BEHAVIOR THERAPY 13, 529-554 (1982)

Association for Advancement

of Behavior Therapy
Task Force Report
Winter, 1982

The Treatment of Self-Injurious Behavior

JUDITH E. FAVELL, Task Force Chairperson
NATHAN H. AZRIN
ALFRED A. BAUMEISTER
EDWARD G. CARR
MICHAEL F. DORSEY
REX FOREHAND
RICHARD M. F o x x
0 . IVAR LOVAAS
ARNOLD RINCOVER
TODD R. RISLEY
RAYMOND G. ROMANCZYK
DENNIS C. R u s s o
STEPHEN R. SCHROEDER
JAY V. SOLNICK

Professional associations can serve their members and respec-

tive fields in many ways. Typically, initial efforts are focused
on identifying and collecting those who share common interests (as
determined by membership in the association), the provision of
a forum for discussion and refinement of ideas, methodology and
clinical procedures (through periodic national and regional meet-
ings and publications of the association), and the formation of
an association structure which is responsive to the field in general
and the membership in particular, so that the association can
serve as a vehicle for addressing important issues.
Often initial efforts of an association continue and are substan-
tially augmented by additional activities as the field the associa-
tion represents matures. For example, AABT has been asked to
address the problem of defining the basis for CHAMPUS reim-
bursement of behavior therapy services. This and similar events
related to reimbursement, certification, research funding, ethical
concerns, and the like have prompted AABT to consider under-
taking additional activities important to the field of behavior
therapy.

529 0005-7894/82/0529~5545l.oo/o
Copyright1982by Associationfor Advancementof BehaviorTherapy
All rightsof reproductionin any formreserved.
530 AABT TASK FORCE REPORT

A A B T Task Force Report:

The Treatment of Self-Injurious Behavior
One such activity is an attempt to determine clinical problems
for which the research literature clearly indicates that behavioral
based procedures provide the most effective treatment. Accord-
ingly, Judith Favell was asked by the AABT Board of Directors
if she would choose a blue ribbon group to determine whether
self-injury in the retarded represented such a clinical problem.
Over the past two years, Dr. Favell and her committee of pre-
eminent researchers and clinicians have reviewed the research
literature comparing behavioral, analytical, and medical ap-
proaches for the treatment of self-injury in the retarded. Their
report follows.

Reprints of this report are available from the Publications

Department, Association for Advancement of Behavior Therapy,
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are sold for $6.00 including postage and handling in the United
States. Please remit an additional $1.50 for foreign postage. Those
interested in purchasing larger quantities should contact the Pub-
lications Director, at the above address, for further information.
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 531

The Treatment of Self-Injurious Behavior

Self-injurious behavior is a term referring to a broad array of responses

which result in physical damage to the individual displaying the behavior.
In the most common professional usage, self-injurious behavior tends to
be characterized as repetitious and chronic, i.e., occurring at frequencies
ranging from hundreds of times an hour to several times a month over a
sustained period. Further, although cumulative damage such as retinal
detachment does occur, self-injury often results in relatively immediate
damage (as opposed to behaviors with more remote adverse conse-
quences such as substance abuse). Finally, although at least transient
self-injury is noted in normal infant and toddler populations (DeLissovoy,
1962; Shentoub & Soulairac, 1961), the incidence and severity of self-
injury is greatest among persons who are developmentally disabled, e.g.,
retarded or autistic individuals, particularly those with severe disabilities
(Baumeister & Rollings, 1976; Green, 1967; Maisto, Baumeister, & Mais-
to, 1978; Ross, 1972; Schroeder, Schroeder, Smith, & Dalldorf, 1978).
Of the various forms of self-injury reported in the research literature,
several generic types emerge:
• Self-striking (e.g., face slapping, head banging).
• Biting various body parts.
• Pinching, scratching, poking, or pulling various body parts (e.g.,
eye poking, hair pulling).
• Repeated vomiting or vomiting and reingesting food (i.e., rumina-
tion).
• Consuming nonedible substances (e.g., eating objects, such as cig-
arettes: pica; eating feces: coprophagia).
The problems and risks for clients displaying self-injurious behavior are
significant. Not only are they in serious jeopardy of physical harm, but
they are usually unable to benefit from habilitative or humanizing activ-
ities while they exhibit frequent or intense self-injury. Further, the phys-
ical and chemical restraint often used for protection also severely restricts
the individual from social and educational opportunities and may itself
result in physical damage; e.g., from tendon shortening caused by pro-
longed immobility. The treatment of self-injurious behavior is therefore
usually given the highest clinical priority.
Evaluating Treatment Approaches
Various approaches have addressed the understanding and treatment
of self-injurious behavior. In evaluating the relative success of these ap-
532 AABT TASK FORCE REPORT

proaches as well as the success of intervention with individual clients,

several guidelines must be considered. First, the objective of any treat-
ment, and evaluation of its success, must be to reduce the strength of the
behavior by a clinically significant amount. Strength is commonly mea-
sured in terms of frequency (how often the behavior occurs) and/or its
intensity (the force applied in displaying the behavior or the physical
harm which results). The objective of treatment is not to interrupt the
behavior temporarily; for example, although a client may stop self-injur-
ing while being comforted by caretakers, the overall amount of self-in-
jurious behavior may remain unchanged or probably worsen under such
a regime. Similarly, physical prevention, although perhaps necessary to
protect individuals in the absence of treatment or in conjunction with
treatment, is not itself treatment; it does not reduce the strength of the
behavior. Thus successful treatment consists of reducing its frequency
and intensity to the extent that the individual refrains from self-injury and
is able to participate in habilitative activities.
Second, the efficacy of any treatment approach, or specific techniques
within an approach, can only be established by scientific clinical research.
The compelling needs of self-injurious clients, and increasing insistence
from consumer groups and health insurance agencies, demand that only
procedures demonstrated by scientific methods as effective and safe be
retained as "routine and acceptable therapy." Such demonstration in-
cludes quantitative, reliable measurement of self-injury before, during,
and after treatment, and the use of appropriate experimental designs
which verify whether the treatment applied actually caused the improve-
ment observed. Scientific research used in the development of effective
treatment may occur on various levels, ranging from studies of the epi-
demiology and demographic characteristics of self-injury, to case studies
in which the self-injurious behavior of a single individual is treated and
the effects of treatment objectively documented, to documentation of the
effects of treatment applied to several clients who are representative of
individuals who display self-injury, to studies directly comparing treat-
ment techniques and isolating the effective components of each. Scientific
research does not include anecdotal, subjective accounts of intervention
and outcome, no matter how authoritative the source.
The purpose of this article is to briefly describe the major approaches
to the treatment of self-injury and the scientific research supporting the
efficacy of each. Its conclusions are derived from the research listed in
the accompanying bibliography.

Causes of Self-Injurious Behavior

Although theories on the etiology of self-injury abound, in fact very
little is known about the causes of the behavior. For example, some cases
of self-injury are closely associated with medical conditions such as
Lesch-Nyhan Syndrome or Otitis Media. Many others seem to be ac-
counted for by learning principles, i.e., that the behavior is learned,
shaped by pathological conditions and contingencies in the environment.
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 533

These and other factors have been addressed from a variety of theoretical
perspectives (Baumeister & Rollings, 1976; Carr, 1977). An equally im-
portant but separate issue concerns the factors which maintain the self-
injury once it has emerged. Etiology and maintenance must be viewed
separately, as it appears that factors responsible for the onset of self-
injury may be quite different from those which subsequently maintain the
behavior. Research is critically needed on isolating and controlling the
causes of self-injury, both in order to prevent the problem from occurring
and to treat the behavior more effectively when it does appear. As re-
search proceeds, an immediate clinical recommendation is clear: Any
therapeutic intervention should explicitly include an attempt to analyze
the biological and environmental factors which caused, and particularly
which now maintain the self-injury, and arrange for an elimination or
alteration of those conditions.
Approaches to the Understanding and Treatment of
Self-Injurious Behavior
Medical Approaches
As already noted, a variety of medical disorders are associated with
self-injurious behavior, for example the Lesch-Nyhan Syndrome (Nyhan,
1976), Cornelia de Lange Syndrome (Bryson, Sakati, Nyhan, & Fish,
1971), and Otitis Media (DeLissovoy, 1963). Research on these and other
medical conditions holds promise in possible prevention and treatment
of self-injurious behavior which is correlated with these disorders and on
biological mechanisms which may underlie other instances of the behav-
ior (Cataldo & Harris, 1982). However, several points must be made
regarding the current capability of medical intervention to reduce self-
injury.
First, although a thorough medical examination is recommended to
identify, and if possible, to control biological factors associated with self-
injurious behavior, currently it is not possible to cure some of the con-
ditions, e.g., Lesch-Nyhan Syndrome, in an attempt to eliminate the cor-
related self-injury. When a cure is possible, e.g., with Otitis Media or
Contact Dermatitis, self-injury often continues, thus requiring additional
treatment (Carr & McDowell, 1980). In general, medical treatment may
not be sufficient.
Chemical intervention such as with carbidopa, hydroxytryptophan and
5-hydroxytryptophan shows promise in treating the self-injury of Lesch-
Nyhan clients (Mizuno & Yugari, 1974; Nyhan, 1976). In contrast, al-
though psychotropic drugs are widely used with developmentally disabled
persons, and anecdotal reports concerning their effects on self-injury
abound, few controlled pharmacological studies have demonstrated suc-
cess in selectively suppressing self-injurious behavior (Picker, Poling,
& Parker, 1979; Ross & McKay, 1979; Sprague & Baxley, 1978).
Finally, increasing evidence suggests that behavioral interventions are
effective in treating self-injury correlated with medical disorders, just as
with self-injury for which there is no known associated biological con-
534 AABT TASK FORCE REPORT

dition. Thus, medical treatment may be neither necessary nor sufficient

(Anderson, Herrmann, Alpert, & Dancis, 1975; Cataldo & Russo, in
press; Duker, 1975a; Shear, Nyhan, Kirman, & Stern, 1971).
Psychodynamic Approaches
Psychodynamic approaches have proposed several theories regarding
the development of self-injury. For example, the behavior has been
viewed as an individual's attempt to alleviate guilt (Beres, 1952), displace
anger directed at others (Menninger, 1935), or establish "body reality"
(Greenacre, 1954) or "ego-boundaries" (Bychowski, 1954). However, the
psychoanalytic perspective has not resulted in the development of treat-
ment techniques which are demonstrated effective in reducing self-injury
in individuals who are developmentally disabled (Bachman, 1972). To the
contrary, in one of the few studies directly comparing treatment derived
from a psychoanalytic orientation with behavioral intervention, Lovaas,
Freitag, Gold, and Kassorla (1965) demonstrated that providing comfort
and reassurance for self-injury (as would be suggested as a method of
alleviating guilt) resulted in substantial increases in self-injury. In con-
trast, behavioral intervention was subsequently effective in decreasing
the self-injury of that client (see also Cain, 1961 ; Lester, 1972; Sandier,
1964).
Behavioral Approaches
A third major approach to the understanding and particularly the treat-
ment of self-injurious behavior derives from the experimental analysis of
behavior. This approach is predicated on decades of research on operant
behavior which has confirmed that the strength of a behavior is effected
by its consequences. Behavior that is followed by a positive reinforcer
(informally, a pleasant event for which an individual will work) will in-
crease in strength. On the other hand, a behavior that is not followed by
a reinforcer or is followed by a punisher (informally, an unpleasant event)
will decrease in strength. Further, the antecedent stimuli which are pres-
ent before and during the time the behavior is consequated (e.g., rein-
forced or punished) acquire control over the behavior. That is, the be-
havior is more likely to occur in the presence of people and in places
and activities where reinforcement for the behavior has regularly oc-
curred. On the other hand, the behavior is less likely to occur in settings
in which it has not been reinforced or has been punished.
Within this framework, self-injury is viewed as an operant behavior,
affected by its consequences and controlled by antecedent stimuli which
signal differential consequences. Specifically, self-injurious behavior is
predominantly viewed as a method of gaining positive reinforcement,
especially attention, or of avoiding or escaping unpleasant situations such
as periods of little reinforcement, teaching demands, or even social con-
tact (Baumeister & Rollings, 1976; Carr, 1977). The precise form of at-
tention or escape/avoidance maintaining an individual's self-injury differs
widely. That is, individuals may self-injure to obtain very different---even
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 535

aberrant forms of attention or escape from unpleasant situations. For

example, physical restraint has been shown to be a reinforcer for some
self-injurious individuals, and thus its use to terminate self-injurious ep-
isodes may directly strengthen and maintain the behavior (Favell,
McGimsey, & Jones, 1978; Favell, McGimsey, Jones, & Cannon, 1981).
Similarly, isolation in a room or vigorous scolding may be forms of escape
or attention, respectively, and thus reinforce self-injury that produces
them (Solnick, Rincover, & Peterson, 1977). In short, the behavioral
approach emphasizes the need to determine---in each client's case--the
precise role of specific environmental events in maintaining that individ-
ual's self-injury (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982). Al-
though attention and escape are most frequently cited as environmental
factors maintaining self-injury, research on noninjurious stereotyped be-
havior may have implications for a third possible motivation of self-in-
jury. Rincover, Cook, Peoples, and Packard (1979) have demonstrated
that noninjurious stereotyped behavior may be maintained by sensory
reinforcement such as visual, tactile, or auditory stimulation. The role of
similar stimuli in maintaining self-injurious behavior is now being consid-
ered (Favell, McGimsey, & Schell, 1982; Rincover & Devany, 1982).
The primary focus of research in the behavioral field has not been on
the etiology of self-injury, but on its treatment. Behavioral treatment
techniques operate either on rearranging consequences for the behavior
(e.g., removing reinforcement or punishing self-injury; reinforcing more
desirable behavior); or rearranging antecedent stimuli which control dif-
ferential occurrences of the behavior. The major emphasis of the behav-
ioral approach has been on experimentally analyzing the effectiveness of
these techniques. This research has yielded an array of treatment pro-
cedures demonstrated effective in varying degrees in reducing self-in-
jury. Following is a brief description of those interventions which have
been most generally researched and the effects obtained with each
(Bachman, 1972; Baumeister & Rollings, 1976; Favell & Greene, 1981;
Forehand & Baumeister, 1976; Frankel & Simmons, 1976; Harris &
Ersner-Hershfield, 1978; Russo, Carr, & Lovaas, 1980; Schroeder,
Schroeder, Rojahn, & Mulick, 1980; Smolev, 1971).
(1) Treatment by differentially reinforcing alternative behavior.
Several techniques employed in the treatment of self-injury rest on the
principle of differential reinforcement. As applied to self-injury, the con-
cept of differential reinforcement involves providing relatively more re-
inforcement for appropriate, noninjurious behavior, and less (ideally, no)
reinforcement for self-injury. Thus appropriate, noninjurious behavior is
heavily reinforced in order to strengthen it, and reinforcement is withheld
or delayed following self-injury in an attempt to weaken it. The objective
is to replace self-injury with alternative behavior, i.e., to establish more
desirable, noninjurious behavior as the predominant means of obtaining
reinforcement.
In one specific form of differential reinforcement, termed Differential
536 AABT TASK FORCE REPORT

Reinforcement of Other Behavior (DRO), reinforcement is provided fol-

lowing periods of time in which no self-injury occurs. Thus, the individual
receives reinforcement for refraining from self-injury. In a second pro-
cedure, termed Differential Reinforcement of Incompatible Behavior
(DRI), reinforcement is provided for specific behavior which is appro-
priate and incompatible with self-injury. Two behaviors are demonstrated
to be incompatible if strengthening one results in a decrease in the other.
Thus, appropriate behavior such as communication skills, toy play, social
behavior, and compliance to requests may be reinforced in an attempt to
increase its strength and thereby decrease the relative strength of the
self-injury. With both the DRO and DRI procedures, while reinforcement
is provided for alternative behavior, occurrences of self-injury typically
delay reinforcement. As self-injury decreases, the time between rein-
forcement or the amount of appropriate behavior required for reinforce-
ment is gradually extended.
In the few published studies in which DRO and DRI were employed
by themselves, they were effective in some instances (Allen & Harris,
1966; Favell et al., 1982; Frankel, Moss, Schofield, & Simmons, 1976;
Lane & Domrath, 1970; Lovaas et al., 1965; Tarpley & Schroeder, 1979;
Weiher & Harman, 1975) but were ineffective in others (Corte, Wolfe,
& Locke, 1971; Measel & Alfieri, 1976; Young & Wincze, 1974).
In practice, the DRO and DRI procedures are often used in conjunction
with other techniques, which typically consist of applying some conse-
quence following self-injury. For example, in addition to the usual DRO
or DRI procedure, occurrences of self-injury might result in the individ-
ual's removal from reinforcing activities (time out). A more extensive
body of research literature supports the use of DRO and DRI combined
with other techniques (e.g., Brawley, Harris, Allen, Fleming, & Peterson,
1969; Favell et al., 1978; Myers, 1975; Myers & Deibert, 1971; Peterson
& Peterson, 1968; Repp & Deitz, 1974).
In general, although differential reinforcement procedures, by them-
selves, may not be effective in completely suppressing self-injury, in good
clinical practice they are an essential part of any treatment program.
Regardless of what other techniques are employed, differential reinforce-
ment is crucial in replacing the self-injury with more appropriate behavior
by which the individual may obtain reinforcement.
(2) Treatment by rearranging antecedent stimulus conditions.
A second major class of treatment procedures is based on principles
of stimulus control. As applied to self-injury, the principle of stimulus
control refers to the fact that self-injurious behavior is much more prev-
alent in some situations than in others. Which specific situations control
high or low rates of self-injury depends on the individual's reinforcement
history in those situations. In many cases, self-injury tends to occur when
reinforcement that was previously given is not forthcoming or when de-
mands are placed on the individual. In such situations, the self-injury is
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 537

likely to have been reinforced by the resumption of reinforcement or the

withdrawal of demands, respectively.
The treatment implications of stimulus control principles are only be-
ginning to be explored. One major approach involves identifying, and then
providing the individual access to, stimulus conditions which are reliably
associated with little or no self-injury. For example, providing the indi-
vidual access to vibratory stimulation (Bailey & Meyerson, 1970), op-
portunities for toy play (Favell et al., 1982; Mulick, Hoyt, Rojahn, &
Schroeder, 1978), or other entertainment such as amusing stories (Carr,
Newsom, & Binkoff, 1976), usually combined with reinforcement for ap-
propriate behavior, have been shown effective in reducing self-injury. In
a somewhat similar approach, providing access to large amounts of food
has been shown effective in decreasing rumination (Foxx, Synder, &
Schroeder, 1979; Jackson, Johnson, Ackron, & Crowley, 1975; Libby
& Phillips, 1979).
Just as self-injury may be treated by identifying and then providing the
individual access to situations which control low rates of self-injury, a
second complementary approach may be to identify and then rearrange
stimulus situations controlling high rates of the behavior. Although re-
search in this area is scant, the clinical value of eliminating or changing
situations which are reliably associated with self-injury is clear. Such
situations will differ across clients, but may include barren environments
with few activities, little reinforcement for appropriate behavior, or lack
of social contact of any kind. When situations (such as the imposition of
training demands) cannot or should not be eliminated altogether, self-
injury may be treated by systematically exposing the individual to those
situations, for example, in a graduated manner, while teaching more ap-
propriate, noninjurious behavior in their presence (CalT et al., 1976).
In general, the principles and procedures of stimulus control have re-
ceived less research attention than the manipulation of consequences per
se. Nevertheless, these principles are instructive and should be taken
into account in two major ways when treating self-injurious behavior.
First, principles of stimulus control account for the fact that self-injury
usually occurs under some very specific conditions and not under others.
Second, they suggest that the identification and rearrangement of these
conditions be included as part of any treatment effort.
(3) Treatment by withholding or removing reinforcement for self-injury.
A third behavioral approach to treatment involves reducing reinforce-
ment following episodes of self-injury. Two procedures are most com-
monly employed: extinction and time out from positive reinforcement.
Extinction involves withholding previously given reinforcement follow-
ing self-injurious behavior. If that reinforcement consists of attention
from caretakers, the extinction technique would require ignoring episodes
of the behavior. If on the other hand, an individual's self-injury is rein-
forced by the opportunity to escape or avoid unpleasant situations, the
538 AABTTASKFORCEREPORT

extinction procedure would involve preventing escape for the behavior.

Thus, with extinction, the self-injurious behavior must occur, and result
in no differential consequences; that is, the caretaker must respond as
though the self-injury has not happened.
This strategy has been used by itself in a small number of studies. It
proved eventually successful in reducing self-injury in some instances
(Anderson, Herrmann, Alpert, & Dancis, 1975; Jones, Simmons, & Fran-
kel, 1974; Lovaas & Simmons, 1969), but was only partially effective
(Duker, 1975b) or ineffective in others (Bucher & Lovaas, 1968; Corte,
Wolfe, & Locke, 1971; Myers, 1975).
The extinction technique is not feasible in cases where the reinforcer
maintaining self-injury cannot be identified, or where that reinforcer can-
not be withheld with the high degree of consistency required. Such con-
sistency is difficult, if not impossible, to achieve in many programs. Un-
less precautions for the safety of the client can be provided, for example
through protective padding on the client and in the environment (Rin-
cover & Devany, 1982), extinction may be extremely dangerous because
of the high rate and intensity of the behavior which typically occurs
during the slow and gradual course of extinction. However, in good clin-
ical practice the removal or reduction of reinforcers for self-injury should
be an essential part of any treatment program.
Time out 1 consists of removing the client from the opportunity to obtain
reinforcement contingent upon, i.e., immediately following, each occur-
rence of self-injury. The procedure presupposes that the individual is
functioning in a "time in" environment which is highly enriched and
reinforcing, e.g., provides highly engaging recreational and educational
activities and differential reinforcement for alternate behavior. When an
episode of self-injury occurs, the individual is typically reprimanded and
reinforcement is removed for all behavior for a period of time. The forms
of time out differ widely. These include: contingent withdrawal of the
caretaker from the client's environment (used when the caretaker is the
major source of reinforcement for the client) (Tate & Baroff, 1966); con-
tingent removal of the client from an activity to an area or room which
is not physically uncomfortable but is relatively barren (White, Nielsen,
& Johnson, 1972); contingent placement of the client in physical restraint,
such as in a helmet (Bucher, Reykdal, & Albin, 1976) or a chair (Ham-
ilton, Stephens, & Allen, 1967); contingent manual restraint by the care-
taker, such as holding the client's hands down (Azrin, Besalel, & Wisotz-
ek, 1982; Saposnek & Watson, 1974); and contingent placement of a cloth
bib over the client's face (Lutzker, 1978). Regardless of the form of time
out, the procedure is to be applied immediately following each episode
of self-injury. The period in time out is usually brief (e.g., from several
seconds to 30 min) and terminated when the individual is calm.

I Time out is sometimes interpreted within a punishment paradigm, and the use of its
varying forms is commonlyregulated under rules governingthe use of punishment.
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 539

Time out has proven effective in reducing self-injurious behavior, pri-

marily under conditions in which reinforcement of alternate behavior and
overall enriched time in are explicitly programmed (e.g., Adams, Klinge,
& Keiser, 1973; Anderson et al., 1975; Brawley et al., 1969; Myers &
Deibert, 1971; Solnick et al., 1977; Wolf, Risley, Johnston, Harris, &
Allen, 1967; Wolf, Risley, & Mees, 1964). However, in some cases it has
been shown to be ineffective (e.g., Corte et al., 1971; Tate & Baroff,
1966).
When using time out with problems of self-injury, care must be taken
to protect the client from further self-injury during the period in time out,
e.g., by placing the individual in physical restraint if necessary. If such
protection cannot be provided, the procedure cannot be employed.
(4) Treatment by punishing self-injury.
A fourth major type of behavioral procedure used to treat self-injury
involves punishment, i.e., delivery of an event contingent upon each
occurrence of self-injury. Although such events are sometimes viewed as
aversive or unpleasant, they may be termed punishers only if their con-
tingent use decreases the future occurrence of self-injury. Following is
a description of the events most commonly found to be punishers for self-
injury. Regardless of which punisher is used, each is typically paired with
a verbal reprimand in an effort to establish that reprimand as a punisher
in its own right and should be used immediately following each occur-
rence of the behavior.
Overcorrection. Developed within the last several years, overcorrec-
tion actually consists of a complex combination of procedures. In the
form of overcorrection used to treat such self-injurious behaviors as self-
striking, poking, or scratching, clients are encouraged to and reinforced
for interacting appropriately with their environments and for positioning
their hands away from the most common sites of their self-injury. Oc-
currences of self-injury are followed by a verbal reprimand and an inten-
sive period of practice in alternate uses of the hands and/or an extended
period of required relaxation. Thus, for example, immediately contingent
upon an episode of face slapping, an individual may be required to prac-
tice "functional" use of his hands such as performing arm exercises on
cue, or may be required to lie on his bed until he has remained calm for
some period of time.
Another form of overcorrection has been applied to pica (eating nor-
mally inedible objects), coprophagy (eating feces), and persistent vom-
iting. When these forms of self-injury occur, clients are required to
cleanse their mouths with oral antiseptic and clean relevant areas of their
bodies and environment.
Although the procedural details of overcorrection vary widely, most
published applications of the technique tend to conform to the following
dimensions (the importance of each of which is not fully known): the
specific alternative behaviors practiced are matched to the form of the
self-injurious behavior, e.g., face-slappers practice appropriate use of their
540 AABT TASK FORCE REPORT

hands; the duration of the overcorrection is usually lengthy, e.g., 20

minutes, and then only terminated when the individual is cooperative;
the practice is effortful; verbal and if necessary manual prompting is
applied if the individual does not perform the overcorrection regime cor-
rectly; and aside from the contact associated with the conduct of the
procedure, positive reinforcement is withheld until the overcorrection
episode is completed.
Overcorrection has proven very effective in suppressing self-injurious
behavior (Azrin, Gottlieb, Hughart, Wesolowski, & Rahn, 1975; Azrin
& Wesolowski, 1975; DeCatanzaro & Baldwin, 1978; Duker & Seys,
1977; Foxx & Martin, 1975; Foxx, Synder, & Schroeder, 1979; Harris
& Romanczyk, 1976; Johnson, Baumeister, Penland, & Inwald, 1982;
Kelly & Drabman, 1977; Rusch, Close, Hops, & Agosta, 1976). It has
been reported ineffective with certain individuals (Measel & Alfieri,
1976). Overcorrection is a complex procedure, and its effective compo-
nents as well as methods of modifying it to fit individual cases are not
yet fully explored. The procedure can be very time consuming and stress-
ful to caretakers and may place clients who are physically resistive at
serious risk.
Aversive electrical stimulation. In this technique, a physically harmless
but subjectively noxious electrical stimulus is delivered by an inducto-
rium (shock prod) to the client's limb or back for a very brief duration
(less than 3 sec) immediately following each occurrence of self-injury
(Butterfield, 1975).
Aversive electrical stimulation (informally termed shock) is the most
widely researched and, within the parameters of shock employed in the
research literature, the most generally effective method of initially sup-
pressing self-injury (Birnbrauer, 1968; Browning, 1971; Bucher & Lo-
vaas, 1968; Cart & Lovaas, 1982; Corte et al., 1971; Cunningham &
Linscheid, 1976; Duker & Gathercole, 1976; Kohlenberg, 1970; Kohlen-
berg, Levin, & Belcher, 1973; Lovaas & Simmons, 1969; Luckey, Wat-
son, & Musick, 1968; McFarlain, Andy, Scott, & Wheatley, 1975; Mer-
baum, 1973; Prochaska, Smith, Marzili, Colby, & Donovan, 1974; Tate
& Baroff, 1966; Toister, Condron, Worley, & Arthur, 1975; Watkins,
1972; Whaley & Tough, 1970; White & Taylor, 1%7; Young & Wincze,
1974). The only published exception to the effectiveness of shock is with
Lesch-Nyhan clients for whom shock appears to be ineffective (Anderson
et al., 1975; Nyhan, 1975).
Although highly effective in initially suppressing self-injury, usually
within a very small number of applications, there are limitations to the
therapeutic benefits of shock. Self-injury tends to decrease only in situ-
ations in which it is punished by shock (Birnbrauer, 1968). Thus, in order
to ensure improvement in all situations, the shock must be employed in
all situations (Corte et al., 1971). Although the suppressive effects appear
to be relatively durable, periodic reapplications of shock may be neces-
sary to maintain improvement (Lovaas & Simmons, 1969).
Although a powerful therapeutic tool with self-injury, shock is consid-
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 541

ered an extremely restrictive procedure: it is painful, very intrusive and

highly susceptible to abuse; i.e., it can easily be employed in nonthera-
peutic and unethical ways. For these reasons, its use is rigorously con-
trolled (May, Risley, Twardosz, Friedman, Bijou, Wexler et al., 1976).
Specifically, shock programs should be reserved for use in the most ex-
treme cases, designed and supervised only by highly qualified behavioral
experts with extensive training and experience in treating self-injury, and
employed in settings which provide the highest standards of professional
service and human rights compliance.
Otherpunishers. Several other events have been demonstrated to func-
tion as effective punishers of self-injury. These events are applied im-
mediately contingent upon each occurrence of self-injurious behavior,
and include aromatic ammonia held briefly under the client's nose (Alt-
man, Haavik, & Cook, 1978; Tanner & Zeiler, 1975), aversive tickling
(Greene & Hoats, 1971), water mist sprayed in the client's face (Dorsey,
Iwata, Ong, & McSween, 1980), and lemon juice squirted in the mouth
(Sajwaj, Libet, & Agras, 1974).
Some of these events are associated with possible physical side effects,
ranging from chapped skin (with water mist) to mucous membrane dam-
age (with ammonia). Further, the number of studies and the number of
clients involved in research on these punishers has been more limited
than in the case of the procedures described previously. In short, their
precise effects and the generality of their effects is less well understood.
General Comments and Recommendations on the Use o f
Behavioral Treatment o f Self-Injury
(1) Although individual behavioral treatment procedures vary in the
quality and quantity of scientific evidence supporting their effectiveness,
these combine into a composite behavioral treatment strategy which is
well substantiated. These generic components, which comprise the rec-
ommended treatment of self-injury, consist of:
• A prior analysis of medical and environmental conditions and con-
sequences which may be maintaining the client's self-injury, and the
explicit inclusion of that information in the design of each of the
features described below. Such an analysis must be done on a sit-
uation by situation basis, since different situations control different
rates and intensities of self-injury, and because even in situations in
which self-injury does occur, the behavior may serve very different
functions. For example, at times the behavior may enable the client
to escape demands, at others it may function to obtain attention.
• The deliberate teaching and reinforcement of behaviors which are
noninjurious and which provide the individual with more appropri-
ate methods of receiving reinforcement (differential reinforcement
procedures).
• The identification and discontinuation of reinforcers for the self-in-
jurious behavior, whether those reinforcers be attention, escape, or
perhaps sensory stimulation (extinction and time out procedures).
542 AABT TASK FORCE REPORT

• The establishment and provision of overall stimulus conditions

which are associated with noninjurious behavior (such as through
an enriched educational and social environment), and the alteration
or elimination of environmental conditions which are reliably cor-
related with self-injury (stimulus control procedures).
All of these generic components should be explicity included in any
intervention, regardless of the specific procedures used to effect each.
This comprehensive approach is in contrast to the sequential application
of single techniques, such as DRO or time out, each of which may only
address one of the features outlined above and thus may be only partially
effective. This recommendation is made in the interests of humaneness,
increasing the effectiveness of treatment, and increasing the likelihood of
maintenance of improvement in self-injurious behavior after intensive
treatment is discontinued.
(2) Based on the assumption that any intervention will include the fea-
tures described above, a crucial clinical decision focuses on the point at
which an additional consequence for the self-injury will be employed.
Although general guidelines regarding the use of punishment cannot re-
place individual clinical decisions, several crucial considerations should
be mentioned. On one hand, punishment, including very intense punish-
ment such as shock, should be considered for immediate inclusion in
treatment: (a) in cases in which the client is in imminent and extreme
physical danger, or when the self-injurious behavior is so intrusive as to
prevent participation in habilitative and humanizing activities, or (b) when
"benign" procedures (outlined in (1), above) have been employed inten-
sively and competently and have not resulted in clinically significant im-
provement in self-injury. On the other hand, punishment should not be
considered if any of the requirements listed in (3), below, cannot be met.
(3) Since self-injurious behavior, by definition, places the client at se-
rious risk, the following requirements should be met in any setting in
which a client is to be treated. These requirements apply regardless of
the treatment procedure used, but particularly in cases in which punish-
ment is considered or employed. These requirements serve to protect
clients and those who conduct their treatment.
• The treatment should be designed and supervised by a highly qual-
ified professional whose explicit training and experience includes
work with self-injurious clients and the behavioral procedures out-
lined here. The apparent simplicity of these techniques may be mis-
leading. They are complex procedures which require a high degree
of competence to design and conduct. The improper use of any
procedure may place a self-injurious client at severe risk.
• Because of the dangerous nature of the behavior, it is recommended
that any treatment be reviewed and approved by a Human Rights
Committee, composed of lay individuals and consumer advocates;
by a Peer Review Committee, composed of independent experts in
applied behavior analysis; and that informed guardian consent be
obtained (May et al., 1976).
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 543

• It is further recommended that treatment be conducted openly, and

that its effects be evaluated rigorously (see below).
(4) This article describes the major generic behavioral procedures
which have been demonstrated effective in the research literature, and
the preceding recommendations represent general ways in which
these procedures can be employed with individual clients. However, at
present there exist no well formulated prescriptive "rules" governing the
many clinical decisions that may optimize the chances for successful treat-
ment. In short, it is not possible to predict in advance if a given procedure
or set of procedures will be effective in an individual case. For example,
although time out has been documented effective in suppressing self-in-
jurious behavior, it has also been shown to have no effect, or under
certain conditions to increase the strength of the behavior it follows (Fav-
ell et al., 1981; Solnick et al., 1977). With each client, treatment must be
tried and rigorously evaluated, then continued, modified, or discontinued
depending upon the results with that individual. Such evaluation is based
upon the quantitative, reliable measurement of occurrences of self-injury
(as well as potential side effects) before, during, and after treatment; and,
if possible, on the use of an experimental design which verifies that the
treatment employed caused the improvement observed.
In general, the criteria for evaluating the effectiveness of treatment
include the:
• Degree and speed of suppression.
• Durability of suppression.
• Generality of effects across situations.
• Clinical significance.
• Side effects.
• Social acceptability.

(Schroeder, Mulick, & Schroeder, 1979.)

(5) The use of a n y procedure for treating self-injurious behavior may
influence other, nontreated behaviors. Although negative side effects
such as emergence of other forms of self-injury do occur, these can be
limited by properly administered procedures and may themselves be
treated. To the contrary, positive side effects such as collateral increases
in social behavior, attention, and cooperation are also observed when
self-injury is suppressed (Newsom, Favell, & Rincover, 1982).
(6) The research literature relates primarily to suppression of self-in-
jurious behavior during treatment (usually across weeks or months).
Much less is known about generalizing the effects of treatment to all
situations and maintaining improvement over time. Research is needed
on methods of producing generalized, durable improvement following
termination of intensive treatment. For the present, however, it appears
that improvement in self-injury is limited to those situations in which
treatment is applied. Thus, regardless of what therapeutic technique is
employed, treatment should be administered throughout each day and in
all environments in which the client lives. Further, it is commonly ob-
544 AABT TASK FORCE REPORT

served that there is a high probability of relapse among self-injurious

clients. Since such remission usually appears to occur after treatment is
discontinued, at present it should be assumed that some form of treatment
must be continued over a lengthy, perhaps indefinite, period. Failure to
program specifically for generalization and maintenance not only denies
an individual's right to treatment, but also risks making the problem more
severe and intractable.
Summary
Self-injurious behavior is a term referring to a broad array of responses
which result in physical damage to the individual displaying the behavior.
The behavior tends to be characterized as repetitious and chronic, re-
sulting in relatively immediate damage, and most prevalent and severe
among persons who are severely disabled, such as autistic or retarded
individuals. Forms of self-injury include head banging, face slapping, eye
poking, self-biting, and eating nonedible substances. Considering the
problems and risks associated with such behavior, its treatment is usually
given the highest clinical priority.
Little is known about the causes of self-injury. Though the behavior is
sometimes correlated with genetic or medical disorders, it is most com-
monly considered to be learned behavior, i.e., shaped and/or maintained
by pathological conditions and contingencies in the environment.
Three major approaches to the understanding and treatment of self-
injury exist: medical, psychodynamic, and behavioral. The efficacy of
each must be based on scientific research demonstrating the effectiveness
of that approach in decreasing the strength (e.g., rate or intensity) of the
behavior.
Medical. Though medical research holds promise in possible preven-
tion and treatment of the biological mechanisms which may underlie self-
injury, at present medical intervention is of limited utility in treating the
behavior itself. First, in many cases medical treatment has not been de-
veloped; for example, it is not presently possible to cure Lesch-Nyhan
Syndrome in an attempt to eliminate its associated self-injury. Second,
medical treatment is often not sufficient, i.e., although effective in treat-
ing a biological condition such as Otitis Media, the self-injury correlated
with that condition continues. Third, medical treatment may be unnec-
essary, i.e., behavioral treatment may successfully decrease self-injury
although the biological disorder continues. Finally, very few pharmaco-
logical studies have scientifically demonstrated the success of psycho-
tropic drugs in selectively decreasing self-injurious behavior.
Psychodynamic. This approach has proposed several theories regard-
ing the etiology of self-injury. However, treatments based on these the-
ories, such as comforting or reassuring self-injuring individuals in an at-
tempt to alleviate their guilt, have not resulted in scientifically verified
improvement in self-injurious behavior, particularly with individuals who
are developmentally disabled.
Behavioral. The behavioral approach has concentrated on the devel-
opment and experimental analysis of a variety of procedures for treating
 THE TREATMENT OF SELF-INJURIOUS BEHAVIOR 545

self-injury. Although individual behavioral procedures vary in the quality

and quantity of scientific evidence supporting their effectiveness, these
combine into a composite behavioral treatment strategy which is well
substantiated in the research literature. The generic components of this
strategy, which comprise the recommended treatment of self-injury, con-
sist of:
• The identification of biological and environmental conditions which
may maintain the client's self-injury and the explicit inclusion of
that information in the design of treatment. Such an analysis should
include identification of medical conditions which may contribute to
the problem, environmental situations which regularly evoke the
behavior, and the consequences of self-injury which may be rein-
forcing it.
• The deliberate teaching and reinforcement of noninjurious, appro-
priate behavior. Such behavioral alternatives to self-injury may in-
clude communication, cooperation with tasks, independent leisure,
and social skills.
• The identification and discontinuation of reinforcers for the self-in-
jurious behavior, typically by arranging conditions so that care-
takers can safely and consistently minimize reactions to the behavior
which might be inadvertently reinforcing it.
• The establishment and provision of overall stimulus conditions
which are associated with noninjurious behavior (such as through
environmental enrichment), and the alteration or elimination of en-
vironmental conditions which are regularly associated with self-in-
jury (such as situations which are unnecessarily frustrating or non-
reinforcing).
• In cases where the behavior is dangerous, interferes excessively
with habilitative or humanizing activities, or has failed to improve
when treated with the less intrusive procedures outlined above, a
punishing consequence such as overcorrection, or in extremely se-
vere cases, shock for self-injury may also be necessary.
• The provision for generalizing improvement into all environments
in which the individual lives and for maintaining improvement over
time.

In summary, current scientific evidence supports this behavioral strat-

egy as the treatment of choice for self-injurious behavior in develop-
mentally disabled persons.
In order to ensure the appropriate, ethical use of this treatment tech-
nology, several specific guidelines should be met. Lack of adherence to
these guidelines may seriously jeopardize clients' safety and right to hu-
mane and effective treatment.
• Treatment should be designed and closely supervised by a profes-
sional who is highly trained and experienced in the behavioral treat-
ment of self-injury.
• The treatment plan should be reviewed for its technical adequacy
546 AABT TASK FORCE REPORT

and appropriateness by behavioral experts (Peer Review Commit-

tee) and for its consideration of the rights of the client by consumer
advocates (Human Rights Committee), and should be approved by
the client or guardian.
Treatment should be conducted openly and its effects evaluated
rigorously. Such evaluation is based on the quantitative, reliable
measurement of the self-injurious behavior before and during treat-
ment and follow-up and, if possible, on the use of experimental
designs which verify whether the treatment employed caused the
improvement observed.
Further research is needed to expand and refine our understanding and
treatment of self-injurious behavior. Current research directions include
the analysis of biological and environmental conditions which cause and
which sustain self-injurious behavior; the refinement of treatment, espe-
cially those methods which facilitate the transfer of improvement to all
aspects of daily living and which sustain improvement in the absence of
intensive treatment; and analysis of the multiple effects of treatment.

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