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Excessive Tantrums and Self-Injurious Behaviour
In Chapter 1, tantrums and self-injurious behaviour are introduced as examples of behavioural excesses often displayed by persons with autism. Such behaviours take several forms, such as screaming, biting, hair pulling, hitting, and throwing objects. Tantrums may be directed at others, toward oneself (as in self-injurious behaviour), or both. Excessive tantrumous behaviour may begin shortly after birth, but it is more likely to be observed in the second year of life and then, possibly, escalate over the next several years to life-threatening levels. As the child grows up, she may become dangerous to caregivers or herself, necessitating placement away from home, the use of physical restraints, or the use of sedative medication. It is important to remember that tantrums are common in childhood and that some typically developing individuals aggress off and on throughout their lives, sometimes to great magnitude, as when they kill others or themselves. Ways in which tantrums and self-injurious behaviour may be managed are discussed in detail throughout this manual, but certain basic information is provided here:
1. Tantrums are triggered out of frustration. This frustration often occurs out of a loss of rewards, such as when the individual is denied access to a favourite food, television program, toy, or place to sit or sleep. Self-stimulatory and ritualistic behaviours appear to contain rewarding properties, and even momentary disruptions of such behaviours can spark tantrums. For example, an individual may want to eat only perfectly shaped Cheerio’s, and the sight of one that is not perfect may trigger screaming, which in turn may cause parents to spend hours sorting out the 'imperfect' pieces of cereal from the cereal box. Being waited on by a male rather than a female food server may result in a tantrum, causing parents to leave a restaurant and in the future seek only restaurants with female servers. Being seated in a car while it backs up to get into or out of a garage may cause major tantrums, causing parents to build a circular driveway to avoid backing up the car. Changing one's route to a familiar place, such as a grandparent's home, may result in such an upheaval that parents have to return and stay home. A person with developmental delays may be reinforced by observing dust floating on a beam of sunlight in the living room and become upset on days with cloudy skies. Leaving a favorite activity, such as lining up objects, to come to a teacher is likely to cause disruptive behaviour. Given the wide range of self-stimulatory rituals and the subtlety of the stimuli that are rewarding for individuals with autism, it is sometimes very difficult to ascertain the antecedents of tantrums.
Frustrating situations are also likely to occur when adults place demands on the individual with developmental delays. As described in Chapter 4, persons with developmental delays fail to understand what well-meaning adults succeed in communicating to typically developing persons. Thus, individuals with developmental delays often fail to correctly follow through when faced with demands, and such situations become frustrating. It follows that one may be able to reduce tantrums by not placing demands on the individual. On the other hand, by removing demands altogether, it is unlikely that the person will learn more effective ways of coping with frustration. Chapter 9 illustrates how one may go about teaching the individual with developmental delays to better deal with frustrating situations, and it outlines how to use differential reinforcement of other behaviours to achieve long-term suppression of tantrums.
Remember, the individual tantrums in order to achieve some control over his environment. Teaching the individual alternate behaviours for controlling his environment will reduce the tantrums or give him the means to replace the tantrums.
2. There is compelling evidence that, by giving an individual attention and love contingent upon tantrums or self-destructive behaviours, one can shape up and increase such behaviours (Lovaas & Simmons, 1969). In the technical literature, the expression of love and attention contingent upon behaviour is referred to as positive reinforcement. The delivery of such reinforcement contingent upon tantrums and self-injurious behaviour places these behaviours on acquisition.
Self-injurious behaviours and tantrums can be strengthened if such behaviours allow the person to escape demands (E. G. Carr, Newsom, & Binkoff, 1980). For example, most persons with developmental delays object to participating in teaching situations. If the teacher gives in to a student's objections and allows the student to get out of the situation while she is tantruming, the tantrumous behaviour may be inadvertently strengthened. In this example, the tantrum serves as an escape-avoidance mechanism. In the technical literature, negative reinforcement is said to be operating in that the behaviour is reinforced (i.e., strengthened) by the removal of a negative situation. Rather than allowing the student to leave the teaching situation contingent on tantruming, she should be allowed to leave contingent on some appropriate behaviour such as not screaming. Through practice of this technique, appropriate behaviour is strengthened while tantrums are reduced.
4. If tantrums are reinforced by the attention the person receives while tantruming, it is likely that the tantrums will decrease if the person tantruming is ignored. In the technical literature, acting as if you do not see or hear the tantrum if it is maintained by attention is known as extinction. Extinction is often hard on the teacher and the student because the student will continue to tantrum, often showing a peak (an extinction burst) before the behaviour gradually decreases. While working through a tantrum by using extinction, protect yourself by wearing a long-sleeved shirt, heavy cotton jeans, a bathing cap (to prevent hair pulling), and a scarf (to protect your throat). Needless to say, working through a tantrum calls for support from members of your treatment team.
Keep in mind that there are numerous ways to inadvertently strengthen a tantrum. Even minor attention such as briefly looking at the student while he tantrums may be sufficient to maintain the tantrum. Data also show that if a child is physically restrained contingent on a tantrum, the intensity of the tantrum increases (Lovaas & Simmons, 1969). The common practice of holding the child while he tantrums may have similarly deleterious effects. Conversely, restraining or holding a child contingent on not throwing a tantrum can decrease the tantrumous behaviour. This can be done by gradually shaping up 'pauses' of non-tantrumous behaviour into increasingly longer intervals (see Chapter 9).
5. Time-out (turning away from the student or placing the student in isolation) is sometimes an effective way to handle tantrums if the tantrums are shaped or maintained by positive reinforcement, but not if the tantrums constitute an escape-avoidance mechanism for that student. In the latter situation, the use of time-out will worsen tantrumous behaviour by the process of negative reinforcement. However, extinction (working through and ignoring the behaviour) is effective in reducing tantrums that emerge from wanting a reward or attempting to avoid the situation.
The treatment of choice is to reduce tantrumous behaviour while building alternative behaviours to replace the tantrums. Young typical children gradually replace their tantrums and fussing as they acquire socially appropriate behaviours, such as language, to control their environment. By the time they are 3 or 4 years old, the worst of the tantrums have subsided, at least in frequency and in most children. Individuals with developmental delays fail to learn appropriate behaviours unless they are explicitly taught. This manual is designed, in part, with the purpose of teaching these individuals better ways of communicating with and controlling their social environment.
6. Some forms of self-injury are not regulated by social consequences. Self-injury may be self-stimulatory in nature (see Chapter 6); that is, some forms of self-injury are strengthened by the sensory feedback generated by the behaviour (Favell, McGimsey, & Schell, 1982). An example of self-injury that appears to be maintained by sensory feedback includes eye poking (this behaviour is often observed in blind or partially blind individuals). Eye poking may be considered a substitute or replacement for the lack of sensory feedback provided by normal or intact vision. Other examples of self-injury that appear self-stimulatory include chewing on the inside of one's cheeks and repeatedly pulling out one's hair. Such behaviours are often observed in individuals who are mentally retarded or non-ambulatory who are placed in restricted environments such as wheelchairs or institutions. These forms of self-injury, in contrast to social forms, are not confined to situations when others are present but rather may occur when the person is alone, as when a person pulls out hair at night. Extinction and time-out do not affect the strength of such behaviours, but the building of socially appropriate alternative behaviours that provide sensory input similar to self-injurious behaviour should be attempted.
Note that it is possible for a person to exhibit more than one form of self-injury in different situations and at different times. Such an occurrence places increasing demands on treatment providers and emphasizes the need for outside consultation.
It is not easy to educate a person who scares parents and teachers or who has to be drugged and restrained to reduce self-injurious and assault behaviours. The very attempt to teach such a person often triggers tantrums or self-injury, causing the teacher to quit. This cycle inadvertently strengthens the tantrumous or self-injurious behaviour. In such a situation, the individual's tantrums or self-injury can be seen as one of the causes of her behavioural delays. From the individual's perspective, she has typically failed in teaching situations, so why not put an end to any more failures that come her way? In the face of this, the teacher or other adult must take control of the situation. The individual must be taught in such a manner that she succeeds and builds confidence and trust in herself and others. The teaching programs presented in this manual are intended to help the student understand what others try to communicate, as well as facilitate the student's communication with others regarding what she wants.
It may help for you to think of tantrums as learned behaviour. Like most people, individuals with developmental delays prefer to be in charge, have access to rein-forcers, and in general be in control of the situation. Such goals are good signs. It is not in the students' favour, however, to be an expert at controlling you while you lose control over her. Do not let the student take control by tyrannizing you—you must take charge. At such times it helps to work in a group (a team) and to take strength from team members or other persons who have worked through or otherwise been able to reduce tantrums.
Some observations from the everyday lives of ordinary persons may help illustrate the universality of self-injurious and assault behaviours and their eventual treatment. Suppose you are in love, and the one you love helps provide you with access to your most significant reinforcers (acceptance, escape from loneliness, warmth, sex, etc.). Now suppose that one day your partner prefers someone other than you, and all the reinforcers you used to receive are no longer available to you. One or all of the following behaviours are likely to be elicited: (a) you try harder to please the person (you go through an extinction burst), (b) you become furious and contemplate hurting that person, and (c) you become depressed and consider hurting yourself. If you have received sufficient reinforcement for suicidal attempts in the past, been shaped up so to speak, you may well succeed if you attempt this option. The treatment of choice, however, is to accept the inevitable. First, you prepare for extinction (i.e., prepare for not receiving the rewards you received in the past for certain behaviours). The first few weeks of extinction are the hardest, but the intensity of the difficult feelings gradually diminishes over the next several weeks or months. It may help to keep an informal record of the amount and frequency of grief experienced, as well as the times when you feel happiness. Both can reassure you that you are headed in a positive direction that life is getting better. You recover when alternate behaviours become established, such as dating someone else who possesses some of the reinforcement properties of the person you lost. Or, perhaps more important, you recover once you acquire access to a larger range of reinforcers that you yourself have better control over. Planting flowers, cooking, painting, bicycling, going back to school, and getting a job where you can meet new people are all examples of helpful strategies. In short, the strategy of choice is learning not to put all your eggs in one basket.
Self-injurious behaviour maintained by sensory reinforcement, such as biting oneself, eye poking, and hair pulling, may seem unique to individuals with autism and other developmental delays unless it is considered that smoking and other forms of drug addiction all have the qualities of self-stimulatory and self-injurious behaviour. Smoking tobacco is a repetitive, stereotyped, and high-rate behaviour that occurs with amazing similarity across cultures. Alterations in the sensory-perceptual feedback from smoking, drinking, and drugs may well be the rein-forcer that maintains these behaviours. As with eye poking in blind or partially blind persons, such self-stimulatory behaviour can be fatal.
Tantrumous behaviours, like some self-injury and assault acts, appear to be instances of learned communicative behaviours. These behaviours are mostly under the control of social consequences, such as the delivery of attention or removal of demands (technically known as instances of positive reinforcement and negative reinforcement, respectively). Tantrumous behaviour is usually instigated by frustration, as when a person fails to obtain a customary reward. These behaviours are rational and lawfully related to the environment, even though they may look bizarre.
There are four ways to reduce tantrumous and self-injurious behaviour. One way is to work through and ignore the tantrum or self-injury, as when the adult behaves as if he or she does not notice the behaviour. This is technically known as extinction. A second way to work through a tantrum or self-injury is by differentially rewarding or reinforcing alternate, socially acceptable behaviours. This is technically known as DRO, differential reinforcement of other behaviours. Third, time-out may reduce tantrums or self-injury in those instances in which the behaviours are maintained by the individual's gaining positive reinforcement. However, time-out will increase these behaviours if they are based on escaping-avoiding a difficult situation, as the tantrums or self-injury are in this situation strengthened through negative reinforcement. Finally, self-injury can be maintained by sensory feedback generated by the behaviour performed. This is technically known as sensory-perceptual reinforcement. Manipulation of social consequences (extinction and time-out) is unlikely to affect this kind of self-injury. The treatment of choice for such forms of self-injury is to build alternate appropriate behaviours that provide stimulation similar to that provided by the self-injurious behaviour (Favell, McGimsey, & Schell, 1982).
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