Virtually every parent has at one time had the heart wrenching experience of seeing his or her child in pain. Sometimes it's an illness, sometimes a fall, but luckily, this doesn't happen very often. When it does, the pain is usually momentary, and a little tenderness, maybe along with a band-aid, is all it takes to "make it go away." An occasional trip to the family doctor might be necessary, but the long-term consequences are rarely serious. Imagine, though, having to see your child injured on a regular basis, often seriously. Then think about what it must be like to see your child inflict those injuries upon him or herself. This is the everyday reality faced by parents of children with self-injurious behaviors. Fortunately, these types of disorders are only seen in a small minority of people with developmental disabilities, as are other serious problem behaviors like aggression and violence. But when they do occur, the financial and emotional costs are enormous.
Severe behavior disorders are among the most perplexing conditions encountered by clinicians, and as a front page article in this past Christmas Day's New York Times illustrates ("Parents defend school's use of shock therapy"), treatment options remain a topic of contentious debate. Not all that long ago physical restraint was the only option, the goal being to make it literally impossible for affected individuals to do things like punch themselves in the face or bang their heads against walls (envision straight-jackets and padded cells). More recently, drugs have been used to medicate those affected, essentially restraining them chemically. These methods, though usually provided with the best intentions, do nothing to address underlying causes, and, of course, they restrained a lot more than just problem behaviors. Fortunately, there are now far better options, and while there is still a long way to go, real help is available for an ever-increasing number of affected individuals.
Research has established that most forms of severe behavior problems are sensitive to the surroundings, suggesting that they serve a "useful" purpose for the affected individual. The fact that these behaviors are often, though not always, sensitive to the reactions of other people provides important opportunities for successful intervention. Perhaps the most significant innovation over the past several decades has been an expanded emphasis on understanding the exact circumstances that "trigger" problem behaviors and the consequences that serve to maintain (or reinforce) them. Once it is determined these conditions can be changed, it often produces a corresponding reduction (or even elimination) of the behavior problems. These methods are known collectively as functional behavioral assessment.
Over the last 20 years or so, several approaches to conducting functional assessments have been under development and refinement. These methods vary with respect to their ease of implementation, but they all strive to determine the regularity with which certain events precede (likely triggers) and follow (likely maintaining consequences--or reinforcers) behaviors of concern, allowing clinicians to make informed guesses about what does and does not cause those behaviors. Indirect assessments are the easiest to do and involve in-depth interviews with parents, teachers, and other caregivers, while detailed and extensive observations of everyday behavior is much more labor intensive. Both of these can be effective, but a third approach, experimental functional analysis, is currently regarded as the "gold standard." It involves systematic manipulation of circumstances to determine their effects on behavior directly. Several conditions are typically arranged to test different hypotheses, and each of these are compared to a control condition lacking the suspected triggers or reinforcers. By comparing levels of the problem behavior during the "test" and "control" conditions, …