Robert

Tamara Quran
Orly Silberstein
Lydia Wagner

Outline
Robert
Theories
Assessments
Interventions
Behaviour Plan

Future Goals

Robert

Robert
4-year old boy diagnosed with autism spectrum disorder
Limited communication skills, play skills, and self help
skills
Doesnt initiate interactions (infrequently displays
affection towards mom)
Spends most of his day engaged in self-stimulatory
behaviours (e.g., rocking, twirling plates, etc.)

Robert
When left alone, does not engage in problem behaviour
His parents or BIs make a demand or request Robert
engages in SIB (hits himself in the face/ears) His parents
or BIs back off (unless the demand is related to his health or
well-being)
For the past month he has been receiving behavioural
intervention 2.5 hours per day, 5 days a week
Attempts at time out for occurrences of SIB resulted in a
significant increase in the frequency of this behaviour

Theories of SIB

Self-Injurious Behaviour
Definition: Self injurious behaviour involves any of a
number of behaviours by which the individual produces
physical damage to his or her own body (Carr, 1977, p. 800)
Prevalence of SIB in individuals with ASD: 33%-71%
(Richards et al., 2012)

Common examples of SIB in individuals with

developmental disabilities are banging their head,
biting, scratching, pinching, and poking (Minshawi, 2008; Carr,
Newsom & Binkoff, 1976)

Theories
There are several hypotheses that seek to explain SIB,

these hypotheses suggest that SIB has different

functions
Furthermore, these hypotheses explain SIB by looking
at the reinforcing consequences the individual is
receiving from their environment
After reviewing the literature, Carr (1977) discussed five
hypotheses concerning the motivational variables of
SIB (p. 801)

Theories

The first hypothesis is that SIB is an operant or a learned

behaviour, maintained by positive reinforcement (Carr, 1977)
o Several studies have shown that SIB can be maintained
by positive reinforcement, either in the form of attention
or access to a tangible
o This hypothesis is supported by research that
demonstrates a decrease in SIB when social attention
and reinforcement is removed (Wolf et al., 1964; Wolf et al., 1967;
Lovaas & Simmons, 1969)

Theories
o On the other hand, when social reinforcement (e.g.
comforting comments) was provided contingent on
SIB, the frequency and magnitude of SIB increased
(Lovaas et al., 1965; Lovaas & Simmons, 1969)

Theories

The second hypothesis is that SIB is an operant

behaviour, maintained by negative reinforcement (Carr, 1977)
o Several studies have shown that SIB can be
maintained by negative reinforcement (Carr et al.,1976; Iwata et
al., 1994)

o In these cases, SIB is used to escape a demand or

an aversive stimulus

Theories
o For example, when escape from a demand was
delivered contingent on the occurrence of SIB, levels
of SIB increased (Iwata et al., 1994)
o In addition, levels of SIB decreased considerably
when a stimulus associated with the escape or
termination of demands was presented (Carr et al., 1976)

Theories

The third hypothesis is that SIB provides automatic

reinforcement (Carr, 1977)
o Research shows that SIB can also be maintained by
sensory stimulation, which means that the behaviour
in and of itself is reinforcing (Iwata et al,. 1994, Favell et al., 1982)
o For example, when the effects of sensory stimulation
were reduced, levels of SIB decreased (Dorsey et al., 1982)

Theories
o Iwata et al. (1994) found that when providing an
individual non-contingent access to a variety of toys
(e.g. alternative sources of stimulation, such as
visual or tactile), SIB decreased but was still
present, this might be given that these items were
not providing the same stimulation as the individual
was getting from engaging in SIB

Theories

The fourth hypothesis is that SIB is maintained by

physiological conditions (Carr, 1977)
o There is limited research to support this hypothesis.
Carr (1977) suggests that an individual may engage
in SIB initially due to a physiological or medical
condition; however, it may then be maintained by
other consequences, such as positive or negative
reinforcement

Theories

The fifth hypothesis is that SIB occurs to alleviate guilt

(Carr, 1977)

Lovaas et al. (1965) suggested that if self-guilt could be

used to explain SIB, then comforting statements (e.g. I
do not think you are bad) could serve to reduce the
participants self-destruction by reducing her guilt- level
(p. 82)
o However, Lovaas et al. (1965) found these comments
actually led to increases in SIB
o

Theories

We suspect that Roberts SIB is maintained by the

second hypothesis: negative reinforcement
o When his parents/BI present him with a demand, he
engages in SIB, which results in his parents/BI
removing the demand

Assessments

Assessments
Practitioners must first identify the function and maintaining
consequences of SIB, in order to determine the most
effective course of treatment (Iwata et al., 1994, Durand & Crimmins, 1988)
If practitioners are unaware of the function of SIB or believe it
is being maintained by the incorrect consequences, they
could in fact be reinforcing SIB
By developing the treatment based on the function of SIB,
practitioners can teach the individual more appropriate ways
of getting that reinforcement and reduce the levels of SIB
(Minshawi, 2008)

Assessments
Self-Injury Trauma (SIT) Scale (Iwata, Pace, Kissel, Nau, & Farber, 1990)
Scale to determine the extent of the damage and to
make predictions of risk of the self-injurious
behaviour.
High versus low risk self-injurious behaviour
Guide the intervention in terms of safety and harm

Assessments
Results from the SIT Scale
Roberts behaviour is estimated to be LOW risk
based on location and severity

Assessments
Functional Assessment Interview (FAI)
An interview for the people closest to the target
person
Introduces the understanding of the problem
behaviour as well as the setting events,
antecedents, consequences, and functions involved
Purpose: to gain enough information to see patterns
of behaviour (Drasgow, Martin, ONeill, & Yell, 2009)

Assessments
Functional Assessment Interview
o An FAI was conducted by interviewing Roberts
family and team to determine the likely function of
his behaviour, when his behaviour is the most likely
to occur, when it is the least likely to occur, what his
preferred activities are, and other information that
will guide the intervention process

Assessments
Sample questions from the UBC-FAI (Mirenda & Lucyshyn, 2011)
I want to ask you about situations in which Robert is
successful, or does well. Can you tell me some situations
in which Robert has NO or FEW problem behaviours?
Are there specific (foods/ drinks, objects, activities, types
of social interactions) that Robert especially enjoys?

Assessments
Now, lets talk about events or situations that might put Robert
in a bad mood and increase the likelihood that he/she will
engage in problem behaviour. Can you think of things that you
have observed that might increase Roberts problem
behaviours?
We will try to figure out the things that trigger or predict
Roberts problem behaviour. Can you give me some examples
of situations when Roberts problem behaviours occur?
Now, lets talk about what happens AFTER Robert engages in
problem behaviour. What do you or other adults do in response
to Roberts problem behaviour?

Assessments
Results from the FAI
Robert is most successful when he is engaged with
his preferred activities by himself in the playroom.
Roberts preferred activities are running, rocking,
twirling plates, rolling balls, and swinging
He is more likely to engage in SIB when there are
more people in the house and noisy environment,
when he hasnt slept well, and when an unfamiliar
person is nearby.

Assessments
Robert will engage in SIB when he is presented with
a demand, such as when asked to clean up, get
dressed, or feed himself.
When Robert engages in SIB the demand or request
is often withdrawn and he is not required to
complete the task.

Assessments

Functional Analysis (FA) (Hanley, Iwata, & McCord, 2003)

A methodology used to identify the variables that
influence problem behaviour.
o Conducted by observing and measuring problem
behaviour under conditions in which the variable is
manipulated.
o Upon determining the condition that produces the most
occurrences of problem behaviour, the therapists can
then use this information to guide their intervention.
o

Assessments
Constraints to functional analyses (Iwata & Dozier, 2008)

Risks for the individual and therapists

Measuring occurrences of problem behaviour is
undesirable when the individual engages in self-injurious
behaviour

Latency Functional Analysis (Thomason-Sassi et al., 2011)

An alternative functional analysis that measures the

latency from the time the session begins to the first
occurrence of problem behaviour.
Allows the session to be terminated upon the first
response.

Assessments
Latency Functional Analysis for Robert (Thomason-Sassi, Iwata,
Neidert, & Roscoe, 2011).

4 conditions to determine the function of Roberts SIB

Play condition/control: The adult places preferred
items near Robert before the beginning of the session
and initiates very brief social contact. All problem
behaviour is ignored in this condition.
Demand: The adult instructs Robert to engage in a
task using a prompting procedure. If Robert complies
he gets verbal praise. If Robert engages in SIB, the
demand is terminated.

Assessments
Alone: Robert is alone in a room or a certain distance
from the adult. There is no interaction or access to
leisure items.
Tangible: Adult directs Robert to play while adult has
to go do work. Robert gets access to leisure items
contingent on problem behaviour

Assessments
Latency FA
All sessions are terminated at 5 minutes if no problem
behaviour occurs.
Sessions begin as soon as the adult signals and are
terminated at first instance of problem behaviour or until
the end of the sessions, whichever comes first.
The adult wears different shirts, or the conditions are
conducted in different rooms or with different toys, to
enhance the discrimination of each condition (Thomason-Sassi,
Iwata, Neidert, & Roscoe, 2011).

Assessments
Results of the Latency FA

Robert engaged in self-injurious behaviour at a

significantly shorter latency in the demand condition than
the other conditions.
The function of Roberts behaviour is believed to be
ESCAPE.
Precursor behaviours: orienting his face or body away,
rocking agitatedly, pushing toys away or handling
aggressively

Assessments
Preference Assessment
We observed what play activities Robert engaged in on
his own in the natural environment, and conducted a free
operant stimulus preference assessment (Roane et al., 1998)
Robert was provided with unrestricted access to multiple
items and activities
We recorded what items and activities Robert chose to
play with when allowed to freely interact with the stimuli

Assessments

Results of the preference assessment

o We combined the results from the FAI with that of
the preference assessment
o We will keep an ongoing list of Roberts preferred
items, including tops, light up wands, balls, balloons,
jack in the box, and bubbles

Assessments
Early Start Denver Model (ESDM) Assessment

To determine Roberts communication, imitation and play

skills prior to intervention, we used the ESDM
assessment
We will continue to use this assessment throughout
intervention
By using this developmental curriculum we will assess
underlying skills that will allow us to promote positive
relationships and increase Roberts skill sets

Assessments
ESDM Assessment

Assessments
ESDM results
Robert possesses a few of the early skills from Level 1
Localizes to sounds (made by objects) by turning
toward sound source
Looks to playful vocal sounds (e.g. whistle)
Responds to preferred objects via gaze, reach, smiles
and movements
We will work on pivotal skills such as basic imitation and
joint attention
Once we begin intervention we will perform ongoing
assessments using the ESDM

Assessments
Summary of assessments
SIT scale - LOW risk
FAI
Setting events: too many people around, too noisy,
unfamiliar adults present, bad sleep
Antecedents: demands
Consequences: demand removed
Latency FA - ESCAPE maintained behaviour
Free operant stimulus preference assessment
ESDM - the intervention must begin with basic skills

Intervention

Intervention Goals
From what you were just told about Robert and his
assessments, we made the decision to focus our
intervention on 6-8 months
Throughout this time we will be targeting rapport
building, functional communication training and basic
imitation and play skills in order to to ease Robert into
working with adults without engaging in SIB

Sessions will be run for half an hour twice a day to start

Intervention
Intervention literature on escape motivated SIB
Extinction + Physical Guidance + Reinforcement
(Iwata et al., 1990)

Extinction + Guidance + Response Blocking +

Reinforcement (Iwata et al., 1990)
Negative Reinforcement Schedules DNRA, DNRO
(Roberts et al., 1995)

Noncontingent Reinforcement (Vollmer et al., 1995)

Intervention
Rapport Building with Robert
The therapists will begin playing with his preferred
toys or activities while he is in the room (have 2 of
each toy in area)
At this time he is not required to play or engage
unless he wants to
When he does come over, the adult maintains
low levels of eye contact, focusing on the play
items

Intervention
Rapport Building with Robert
If Robert engages in any SIB, the therapist will
slightly turn their body away
As Robert becomes more comfortable playing near
the adult, they can start handing toys to Robert
After Robert is compliant taking toys from the
therapist, while they are playing on floor they can
begin with some very basic demands, such as
imitation tasks with the play toys

Intervention
Functional Communication Training (Carr & Durand, 1985)
Problem behaviour can be reduced by teaching
individuals communicative verbal or gestural attempts
that are effective at changing the environmental
conditions that control the behaviour
It is not sufficient to only decrease the frequency or
severity of SIB, it is crucial to teach a replacement
behaviour that is more appropriate to allow the
individual to obtain the desired reinforcement

Intervention
Functional Communication Training (Carr & Durand, 1985)
With Robert
Have access to a Big Mack button (that has a
picture of break) that he can press when he wants
a break
When he shows signs of precursor behaviour, full
prompt a quick button press while saying looks like
you want a break and allow him to leave
Honour every request for a break

Intervention
Involving the parents
In the beginning of intervention, only the therapist will be
with Robert to ensure that a positive rapport between
Robert and the therapist has been established.
Upon the establishment of this relationship, the parents
can begin to observe the interactions between the
therapist and Robert.
Slowly, one at a time the parents will interact with Robert,
with the therapist present and interacting as well,
providing no demands on Robert.

Intervention
Imitation through play using Reciprocal Imitation
Training (RIT; Ingersoll, 2008; Ingersoll, 2010)
Step 1 Pre-intervention observation of Robert during
free play to record sounds and actions which the child is
performing independently.

Intervention
Step 2 Contingent imitation: The therapist starts by
imitating Roberts actions and sounds with the toys and
his gestures and body movements

Video

Intervention
Step 3 Linguistic Mapping: The therapist incorporates
simple descriptions of the childs actions (e.g., top is
spinning)

Video

Intervention
Step 4 Imitation Training: The therapist implements
this procedure on average once a minute during play.
Once Robert has successfully imitated, the therapist
goes back to imitating him and describing his actions.

Video

Imitation Training Procedure

1. The therapist begins by modeling familiar actions and sounds
(collected in the pre-intervention observation)

2. As Robert becomes more responsive to the therapists

modeling, novel actions and sounds can be introduced.
* If Robert does not respond after the therapist models the
action 3 times, then the therapist uses partial physical
guidance to help him perform the actions then provides
reinforcement- praise + 10 seconds of free play

Imitation Training Procedure

3. The therapist models a descriptive gesture that
is related to Roberts play
4. After every imitation training interval the
therapist returns to imitating Roberts sounds
and actions

Involving The Parents

Similar to the introduction of parents during the rapport
building phase, the therapist will assist the parents by
providing them with strategies for playing with Robert

These strategies will follow the later stages of the

imitation training procedure

Behaviour Plan
During the Rapport Building Phase when Robert engages in SIB the
therapist will shift to slightly face away from Robert and move back
a little (1 ft) but will not leave the area (The Big Mack should always
be present in the playing area, even if it is not being used). After 1
minute the therapist will move back to previous position and
continue the rapport building procedure
During Functional Communication Training the therapist will:
1. Prompt Robert (physically) to push the Big Mack
2. Say ok you can have a break
3. Turn their body to slightly face away from Robert

Behaviour Plan
During Imitation Training Roberts behaviour will be placed
on extinction with a schedule of Differential negative
reinforcement of alternative behaviour (Roberts et al., 1995)
Alternative behaviours pushing the Big Mack, gesturing
towards (pointing to) the Big Mack, and verbalizing and
looking at the Big Mack = 2 minute break (therapist
moves away)
IF Robert engages in SIB the therapist will not move
away, until Robert pushes the button or performs any of
the alternative behaviours (Extinction; Iwata et al., 1990)

Future Goals

Future Goals
Depending on Roberts verbal communication skills we might need to
introduce communication system (PECS, Sign Language)
Increase Roberts compliance with parents across settings
Working on self-help skills and following parent demands
In preparation for preschool/kindergarten
Work on imitation of actions in songs (such as wheels on the bus,
slippery fish)
Add school activities such as colouring, painting, play-dough, and
turn-taking activities
Expanding his repertoire of functional and pretend play skills

Future Goals
Increase session time
Gradually increase session time to work up to 2.5 hours
sessions
Following the guidelines of the ESDM and RIT
Slowly target new goals as his list of skills increases
Increase structure of sessions with therapists
Slowly introducing the table into his sessions beginning
with preferred activities then gradually introducing table
work that he might be exposed to at school

Questions?