NADD Bulletin Volume VI Number 2 Article 3

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Diagnostically-Based Treatments of Biomedical and Psychosocial Conditions that Influence Self-Injurious Behaviors: A Multimodal Contextual Case Formulation

William I. Gardner, Ph.D.

Persons with mental retardation display a wide array of psychological and behavioral problems that create emotional, social, and physical challenges both to the individuals and to those responsible for their care and support. The majority of these difficulties that require mental health diagnostic and treatment services are predominately of an overt behavioral presentation. These include such personally and socially harmful acts as repetitive bouts of self-injury, including pica and rumination. Most typically, persons presenting problems of self-injury also engage in acts of physical and verbal aggression, property destruction, and related agitated/disruptive outbursts. Survey data indicate that prevalence of self-injury tends to increase in frequency and intensity as the severity of cognitive disability increases (Oliver, Murphy, & Corbett, 1987; Rojahn & Esbensen, 2002). Jacobson (1982), as illustration, noted prevalence rates of 2%, 3%, 9%, and 14% among adults with mild, moderate, severe, and profound mental retardation.

Other psychological problems presented by persons with mental retardation have a predominate emotional presentation. These include such concerns as excessive fearfulness, specific phobias, dysphoric mood, excessive anger, specific and generalized anxiety, and generalized irritability. Even in persons who present major difficulties of an emotional nature, in most instances these psychological features contribute to an increased likelihood of overt behavioral symptoms including self-injury. In fact, referrals for mental health services typically are initiated by the presence of recurring and severe behavioral concerns involving self-injury and aggression (Benson, 1985; Davidson et al., 1994). These and similar observations emphasize the need for diagnostically-based treatment models that address the range of potential multiple factors contributing to various forms and intensities of self-injurious acts of persons with mental retardation.

Features of Behavioral Challenges Involving Self-Injury

Certain central features of self-injury and co-occurring problem behaviors should be addressed regardless of the treatments used. These include the following:

1.Behavioral challenges involving self-injury in most instances represent the joint effects of a person with psychological and biomedical (physical, psychiatric, neuropsychiatric) features in dynamic interaction with physical and social/ interpersonal/ program environments (Gardner, 2002; Schroeder, Oster-Granite, & Thompson, 2002). This transactional view of behavioral challenges involving self-injury suggests that person-centered treatments can be successful only to the extent that the interventions selected are derived from an understanding of the multiple personal and environmental influences that in combination result in the actions. To illustrate, a person when in a highly irritable mood state and without alternative coping skills may engage in bouts of self-injury when exposed to taunts from peers. The behavioral outbursts may never occur following taunts when these taunts occur in the absence of a psychologically distressful irritable mood. In this example, neither the irritable mood nor the taunts in isolation is sufficient to produce the self-injurious and related behavioral episode. Therapeutic attention thus must be given both to the irritable affective state and to the lack of coping alternatives available to the person when under the joint influence of a heightened mood state and socially aversive conditions.

This transactional view indicates that behavioral challenges involving acts of self-injury do not occur continuously, haphazardly or randomly but rather occur selectively under specific conditions of instigation that are unique to each person. The diagnostic endeavor is designed to locate these individually unique sources that precede the occurrence, severity, and variability of these self-injurious acts. To illustrate, a person may engage in 15 episodes of self-injury over a period of 30 days. welve of these episodes may occur within a four-day span early in the month with the remaining three in one day during the last week of the month. Additionally, only five of these episodes result in moderate to severe facial scratches with the remainder representing only minor face slapping or head banging. The assessment protocol, the interpretation given to the assessment results, and related diagnostically-based interventions should account for and address these antecedent controlling conditions. What are the controlling conditions and why do these produce episodes of self-injury only on 5 out of the 30-day period? What influences account for the more severe episodes? How will the interventions address these fluctuating pathological influences? Will the interventions treat or merely manage these influences (Gardner & Cole, 1987; Gardner, Graeber, & Ford, 2001)?

2.Behavioral challenges involving self-injury represent purposeful or functional actions that represent the person's means of coping with undesired conditions of distressful emotional and sensory-stimulation states (Gardner, 2002; Repp, 1999). In most instances, behavioral challenges involving self-injury are learned behaviors and as such have become functional in producing effects of value to the person (Iwata, Roscoe, Zarcone, & Richman, 2002). A learning approach views self-injury as a coping response that has been strengthened by the consequences produced by the self-injurious acts. Even though biobehavioral views of self-injury suggest that various biomedical conditions may contribute to the initial occurrences of self-injury and/or influence its severity and variability, self-injury in most instances evolves as a learned response with useful coping functions for the person. Iwata et al. (1994), in an eleven-year study of 152 assessments involving persons presenting recurring problems of self-injury, reported the following prevalence rates for different maintaining conditions:

"Social-positive reinforcement, 26.3%

"Social-negative reinforcement, 38.1%

"Automatic reinforcement, 25.7%

"Multiple controlling influences or uncontrolled outcomes, 9.9%

 Psychosocial interventions are selected that address the motivational basis for each of these subtypes (Gardner, Graeber, & Ford, 2001; Gardner & Sovner, 1994; Shores & Iwata, 1999; Thompson & Caruso, 2002).

The professional thus must be skillful in detecting what the person is experiencing (i.e., thinking, feeling, perceiving) that renders those disruptive acts involving self-injury necessary. Is the person highly anxious? depressed? Bored and understimulated? angry? fatigued? experiencing irritability? overstimulated? in pain? jealous? enraged? experiencing panic? deprived of social attention or desired tangibles or activities? deprived of neurochemically-produced emotionally pleasurable stimulation? fearful? Does the person view the actions of others as signifying hostile intent or as posing a threat to his/her space, property, or physical and psychological well-being? In short, from the current cognitive and/or affective perspective or experiences of the person, regardless of his or her developmental level or degree of cognitive or emotional impairment, what gives impetus and meaning to these acts of self-injury? The function or purpose of these behavioral challenges has meaning only relative to these personal sources of impetus. Thus, treatments must be sensitive to these dyads of interrelated antecedent motivational states behavioral consequences influences (Gardner, 2002; Dosen, 1993; Thompson & Caruso, 2002). Further, why was a challenging behavior such as self-injury selected rather than some other mode of coping, including use of socially-appropriate communication skills, with these personally distressful conditions involving aversive over-stimulation or states of deprivation. Does the person have alternative coping skills in his or her repertoire? If so, why were these alternative means of coping not used?

3. Although behavioral challenges may represent major coping responses of an individual, these nonetheless represent only one component of the person's total repertoire of behaviors. The major goal of treatment represents a joint one of reducing the pathological influences controlling the self-injurious acts and concomitantly enhancing the person's emotional, cognitive, and behavioral competencies. These competencies represent alternative means of coping with the distressing producing conditions.

Comorbidity: Risk Factors

Personal Characteristics. Although acts of self-injury may occur among persons with mild to moderate levels of mental retardation, the greatest frequency and severity is observed among individuals with severe and profound impairments (Rojahn & Esbensen, 2002). Additional characteristics serving as risk or predisposing factors for development and continuation of self-injurious acts include communication deficits (especially those reflecting receptive skills more advanced than expressive skills), sensory disabilities, seizure disorders, severe social impairments, and lengthy history of institutional living (Gardner & Sovner, 1994; MacLean, Stone, & Brown, 1994; Thompson & Caruso, 2002).

Genetic Disorders. An increased incidence of self-injury has been reported among persons presenting various genetic disorders (Bodfish & Lewis, 2002; Dykens, Hodapp, & Finucane ,2000). The term behavioral phenotype, introduced by Nyhan (1972), refers to "the heightened probability that people with a given syndrome will exhibit certain behavioral sequelae relative to those without the syndrome" (Dykens, 1995, p. 523). The Lesch-Nyhan syndome is the most prominent genetic disorder with almost 100% of cases with the associated phenotype showing a disposition to compulsive self-biting (Lesch & Nyhan, 1964). In a number of other genetic syndromes, the disposition to engage in self-injury is significantly lessened. Persons with such syndromes as Cornelia de Lange, Rett, Smith-Magenis, Praeder-Willi, Tourette, and Fragile X present a range of psychological symptoms that represent significant vulnerability conditions for self-injury and other behavioral difficulties. These psychological risk factors include pervasive hyperactivity, impulsivity, anxiety, attentional deficits, panic, agitation, emotional lability, and compulsive tendencies (Schroeder et al., 1999; Tuinier & Verhoeven, 1993). To illustrate the role of these psychological conditions as antecedent instigating conditions influencing occurrence of SIBs, Gualtieri (1991) reported that self-injury in persons with Cornelia de Lange occurred most frequently when the persons was angry, frustrated, sick, or in pain. Sanson, Krichnan, Corbetts, and Keri (1993) suggested that the self-injury in Rett's syndrome is correlated with anxiety attacks, panic, and agitation. These observations would suggest that treatment that reduced or eliminated these influential antecedent instigating conditions would hold promise of reducing the associated self-injury.

Psychiatric Disorders. Prevalence studies report an increased incidence of psychiatric abnormalities among persons who engage in self-injury (Bodfish & Lewis, 2002; Gardner & Sovner, 1994; Mace & Mauk, 1999; Rojahn, 1994; Sovner & Fogelman, 1996). As described by Gardner and Sovner (1994), mood and related features of the psychiatric disorders contribute to the instigating stimulus complex that influences frequency, severity, and variability of self-injury. In these instances, reduction in self-injury would result from successful treatment of the diagnosed psychiatric disorder and reduction or removal of those symptoms (e.g., dysphoric mood, irritability) that serve as instigating antecedents.

General Medical Conditions. A number of writers have reported a relationship between frequency, severity, and variability of occurrence of self-injurious episodes and presence of various medical illnesses such as gastroesophagael reflux, otitis media, or severe dental caries (Carr & Smith, 1995; Gardner & Sovner, 1994; Gardner & Whalen, 1996: Poindexter, 1998). As illustrations, Gunsett, Mulick, Fernald, & Martin (1989) documented a correlation between otitis media and occurrence of head banging; Taylor, Rush, Hetrick and Sandman (1993) reported an increase in self-injury among women during menses. In these and related instances of medical contributions to self-injury, Gardner and Whalen (1996) suggested that the distress resulting from the physical conditions serve as antecedent stimulus conditions that typically combined with other sources of aggravation to influence occurrence and severity level of each episode of self-injury. Treatment of the medical conditions and the associated reduction or elimination of the psychological distress would result in reduction in the self-injury controlled by these antecedent distressful states.

Needed: A Comprehensive Case Formulation

As is evident, self-injury is a complex phenomenon. The self-injuries of one person may be influenced by biomedical and psychosocial conditions that differ from the unique set of conditions controlling the self-injuries of another person. In view of the numerous biomedical and psychosocial conditions that potentially may influence occurrence, severity, variation in occurrence and severity, and durability of self-injurious acts, a case formulation approach is needed to integrate these multiple contributing conditions into a common explanatory model. Such an integrative model would be useful as a guide for completing comprehensive individual-specific diagnoses as a basis for providing individualized treatments of those conditions identified as influencing the self-injury.

A diagnostic case formulation model that accounts for self-injury should consider (a) the complete environmental, psychological, and biomedical stimulus complex that precedes and serves to instigate specific episodes of a person's self-injury, (b) the person's current biomedical and psychological central processing features that serve as risk factors for engaging in these acts when confronted with an antecedent instigating stimulus complex, as well as (c) those proximate consequences that follow occurrences of self-injury and contribute to their functionality and strength. The instigating stimulus complex may include both the arousing/activating features of a range of external physical and social environmental and internal psychological and biomedical conditions. These are processed centrally, both neurochemically and psychologically, and transported into the motor tract as acts of self-injury or as other coping actions. The objective of a comprehensive diagnostic assessment is "to see past" the specific psychosocial and biomedical conditions and to ascertain the specific role(s) served by features of each of these conditions in contributing to the occurrence, severity, fluctuation, and chronic recurrence of the self-injury. Factors that account for the severity and variability of self-injury may differ somewhat from those that influence frequency of occurrence. In this manner, informed speculation can be made about the extent of reduction in critical features of a person's self-injury to be expected following effective treatment of each of the diagnosed psychosocial and/or biomedical conditions (Gardner & Sovner, 1994).

Multimodal Contextual Case Formulation Paradigm

One such case formulation model has been offered by Gardner and Sovner (1994) and expanded by Gardner (Gardner, 1996; 1998: 2002). This multimodal (bio-, psycho-, and socioenvironmental modalities of influences) contextual (three contexts of instigating, central processing, and maintaining conditions) case formulation approach directs the diagnostician to evaluate both psychosocial and biomedical conditions as possible contributors to occurrence, severity, variability, and habitual recurrence of self-injury. The model also provides a means of interfacing various biomedical diagnostic insights and related diagnostically-based interventions with those addressing psychological and social/ environmental influences.

The initial diagnostic task is undertaken to place self-injurious episodes of an individual in the three contexts of instigating, central processing, and maintaining conditions.

Context 1: Instigating Influences. These influences consist of current external (e.g., specific task demands, reduced social attention, peer invading personal space) and internal (e.g., high arousal level, anger, distress from pain, deprivation states, dysphoric mood) stimulus conditions that contribute to the occurrence of specific self-injurious episodes. These are highly specific to each person and represent risk factors for occurrence of self-injury. Most typically, these controlling antecedent conditions consist of multiple psychosocial and biomedical influences unique to each person.

Context 2: Central Processing Influences. Central processing influences refer to those personal features of a biomedical and psychological nature that place a person at increased risk for self-injurious behaviors when exposed to conditions of instigation. Two subtypes of vulnerability features are of significance. Subtype 1 includes those biomedical and psychological conditions that by their presence and/or intensity increase the likelihood of self-injury in persons who use self-injury as a functional coping behavior. These conditions are viewed as pathological, excessive, or deviant features as illustrated by migraine headaches, Bipolar Mood Disorder, hyperirritability, and otitis media. These typically are dormant for periods of times and only become involved as influences on self-injury when these produce aversive stimulus states that are distressful to the person and thus influence the manner in which antecedent instigating conditions are interpreted and processed. This emotional distress, by changing the meaning of other stimulus conditions, influence the occurrence, severity, and variability of self-injurious episodes (Gardner, 2002). Subtype 2 refers to those personal features that by their low strength or absence increase the likelihood of self-injury when a person is exposed to instigating conditions that require use of the deficit skill. To illustrate, a communication skill deficit may render a person at increased risk for self-injury when exposed to situations that require some form of communication. Under these conditions self-injury may serve a communicative function in producing valued consequences (Schroeder et al., 1999).

Context 3: Maintaining Conditions. In most instances as noted earlier, the self-injurious acts become functional for the person based on the type of feedback effects on the antecedent instigating conditions. That is, the self-injury serves to influence the conditions that prompted its occurrence. Self-injury may remove, reduce, or avoid internal or external instigating conditions experienced by the person as distressful, unpleasant, or aversive or may produce or maintain internal or external conditions experienced as pleasant or emotionally desirable.

The diagnostic information about psychosocial and biomedical instigating, central processing, and maintaining conditions presumed to influence occurrence, severity level, variability over time in occurrence and severity, and the habitual recurrence of a person's self-injury is translated into a matched set of treatment approaches, that is, all interventions become diagnostically based. Therapeutic efforts are designed to remove or minimize biomedical and psychosocial instigating and maintaining influences and eliminate or minimize related central processing vulnerabilities. These efforts include the reduction or elimination of pathological biomedical conditions and impoverished and disruptive features of the social and physical environments that place the person at continued risk for self-injury.Treatment efforts also include programs for teaching coping communicative and social alternatives to self-injury and for increasing the personal motivation to use these newly acquired skills as adaptive functional replacements for the self-injurious acts. A skill enhancement program focus to offset psychological central processing vulnerabilities is especially pertinent for those with highly restricted repertoires of coping behaviors. Self-injury may represent highly effective and efficient functional acts and must be replaced by equally effective and efficient functionally equivalent coping skills if the self-injury is to be minimized or eliminated (Gardner & Sovner, 1994; Gardner, Graeber, & Ford, 2002; Schroeder et al., 1999).


Self-injury is a clinically significant problem that occurs most frequently among persons with severe and profound levels of cognitive and adaptive behavior impairment. Self-injury as a functional means of coping with a wide range of motivational states reflecting external and internal psychosocial and biomedical conditions may become quite habitual and resistant to treatment. A multimodal contextual case formulation model is offered (a) to guide the diagnostic search for the unique set of conditions influencing self-injurious responding in a person and (b) to provide direction to the translation of this diagnostic information into a set of related interventions that target each of the conditions presumed to influence occurrence, severity, variability, and habitual recurrence of the self-injury.


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