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How Do ABA Practitioners Help with Clients’ Self-Harming or Dangerous Behaviors?

In our very first blog post on the Waypoints website, I briefly wrote about “how ABA can help with dangerous behavior” and called out the fact that it is not up to the judgment of the clinician to determine what is and is not a “problem.”

In this post, I want to elaborate on that, while also providing specific examples of ways that we can help with addressing unwanted behaviors, including self-injurious behaviors like head banging, hair pulling, or skin picking, at the request of our clients themselves.

autism and self-harm

Is the Behavior Harmful or Not?

Part of the diagnostic criteria for autism spectrum disorder (ASD) includes “restricted, repetitive patterns of behavior, interests, or activities,” but these may or may not be problematic from the client’s point of view or that of their loved ones.

“Stereotyped or repetitive motor movements, use of objects, or speech” might include spinning a fidget toy in front of one’s eyes, stacking up blocks in a very particular way, or repeating favorite lines from a TV show. Between writing sentences of this blog post, I’m rubbing my hands together and tapping my feet. In my household, we constantly reference quotes from shows and Internet jokes to each other! These repetitive behaviors are in no way problematic, and may stand out on the part of an autistic person only because of differing contexts or frequency.

We would only suggest helping with reduction of such behaviors if the client actively wished to change these habits, or if they directly affected day-to-day safety. For example, high-intensity rocking back and forth while driving a car could be dangerous, and we could look into ways of meeting the needs served by that behavior in other, safer ways.

Some behaviors, though, more obviously run the risk of harm. Self-harm to the extent of bruising or breaking the skin can cause lasting physical damage, and aggression towards others is not only illegal in most contexts but can also prevent access to important resources like educational environments and assisted living supports. Even behaviors that don’t cause direct physical harm, like intense tantrums or verbal abuse, can still prevent important needs from being met in day-to-day life and lead to social stigmatization and ostracization.

It’s important to keep in mind that such behaviors are not inherent or exclusive to someone with a diagnosis of autism. Neurotypical people obviously harm themselves and aggress against others as well.

The prevalence of these behaviors, however, can be influenced by other diagnostic criteria for autism: “hyper- or hypo-reactivity to sensory input” and “deficits in verbal communicative behaviors used for social interaction.” If an autistic person is experiencing something painful or otherwise aversive, and is unable to communicate that clearly in order to get help, it makes sense that behavior would escalate. All behavior happens for a reason! Figuring out those reasons can help prevent the need for them to occur in the first place, as well as get those needs met more effectively.

The Causes of Behavior

From the behavior-analytic perspective, behavior (whether potentially harmful or not) is the result of environmental influences, not something inherent to an individual.

For example, we would never say that someone picks at their skin because they “lack willpower” or “don’t care about their well-being.” Clearly, that repetitive behavior is fulfilling a need. A behavior-analytic assessment would then help us define what that need is, what the consequences of that behavior are for the client, and why those consequences are causing the behavior to continue.

Reinforcement is a consequence that increases the future probability of behavior. Reinforcement can be considered positive if the behavior produces something desirable, or negative if it removes something unpleasant. It can also be automatic in the sense of the behavior itself producing the consequence, or social in the sense of someone else in the environment providing a consequence.

In the context of skin-picking, here are some potential kinds of reinforcement:

  • Automatic positive—the physical sensation of scratching the skin. What may be painful for one person could be pleasant to another!
  • Automatic negative—removing a distractingly rough patch of skin, or relieving another kind of pain by focusing on this stimulation.
  • Social positive—someone providing attention or showing concern when this behavior is performed.
  • Social negative—someone removing a demand, e.g., “oh, I can see that this is stressing you out, we don’t have to work on this right now!”

On the other side of the coin, we have antecedents—things that happen before the behavior occurs that might make it more or less likely. There are many kinds of antecedents analyzed within the science of behavior analysis, but for now I’ll focus on what are called motivating operations. These are essentially the “needs” that a behavior fulfills.

There are two broad categories of motivating operations which increase or decrease motivation to engage in a behavior. The former category is relevant here—they are called establishing operations.

  • The absence of pleasant physical stimulation would establish the value of automatic positive reinforcement.
  • A rough patch of skin or other aversive stimulation would establish the value of removing that stimulation in some way.
  • The absence of attention would establish the value of getting it in the form of concern, help with a problem, etc.
  • A difficult demand or task would establish the value of escaping from it or making it easier in some way.

Behavior Reduction Techniques

In a nutshell, if a client wishes to work toward reducing the occurrence of a challenging behavior that they engage in, we can help change the antecedents and/or the consequences of the behavior, as well as make sure that reinforcing consequences follow other, preferable behaviors. Continuing to work with the same example from above…
  • If skin-picking is maintained by automatic positive reinforcement, we could make sure that there are many other options to access pleasant physical stimulation, such as a bristly brush or a pumice stone. We might also suggest that the client keep their nails trimmed short, so that those safer alternatives are actually more pleasant than picking would be.
  • If it’s maintained by automatic negative reinforcement, we could help to teach skincare routines to prevent and reduce rough patches ahead of time. Another option would be to start engaging in the habit of applying lotion or even just putting on a long-sleeved shirt when a patch of skin becomes distracting, instead of picking.
  • If it’s maintained by social positive reinforcement, we would work with caregivers and others in the environment to increase the amount of engagement on a day-to-day basis, and also potentially teach the client alternate ways to ask for help or comfort.
  • If it’s maintained by social negative reinforcement, we would again work with others on ways to present demands in less overwhelming ways and/or with additional support offered, and would also likely teach the client methods of asking for assistance and/or self-soothe in safer ways.
If you read those examples and think to yourself that they wouldn’t work for you or your loved one, keep in mind that no one intervention is a perfect fit for everyone! Every behavior intervention plan is extremely individualized to the causes of a behavior, as well as “client preferences, supporting environments, risks, constraints, and social validity.

“Balancing the Right to Habilitation with the Right to Personal Liberties”

To reiterate, it is not the place of a behavior analyst to judge what someone should or shouldn’t do. All interventions should be informed by the client, first and foremost.

A classic article within the field of behavior analysis emphasizes exactly that: Balancing the Right to Habilitation with the Right to Personal Liberties: The Rights of People with Developmental Disabilities to Eat Too Many Doughnuts and Take a Nap. 

Who among us doesn’t engage in behaviors that have the chance of causing harm to ourselves in one way or another? I would not take kindly to someone coming into my life trying to change my diet uninvited, but I sought out the services of a personal trainer when I wanted help learning how to engage in new exercises safely. I chose the example of skin-picking to discuss in this blog because I personally struggle with the bad habit of picking at my cuticles, and over the years I’ve managed to intervene on that successfully with the science of behavior analysis.

At Waypoints, we want to clearly communicate what supportive and skill-building resources we can offer, but will never presume to know best about what behaviors should be changed in the first place. If you’d like to brainstorm together about what behavior changes might be possible and how, I hope you’ll reach out to us at info@waypoints.life!

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