Applied Behavior Analysis: Reducing Incidences of Skin Picking

Amy Wallace SPED 471, Fall 2013

Applied Behavior Analysis Student Description The student, JB, is a fourth grade boy who has Autism. When presented with class work and materials, he frequently engages in self-injurious skin picking. This seems to be an automated behavior with little conscious control attached, as he often does not notice or stop

when his skin begins to bleed, unless his peers bring it to his attention. He is performing at grade level academically, and always verbalizes a wish to finish his work. Despite this wish to complete all activities, many do not become started due to the constant behavior of skin picking. This is not a continuous activity throughout the entire day, but does occur to excess during certain subject areas, namely writing and mathematics. The problem behavior of skin picking will be defined as pulling or picking of the skin or hair resulting in irritation, bleeding, or flaking of the skin for a consistent period of ten seconds or more within a one-minute span. An example of this would be if the student was pinching and tugging at his skin for a period of fifteen seconds to an extent where there were red marks on his forearms. A non-example would include itching the back of his neck for five seconds or playing with the sleeves of his shirt for an extended period of time by pulling them up and down if it does not result in irritation of the skin.

A-B-C Observation Throughout this ABC observation, it was noted that not only do these behaviors occur when individualized assignments are given within these subjects, but also as soon as the student was in an independent, quieter environment, such as a gym class or lecture for classes. What was observed confirmed what was had seen informally through working with this student previously.

Applied Behavior Analysis The student, JB, frequently picks at his skin when given an assignment, often times continually picking for periods of three minutes or greater.

There is not much of a reaction from the class or teacher as a result of this behavior, but it does prevent him from finishing work due to his preoccupation. Sometimes students will point out when he is bleeding, and he will be excused from class to get a bandage, but he always appears to be surprised at their comment. This observation was very important as it noted that the behavior didnt only happen in the environments that had been anticipated it happening in. It was also noted that the behavior didnt seem to just be a way for the student to gain attention from his teacher, but also as a self-stimulatory behavior. This self-stimulation seems to occur more often than anything else, as there is often not a noted antecedent beyond not having strict instructions to do something else with his hands. Copies of the A-B-C Observation forms are attached at the end of this essay on pages 20-22.

Functional Assessment Interview To complete this conference, the resource teacher who is his case manager as well as his classroom teacher was interviewed. While she does not see JB for the majority of the day, she is in constant communication with his classroom teacher, and he frequently comes in and out of the resource room to complete tasks and have a quieter work environment. The case manager is also in constant close contact with the students parents, which enabled them to provide insight into the familys feelings about the students interactions with others. While she didnt know exacts of things that occurred in the home environment, she did know some information that was relevant to this interview. From this interview, it was learned that the issue of JBs skin picking is not just a school based activity. It has been a problem for a few years, and often can end with

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his arms scabbing and overly dry for weeks at a time. Despite the fact that it has been mentioned to his parents as a problem and self-injurious behavior, his parents refuse to cut his nails shorter as they state that he is very defiant to this action, so it is easier to allow him to have slightly longer nails. This behavior is often observed in class and in the resource room after he has been given instructions to perform a task that is not preferred or too difficult, such as a math sheet, examination in any subject, or a writing exercise. As a result of this behavior, he is commonly give extra attention from the instructor present to try to stop this behavior, in addition to receiving assistance on work while this behavior persists. He also seems to frequently be oblivious to this behavior, as the teacher states that at times when she asks him to stop, he appears confused to the fact that he was picking at his arms to begin with. The teacher also expressed concern at the fact that he frequently ignores class directions. He often sits without following explicit instructions, provided both in verbal and written forms. Also, despite the regularity of the daily routine, he becomes lost with the routine and has difficulty following his classmates during transition times. It is also at these times that he often yells out verbally comments that are not age appropriate, such as, I want my mom and, I want to go home. These are done in a repetitive manner, and frequently lead up to a total breakdown in emotion for the student. A copy of this interview is attached at the end of this essay on pages 23 to 30.

Functional Assessment Observation The main behavior that was being looked for during these observations was skin picking or scratching. This was defined as scratching or picking at the skin for more than ten seconds

Applied Behavior Analysis within a one-minute period that resulted in the skin becoming irritated, flakey, or bloody. Noncompliance was also looked for, which was defined as ignoring an instruction given to the student or class as a whole, such as, take out your pencils or, write this in your notebook. Lastly, the other behavior that was looked for was shouting out or yelling. This was defined as a vocalizations unrelated to class topics that are made at a volume level greater than that of the

students normal speaking volume. Within this school setting, the volume was defined as a three or greater on their volume scale, which means that they could be heard from three feet or further away. The observations were focused on the times that were addressed within the interview, which were writing class and mathematics time. Along with these times, some random unstructured times throughout the day were chosen where he does not have an activity that keeps his hands occupied, such as independent reading, music, and lunch, to see if this behavior would occur in other environments, or if it was limited to these classroom times. The reactions or consequences that were looked for were redirection to a different task, or having the behavior be ignored. These two actions were the most commonly observed reactions to behavior that were noted during the A-B-C observation, so these were chosen to see the frequency of occurrence. Through this, it became clear that while the behavior increased during independent work times in math and writing, it also was a behavior that was displayed consistently across all settings. JB seemed to gravitate towards this behavior in downtimes during lessons or classes when he did not have an activity that kept his hands occupied, as well. It appeared to be slightly irregular, as some times there were no instances of problem behavior, but the majority of the observation times had multiple instances of skin picking behavior. His most frequent and

Applied Behavior Analysis unfailing behavior was that of skin picking, which reaffirmed it as being a priority behavior. It also was commonly met by being ignored, as often people surrounding him did not notice this

behavior or have become accustomed to ignoring it. This made it seem even more likely that this behavior serves self-stimulatory purposes beyond just receiving additional attention at times due to redirection. This observation was beneficial as it allowed me further insight to all the environments that had not previously seen in observations. It also reaffirmed that this behavior is the most important one to tackle, as it happens most frequently, even if it does not cause class disruptions. A copy of this observation is attached on page 31.

Functional Analysis Manipulations As a result of all observations, two hypotheses could be formed. One states that when the student is in a time where there is no active activity to keep their hands occupied, the student will pick at their skin for self-stimulatory purposes. The second hypothesis states that during independent class work during math and writing times, the student will engage in skin picking to receive additional attention and support from the classroom teacher. An outline of the summary statement model is attached at the conclusion of this essay on page 32. For the hypothesis with the consequence of self-stimulation, a manipulation that may change the frequency of behavior would be to provide the child with some tactile toy or squeeze stress ball so that they will have another activity to keep their hands busy. This will ensure that they will not have the free time with their hands that can be used to self-harm themselves. This conclusion was reached as a result of the Functional Analysis Observation, in which the student was observed picking at his skin and arms at most any time in which he wasnt given a

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designated task to write something down, or follow along on a worksheet. This downtime left his hands void of a tangible item, thus enabling him to have his hands free to tug at his skin. The FAM for this hypothesis could be tested through an ABAB testing model. This means that baseline would be taken, treatment would be implemented, then treatment is removed for a second baseline, and finally the treatment is reintroduced. This would help to see the direct impact of this treatments presence on the students behavior and actions. For this particular hypothesis, it would be conducted through gathering baseline data on the hypothesis until consistency is reached. This would mean that the student would be observed during class time for twenty-minute increments, with data being taken on a partial interval recording of one-minute increments. This meaning, during each sixty-second increment, if the student were actively displaying the behavior, then it would count as a tally for skin picking. If the student did not pick at his skin during those sixty-seconds, no tally would be recorded. This time of observation would be referred to as baseline1 for the data collection sheet Then, a treatment of providing JB with the tactile stress toy and allowing him to use this as an alternative to skin picking would be implemented and data would be collected following the same procedures outlined previously. This time would be called treatment1 on the data collection sheet. After several trials under these conditions, the tactile toy would be removed, and JB would be observed in the same settings under the conditions of baseline1. This period would be recorded as baseline2. Lastly, the treatment would be reapplied, and JB would be permitted to hold the stress relief toy again as a fidget release. Data would be recollected using the same procedures as each time, being recorded as treatment2. This procedure was implemented within the classroom, for a period of one week, with data collected during his math course after lunch and daily writing towards the end of the day.

Applied Behavior Analysis Each time of an observation lasted twenty minutes, with the data recorded on an intervalrecording basis of one-minute intervals, as illustrated previously. These periods of the day were chosen as they were previously observed to be instances where his skin-picking behavior was most frequent. If testing the second hypothesis, in which the purpose of the behavior being attention from the teacher, then the manipulated variable would be the amount of attention given to the student. Data would be collected using the same methods of interval recording as described for testing hypothesis one. For baseline1 with this dependent variable, the student would receive no attention from the teacher for the duration of the observational time of twenty minutes. After a consistent baseline was reached, then treatment1 data could be gathered, using the same interval recording technique. During this time, the teacher would constantly be standing by the student and providing them with feedback. The data would be recorded to see if this attention had any effect on decreasing the students skin picking frequency. Following this, baseline2 would be collected as previously described, and after, treatment2 would be recorded by implementing the treatment period of excessive attention again. This treatment was chosen as a result of the interview with JBs case manager. She indicated that he prefers to have the attention of his teachers, and frequently will complete more work within a given amount of time when he has someone standing within close proximity to

him. It was also observed during the observation time that when the teacher offered JB assistance on his assignments, he stopped picking and began working on the provided assignment.

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Preference Assessment A preference assessment was conducted through interviewing the student in question about his preferences within the classroom and school environment. This was conducted in an informal conversational setting at the end of the school day, when the student is generally most relaxed and open to conversing. He expressed that he really likes Cheetos chips, as he was eating them during the interview. He also greatly enjoys spending time with his friends on the playground, where they often play games that they create, as well as imaginative games such as army or monsters and dinosaurs. He enjoys the idea of creatively inventing his own game, and enjoys his friends input to creating these distant worlds, as he refers to them. He also enjoys swinging by himself on the swings, but only if he can use the good swing, which he identified as the first one on the far left side of the swing set. JB also expressed his love for Minecraft and Temple Run, stating that playing those on the iPad is one of his favorite things to do. When asked about academic subjects, he said that he hated writing, as it was too difficult to write as fast as he was able to think about topics. He also greatly preferred writing about creative subjects to writing book reports. He also stated a dislike for math class, as he believes it is stupid and moves too quickly. JB was then presented with a few different tangible stress relief balls. One was a long squishy worm-like item, another was a standard stress ball, and lastly there was a slightly oozy gel-like ball. JB preferred the worm-like item to the others, stating that the oozy slime ball was the worst because it felt dirty. A copy of this interview is attached on page 33. Later, JB was presented with a grouping of the things he stated to prefer, these including a representative for a swing, an iPad, the squishy worm, and Cheetos, as well as a few items that

Applied Behavior Analysis he expressed he disliked, such as the oozy ball, and multiplication flash cards. A preference

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assessment was conducted on four different trials using these items over the course of two days, and his answers were rather consistent. JB most preferred the iPad, followed by the worm and Cheetos, then the swing, then the oozy ball, and lastly the multiplication cards. A copy of the preference assessment is attached on page 34.

Data Collection Technique As previously described, data will be collected during mathematics class from 12:15 until 12:35pm each day, as well as during writing from 1:30 until 1:50om each day. During these times, a partial interval recording would be taken. The steps for collecting data will be as follows: 1. For each recording trial, the class observed should be recorded on the data sheet in the column labeled class. 2. Each interval would consist of one minute. A running stopwatch shall time this for the duration of the observation period. 3. During the one minute interval, if the student picked at his skin for a period of ten consecutive seconds, it would count as an occurrence, and an X should be recorded on the data sheet. a. If the student begins picking at his skin towards the end of one interval, but has not completed ten seconds before the interval ends, the X should be marked in the box for the following interval of time.

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4. If the student did not pick at his skin during that one-minute period, nothing will recorded for that interval and the data box should remain blank. 5. This time sampling will continue for a period of twenty minutes. At the end of that time, the data collection period will end. 6. Data will be collected until a consistent baseline can be established, and for at least five times.

A partial interval recording technique was chosen as it allows for the data collector to see the frequency of the behavior over a period of time. It also allows for the data collector to see if the behavior is absent for long intervals of time, or if it is such a frequently occurring behavior that not even a minute goes by between instances. Overall, this was chosen as it allows to see how long the child can go without picking at his skin during a given period of time. As we know that the behavior is a frequent one, seeing the time between occurrences decrease would be a step in the right direction towards minimizing skin picking.

Baseline Data A completed data sheet, as well as a graph of the data is attached at the end of this report on pages 35 and 37. As visible in the graph, the students skin picking occurred during at least half of the intervals, usually more than half. The number of intervals was relatively consistent, within a range of three during all five-baseline trials.

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Inter-observer agreement was conducted during two of the baseline data collection trials. A high school volunteer student who comes into the classroom to assist the teacher twice a week completed these observations. These were completed at the same time as observations by the author during math class on two consecutive days. The alternative observer was instructed of what steps to follow to complete the observation as outlined in the Data Collection Technique section of this essay. The other observer sat across the room from the author, as to not be influenced by the recordings being written on alternative collection sheets. From these two observations by the class volunteer, the average agreement was 82.5%. For the first interval that was taken by both recorders, Interval 1 on the data sheet, the agreement was an 80%, with only four differences in observation. This means that there were four intervals out of the twenty that one reporter stated the behavior was present while the other said it was absent. For the second interval, Interval 3 on the data sheet, the agreement was 85%, with only three differences between intervals. The observation sheet filled by the alternative observer is attached on page 36.

References Lane, K., Thompson, A., Reske, C. L., Gable, L. M., & Barton-Arwood, S. (2006). Reducing skin picking via competing activities. Journal Of Applied Behavior Analysis, 39(4), 459-462. doi:10.1901/jaba.2006.62-05 The researchers in this study took data on both the amount of time the student was participating in the skin picking activity, as well as the amount of time their hands were busy with any other activity. This relates to my research, as it is believed that the student participates in skin pulling when they have no other activity to keep their hands active and distracted. The

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student then was provided with three different small tactile items of different textures that he was able to hold onto during instructional periods as well as throughout the school day. It was shown throughout their data that while the student was in possession of the toy, he was constantly rolling it between his hands, or just simply holding on to it, which kept his hands occupied and unable to tug at his skin. As a result, occupied time increased greatly while skin tugging time decreased to near zero.

Lang, R., Didden, R., Sigafoos, J., Rispoli, M., Regester, A., & Lancioni, G. E. (2009). Treatment of chronic skin-picking in an adolescent with asperger syndrome and borderline intellectual disability. Clinical Case Studies, 8(4), 317-325. The student chosen for this study was chosen as they were aware of their behavior, as well as the negative social impacts associated with it, but despite being aware of the behavior, she still could not find herself able to stop participating in skin picking. She strived to remove imperfections in her skin and have her all of her skin be smooth, thus constantly peeling off scabs and sores. As a treatment, the researchers covered the parts of her body that were identified as areas frequently picked with large bandages. The idea was that this would serve as a visual reminder to the student of their behavior, as well as preventing them from being able to reach their skin to pick at it. As data was taken by counting the number of open sores on the body, by covering the sores up for long periods of time, the number of open ones drastically reduced. Shortly after, the students skin had healed, which provided her with the smooth surface that she was seeking by pulling off scabs to begin with.

Tiger, J. H., Fisher, W. W., & Bouxsein, K. J. (2009). Therapist- and self-monitored DRO contingencies as a treatment for the self-injurious skin picking of a young man with asperger syndrome. Journal Of Applied Behavior Analysis, 42(2), 315-319.

Applied Behavior Analysis This study used a differential reinforcement of other behavior throughout its implementation, providing the student with $.10 for every five minutes they were able to go without picking at their skin. He was prompted prior to each trial by being told the same

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instructions to avoid picking at his skin for the described amount of time in order to receive the money, and then a visual timer was started so that he could see the time left. During the time of the study, the time that had to elapse before receiving monetary reward eventually was pushed to ten minutes, and finally to fifteen minutes. By distancing the time before the reinforcer that the behavior was necessary to be present of not picking his skin, it was lengthening the students ability to refrain from picking. In the end, the student was left alone and observed through twoway mirrors, and his picking still remained near zero for a twenty-minute period, despite not having a researcher present within their eyesight. Twohig, M. P., & Woods, D. W. (2001). Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings. Journal Of Applied Behavior Analysis, 34(2), 217-220. In this study, conducted on two brothers who have reported a long history of picking their skin, researchers lowed for the participants to play a large part within their interventions. The participants were their own data collectors, recording the number of instances that they picked at their fingers as tallies on an index card as they went throughout their day. This procedural step allowed for the brothers to be self-reporting their behavior back to the researcher as to allow them to participate in their day as fully as possible, while making them aware of the behavior as they had to consciously think of each time they recorded a tally. The researchers also took photographs of the participants skin, and showed them to graduate assistants in a blind testing, asking for their opinions about these boys skin without them knowing the condition that these boys had.

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The intervention provided in this program consisted of teaching the boys to in essence, be their own data monitor, and teaching them to become aware of setting events and antecedents that led to their picking behavior. Through the daily trials, they were then told that each time they were in an identified setting, or experienced an antecedent, to make a closed fist with their hand for one minute in an attempt to curb behavior. Participants received praise and reinforcement upon their daily tally reporting calls to researchers. Overall, the method of teaching the boys to be self-aware worked wonders on their picking, as it decreased to near zero for both boys. At the end of the experiment they were shown the photographs of their skin that were taken when they started the program, as well as informed of the responses the graduate assistants provided, which served as an extra incentive to each brother to continue with the research methods even after the conclusion of the study.

Interventional Program Antecedent-based As a result from all of the observations and data collections conducted throughout this functional assessment of student JBs behavior, the antecedent that was most noted was the absence of activity of the hands. The first step to be taken in intervention is to make JB aware of this behavior and the antecedents through guiding him to reflect upon his behavior. The student, through guidance with the researcher, would create a list of perceived antecedents. This list would then be put inside the students folder that is kept with him throughout the school day and brought to each class. These antecedents would be noted throughout the day, and the student would be asked to keep their own tally sheet. On this tally sheet, it would have a spot for tallying skin pulling instances, as well

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as a spot to tally under the list of antecedents to see which antecedent he most frequently felt occurred prior to behavior. This would build independence in the student as well as allow for him to move freely throughout his day without having the stigma of having a researcher follow him throughout the building. Alternative Skills The student would also be provided with a tactile toy, such as the worm he had identified as a preference in the preference assessment conducted earlier. JB would be instructed, at the start of each morning as well as immediately following lunch and recess, that if he felt stressed or recognized an antecedent occurring, that he could take the toy out of his desk, and hold onto it. This would redirect his behavior from having idle hands to pick at his skin, to having his hands occupied with a replacement skill. As he always needs his hands to be occupied to avoid the skill, by teaching him to use the tactile toy when he recognizes as needing it, rather than handing it to him when picking is observed, he is building independence that he could transfer to home and other environments where skin picking occurs. Consequent Based As JB greatly enjoys iPad time that he is able to receive during his free time, he would be able to turn in his tally sheets in return for iPad dependent on the number of tallies. As he currently exhibits such frequent skin picking, for the first interventional period and beginning of the second, he would be able to trade in his card at the end of each school day, at approximately 3:00 during his study hall time, for ten minutes of iPad time to do as he pleases until the bell rings if he has only eight of fewer instances of skin picking throughout the day. If he has more, he will still receive the verbal praise for

Applied Behavior Analysis tracking his behavior as well as for potentially decreasing his number of tallies, but he will not receive iPad time on that given day. After intervention has continued for a time, the number of tallies accepted for

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iPad time will decrease to five or fewer, then further decreasing to three or fewer, before he must finally have only no tallies before iPad time will be granted at the end of the day. He has identified the iPad as one of his favorite activities through the preference assessment, as well as stating that he enjoys the alternative environment of the resource room in his interview. It is because of these preferences that he will be permitted to play on the iPad in the resource room, as it would be a positively reinforcing to him. Data Collection Procedures JB would be collecting the data for himself on a daily basis. This consists of him holding a small index card divided into two halves. On one side he would simply tally the number of times he picked at his skin on a daily basis. On the other side there would be a list of antecedents that he identified in previous steps of the intervention. He would also tally under each antecedent of what was occurring when he began pulling at his skin. At the end of each day (approximately 3:00 each day), this card would be brought to the resource room to his case manager. She would then exchange this card for verbal praise and iPad time if conditions were met, or simply verbal praise before sending the student back to his classroom. The teacher would then record the number of tallies of skin picking in a data chart that would be used daily. The antecedent tallies are not to be recorded, but rather to serve as a visual reminder to the student to make him think of the antecedents associated with

Applied Behavior Analysis his behaviors. A sample of the teacher data sheet, as well as a sample student card has been attached at the end of this report on pages 37 and 38

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Attached Resources