This is a column where readers share feedback on previous BLOOM stories. The aim is to better balance perspectives on topics.
 

A different approach

A behaviour analyst responds to a BLOOM article about self-injury

BY DR. LOUISE LAROSE

It goes without saying that children with developmental disabilities deserve compassion.

Felicia Jervis, in a recent BLOOM article Summer 2008, outlined her approach to dealing with self-injury in children with developmental disabilities. I’d like to address this approach and suggest other ways to reduce self-harming behaviour.

I agree with Felicia that whenever children are hurting themselves, the last thing we want to do is punish them. When a child doesn’t speak and has no functional means of communication, self-harm can be the only way the child knows to bring attention to a problem. Children with developmental disabilities hurt themselves for a reason, so the first thing we need to do is figure out that reason.

Where I part ways with Felicia is in responding to self-injury with food, drinks, hugging or holding the child. We don’t want the child to associate hurting themselves with getting something desirable, like a hug. We don’t want self-harm to become the request for something nice. There is a lot of good research to show that children will continue to self-injure when something positive follows the behaviour. That’s why it’s so important to give your child affection, comfort and love when they are not self-harming.

But doing this alone may not reduce the frequency of the problem. We usually have to teach the child a different way to express needs. So, if a child doesn’t want to do something, we teach him or her to exchange a picture or use a hand sign to indicate ‘stop.’ The emphasis here is on teaching, not punishing. Punishment only suppresses behaviour.

As Felicia wrote, it’s important for a parent to be quiet, calm and still when faced with self-harm. If a parent is unsure of what a child is trying to communicate, the parent needs to ensure the child’s safety (e.g., putting a pillow under their head if they’re banging it on the floor). It’s important to not give undue attention to the problem behaviour, which can reinforce it.

Research shows that there are two common causes of self-injury in children with developmental disabilities: wanting to escape something and wanting something. 

Why might families have a hard time finding someone to provide sound behaviour interventions? There are not a lot of well-trained behaviour therapists out there. And there are too many people who revert to punishment as the first line of defence. The standards of practice for applied behaviour analysts state that we should always consider positive reinforcement first and teach alternative behaviours.

In recent years, many agencies have had extensive training in a program from Australia called Positive Parenting Program, or Triple P. It is a great program where parents meet individually with a therapist or in groups to learn non-punitive, positive ways of dealing with a range of problem behaviours, including self-injury. This program can be adapted to a wide range of populations, including children with disabilities.

Editor’s note

Bloorview is offering a Triple P program for parents of children aged two to 12 with intellectual disability and behaviour issues, beginning April 15.
Call 416 425 6220 ext. 3799 to register.

What to ask

When looking for a therapist to treat self-injury in your child, Dr. LaRose suggests you ask these questions:

  1. Are you a certified behaviour analyst?
  2. If not, are you supervised by someone with extensive behaviour experience? The certifying board in the United States recommends that complex cases be supervised by a therapist with a PhD.
  3. How do you assess self-injury? You want to hear that they will: observe firsthand the behaviour, collect data, have you or someone else who knows your child well complete a questionnaire, and possibly do an interview.
  4. How do you interpret self-harming behaviour? The most effective techniques for treating self-injury are preventative. You want to hear that the therapist will figure out which situations trigger your child’s problem behaviour and maintain it. Sound assessment techniques don’t assume that the behaviour is fuelled by vague internal states like anxiety, because we don’t really know how a child is feeling. We only know what they’re doing.
  5. What are your typical recommendations for treating self-harm?  If punishment, restraints and seclusion are included, look elsewhere!

Dr. LaRose is a board-certified behaviour analyst who is a consulting psychologist with the pervasive developmental disorders program at the Child and Parent Resource Institute in London, Ont. To comment on her piece, please e-mail BLOOM’s editor at lkinross@bloorview.ca

 

Felicia Jervis replies

I welcome a dialogue with Louise LaRose. Regardless of whether self-injury intensifies initially, children always need unconditional love and acceptance, best expressed through warm hugs, reassuring words, soothing drinks and food. It is unfortunate that these vital expressions of unconditional love are appropriated as reinforcers for instructional purposes such as teaching alternate communication skills. It is sad that in the name of therapy or education, parents are sometimes advised to withhold affection, comfort and love when children are hurting the most.

 


Comment on these letters or send your own to lkinross@bloorview.ca