged in such behaviors
(Baghdadli, Pascal, Grisi, & Aussilloux,
2003). The diagnosis of ASD in increasing across the w orld and
with the increase of diagnoses
there has been concern in developing successful interventions
for SIB in individuals with ASD
(O’Reilly, Sigafoo, Lancioni, Edisinha, & Andrews, 2005).
Depending on the case and the individual, some triggers to SIB
have been proposed as a
self-stimulation, which often occurs without apparent
environmental causes (Edelson, 2013).

This means that SIB are understood as being sustained by self-
induced stimulation of the senses
and helps strengthen both sensory and social development.
Neuropsychological models and cases
result in either under or over-sensitivity to stimulation (Richard
et al., 2012). SIB can also be a
form of self-stimulation that corresponds with the idea that
respective behaviors provide under-
aroused individuals with stimulation. One study (Richard et. al.,
2012) showed that allowing an
2
individual to replace the stimulating effects of SIB with more
appropriate behaviors could
decrease the negative and problematic behaviors. An ABAB
design research study by O’Reilly,
Sigafoo, Lancioni, Edisinha, and Andrews in 2005 used visual
supports as an intervention to
decrease SIB in a twelve-year-old boy with ASD. This study
examined the effects of an
individualized schedule, based on a functional analysis,
produced substantial reduction in SIB

and increase engagement. The schedule of activities was
evaluated within the context of his
regular curriculum. The results of the functional analysis
suggested that the SIB was associated
with the academic demands and rarely during play or peer
interaction. The schedule was
implemented at the start of each day and during transition
periods. Not only did this intervention
decrease the SIB, it also increased academic engagement by
70% and was maintained for 5
months (O’Reilly et al., 2005).
Assessment for SIB Intervention and Antecedents
When collecting assessment information, it is important to
collect baseline data of the
self-injurious behaviors. This baseline might include historical
data concerning the individual’s
physical and mental health, cognitive and emotional regulation,
behaviors, family history,
cultural values, and peer relationships (Walsh, 2006). These
data might also consist of the
number of physical wounds, their patterns, and how often the
individual is engaging in any
particular behaviors. Prior to SIB treatment, having adequate
baseline data on the individual’s

behaviors and history will inform the target of the intervention
and provide a foundation for
measurement of the individual’s progress (Walsh, 2006).
Identifying the antecedent is crucial in creating an appropriate
intervention program for
the individual suffering from SIB (Manhatmya, Zobel, &
Valdovionos, 2008). All interventions
ought to examine the relationship between antecedents and the
undesired behaviors. When
3
antecedent stimulus can be identified, an intervention can be
created to ultimately reduce SIB.
Functional behavior assessments and analyzing the individual’s
actions can help identify the
antecedents to the SIB. For successful treatment, it is important
to determine these functions and
then create a treatment based on these functions (Manhatmya et
al., 2008). Antecedent
intervention methods emphasize the use of positive
interventions that manipulate the antecedents
that set the occasion for SIB (Humenik, Curran, Luiselli, &

Child, 2008). When identifying a
behavior it is essential that the behavior is defined objectively
with clarity and completeness
(Kazdin, 2001). The criteria for defining behaviors must start
with specifying the general
domain; in this case the domain would be self-injurious.
Objectively defined behavior measures
observable characteristic of a behavior or events. Clarity i s
defined as the behavior’s description
is unambiguous to the extent that it could be replicated (Kazdin,
2001). Completeness is a
delineation of the boundary conditions maintaining a response
that is to be included and
excluded is enumerated (Kazdin, 2001). If the range of
responses included in the definition is not
described carefully, observers have to infer whether such
behavior has occurred and failure to
have a delineated definition allows for inaccurate data
collection (Kazdin, 2001). These are the
very first steps in a functional analysis.
Direct Observation is the viewing of the targeted behaviors in a
situation while taking
data on the antecedents and consequences associated with the
behavior and is the functional

analysis. This information is required for a functional analysis
(Cooper, 2007). This process can
occur through a two-sided mirror or in the same environment as
the subject. It is important not
to place any gaps between the antecedents, the behavior and the
consequence (ABC). The intent
of the behavior assessments is to determine the function of the
behavior, which is the first step
towards developing a treatment plan. When an individual
engages in SIB, these behaviors
4
become the primary treatment target. A functional analysis will
collect data on the behaviors to
determine the antecedent of the behaviors. The functional
analysis, then, will support the
reasoning for the intervention with the possible use of visual
supports.
Intervention with Strengths for Visual Supports
Social skills, especially in areas of verbal and physical
communication, are common
challenges for individuals who have ASD. Communicating with

others is an important aspect of
life and having a difficult time communicating can negatively
affect other areas of an
individual’s daily routine. Many individuals with autism have
deficits understanding even the
seemingly simplest forms of communication from others
(Hodgdon, 2000).
Visual Skills and Visuals Supports
Many individuals with ASD have strong visual skills and these
strengths can be
capitalized on with visual supports; though verbal
communication can be an area of difficulty
when treating an individual with ASD, using an individual’s
strengths to exploit their area of
weakness could help compensate for that particular weakness.
With the help of visual supports,
an individual with ASD has a better opportunity to understand
and comprehend what is expected
(Wilkinson, 2008). Visual communication tools such as objects,
photographs, symbols,
checklists, and schedules could all provide that necessary
support to improve an individual’s
communication, which in turn would help prevent SIB stemmed
from communication issues.

Visual acuity (color, texture, etc.) and visual discrimination do
not appear to be affected
by autism. For many nonverbal individuals with ASD, measures
of ability are obtained skills
through assessments of visual motor skills. Recent studies have
suggested that the extraordinary
skill in noticing minor features and changes in the environment
reflects an enhanced visual
processing ability for individuals with ASD (O’Riordan &
Passetti, 2006; Hayes, 1987).
5
Visual supports are made to improve communication,
interaction, and understanding all
while reducing anxiety, confusion, and frustration (Hodgon,
2000). Because individuals
diagnosed with ASD have a tendency to respond to visual cues,
visual supports may be used to
create positive behavior supports for the individual. The visual
support teaches the individual a
way to cope, self- regulate, or communicate in an easy and
efficient manner (Roa & Gagie

2006). These supports include the use of illustrations, photos,
sketches, symbols, and text that are
customized, in regard to both function and design, to the
individual’s assessment (Schneider &
Goldstein, 2009). It is important to ensure that the visual
supports are appropriate for the
individual and modified uniquely for his or her needs. Visual
supports can help an individual
learn how to recognize and manage the antecedent behaviors,
that which typically escalate into
SIB (Roa & Gagie, 2006). Managing those undesired behaviors
through visual supports helps
create a learned behaviors to decrease the occurrences of SIB
(Schneider & Goldstein, 2009; Roa
& Gagie, 2006).
How Visual Supports Work
Roa and Gagie (2006) report that visual supports
improve communication skills in
individuals with ASD. Visual supports can serve in the
facilitation of task analysis and the
breakdown of tasks into manageable steps (Wilkinson, 2008).
This allows for independence in
areas such as adaptive social skills and academic tasks.

Visual supports are beneficial for focus, concentration,
imaginations, transition, and
creating mental pictures (Roa & Gagie, 2006). Visual memories
also help connect the smaller
parts of a conversation to an entire schema, aid in
communication, and reduce frustrations (Roa
& Gagie, 2006). Visual supports are critical aspects of an
intervention program because they
6
enable students to integrate the elements of their experience
and, thereby creating less demand
on the individual’s memory (Schneider & Goldstein, 2009).
Video Modeling
Video modeling is a form of observational learning in
which the individual, through
watching and imitating a video demonstrating the modeled
behavior, learns the preferred
behaviors. Through imitation and role-playing, video modeling
can be used to strengthen social
skills, communication, and athletic performance. A variety of
behaviors can be observed in these

models such as functional and academic language skills, social
skills, and cognitive abilities
(Roa & Gagie, 2006). Video modeling also helps decrease
certain behavioral problems including
tantrums and aggression. Video modeling supplants face-to-face
interactions and allows the
individual to process visual information more readily than
verbal information; this modeling also
provides support for attention, stimuli, and visually cued
instruction. Video modeling creates a
learning opportunity for individuals with ASD to acquire self-
regulating skills used to decrease
SIB (Roa & Gagie, 2006; Schneider & Goldstein, 2009).
Social Stories
Although social stories are not necessarily visual supports, per
se, they are often used in
conjunction with other visual supports and so are included here.
The goal of a social story is to
share accurate information in descriptive sentences that coach
an individual to clearly identify a
topic. Social Stories can be written as visuals guides for
individuals with ASD that have
accurate information that describes social interactions,

behaviors, situations, or skills that is
easily understood by the individual (Gray, 2010).
Social stories are created on an individualized basis and
assist individuals with ASD to
understand social situations by delineating an appropriate
behaviors while providing appropriate
7
responses. These stories outline steps for implementing the
appropriate skills that include
information in a variety of circumstances. Social stories can be
used to aid the individual in a
variety of ways, ranging from social interactions to dealing with
their own emotions; they can
also aid in medical, personal care, and safety. Individuals may
revisit their stories with some
frequency to continue to benefit from the desired effects
(Schneider & Goldstein, 2009). Social
stories can be used to educate and model appropriate social
interaction by describing a situation
with relevant social cues, alternative perspectives, and
suggested appropriate behaviors

(Schneider & Goldstein, 2009). Social Stories need to have
descriptive sentences that give
details about the situation so a child could recognize when the
situation actually occurs.
Perspective sentences ought to tell the details of one of the
child’s possible feelings and
appropriate responses. When the antecedent to the SIB occurs, a
social story can be referenced
for assistance on future events. After SIB occur, social stories
can be used to give examples of
what more preferred responses ought to be (Schneider &
Goldstein, 2009). Social Stories are
visual supports because they similar to “mini personalized
books” created particularly for an
individuals need. These “personalized books” (social stories)
can be a tangible such as created on
an iPad or paper form.
Checklists
A checklist provides a firm foundation for organization
and structure for an individual
with ASD. Individuals with ASD benefit from having checklists
to decrease challenging
behaviors, by providing a more specific routine for any given
procedure. Checklists can be used

as a helpful device for an individual to predict and choose their
daily activities; a checklist might
become especially useful when the individual is experiencing
changes in his or her typical
8
routine. Checklists often provide skill development and promote
independence (McClannahan &
Krantz, 2010).
It is evident that SIB is a distraction from one’s constructive
use of time, but the uses of
checklists provide organization and structure, which allows for
productivity throughout the day.
Checklists help reduce confusion and aid in the initiated task
more quickly and efficiently. An
individual using a checklist can be more accountable by
providing visual reminders and cues for
their behaviors, routines, and expectations. Like all visual
supports, checklists can be used to
address needs in an individualized way for adults and children
with ASD to reduce SIB (Roa &
Gagie, 2006).

Traditional tools such as calendars, planners, maps, and books
can be used as visual
supports for assisting in daily life. Visual supports can be used
for students with ASD starting as
early as possible and then can be carried into adulthood, as they
are a connecting piece between
communication and behavioral challenges. Visuals supports can
be used in any environment
necessary to ensure proper communication, social interaction,
and positive behaviors (Hodgdon,
2000). With the help of visual supports, it is expected that more
tasks will be completed and an
individual will thus increase their independence (Wilkinson,
2008). Using visual supports as an
intervention may increase the processing of learning while
decreasing the levels of frustration,
anxiety, and aggression (SIB) related to task, transition, and
other challenging situations
(Wilkinson, 2008).
Thesis Introduction
In this study, visual supports were used to create functional
communication and alterative
behaviors. I used a checklist to identify the proper sequence of

events or tasks. Video modeling
was used to model the desired behaviors during tasks or
transitions. Social stories were used to
9
help identify appropriate behaviors when in the same
environment as peers as a visual support.
These interventions were systematically implemented during the
times in which previous data
indicated the antecedent to the highest probability of SIB
(during unsuccessful task, transitions,
avoidance, and lower-level noncompliant behaviors). These
materials were introduced prior to
the intervention process to formularize the child.
Will the use of visuals supports in conjunc tion with other
methods of ongoing therapy
further reduce the incidence of SIB? The ongoing treatment,
which will be described later, had
been in place prior to the visual supports intervention. Both the
ongoing treatment and visual
support intervention will be described in the methodology
section. The visual supports are

additional components to the treatments with the goal of further
reductions (goal of reducing) in
SIB.
It is hypothesized that with the assistance of the implemented
visuals supports, the SIB
will be further reduced by, either decreasing the behavior or
changing the behavior completely.
Consistency is important for maintaining and expanding on
productivity of the services and its
effectiveness. It is important for all caregivers to learn
techniques thought communication
training in order to assist in the elimination of the injurious
behavior.
Methodology
This single subject study focuses on self-injurious behaviors
(SIB) and is based on the
assumptions that visual supports will help decrease the
frequency of SIB. This is a case study of
a 5-year old boy with high-functioning autism whose motive for
this behaviors might be inferred
as “frustration” in as much as the SIB appears to be triggered by
the unsuccessful completion of
tasks, unavailable access to tangibles, transitions between a
preferred and less preferred activity,

an insertion of control in a less preferred task or when he
simply wishes to avoid a less preferred
10
tack. There were three specific SIB targeted in this thesis they
are as follows: a forceful open-
hand hit (slap) to the head, forcefully running into a wall head
first and forcefully bringing those
objects that were in close proximity to strike himself in the
head with the object. All three of
these targeted behaviors were repeated during each occurrence.
The occurrence was defined as
an interval of rapid/repeated occurrence of one or more of the
targeted behaviors with no more
than a 5 second laps between repetitions of behaviors.
The antecedents are believed to be the conditions that lead the
student to engagement in
SIB. I have identified contextual antecedents of the student’s
behavior prior to SIB. I have
recorded the frequency of SIB as baseline data. I then
implemented the use of visual supports
described earlier as an additional intervention for decreasing the

frequency of SIB in these
contexts. The data indicated that the SIB most often occurs
during times of transition and the
task of hand-washing. Transitions may results in challenges in
behaviors for a child with ASD
when having to move from one task to another, from one place
to another, or from one
experience to another. Transitions often signify moving from
known to unknown or simply a
change in expectations. Transitional warnings allow an
advanced notice before a change occurs
to make the coming events predictable and less surprising. In
the initial stage (before visual
supports were added), transitional verbal warnings were given
prior to the changes in activity.
(For example, “Johnny, in 2 minutes we will be going outside.”)
During the intervention stage
which included visual supports, transitional warnings were
changed to a visual checklist
(schedule), with verbal prompting 2 minutes prior to the
transition. The student was required to
participate in the reading of his visual checklist to ensure
paying attention. The student was given
another transitional warning at 1 minute prior to the transition.

Prior to the task of hand washing
required that tutor used a hand-over-hand partial prompt
technique to ensure effective hand
11
washing. During hand-washing is when objects in the close
proximity grabbed by the student and
then was used to make forceful contact to his head. The sink is
located near a wall in the
bathroom, during this time the student would often engage in
SIB by banging his head into the
wall next to him. It was important to ensure that all blocking of
these behaviors was required, to
the best of the ability of the staff member involved. During the
task of hand-washing no visuals
were used prior to the intervention, however during the
intervention I used video modeling and a
checklist as a prompt for effective hand-washing without SIB.
Based upon prior sessions, I
knew the task of hand-washing was going to occur for the first
time in a session the video model
clip was to be watched and commented on accordingly. During
hand-washing a visual checklist

was posted on the wall in sight for the student to reference.
Both expressive and physical
prompts were used and faded as the student became familiar
with the visual support. Other
incidents in which SIB occurred was in avoidance to task and
non-compliance when a demand
was placed. When transitioning from a preferred to a non-
preferred task, the student would hit
himself in the head with an open hand along with running into
walls head first and verbal
behaviors. The visual supports will give alterative behaviors
that are rewarded via a token
economy system. The intervention created will be a visual
support that will aid in socio-
emotional control with the goal of decreasing SIB. The goal of
the behaviors modification is to
teach an individual how to control the individuals’ behaviors,
achieve self-selected goals, and
participate adaptively in everyday life without the support of an
intervention. Capitalizing on the
student’s strength of visual perception, visual supports ought to
target the antecedent behavior
prior to SIB with the anticipation of decreasing the SIB.

Positive reinforcement is the increase in the frequency of a
behavior following the
presentation of a (positive) stimulus. The main goal of a
reinforcement program is to reduce the
12
undesirable behavior. Though, this is a technique for increasing
the desired behaviors and
engages in any behaviors of the targeted response (Cooper,
2007). On the contrast, negative
reinforcement is a stimulus whose termination functions as a
reinforcement, ending a task or
environmental effect early upon compliance or completion
(Cooper, 2007). Escape is known to
be a contingency that the response terminates the ongoing
activity or environmental effect. The
antecedent is the environmental condition that in which occurs
immediately prior to a behavior
of interest. The behavior is the activity of living organisms that
portion of an organism
interaction with its environment (Cooper, 2007). Through space
and time the organisms’
interaction can be measured through public events. In this thesis

the behavior is self-injurious.
Participant
The student was clinically diagnosed with Autism at the age of
3.11 when his parents had
concerns about his social delays and self-injurious behaviors
(SIB). This student has recently
enrolled into an early intervention program for 15 hours a week,
working with a behavior tutor
and a board certified behavior analyst. This student has
strengths in visual perception and
retention to memory. In terms of visual perception, this student
has demonstrated strong visual
acuity with 20/20 vision. In terms of memory, this student has
previously shown the ability to
recite and recall previous events with delineated details. During
this student’s intake for services,
our behavior analyst administered the Assessment of Basic
Language and Learning Skills
(ABLLS) for evaluation to identify what needs to be targeted
for educational goals. These
results indicated that the student has high levels of behavioral
deficits that are commonly
associated with Autism. These behavioral deficits are in the
area of noncompliance, mild to

moderate behavior escalation, repetition, and unusual intensity.
By the age of 5, the student has
memorized third grade reading level books and often scripts his
favorite movies and television
13
shows. This student is able to read at a level significantly
higher than his peers. We are unsure if
this student’s behavior if to fulfill a sensory need, escape the
demands of undesired situations or
events, gain attention, or obtain tangibles. The student is in
need of early intervention to help
control his SIB and self-regulation of socio-emotions.
Operational Definitions
Through observation, it has been identified that the student
partakes in SIB with
unsuccessful completion of tasks, transitions, avoidance, or
noncompliant behavior and
unavailable access to tangible items. The student typically will
grind or clench his teeth and
begin making a “groaning” sound in the back part of his throat
that is associated with heavy

breathing following a antecedent to the behavior. At this point,
his behavior tutor will attempt to
prevent this behavior from escalating into SIB. When the
escalation occurs, this student will
frequently open-hand bring his hand to the temporal region of
his head with force (slapping).
Depending on the location, the SIB can escalate to the extremity
of forcefully bring objects in the
close proximity to the temporal region of his head. The
escalation of his behavior also may result
in running at his fastest into a wall and simultaneously hitting
his head. The student appears to be
unaware of the severity and extremity of his SIB. The duration
of this behavior varies depending
on the reinforcer and antecedent.
Procedure
During this study the use of baseline data from a functional
assessment was used in order
to form a hypothesis of the functions of the behaviors. The data
collected disclosed the
relationship between the SIB and the antecedents and
consequences of the behavior. I observed

this individual in clinical and home environments to create a
conclusive collection of data. I
looked at two applications of design that include multiple
baselines and the A-B-A-B design.
14
An A-B-A-B design is an experimental design consisting of a
baseline counter therapeutic trend,
an intervention phase a return to baseline (no intervention) and
finally a second intervention
phase to identity whether the initial treatment effects are
replicated (Cooper, 2007). This is a
single subject research that will compare different conditions
presented to one individual over
time and this design will allow me, the researcher to examine
the pattern and stability of
performance of the single subject. The A-B-A-B design allows
for the intervention to follower
the pattern of examine the behaviors with the influence of no
intervention and with intervention.
It was critical in this research project to gather pre-test
information (baseline data). The baseline
data serves two functions, describing the existing level of

performance and for predicting the
level of performance (Kazdin, 2001). I measured dependent
variables (antecedent behaviors)
prior to administering any interventio ns. Without this
information, it would have been difficult
and unlikely impossible to determine if any changes have
occurred. I took data for the existence
and duration of the SIB. These data were collected during my 3-
hour Applied Behavioral
Analysis session at a private clinic in Ann Arbor, Michigan.
The use of the baseline data that were collected across 3 days
that determine the time of
day that had the highest prevalence, the average amount SIB
occurring in one session, and the
duration of the behavior for my intervention. Once I had
analyzed the baseline data that indicated
when the behavior is most prevalent, I took ABC (antecedent
behavior, consequence) data on the
behavior. These data helped to identify what factors are causing
the SIB. Once the antecedent
was identified, the visual support was created. The visual
supports capitalized on the individual’s
strength of visual perception and memory. Based on the baseline
data collected, the use of

checklists, video modeling and social stories were methods for
intervention. All of these methods
were used across one week depending upon on the context (for
example, hand-washing was
15
supported through a visual checklist, transitions were supported
by video modeling and visual
schedules, social interactions were supported by social stories
and video modeling). During the
weeks with verbal only or verbal and visual supports, I took
observational data to determine if
there is a change in behavior. Data were then tabulated and
used to formulate a conclusion.
Results
The verbal warnings were not sufficient in ensuring a successful
transition as suggested
in the baseline data of the frequency of the SIB. During the first
week, the data indicated that
there were 35 total incidents of Self-Injurious Behaviors, while
at the end of the intervention the
data indicated there were 22 incidents of Self-Injurious

Behaviors (see Table 1). Table 1
indicates a 37% decrease in the number of Self-Injurious
Behaviors indicating the effectiveness
of visual support in reducing SIB for a child diagnosed with
ASD. As a result of the significant
decrease in SIB, this intervention will become a part of this
child’s behavior plan with hopes of
making further changes in the SIB. In light of the seriousness of
SIB, these results are viewed as
quite encouraging. In this case study, visual supports have
helped decrease a problem behavior
that is a barrier for independent learning and communication for
this student. With continui ng
the intervention, it is anticipated that the SIB will continue to
decrease and create the opportunity
for a better quality of life for this individual
It is very important to note that there are dissimilar and varying
reasons why someone
might inflict SIB. It is important to have a positive outlook
when trying to understand and treat
this behavior. Self-injurious behaviors can be controlled
through various interventions. It is
highly recommended that an individual who suffers from SIB
ought to be evaluated by a mental

health professional for an assessment. Creating a behavioral
program from a behavioral
assessment is beneficial. The evaluation of a mental health
professional will allow for assistance
16
in identifying an interventi on and treating the underlying causes
of SIB. There is no single
intervention to decrease SIB in children with ASD. It is
important to base the intervention on the
results of the functional behavioral assessments and
individualize each of these supports. In this
study I provided alternative behaviors and I have not reduced
triggers and some discretion. In
this study all data collection was done at the same time each
day that indicated to be the highest
prevalence of SIB expect one day. During Week 3, the session
occurred at a different time of day
than the rest of the interventions. These may have caused a
weakness in the consistency of the
data collection. Prior to this intervention, this student had had
other interventions in the past

with attempts to reduce the SIB.
Table 1 (Appendix I) represents the occurrence of self-injurious
behaviors across each
week. The first week, a non-intervention week, had 35 total
occurrences of SIB. During the first
intervention in Week 2, the visual supports seemed to enhance
the current intervention by
resulting in 22 total behaviors. Week 3 was a non-intervention
week and indicated a slight
increase in total behaviors by 3. At the end of Week 3, the total
SIB recorded was 26. Finally, at
Week 4, the behavior decreased in the last week of intervention.
Week 4 had 22 occurrences of
SIB, as it was the same in Week 2 (both intervention weeks had
the same total SIB’s
occurrences).
Table 2 (Appendix II) represents the data collection for the
intervention of using visual
supports to potentially decrease SIB with a student diagnosed
with autism and the patters of the
behaviors are changing. All of the data were collected within
one hour of a three-hour behavior
therapy session.

17
In Week 1, a non-intervention week, the data indicate that this
student engaged in 24
occurrences of open hand hits to his head, 2 occurrences of
running into a wall head first, and 9
occurrences of hitting himself with objects in the close
proximity.
In Week 2, an intervention week, the data indicate a decrease in
the SIB. (Week 2 is
when the intervention first was introduced). The data for Week
2 indicate that there were 17
incidents of open head hits to his head, 0 running into walls
head first, and 5 hitting his head with
objects in the close proximity.
In Week 3, a non-intervention week, the SIB either decreases or
was unchanged, besides
in the SIB of running into a wall head first. This behavior
increased to 8 times total that week.
During Week 4, an intervention week, the data indicate 14
occurrences of open hand hits
to the head, 4 occurrences of running into a wall head first (4
fewer than the previous week), and

4 hitting his head with objects in the proximity. Interesting
enough, the patterns of behaviors
changed during each week. Weeks 2 and 4 indicate the lowest
number of total behaviors;
however, the SIB of open hand hitting to the head had increased
in comparison to Week 3, a non-
intervention week. Notably, the frequency in SIB did not come
back to pre-treatment levels,
even during the non-intervention Week 3 period. This may
reflect the stimulus control of
concurrent verbal interventions. Meanwhile, the lowest levels
of SIB were observed during the
verbal and visual intervention periods.
Overall, during the weeks of intervention the SIB had decreased
in total number of
occurrences, while during the weeks of no intervention the
number of occurrences increased. The
data indicate that during the period in which visual supports
were presented, there was a decrease
the SIB by a total of 12 occurrences. These data suggest that the
visual supports assisted in
decreasing the total number of occurrences of SIB for one
student.

18
Had I extended the intervention longer than a week, it may have
changed the rate of
behavior. The extension in the intervention would also create a
larger data collection across
periods which could have resulted in more powerful results.
The data collected in this
intervention illustrate pairing with visual supports and seem to
enhance the intervention of
decreasing self-injurious behaviors, to what extent is unsure.
Disclaimer
There are many challenges faced when teaching children with
autism, even more so when
the behaviors are as serious as SIB. It is important to recognize
that many skills take time to
develop and while interventions are taken place; it is important
to ensure ongoing supports are
implanted for continues efforts to decrease SIB. Parent consent
was given before any additional
supports were included. Changes in the behavior could
additional be influenced by maturation,

and/or other environmental factors. To track progress I
collected data based on the response to
the intervention the plan was effective. During this
intervention, I used the skills taught by my
professors in the course work at Eastern Michigan University,
and I was closely observed and
guided by highly trained professionals in the field of applied
behavior analysis and special
education.
19
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Research, Volume I, 47, 622-627.
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Upper Saddle River: Pearson. 28, 40,
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supporting behavior improvement?
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approach. Retrieved January,
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treating self-injurious behavior.
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institute.com
Gray, C. (2010). What are Social Stories? In The Gray Center.
http://www.thegraycenter.org/social-stories/what-are-social-
stories.
Hayes. (1987) Enhanced visual, search for a target. University
of Cambridge. Retrieved January

1, 2014, from: www.pages.uoregon.edu/.pdf
Hodgdon, L. (2000). Visual strategies for improving
communication: Practical supports for
school and home. 2-6, Troy, MI: Quirk Roberts.
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(2008). Intervention for self-injury in a
child with autism: Accepts of choice and continuous access to
preferred stimuli.
Behavioral Development Bulletin, 8, 11
http://www.autism-research-institute.com/
http://www.thegraycenter.org/social-stories/what-are-social-
stories
http://www.pages.uoregon.edu/.pdf
20
Mahatmya, D., Zobel, A., & Valdovinos, H. G. (2008).
Treatment approaches for self-injurious
behavior in individuals with autism: Behavioral and
pharmacological methods. Journal of
Early and Intensive Behavior Intervention, 17-21
McClannahan, L., & Krantz, P. How to teach self-management
to people with serve disabilities,

a training manual. (2nd ed.). Woodbine House; Retrieved
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Meadan, H., Ostrosky, M., Triplett, B., Michna, A., & Fettig, A.
(2011). Using visual supports
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O’Reilly, M., Sigafoos, J., Lancioni, G., Edrisinha, C., &
Andrewsons, A., (2005). An
examination of the effects of a classroom activity schedule on
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and Developmental
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Passetti, F., & O'Riordan, M. Discrimination in autism within
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Rao, S. M., & Gagie, B. (2006). Learning through seeing and
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Schneider, N., & Goldstein, H. (2009). Using social stories and
visual schedules to improve
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New York, NY: Guilford.
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Autism Task Force
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reduce self-injurious behavior in
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22
Appendix I
Occurrences of SIB each week
Table 1

0
5
10
15
20
25
30
35
40
Total SIB
Week One
Week Two
Week Three
Week Four
23
Appendix II

Patterns of Behaviors
Table 2
0
5
10
15
20
25
Week 1 (A) Week 2 (B) Week 3 (A) Week 4 (B)
9
5 5
4

Open Hand to Head
Running Into Wall
Hitting with Object
Eastern Michigan University[email protected]2014Study of self-
injurious behaviors and the intervention with visual
supportsKaroline KenvilleRecommended
Citationtmp.1521047519.pdf.KMTJm
Running head: SELF-INJURIOUS BEHAVIOR 1
SELF-INJURIOUS BEHAVIOR 12
Self-Injurious Behavior
O Z
University
Self-Injurious Behavior
For this final assignment a research of self-injurious behavior
has been conducted. Self-injurious behavior, also known as
SIB, is described an instance of behavior that results in physical
injury to a person’s own body. SIB includes head banging,

using objects to cut or puncture self, pinching self, consuming
inedible substances, vomiting, pulling own hair, sucking, biting,
scratching body parts and use of drugs, among others (Yang,
2003). SIB, is usually displayed by individuals with autism and
intellectual disabilities. SIB can result in serious injuries and
in severe cases even death. According to Yang (2003), the
treatment of SIB has become one of the most serious issues for
clinicians and other professionals due to the injury, risk,
prevalence, and cost involved.
Article 1
Overview
The first article discussed is "Combination of extinction and
protective measures in the treatment of severely self-injurious
behavior" by Lizen Yang from Behavioral interventions journal.
Yang explores and discusses the advantages of using extinction
in conjunction with the non-intrusive protective measures to
treat SIB. In the study, extinction in combination with non-
intrusive protective measures was selected as the intervention
strategy to reduce SIB.
Subjects and setting
The study was conducted on two adolescent females with
profound mental retardation and physical disabilities at a state
facility. In this case both subjects exhibited self-injurious
behavior (SIB) and had been wearing restrains mechanisms for
more than two years to prevent injuries. The treatment sessions
were conducted in the morning for one of the subjects and in the
afternoon for the other subject in a multipurpose 12’ x 13’room
in their residential building. The room contained a table, a
desk, and three chairs. Fingernail clippers, a pair of scissors,
and a bottle of white petroleum jelly were used, since the target
behavior for both subjects was scratching. Soft music at a
moderate volume was played during sessions. There also were
several activity materials available and placed on the table for
participants to access during treatment. Only the therapist and
the participant were in the room.
Design and results

Data was collected using event recording during each 30 minute
treatment session. Observers used two hand held counters to
record the target behavior. In order to constantly analyze data,
and monitor the behavior, as well as to avoid medical issues,
each treatment session was divided into three 10 minute
intervals. Initially a within-subject reversal design was in
which baseline (A) and treatment (B) were alternated in an
ABAB sequence, but due to frequent and severe self-injuries
and for safety reasons, an AB probe design was implemented.
During the baseline period, staff were instructed to respond to
the target behavior as they normally did. In addition to the
continuous application of non-contingent intrusive protective
devices, staff was instructed to use verbal instructions to
prevent injury. No SIB occurred during baseline because of
continuous use of protective measures to prevent injuries.
Subjects were given two days in between the baselines and the
treatment to allow for healing from any injuries caused during
the sessions. During treatment, the subjects’ nails were checked
for length and petroleum jelly was applied to their fingertips
and target areas. Both subjects’ hands then were guided to
touch and manipulate the provided activity materials for about
30 seconds before they were released to start the extinction
procedure. During the extinction procedure, no further verbal
instructions or physical blocking were used. During extinction,
SIB was observed and recorded. No verbal instructions nor
physical intervention were employed to stop the SIB.
Internal, External, & Social Validity
The data was displayed on an interval graph that portrayed
baseline and treatment. Internal validity was displayed i n this
study as each graph of the participants in the study show that
there was a functional relationship between the use of
continuous intrusive measures (Condition A) and non-intrusive
measures during treatment (Condition B). The study results
showed that extinction was both effective and efficient in
eliminating severe SIB. The results also indicated that using
the non-intrusive protective measures (petroleum jelly and

checking nails) and allowing the target behavior to occur while
minimizing self-injuries made it possible to implement the
extinction procedure. External validity was also displayed
because the intervention was applied effectively on more than
one participant. Social validity was also present in this study,
as each of the participant’s behaviors were eliminated. This
research study was beneficial to subjects involved as the
procedure help decrease the need for medical attention, it
increased physical freedom from restraints, and even the re-
growth of hair on the participants (Yang, 2003). The study
results showed that extinction was both effective and efficient
in eliminating severe SIB. The results also indicated that using
the non-intrusive protective measures (petroleum jelly and
checking nails) and allowing the target behavior to occur while
minimizing self-injuries made it possible to implement the
extinction procedure.
Article 2
Overview
The second article under review is called “Functional analysis
and treatment of self-injurious behavior in young children, a
summary of 30 cases” from the journal of Applied Behavior
Analysis, by Kurtz et al. The authors review the onset of SIB in
young children below the age of five and discuss on how to
effectively manage this behavior at early stages of development.
They further discuss the implications of their findings for the
development of early programs of intervention for SIB.
Subjects and Setting
The researchers use 30 children under the age of 5 years, the
youngest being 2 years, all of whom had been referred in the
period of 3 years for exhibiting severe SIB. 17 f them were boys
while 13 were girls. They each were simulated to conditions
that acted as stimuli for their SIB. Some of the set conditions
included physical attention being given by the caregivers
including rocking the child. Another condition set was where
the child was not given full attention, that is, the adult was
engrossed with another adult talking thus giving the child

divided attention, then once in a while reprimanded the child. A
third simulated condition was set where the caregiver left the
child then returned and reprimanded the child. There were
concerns about isolation and therefore conditions were set
where none of the children were solely left. Also, normal living
conditions like watching TV and house chores and daily
activities like personal hygiene were simulated. This way, the
typical behavior of the children was able to be studied (Kurtz et
al, 2003 ).
Design and Results
Each of the participants were assessed for 2 to 3 hours a day, 2
to 3 days a week for 12 to 16 weeks. Trained staff were placed
strategically behind one-way view mirrors to observe the
behavioral characteristics of the children during the period of
assessment. The room only had the therapist and the child
during the periods of assessment.
The data that was received was then constantly and
progressively recorded on computers stored for analysis. The
data received from the responses was subjected to rigorous
analysis by computer programs and output displayed. The mean
age for the onset of SIB was found out to be 17 months. The
behavioral characteristics were also analyzed and the results
calculated as follows. Head banging was found to be the most
common and first indicators of SIB with prevalence of about
70% in all the cases that were analyzed. 10% of the participants
exhibited self-biting, 6.7% exhibiting body slapping behavior.
Body slamming, body slapping and scratching each accounted
for 33% of the early signs of SIB in children.
Internal, External and Social validity
The data retrieved from this study was found to be valid in
all the three aspects of validity including internal, external and
social validities. The internal validity comes in where,87% of
the studied participants who exhibited SIB were found to
change their behavior with functional interventions. The
external validity results from the fact that each of the categories

of the children exhibited SIB with environments independent
from each other. The social validity comes about where, there
was a 43% decrease in the SIB behavior exhibited by the
children who participated when the different functional stimuli
that aggravated the situation were altered.
Article 3
Overview
Article 3 discusses “Study of Self-Injurious Behaviors and
interventions by visual supports” by Kenville. The author
studies the causes of SIB in children with autism and further
attempts to employ the use of visual aid to reduce the levels of
SIB exhibited in these children. The author believes that the use
of visual aids with further reduce the SIB particularl y in
children with autism.
The participant in this survey is a 5-year-old boy with
autism (Kenville, 2014). The author investigates the certain
behavioral changes that visual aid can impact on the boy by
using daily activities of the child. In the setting, the author
prefers to investigate these conditions at home. This is the
natural habitat of the child and no alterations are made in regard
to changing the environment. The author observes the different
activities the child engages in over a period of four weeks. The
normalcy is applied to both the subject and the parents while the
study is underway.
A digital reminder was used however to remind the child
of some activities to carry out and some transitions to make,
prior to these transitions. These were done during the weeks of
intervention only. These aids were meant to be assessed for
their impacts on the changing or in this case reduction of SIB
behavior being exhibited by the child.
Design and results
The study was conducted over-period of four weeks, the
researcher employing an A-B-A-B fashion. Here, the child was
subjected to no intervention in the first week, there was

intervention by use of the visual aids in the second week. In the
third week, the researcher withdrew the aids and then returned
the use of visual aids in the fourth week. The results obtained
from the observations made were analyzed using baseline data.
During the first week which was a non-intervention week, the
child exhibited a total of 35 incidences of SIB including
running into the wall and hitting the head with objects in his
proximity. In the second week, visual aid was deployed to help
the child in transitions and carrying out tasks. This is because it
had been noted that incidence of SIB came as a result of failure
to complete tasks successfully or transition times. During this
week, incidences reduced to 22. In the next non-intervention
week, cases rose to 26 and in the fourth week they dropped to
22 again with the reintroduction of the visual aids.
Internal, External and Social validity.
Internal validity is obtained since the child shows SIB
incidences when they are unable to complete tasks and in the
case where they are unable to smoothly transition from one
event to the other. The external validity is supported by
findings that the same behavior is exhibited by children with
autism when they are incapable of performing some tasks
successfully. Social validity is attained by the fact that the child
shows decrease in SIB behavior with the help of visual aids.
This proves the hypothesis of the researcher that implemented
use of these visual aids can help reduce cases of SIB in children
with autism.
Article 4
Overview
In their article “Self-injury in Autism Spectrum Disorders and
Intellectual Overview disability: Exploring the role of reactivity
to pain and sensory input”, Savage and her colleagues attempt
to explore the possibility that people with Autism have a high
likelihood of pain tolerance and therefore more likely to exhibit
SIB.
Subjects and setting

Tordjman and his colleagues measured the reactivity to
pain of children and adolescents with ages averaging to about
11.7 years with ASD and Intellectual Disorders. This accounted
for about 72% of those who were considered to be non-verbal. A
control group consisting of 115 children was also used in the
study. These children were those without autism. The setting
was in a hospital setup where the parents were asked to
categorize their children according to their response to life
events for instance accidents or illnesses. This same scale was
used by the medical research staff to categorize the children
under study for their response to pain during medical
procedures (Savage et al, 2017).
Design and Results
The heat rate of the children was monitored to see their
reactions to pain before and after the procedure. Also, their
plasma B- endorphin concentration levels were measured prior
to the procedure and after to see their natural reaction to pain.
Over half of the children under study with AD exhibited no
response to pain. This is because they lacked hypo-reactive
responses during the medical procedures. The control group
however showed a 39% lack of reaction to pain during the
procedure. Heightened reactions were exhibited in 38% of the
children with AD as opposed to a higher percentage of 60% in
those children without AD.
Internal, External and Social Validity
The internal validity is obtained where a higher percentage of
children with autism exhibited no reaction to pain as compared
to their counterparts without the disorder. Also, external
validity is achieved in the comparison of the different children
who had autism since most of them experienced the same
reactions to pain but remained silent meaning that the
characteristics were shared. Finally, social validity is obtained
where there have been other systems of communication evolved
to enable the children with autism to communicate their feelings
and express emotions.
Article 5

Overview
The article under review is called “Self-Injurious behavior
in patients with anorexia nervosa: a quantitative study” by
Linda et al. The study aims to quantitatively determine the
number of patients with eating disorder who experience SIB.
The authors hypothesize that sometimes eating disorders
experience frequent emotional instabilities and have high
chances of exhibiting SIB.
372 patients in a health facility over 16 years and above
participated in the survey. While in the hospital they were
issued with questions to find out about their background with an
aim of understanding if they experience emotional instabilities
thus their likelihood of experiencing SIB. There were no
alterations in the setting of the environment since the aim was
to find out information about the past and not present
circumstances.
Design and Results
The researchers used questionnaires to ask the individual
patients about their background experiences with having eating
disorder. Some personal interviews were also carried out to
determine emotional and psychological states of the
participants. 137 of the 362 who participated in the survey
returned their questionnaires (Linda et al, 2018). Out of
this,41% reported having psychiatric conditions diagnosed. 15%
of them had traumatic disorders ,10% had personality disorders
and 9% had pressure disorders. These results were obtained
from chi-square analysis of the data obtained from the patients.
Internal, External and Social validity.
Most of the patients in the facility showed high likelihood
of having SIB thus internal validity. Most of the results
obtained were independent of each other yet most of the patient
exhibited almost the same types of stigma related issues. This
contributes to the external validity. The hypothesis of the
writers that most of the people with eating disorders have a
likelihood of exhibiting SIB was accepted thus a social validity.

Conclusion
SIB can greatly affect individuals who engage in it. From the
purpose standpoint of each study, it presented that SIB can
affect individual’s ability to interact with others, it can also
make it hard to form relationships, and it has a potential of
causing severe injuries if not monitored or targeted. This paper
discusses effective, evidence based treatments that help reduce
SIB. From non-intrusive measures, to visual aids, to sensory
based interventions, we can see that SIB can be addressed,
reduced and in cases, it can be completely gone. As behavior
analysts, we always look for the safest and less intrusive,
effective methods to help our clients. As long as we can
remember to create individual plans in our client’s best interest,
we can safely implement these.
References
Kurtz, P. F., Chin, M. D., Huete, J. M., Tarbox, R. S.,
O'Connor, J. T., Paclawskyj, T. R., & Rush, K. S. (2003).
Functional analysis and treatment of self-injurious behavior in
young children a summary of 30 cases. Journal of applied
behavior analysis, 36(2), 205–219.
https://doi.org/10.1901/jaba.2003.36-205
Kenville K. (2014) Study of self-injurious behaviors and the
intervention with visual supports. Eastern Michigan
University. Retrieved from

https://commons.emich.edu/cgi/viewcontent.cgi?article=22
12&context=theses
Smithuis, L., Kool-Goudzwaard, N., de Man-van Ginkel, J.M. et
al. (2018) Self-injurious behaviour in patients with anorexia
nervosa: a quantitative study. J Eat
Disord 6,26.https://doi.org/10.1186/s40337-018-0214-2
Summers, J., Shahrami, A., Cali, S., D'Mello, C., Kako, M.,
Palikucin-Reljin, A., …Lunsky, Y. (2017). Self-Injury in
Autism Spectrum Disorder and Intellectual Disability:
Exploring the Role of Reactivity to Pain and Sensory
Input. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5704147/
Yang, L.J. (2003). Combination of extinction and protective
measures in the treatment of severely self-injurious
behavior. Behavioral interventions (1072-0847), 18 (2), p.
109.

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