why ethics is important (w9)

Analyze ethical considerations and implications involving functional behavior assessment and the implementation of specific intervention techniques, including the use of aversives and physical restraint.

Assignment:
Part 1: Functional Behavior Assessment Interventions (2pages)
• Identify relevant sections in the BACB® Ethics Code for Behavior Analysts that apply to functional behavior assessment. Explain how each relevant section applies to functional behavior assessment interventions.
• Explain the differences between functional behavior analysis and functional behavior assessment.
• Explain the importance of conducting a functional behavior analysis or functional behavior assessment to develop an efficacious intervention.
Part 2: Aversives (1page)
• Identify relevant sections in the BACB® Ethics Code for Behavior Analysts that apply to the use of aversives. Explain how each relevant section applies to the use of aversives.
• Explain whether you believe in the use of corporal punishment in both home and school settings. How might this impact your personal attitudes and beliefs versus your professional ethical responsibilities?
Part 3: Restraint and Physical Management (1 page)
• Identify relevant sections in the BACB® Ethics Code for Behavior Analysts that apply to restraint and physical management. Explain how each relevant section applies to the use of restraint and physical management.
• Explain whether you believe in the use of restraint and physical management in a self-contained classroom for children with autism; focus on ethical considerations and why.
Be sure to support your Assignment with specific references to behavior-analytic theory and research, Search the internet for peer-reviewed articles to support your Assignment. Use proper APA format and citations, including those in the Learning Resources.
© 2010 Association of Professional Behavior Analysts 1 
 
www.apbahome.net Position Statement on the Use of Restraint and Seclusion as Interventions for Dangerous and Destructive Behaviors: Supporting Research and Practice Guidelines Severe Problem Behavior Some individuals with mental health or developmental disorders display problem behavior that puts themselves or others at risk of injury. Prevalence rates of such problem behavior among individuals with developmental disabilities in the U.S. range from 2-28% for aggression, 10-31% for self-injury, and 7-30% for property destruction, with rates consistently higher for individuals with more severe difficulties and those who are diagnosed with autism (Borthwick-Duffy, 1994; Eyman, Borthwick-Duffy, & Miller, 1981). Levels of severity can range from relatively minor and brief to very severe, chronic, and potentially life-threatening (Totsika, Toogood, Hastings & Lewis, 2008). Among individuals with developmental disorders who display self-injurious behavior (SIB), head-hitting and head-banging are among the most commonly reported forms (Kahng, Iwata, & Lewin, 2002). Other forms of SIB include self-biting, body-hitting, self-scratching, and eye-poking. Injuries that have been documented to result from SIB include soft tissue injury, lacerations, contusions, infections, permanent scars, callus formation, and permanent damage to the eye such as retinal detachment (Hyman, Fisher, Mercugliano, & Cataldo, 1990). These injuries sometimes require suturing of lacerations, skin grafts to replace damaged tissue, and retinal reattachment surgery (Patton, 2004).

2 Pica Ð ingesting inedible items Ð is another form of SIB that can be dangerous and potentially life threatening. Materials that have been reported to be ingested include feces (Hagopian & Adelinis, 2001), car keys (Piazza, Roane, Keeney, Boney, & Abt, 2002), rocks, glass, dirt, wood, hair, grass, plants (McCord Gorsser, Iwata, & Powers (2005), and cigarette butts (Goh, Iwata, & Kahng, 1990; Piazza, Hanley, & Fisher 1996). Pica has been reported to result in lead poisoning, choking, parasitic infections, dental injury, gastrointestinal obstructions and perforations, and death (Ali, 2001; Steigler, 2005; Williams, Kirkpatrick-Sanchez, Enzinna, Dunn, & Borden-Karasack, 2009). Aggressive behavior such as biting, hair-pulling, hitting, choking, punching, and head-butting can also be severe (see Sigafoos, Elkins, Kerri & Attwood, 1994). Aggression is the most common form of problem behavior leading to referral of people with developmental disorders for specialized treatment, and is one of the main barriers to placement in integrated educational and community settings. It is also associated with high service costs and high staff turnover rates in service programs (Allen, 2000). The financial cost of problem behaviors is significant. Matson and Sevin (1994) reported that half of U.S. mental health beds may be taken by patients with developmental disorders, while Paclawskyj, Kurtz, and OÕConnor (2004) estimated annual costs at greater than $3 billion for individuals with developmental disorders who exhibited severe problem behaviors. The cost of problem behaviors is not limited to the healthcare dollars spent in treating injuries that result from them, however. If not treated effectively, these behaviors tend to persist and stabilize over time, often impairing social and adaptive functioning and limiting access to services across the lifespan (Allen, 2000; Borthwick-Duffy, Lane, & Widaman, 1997; Paclawskyj et al., 2004; Thompson & Reid, 2002). For many individuals with developmental disorders, problem behavior may represent the greatest barrier to integration and participation in typical educational, family, and community activities (Lowe, Allen, Jones, Brophy, Moore, & James, 2007). Severe behavior problems have been shown to cause significant stress in families, and to be correlated with decreased parental well-being as well as decisions to seek residential placement for children who exhibit these behaviors (Hauser-Cram et al., 2001; McIntyre, Blacher, & Baker, 2002). Effective Treatment Fortunately, research has demonstrated that even individuals with the most severe behavior problems can be helped Ð and many of the aforementioned negative consequences can be avoided or alleviated — with interventions developed by the discipline of applied behavior analysis (ABA). Those interventions, which involve the application of scientific principles of learning and behavior, have broad efficacy for building useful skills and reducing

3 challenging behavior in people with and without intellectual, developmental, and other disorders. ABA interventions for problem behaviors focus on establishing and reinforcing new skills, providing access to preferred activities and items, providing choice-making opportunities, increasing appropriate communication, making complex situations more predictable, and reducing maladaptive behaviors. Effective ABA techniques range from focused interventions for increasing specific functional skills and/or decreasing specific problem behaviors to comprehensive programming. For some reviews and meta-analyses of the hundreds of studies documenting the effectiveness of these interventions, see Campbell (2003); Didden, Duker, and Korzilius (1997); Eikeseth (2009); Green (in press); Grey and Hastings (2005); Hanley, Iwata, & McCord, 2003; Horner et al. (2002); Kahng, Iwata, and Lewin (2002); McClannahan, MacDuff, and Krantz (2002); National Autism Center (2009); Weisz, Weiss, Han, Granger, & Morton, 1995; and Wolery, Barton, and Hine (2005). There is also evidence that comorbid psychiatric conditions are common in people with developmental disabilities, and that certain medications can be effective when used in conjunction with behavioral treatment (see Aman et al., 2002; Thompson, Moore, & Symons, 2007). Within the field of ABA, there is a general consensus that interventions should focus on increasing adaptive behavior and altering the environment as means of preventing and decreasing problem behaviors. Interventions should be individualized, and based on functional behavioral assessment to identify environmental events that trigger and reinforce the problem behavior. Interventions are designed to engineer the environment to decrease the probability that problem behaviors will occur and to make sure that they are not reinforced (to the extent possible) while simultaneously building communication, academic, social, leisure, and other adaptive skills using positive reinforcement. The individualÕs preferences for activities and items should be assessed frequently, and those preferred stimuli are used as reinforcers to both strengthen adaptive behavior and decrease problem behavior. These ABA procedures can ensure that even individuals with the most severe disabilities have ample opportunities to express their preferences and choices and to develop useful skills, thus empowering them to actively participate in educational programming as well as family and community life. Safe and Effective Use of Interventions Involving Restraint and Seclusion Advances in behavior analytic assessments and interventions have made it possible to reduce many severe problem behaviors without using restraint, seclusion, or other techniques that might be considered restrictive (Horner et al., 2002; Kahng et al., 2002; Pelios, Morren, Tesch, & Axelrod, 1999). There is widespread consensus among professionals who treat individuals with severe

4 challenging behaviors that more restrictive interventions should be used only when less restrictive interventions have failed, or are determined to be unsafe or insufficient. In some cases, however, severe problem behaviors can be resistant to positive interventions, and carefully designed and monitored restraint or seclusion procedures can be essential for minimizing the risk of harm. Many investigations of the inappropriate use of restraint and seclusion have revealed that individuals implementing such procedures were inadequately or inappropriately trained, and that their use of those procedures was not consistent with research and ethical guidelines on the safe and effective use of restraint and seclusion. Additionally, the procedures were not part of an intervention plan that was based on a functional assessment of the dangerous behaviors conducted by a qualified behavior analyst. It is APBAÕs position that restraint and seclusion procedures should never be implemented in isolation, but should only be used as components of properly designed and approved behavior intervention plans that emphasize state-of-the-art strategies for reinforcing adaptive skills and preventing problem behavior. They should only be implemented by individuals who are trained in behavioral intervention and in the use of the specific restraint or seclusion procedures included in the plan, and who are supervised by a behavior analyst with experience in treating dangerous behaviors. When restraint is used as a component of such an intervention plan, it generally consists of gently holding a person (e.g., at the wrists) for a brief period of time (e.g., 30 to 60 seconds) to interrupt and reduce the future occurrence of a dangerous behavior (such as hand-to-head SIB). For a small subgroup of people who display very severe SIB that occurs almost continuously, specialized mechanical restraints such as soft arm splints or mitts may be used to prevent injury. Such restraint is intended to be faded (gradually decreased) over time as the behavior decreases. Seclusion is used rarely, and only when the behavior of concern presents an immediate danger to others. It generally consists of a brief room timeout (i.e., of 2-10 minutes, 15 minutes at the most) when non-exclusionary timeouts are not feasible because of risks to others, or have proved ineffective. Summaries of three sources of support for APBAÕs position follow: (I) research on seclusion and restraint procedures as components of interventions for dangerous behaviors; (II) reviews of research on the treatment of severe problem behaviors; and (III) other organizationsÕ position statements and practice guidelines pertaining to the use of restraint and seclusion procedures.

5 I. Research on Safe and Effective Use of Restraint and Seclusion Procedures IMPORTANT NOTE: In behavior analysis, the term ÒpunishmentÓ does not mean retribution as it does in everyday language, or the delivery of some unpleasant or uncomfortable (ÒaversiveÓ) consequence. Instead, punishment occurs when a consequence follows a behavior with the result that the behavior is less likely to occur in the future. Following are descriptions of some procedures that can reduce the occurrence of dangerous behaviors. A. Response blocking or response interruption involves momentarily physically preventing the individual from engaging in certain movements that produce trauma. Although these procedures do not involve holding, some view them as a form of restraint. For example, response blocking for hand-to-head SIB might involve the care provider moving his arm between the individualÕs hand and head (once the individual begins the hand-to-head motion) in order to prevent the individualÕs hand from contacting his head. Depending on the form and speed of the dangerous behavior, it may not be possible to successfully block all occurrences. That is, response blocking or response interruption may not offer sufficient protection in cases where the problem behavior is intense and occurs with little warning, and risk of significant injury is great. These procedures have proved effective, however, when used as part of a comprehensive reinforcement-based behavior intervention for reducing many forms of dangerous behavior, including SIB, pica, aggression, and elopement (Hagopian & Adelinis, 2001; Lerman & Iwata, 1996; McCord, Grosser, Iwata, & Powers, 2005; Reid, Parsons, Phillips, & Green, 1993; Smith, Russo & Le, 1999). B. Timeout from reinforcement. Timeout involves removing access to reinforcers for a brief period of time following occurrences of a problem behavior. It is used as part of an intervention that includes abundant positive reinforcement for adaptive behaviors. Studies describing the use of timeout with seclusion (ÒroomÓ or ÒexclusionaryÓ timeout) are rare. Those procedures generally are used only when the problem behavior poses imminent risk to others, and then each timeout is brief (2-15 minutes). In nearly all published studies, timeout was non-exclusionary and involved removing preferred materials, preventing access to preferred activities or items, or using screens to prevent the individual from seeing reinforcing activities for a few minutes following each occurrence of problem behavior (Falcomata, Roane, Hovanetz, & Kettering, 2004; Keeney, Fisher, Adelinis, & Wilder, 2000). C. Timeout procedures involving physical restraint refers to care providers holding the individual during timeout in order to limit movement. In some cases, directing the individual to sit in a chair during timeout can be effective; however, for individuals with severe behavior problems, the individual may

6 need to be physically held to prevent aggressive or self-injurious behavior that would place her or others at risk of injury and to keep her in timeout. Techniques include brief holds (typically 30 to 60 seconds in duration) that involve a single care provider securing the individual or his hands during timeout contingent upon problem behavior, or holding the individualÕs hands in her lap or at her sides for 30-60 seconds (e.g., Lerman, Iwata, Shore, & DeLeon, 1997). These procedures are used along with reinforcement of adaptive behaviors, and are distinct from crisis management procedures, which often involve multiple people physically holding the individual after problem behavior has escalated to some level, and then releasing her when certain criteria are met (discussed later). Examples of studies on the use of the procedures just described include: Hanley, G.P., Piazza, C.C., Fisher, W.W., & Maglieri, K.A. (2005). On the effectiveness of and preference for punishment and extinction components of function-based interventions. Journal of Applied Behavior Analysis, 38, 51-65. The relative effectiveness of functional communication training (FCT) with and without a punishment component was evaluated with 2 children for whom functional analyses demonstrated behavioral maintenance via social positive reinforcement. The results showed that FCT plus punishment was more effective than FCT in reducing problem behavior. Subsequently, participants’ relative preference for each treatment was evaluated in a concurrent-chains arrangement, and both participants demonstrated a clear preference for FCT with punishment. These findings suggest that the treatment-selection process may be guided by person-centered and evidence-based values. Hagopian, L. P., Fisher, W. W., Sullivan, M. T., Acquisto, J., & LeBlanc, L. A. (1998). Effectiveness of functional communication training with and without extinction and punishment. Journal of Applied Behavior Analysis, 31, 211Ð235. FCT with extinction was effective in reducing problem behavior for the majority of clients (n=21) and resulted in at least a 90% reduction in problem behavior in nearly half the applications. However, when demand or delay-to-reinforcement fading was added to FCT with extinction, treatment efficacy was reduced in about one half of the applications. FCT with punishment (both with and without fading) resulted in at least a 90% reduction in problem behavior for every case in which it was applied. Perry, A. C., & Fisher, W. W. (2001). Behavioral economic influences on treatments designed to decrease destructive behavior. Journal of Applied Behavior Analysis, 34, 211-215. In this study, behavioral economics principles were used to develop and evaluate a treatment package that reduced destructive behavior to zero while communication and compliance were increased. Vorndran, C.M., & Lerman, D.C. (2006) Establishing and maintaining treatment effects with less intrusive consequences via a pairing procedure. Journal of Applied Behavior Analysis, 39, 35-48. The generality and long-term maintenance of a pairing procedure designed to improve the efficacy of less intrusive procedures were evaluated for the treatment of problem behavior maintained by automatic reinforcement exhibited by 2 individuals with developmental disabilities. Results suggested that a less intrusive procedure could be established as a conditioned punisher by pairing it with an effective punisher contingent on problem behavior. Generalization

7 across multiple therapists was demonstrated for both participants. However, generalization to another setting was not achieved for 1 participant until pairing was conducted in the second setting. Long-term maintenance was observed with 1 participant in the absence of further pairing trials. Maintenance via intermittent pairing trials was successful for the other participant. Wacker, D. P., Steege, M. W., Northup, J., Sasso, G., Berg, W., Reimers, T., Cooper, L., Cigrand, K., & Donn, L. (1990). A component analysis of functional communication training across three topographies of severe behavior problems. Journal of Applied Behavior Analysis, 23, 417-429. We evaluated the separate treatment components of a functional communication training program for 3 severely handicapped persons who each displayed different topographies of aberrant behavior. Following a functional analysis of maintaining conditions for inappropriate behavior (self-injury, stereotypy, aggression), each participant was trained to emit a communicative response that functioned to solicit reinforcement. For 2 participants, consequences (time-out or graduated guidance) for inappropriate behavior were also included. Treatment continued until the participants emitted the communicative response independently and no occurrences of inappropriate behavior were observed for at least two sessions. Following treatment, the separate contributions of the treatment components for communicative responding and for inappropriate behavior were evaluated with a reversal design. The results indicated that both sets of treatment components were necessary for maximal control over aberrant behavior. These results are discussed in relation to the efficiency, history, and control over reinforcement of both appropriate and inappropriate responses. Lerman, D. C., Iwata, B. A., Shore, B. A., & DeLeon, I. G. (1997). Effects of intermittent punishment on self-injurious behavior: An evaluation of schedule thinning. Journal of Applied Behavior Analysis, 30, 187-201. Although the use of punishment often raises ethical issues, such procedures may be needed when the reinforcers that maintain behavior cannot be identified or controlled, or when competing reinforcers cannot be found. Results of several studies on the effects of intermittent schedules of punishment suggest that therapists must use fairly rich schedules of punishment to suppress problem behavior. However, residential caretakers, teachers, and parents often have difficulty implementing programs that require constant monitoring of the client’s behavior. In this study, we examined the feasibility of gradually thinning the delivery of punishment from a continuous schedule to an intermittent schedule during the course of treatment for self-injurious behavior (SIB). Results of functional analyses for 5 individuals who had been diagnosed with profound mental retardation indicated that their SIB was not maintained by social consequences. Treatment with continuous schedules of time-out (for 1 participant) or contingent restraint (for the other 4 participants) produced substantial reductions in SIB. When they were exposed to intermittent schedules of punishment (fixed-interval [FI] 120 s or FI 300 s), SIB for all but 1 of the participants increased to levels similar to those observed during baseline. For these 4 participants, the schedule of punishment was gradually thinned from continuous to FI 120 s or FI 300 s. For 2 participants, SIB remained low across the schedule changes, demonstrating the utility of thinning from continuous to intermittent schedules of punishment. Results for the other 2 participants showed that intermittent punishment was ineffective, despite repeated attempts to thin the schedule. D. Mechanical restraint refers to the use of devices that limit movements that produce injury. Research on the use of mechanical restraint is limited to the management of severe SIB. Mechanical restraints include devices such as arm splints (which limit or prevent elbow flexion) and mitts (which cover the hands

8 and limit use of the fingers; e.g., Fisher, Piazza, Bowman, Hanley, & Adelinis, 1997; Lerman, Iwata, Smith, & Vollmer, 1994; Pace, Iwata, Edwards, & McCosh, 1986; Powers, Roane, & Kelley, 2007). Extensive research on the use of mechanical arm restraints illustrates how those devices can reduce severe SIB through (a) continuous application and subsequent fading (Fisher et al., 1997; Pace et al., 1986; Powers et al., 2007); (b) when applied as a consequence to reduce SIB (Rapoff, Altman, & Christophersen, 1980); and (c) when applied as a reinforcing consequence to increase appropriate behavior (Favell, McGimsey, & Jones, 1978; Favell, McGimsey, Jones, & Cannon, 1981). Use of such devices in the context of a reinforcement-based intervention can reduce severe SIB and increase appropriate behavior (Lindberg, Iwata, & Kahng, 1999). These devices are more commonly applied continuously but removed periodically to avoid problems with circulation and skin breakdown, and their restrictiveness is gradually reduced over time to permit increased range of motion. A number of studies have described effective fading of arm restraints to gradually permit increased elbow flexion while minimizing risks of self-injury (Fisher et al., 1997; Lerman et al., 1994; Pace et al., 1986). Mechanical restraints should only be used by appropriately trained persons and with careful monitoring, as they are highly restrictive, can cause long-term negative side effects, and can interfere with client training goals if used improperly (Lovaas & Simmons, 1969; Rojahn, Schroeder, & Mulick, 1980). Relevant studies include: Fisher, W. W., Piazza, C. C., Bowman, L. G., Hanley, G. P., & Adelinis, J. D. (1997). Direct and collateral effects of restraints and restraint fading. Journal of Applied Behavior Analysis, 30, 105-119. Mechanical restraints are commonly used to reduce the risks associated with severe self-injurious behavior (SIB), but may result in movement restriction and adverse side effects (e.g., bone demineralization). Restraint fading may provide a method for decreasing SIB while increasing movement and reducing these side effects. In the current investigation, rigid arm sleeves and restraint fading (gradually reducing the rigidity of the sleeves) were used with 3 clients who engaged in hand-to-head SIB. Restraints and fading reduced the hand-to-head SIB of all clients. However, for 1 client, the addition of a water mist procedure further reduced SIB to near-zero levels. For a 2nd client, another form of SIB developed that was not prevented by the rigid sleeves. For a 3rd client, a topography of SIB that was not physically prevented by the rigid sleeves was also reduced when restraints and fading were introduced. Lerman , D. C., Iwata, B.A., Smith, R.G., Vollmer, T. R. (1994). Restraint fading and the development of alternative behaviour in the treatment of self-restraint and self-injury. Journal of Intellectual Disability Research, 38, 135-148. Restraint fading and differential reinforcement were used to reduce the self-injurious behaviour (SIB) and self-restraint of a profoundly retarded man. The variables maintaining both behaviours could not be identified via pre-treatment functional analysis; however, self-restraint exerted at least some stimulus control over SIB. In Phase 1, the subject’s topography of self-restraint (wrapping arms in shirt) was replaced with another topography (wrapping wrists in towel) that

9 could be more easily faded to a headband. However, the subject’s restraints could not be completely faded, and any movement was accompanied by SIB; thus, in Phase 2, a compliance training procedure was implemented to reduce his SIB while increasing time out of restraint. In Phase 3, the subject was taught to mand for edibles during training sessions. Results indicated that restraint fading combined with the development of alternative behaviour could be an effective treatment procedure for those who engage in both self-restraint and SIB. Oliver, C., Hall, S., Hales, J., Murphy, G., & Watts, D. (1998). The treatment of severe self-injurious behavior by the systematic fading of restraints: Effects on self-injury, self-restraint, adaptive behavior, and behavioral correlates of affect. Research in Developmental Disabilities, 19, 143-165 Severe self-injurious behavior (SIB) in people with mental retardation is difficult to treat when dangerously frequent or intense responding rules out functional analysis and interventions that permit free responding. This situation is common when restrictive devices, such as straight arm splints, are used. In this study, the effects of introducing flexion into a straight-arm splint, on SIB, self-restraint, adaptive behavior, and behavioral correlates of affect were examined for three individuals with severe mental retardation. Using single-case design methodology, for two individuals self-injury was reduced to zero, while the overall level of restriction was also significantly reduced. From the observed behavioral correlates of affect, there was no evidence of an increase in negative affect with the introduction of the new splint and the fading procedure, but there was evidence of an increase in positive vocalizations. Engagement in activities and social contact were not affected by the introduction of the new splint. The reasons for a decrease in SIB with a corresponding decrease in restriction in the absence of any manipulation of contingencies for SIB are discussed, with particular reference to stimulus control. E. Restraint during crisis management. Little research has examined the efficacy of crisis management techniques for managing problem behavior. The few studies that have been done compared the use of ÒplannedÓ restraint (programmed contingent application as part of a behavior intervention plan) to ÒemergencyÓ restraint (applied as a crisis management technique). They showed that programmed restraint is considerably safer for consumers than restraint applied under emergency circumstances (e.g., Spreat, Lipinski, Hill, & Halpin, 1986). Moreover, programmed contingent restraint (either physical or mechanical) has been found to produce fewer staff injuries than the emergency use of restraints (Hill & Spreat, 1987). This applies to both physical restraint and mechanical restraint. Overall, it appears that the programmed, therapeutic use of restraints differs along several dimensions from the emergency, unplanned use of restraint. The planned and careful use of restraint is less dangerous to both consumers and caregivers, can be faded to the point that it is used only infrequently, and can therefore result in less restraint over extended periods. Spreat, S., Lipinski, D. P., Hill, J., & Halpin, M. (1986). Safety indices associated with the use of contingent restraint procedures. Applied Research in Mental Retardation, 7, 475-481. The safety of four general classes of contingent restraint was evaluated in a sample of 2331 institutionalized mentally retarded persons. The use of mechanical restraints resulted in a significantly lower injury rate than did personal restraint. The use of restraint in emergency situations was found to be more dangerous than the planned use of such procedures.

10 Henderson, L., Sidders, K., Wasser, T., Gunn, S., & Spisszak, E.,, (2005). Frequency of client and staff injury during physical restraint episodes: A comparison of two child restraint systems. Journal of Clinical Outcomes Measurement, 12 (4), 193-198. Youth admitted under both voluntary and involuntary commitments to residential behavioral and mental health programs in Pennsylvania and New York and staff from these institutions. Methods: Restraint events that occurred during 2003 were reviewed and stratified by method of restraint: Therapeutic Crisis Intervention (TCI) and Professional Crisis Management (PCM). Results: There were 5580 restraint applications in the PCM group (n = 813) and 1274 in the TCI group (n = 194). The mean (SD) hold duration was significantly shorter for the PCM method (8.5 min [14.4] versus 15.1 min [13.7]; P < 0.001). TCI was associated with significantly more critical and serious client injuries (both, P < 0.001). No difference between PCM and TCI was noted for critical staff injuries (P = 0.404), although a trend toward significance was seen in serious staff injuries (P = 0.094). More injuries occurred at higher restraint levels with TCI than with PCM. Conclusion: The PCM method was associated with a lower frequency of client injuries compared with the TCI method. We recommend the PCM method over TCI for use in children. Despite the limited research on crisis management techniques and data supporting the advantages and efficacy of programmed procedures, crisis management procedures have a role in the safe management of severe problem behavior. Formal crisis management systems, such as Professional Crisis Management (PCM), provide numerous safeguards to prevent the use of unsafe techniques, and the misuse of appropriate procedures. PCM is a rigorous and structured program that includes intensive training and in-servicing requirements, data collection and monitoring, and ongoing review and oversight. Crisis management systems should not be viewed as a replacement for appropriate behavioral treatment, but as an adjunct. They are appropriate when behavioral interventions are not effective in averting an escalation of problem behavior that reaches crisis levels (Winston, Fleisig, & Winston, 2009). Information about PCM can be obtained from the organizationÕs website: http://www.pcma.com/Default.asp 
11 II. Reviews of Research on the Treatment of Severe Problem Behavior Campbell, J.M. (2003). Efficacy of behavioral interventions for reducing problem behavior in persons with autism: A quantitative synthesis of single-subject research. Research in Developmental Disabilities, 24, 120-138. The efficacy of behavioral interventions for problem behaviors in persons with autism was reviewed. One hundred and seventeen published articles representing 181 individuals with autism were examined. Articles were selected from 15 journals. Participant, treatment, and experimental variables were evaluated. Three effect sizes were calculated for each article. Behavioral treatments are effective in reducing problematic behaviors in individuals with autism. Type of target behavior and type of treatment did not moderate the average effect of treatment. As measured by percentage of zero data (PZD), three variables were predictive of behavioral suppression beyond that accounted for by behavioral topography and treatment type. Reliability of observation and number of treatment data points were positively related to PZD scores. Treatments based on experimental functional analysis (EFA) produced higher average PZD scores than treatments that did not include an EFA. The implications of the findings, study limitations, and suggestions for future research are discussed. Didden, R., Duker, P. C., & Korzilius, H. (1997). Meta-analytic study on treatment effectiveness for problem behaviors with individuals who have mental retardation. American Journal on Mental Retardation, 101(4), 387-399. Meta-analysis of 482 empirical studies on treatment of problem behaviors of individuals with mental retardation was conducted. A metric of treatment effectiveness was computed for 1.451 comparisons between baselines and treatments, 34 topographies of problem behavior, and 64 treatment procedures. Analysis of variance with percentage of nonoverlapping data as the dependent variable and comparison as the basic unit of analysis revealed that treatment of externally destructive behaviors had significantly lower mean percentage of nonoverlapping data scores than did treatment of socially disruptive and internally maladaptive behaviors. Response contingent procedures were significantly more effective than were other procedures. No significant interactions were found. Results of a stepwise regression showed that only performing a functional analysis made a significant contribution. These results may lead to more objective assignment of treatment procedures to problem behaviors. 
12 Grey, I. M., & Hastings, R. P. (2005). Evidence-based practices in intellectual disability and behaviour disorders. Current Opinion in Psychiatry, 18, 469-475. Literature published in the review period was from three traditions: applied behaviour analysis, psychopharmacology, and service evaluation. Applied behaviour analysis treatments have a large evidence base, and recent research has focused on refining issues such as dealing with low rate behaviours, improving generalization, the effects of choice-making, and setting event variables that may affect treatment outcomes. Recent interest in risperidone as a treatment for behaviour disorder has dominated the literature on pharmacological interventions. Several empirical studies support the use of risperidone in children, although a recent review is more sceptical of the quality of the evidence to date. A small number of service evaluation studies suggest in particular that applied behaviour analysis technologies can be scaled up to benefit large numbers of patients. Applied behaviour analysis methods for the assessment and treatment of behaviour disorders continue to be the focus of research, and continue to result in positive outcomes. Recent data show the value of using applied behaviour analysis technologies as a service model for people with behaviour disorders. Pharmacological treatments, especially risperidone, also have a developing evidence base despite a lack of understanding of their mechanisms of action. A number of questions about behaviour disorders remain unanswered, especially whether early intervention may be effective and their putative relationship with psychiatric conditions. Kahng, S., Iwata, B.A., & Lewin, A. (2002). Behavioral treatment of self-injury, 1964 to 2000. American Journal on Mental Retardation, 107, 212Ð221. A quantitative analysis of behavioral research on the treatment of self-injurious behavior (SIB) over the past 35 years is provided. A literature search covering the period from 1964 to 2000 yielded 396 articles (706 participants) on the treatment of SIB. Most research participants have been male and diagnosed with severe/profound mental retardation. The use of reinforcement-based interventions has increased during the past decade, whereas the use of punishment-based interventions has decreased slightly; both of these trends coincide with the increase in the use of functional assessments. Most treatments have been highly effective in reducing SIB; nevertheless, the disorder persists in spite of an abundance of research, suggesting that a greater emphasis should be placed on prevention. 
13 Matson, J. L., & LoVullo, S. V. (2008). A review of behavioral treatments for self-injurious behaviors of persons with autism spectrum disorders. Behavior Modification, 32, 61-76. Autism spectrum disorders (ASD) are considered to be among the most serious of the mental health conditions. Concomitant with many cases of ASD is intellectual disability. Further compounding the disability is the fact that both conditions are known risk factors for self-injurious behavior (SIB). To date, the most effective intervention methods, based on the available data, appear to be variants of behavior modification. This article provides an overview of the current status of learning-based interventions for SIB in ASD and provides a review of specific studies. Although most studies describe some combination of reinforcement and punishment procedures, efforts are under way to develop more positively oriented strategies, such as functional assessment, to decrease the use of punishment. However, almost all the treatment studies employ single case designs, thus preventing a comparison of treatment efficacy. These issues are discussed along with other strengths, weaknesses, and future directions for clinical practice and treatment. Pelios, L., Morren, J., Tesch, D., & Axelrod, S. (1999). The impact of functional analysis methodology on treatment choice for self-injurious and aggressive behavior. Journal of Applied Behavior Analysis, 32, 185-195. Self-injurious behavior (SIB) and aggression have been the concern of researchers because of the serious impact these behaviors have on individualsÕ lives. Despite the plethora of research on the treatment of SIB and aggressive behavior, the reported findings have been inconsistent regarding the effectiveness of reinforcement-based versus punishment-based procedures. We conducted a literature review to determine whether a trend could be detected in researchersÕ selection of reinforcement-based procedures versus punishment- based procedures, particularly since the introduction of functional analysis to behavioral assessment. The data are consistent with predictions made in the past regarding the potential impact of functional analysis methodology. Specifically, the findings indicate that, once maintaining variables for problem behavior are identified, experimenters tend to choose reinforcement-based procedures rather than punishment-based procedures as treatment for both SIB and aggressive behavior. Results indicated an increased interest in studies on the treatment of SIB and aggressive behavior, particularly since 1988. Weisz, J.R., Weiss, B., Han, S.S., Granger, D.A., & Morton, T. (1995). Effects of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117(3), 450-468. A meta-analysis of child and adolescent psychotherapy outcome research tested previous findings using a new sample of 150 outcome studies and 
14 weighted least squares methods. The overall mean effect of therapy was positive and highly significant. Effects were more positive for behavioral than for nonbehavioral treatments, and samples of adolescent girls showed better outcomes than other Age × Gender groups. Paraprofessionals produced larger overall treatment effects than professional therapists or students, but professionals produced larger effects than paraprofessionals in treating overcontrolled problems (e.g., anxiety and depression). Results supported the specificity of treatment effects: Outcomes were stronger for the particular problems targeted in treatment than for problems not targeted. The findings shed new light on previous results and raise significant issues for future study. III. Other Professional and Scientific OrganizationsÕ Practice Guidelines Related to Restraint and Seclusion Several professional and scientific organizations outside the field of ABA have reviewed research findings and articulated best practice guidelines that support the appropriate use of procedures involving restraint and seclusion. ¥ The National Institutes of Health Consensus Conference on Destructive Behavior (NIH, 1989) concluded that ÒBehavior reduction procedures should be selected for their rapid effectiveness only if the exigencies of the clinical situation require such restrictive interventions and only after appropriate review. These interventions should only be used in the context of a comprehensive and individualized behavior enhancement treatment package.Ó ¥ American Association on Intellectual and Developmental Disabilities (formerly the American Association on Mental Retardation Ð the largest and oldest professional organization concerned with mental retardation) ÓGuidelines on Psychosocial Treatments,Ó published in Rush, A. J. & Frances, A. (Eds.) (2000). Expert consensus guideline series: Treatment of psychiatric and behavioral problems in mental retardation [Special Issue]. American Journal on Mental Retardation, 105 (3). According to these best practice guidelines, the use of more intrusive interventions can be recommended when less intrusive interventions are insufficient. With regard to contingent procedures for reducing problem behavior, the guidelines indicated that when reinforcement-based interventions fail, then the Òfirst lineÓ treatment is response interruption. ÒSecond lineÓ treatments include response cost, non-exclusionary timeout, positive practice overcorrection, restitution overcorrection, exclusionary timeout, and mechanical restraints. 
15 ¥ American Psychological Association, Division 33 ÒGuidelines on Effective Behavioral Treatment for Persons with Mental Retardation and Developmental DisabilitiesÓ (APA, 1994) recommended that ÒHighly restrictive procedures shall not be employed until there has been sufficient determination that the use of less restrictive procedures was or would be ineffective or harm would come to the client because of gradual change in the client's particular problematic behavior.Ó Retrieved February 1, 2010, from http://www.apa.org/divisions/div33/effectivetreatment.html ¥ Technical Assistance Center on Positive Behavioral Interventions and Support (PBIS), U.S. Department of Education, Office of Special Education Programs April 2009 statement on ÒSeclusion and Restraint Use in School‐wide Positive Behavior SupportsÓ noted that ÒSeclusion and restraint should only be implemented (a) as safety measures (b) within a comprehensive behavior support plan, (c) by highly trained personnel, and (d) with public, accurate, and continuous data related to (1) fidelity of implementation and (2) impact on behavioral outcomes (both increasing desired and decreasing problem behaviors).Ó Retrieved February 1, 2010, from http://www.pbis.org/common/pbisresources/publications/Seclusion_Restraint_inBehaviorSupport.pdf Professionals treating other populations, including individuals with mental illness and substance abuse problems, have expressed the understanding that restraint and seclusion interventions may be necessary in some cases: ¥ The American Psychiatric Association, American Psychiatric Nurses Association, and the National Association of Psychiatric Health Systems jointly published a document on the use of restraint and seclusion, stating that ÒRestraint and seclusion, when used properly, can be life-saving and injury-sparing interventionsÓ Retrieved February 1, 2010, from http://www.naphs.org/rscampaign/Learning.pdf 
16 References Ali, Z. (2005). Pica in people with intellectual disability: a literature review of aetiology, epidemiology and complications. Journal of Intellectual and Developmental Disability, 26, 205-215. Allen, D. (2000). Recent research on physical aggression in persons with intellectual disability: An overview. Journal of Intellectual & Developmental Disability, 25, 41Ð57. Aman, M. G., De Smedt, G., Derivan, A., Lyons, B., Findling, R. L., & Risperidone Disruptive Behavior Study Group (2002). Double-blind, placebo-controlled study of risperidone for the treatment of disruptive behaviors in children with subaverage intelligence. American Journal of Psychiatry, 159, 1337-1346. American Psychiatric Association (APA), American Psychiatric Nurses Association (APNA), and the National Association of Psychiatric Health Systems (NAPHS). (n.d.). Learning from each other: Success stories and ideas for reducing restraint and seclusion in behavioral health. Retrieved February 1, 2010, from http://www.naphs.org/rscampaign/Learning.pdf Borthwick-Duffy, S. A. (1994). Epidemiology and prevalence of psychopathology in people with mental retardation. Journal of Consulting and Clinical Psychology, 62, 17-27. Borthwick-Duffy, S. A., Lane, K. L., & Widaman, K. F. (1997). Measuring problem behaviors in children with mental retardation: Dimensions and predictors. Research in Developmental Disabilities, 18, 415-433. Campbell, J.M. (2003). Efficacy of behavioral interventions for reducing problem behavior in persons with autism: A quantitative synthesis of single-subject research. Research in Developmental Disabilities, 24, 120-138. Didden, R., Duker, P. C., & Korzilius, H. (1997). Meta-analytic study on treatment effectiveness for problem behaviors with individuals who have mental retardation. American Journal on Mental Retardation, 101, 387-399. Eikeseth, S. (2009). Outcome of comprehensive psycho-educational interventions for young children with autism. Research in Developmental Disabilities, 30, 158-178. Eyman, R.K., Borthwick-Duffy, S.A., & Miller, C. (1981). Trends in maladaptive behavior of mentally retarded persons placed in community and institutional settings. American Journal of Mental Deficiency, 85, 473-477. Falcomata, T. S., Roane, H. S., Hovanetz, A. N., Kettering, T. L., & Keeney, K. M. (2004). An evaluation of response cost in the treatment of inappropriate vocalizations maintained by automatic reinforcement. Journal of Applied Behavior Analysis, 37, 83-87. Favell, J. E., McGimsey, J. F., & Jones, M. L. (1978). The use of physical restraint in the treatment of self-injury and as positive reinforcement. Journal of Applied Behavior Analysis, 11, 225Ð241. 
17 Favell, J. E., McGimsey, J. F., Jones, M. L., & Cannon, P. R. (1981). Physical restraint as positive reinforcement. American Journal of Mental Deficiency, 85, 425-432. Fisher, W. W., Piazza, C. C., Bowman, L. G., Hanley, G. P., & Adelinis, J. D. (1997). Direct and collateral effects of restraints and restraint fading. Journal of Applied Behavior Analysis, 30, 105-119. Goh, H., Iwata, B. A., & Kahng, S. (1999). Multicomponent assessment and treatment of cigarette pica. Journal of Applied Behavior Analysis, 32, 297- 316. Green, G. (in press). Early intensive behavior analytic intervention for autism spectrum disorders. In E. Mayville & J.Mulick (Eds.), Behavioral foundations of effective autism treatment. Sloan Publishing. Grey, I. M., Hastings, R. P. (2005). Evidence-based practices in intellectual disability and behaviour disorders. Current Opinion in Psychiatry, 18, 469- 475. Hagopian, L. P., & Adelinis, J. D. (2001). Response blocking with and without redirection for the treatment of pica. Journal of Applied Behavior Analysis, 34, 527Ð530. Hagopian, L. P., Fisher, W. W., Sullivan, M. T., Acquisto, J., & LeBlanc, L. A. (1998). Effectiveness of functional communication training with and without extinction and punishment. Journal of Applied Behavior Analysis, 31, 211Ð235. Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem behavior: A review. Journal of Applied Behavior Analysis, 36, 147 185. Hanley, G. P., Piazza, C. C., Fisher, W. W., & Maglieri, K. A. (2005). On the effectiveness of and preference for punishment and extinction components of function-based interventions. Journal of Applied Behavior Analysis, 38, 51-65. Hauser-Cram, P., Erickson Warfield, M., Shonkoff, J. P., Wyngaarden Krauss, M., Sayer, A., Christofk Upshur, C., et al. (2001). Children with disabilities: A longitudinal study of child development and parent well-being. Monographs of the Society for Research in Child Development, 66, 1-126. Henderson, L., Siddons, K., Wasser, T., & Gunn S., & Spisszak E. (2005). Frequency of client and staff injury during physical restraint episodes: A comparison of two child restraint systems. Journal of Clinical Outcomes Management, 12, 193-198. Hill, J., & Spreat, S. (1987). Staff injury rates associated with the implementation of contingent restraint. Mental Retardation, 25, 141-145. Horner, R.H., Carr, E.G., Strain, P.S., Todd, A.W., & Reed, H.K. (2002). Problem behavior intervention for young children with autism: A research synthesis. Journal of Autism and Developmental Disorders, 32, 423-446. Hyman, S. L., Fisher, W., Mercugliano, M., & Cataldo, M. F. (1990). Children with self-injurious behavior. Pediatrics, 85, 437-441. 
18 Kahng, S., Iwata, B.A., & Lewin, A. (2002). Behavioral treatment of self-injury, 1964 to 2000. American Journal on Mental Retardation, 107, 212Ð221. Keeney, K. M., Fisher, W. W., Adelinis, J. D., & Wilder, D. A. (2000). The effects of response cost in the treatment of aberrant behavior maintained by negative reinforcement. Journal of Applied Behavior Analysis, 33, 255-258. Lerman, D. C., & Iwata, B. A. (1996). A methodology for distinguishing between extinction and punishment effects associated with response blocking. Journal of Applied Behavior Analysis, 29, 231-234. Lerman, D. C., Iwata, B. A., Shore, B. A., & DeLeon, I. G. (1997). Effects of intermittent punishment on self-injurious behavior: An evaluation of schedule thinning. Journal of Applied Behavior Analysis, 30, 187-201. Lerman , D. C., Iwata, B.A., Smith, R.G., & Vollmer, T. R. (1994). Restraint fading and the development of alternative behaviour in the treatment of self-restraint and self-injury. Journal of Intellectual Disability Research, 38, 135-148. Lindberg, J. S., Iwata, B. A., & Kahng, S. W. (1999). On the relation between object manipulation and stereotypic self-injurious behavior. Journal of Applied Behavior Analysis, 32, 51-62. Lovaas, O. I., & Simmons, J. Q. (1969). Manipulation of self-destruction in three retarded children. Journal of Applied Behavior Analysis, 2, 143Ð157. Lowe, K., Allen, D., Jones, E., Brophy, S., Moore, K., & James, W. (2007). Challenging behaviours: Prevalence and topographies. Journal of Intellectual Disability Research, 51, 625-636. Matson, J. L., & LoVullo, S. V. (2008). A review of behavioral treatments for self-injurious behaviors of persons with autism spectrum disorders. Behavior Modification, 32, 61-76. Matson, J. L., & Sevin, J. A. (1994). Theories of dual diagnosis in mental retardation. Journal of Consulting and Clinical Psychology, 62, 6-16. McClannahan, L.E., MacDuff, G.S., & Krantz, P.J. (2002). Behavior analysis and intervention for adults with autism. Behavior Modification, 26, 9-26. McCord, B. E., Grosser, J. W., Iwata, B. A., & Powers, L. A. (2005). An analysis of response-blocking parameters in the prevention of pica. Journal of Applied Behavior Analysis, 38, 391-394. McIntyre, L. L., Blacher, J., & Baker, B. L. (2002). Behaviour/mental health problems in young adults with intellectual disability: The impact on families. Journal of Intellectual Disability Research, 46, 239-249. National Autism Center (2009). National Standards Project Findings and Conclusions. Randolph, MA: Author. National Institutes of Health. (1989, September 11-13). Treatment of destructive behaviors in persons with developmental disabilities. NIH Consensus Statement Online, 7, 1-15. Retrieved January 26, 2010, from http://consensus.nih.gov/1989/1989DestructiveBehaviorsDevelopment075html.htm 
19 Oliver, C., Hall, S., Hales, J., Murphy, G., & Watts, D. (1998). The treatment of severe self-injurious behavior by the systematic fading of restraints: Effects on self-injury, self-restraint, adaptive behavior, and behavioral correlates of affect. Research in Developmental Disabilities, 19, 143-165. OSEP Center on Positive Behavioral Interventions and Supports. (2009, April 29). Considerations for seclusion and restraint use in school-wide positive behavior supports. Retrieved February 1, 2010 from http://www.pbis.org/common/pbisresources/publications/Seclusion_Restraint_inBehaviorSupport.pdf Pace, G. M., Iwata, B. A., Edwards, G. L., & McCosh, K. C. (1986). Stimulus fading and transfer in the treatment of self-restraint and self-injurious behavior. Journal of Applied Behavior Analysis, 19, 381Ð389. Paclawskyj, T. R., Kurtz, P. F., & OÕConnor, J. (2004). Functional assessment of problem behaviors in adults with mental retardation. Behavior Modification, 28, 649-667. Patton, N. (2004). Self inflicted eye injuries: A review. Eye, 18, 867-872. Retrieved January 26, 2010, from http://www.nature.com/eye/index.html Pelios, L., Morren, J., Tesch, D., & Axelrod, S. (1999). The impact of functional analysis methodology on treatment choice for self-injurious and aggressive behavior. Journal of Applied Behavior Analysis, 32, 185-195. Perry, A. C., & Fisher, W. W. (2001). Behavioral economic influences on treatments designed to decrease destructive behavior. Journal of Applied Behavior Analysis, 34, 211-215. Piazza, C. C., Hanley, G. P., & Fisher, W. W. (1996). Functional analysis and treatment of cigarette pica. Journal of Applied Behavior Analysis, 29, 437- 449. Piazza, C. C., Roane, H. S., Keeney, K. M., Boney, B. R., & Abt, K. A. (2002). Varying response effort in the treatment of pica maintained by automatic reinforcement. Journal of Applied Behavior Analysis, 35, 233-246. Powers, K. V., Roane, H. S., & Kelley, M. E. (2007) Treatment of self-restraint associated with the application of protective equipment. Journal of Applied Behavior Analysis, 40, 577Ð581. Rapoff, M. A., Altman, K., & Christophersen, E. R. (1980). Elimination of a blind childÕs self-hitting by response-contingent brief restraint. Education and Treatment of Children, 3, 231-236. Reid, D. H., Parsons, M. B., Phillips, J. F., & Green, C. W. (1993). Reduction of self-injurious hand mouthing using response blocking. Journal of Applied Behavior Analysis, 26, 139Ð140. Rojahn, J., Schroeder, S. R., & Mulick, J. A. (1980). Ecological assessment of self-protective devices in three profoundly retarded adults. Journal of Autism and Developmental Disorders, 10, 59-66. Rush, A. J. & Frances, A. (Eds.) (2000). Expert consensus guideline series: Treatment of psychiatric and behavioral problems in mental retardation [Special Issue]. American Journal on Mental Retardation, 105, 159-228. 
20 Sigafoos, J., Elkins, J., Kerr, M., Attwood, T (1994). A survey of aggressive behaviour among a population of persons with intellectual disability in Queensland. Journal of Intellectual Disability Research, 38, 369-381. Smith, R., Russo, L., & Le, D. (1999). Distinguishing between extinction and punishment effects of response blocking: A replication. Journal of Applied Behavior Analysis, 32, 367Ð370. Spreat, S., Lipinski, D. P., Hill, J., & Halpin, M. (1986). Safety indices associated with the use of contingent restraint procedures. Applied Research in Mental Retardation, 7, 475-481. Steigler, L. (2005). Understanding pica behavior: A review for clinical and education professionals. Focus on Autism and Other Developmental Disabilities, 20, 27-38. Thompson, C. L., & Reid, A. (2002). Behavioural symptoms among people with severe and profound intellectual disabilities: A 26-year follow-up study. The British Journal of Psychiatry, 181, 67-71. Thompson, T., Moore, T., & Symons, F. (2007). Psychotherapeutic medications for positive behavior support. In Odom, S., Horner, R., Snell, M., Blacher, J. (Eds.), Handbook on Developmental Disabilities. New York: Guilford Publications, Inc. Totsika, V., Toogood, S., Hastings, R. P., & Lewis, S. (2008). Persistence of challenging behaviours in adults with intellectual disability over a period of 11 years. Journal of Intellectual Disability Research, 52, 446-457. Vorndran, C. M., & Lerman, D. C. (2006). Establishing and maintaining treatment effects with less intrusive consequences via a pairing procedure. Journal of Applied Behavior Analysis, 39, 35-48. Wacker, D. P., Steege, M. W., Northup, J., Sasso, G., Berg, W., Reimers, T., et. al. (1990). A component analysis of functional communication training across three topographies of severe behavior problems. Journal of Applied Behavior Analysis, 23, 417-429. Weisz, J.R., Weiss, B., Han, S.S., Granger, D.A., & Morton, T. (1995). Effects of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117, 450-468. Williams, D.E., Kirkpatrick-Sanchez, S, Enzinna, C, Dunn, J, & Borden-Karasack, D. (2009). The clinical management and prevention of pica: A retrospective follow-up of 41 individuals with intellectual disabilities and pica. Journal of Applied Research in Intellectual Disabilities, 22, 210 Ð 215. Winston, M., Fleisig, N., & Winston, L. (2009). The premature call for a ban on prone restraint: A detailed analysis of the issues and evidence. Retrieved January 26, 2010, from http://www.pcma.com/Premature%20Call%20for%20a%20ban%20on%20prone%20restraint.pdf Wolery, M., Barton, E. E., & Hine, J.F. (2005). Evoluation of applied behavior analysis in the treatment of individuals with autism. Exceptionality, 13 (1), 11-23. Ethics Code for Behavior AnalystsThe Ethics Code for Behavior Analysts (Code) replaces the Professional and Ethical Compliance Code for Behavior Analysts (2014). All BCBA and BCaBA applicants and certificants are required to adhere to the Code effective January 1, 2022.This document should be referenced as: Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. https://bacb.com/wp-content/ethics-code-for-behavior-analysts/Copyright © 2020, BACB®, All rights reserved. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 2Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.Table of ContentsIntroduction ........................................................................3Scope of the Code ...................................................................................................3Core Principles .........................................................................................................4Application of the Code ..........................................................................................5Enforcement of the Code .......................................................................................6Glossary .............................................................................7Ethics Standards ................................................................9Section 1—Responsibility as a Professional ......................................................91.01 Being Truthful ...........................................................................................91.02 Conforming with Legal and Professional Requirements...........91.03 Accountability..........................................................................................91.04 Practicing within a Defined Role .......................................................91.05 Practicing within Scope of Competence .......................................91.06 Maintaining Competence ....................................................................91.07 Cultural Responsiveness and Diversity ..........................................91.08 Nondiscrimination ..................................................................................91.09 Nonharassment ......................................................................................91.10 Awareness of Personal Biases and Challenges ...........................91.11 Multiple Relationships ...........................................................................101.12 Giving and Receiving Gifts .................................................................101.13 Coercive and Exploitative Relationships .......................................101.14 Romantic and Sexual Relationships.................................................101.15 Responding to Requests .....................................................................101.16 Self-Reporting Critical Information ...................................................10Section 2—Responsibility in Practice ...............................................................102.01 Providing Effective Treatment..........................................................102.02 Timeliness .............................................................................................102.03 Protecting Confidential Information ..............................................102.04 Disclosing Confidential Information ................................................112.05 Documentation Protection and Retention ....................................112.06 Accuracy in Service Billing and Reporting ...................................112.07 Fees ..........................................................................................................112.08 Communicating About Services ......................................................112.09 Involving Clients and Stakeholders ................................................112.10 Collaborating with Colleagues ..........................................................112.11 Obtaining Informed Consent ...............................................................112.12 Considering Medical Needs ..............................................................122.13 Selecting, Designing, and Implementing Assessments ...........122.14 Selecting, Designing, and Implementing Behavior- Change Interventions ..............................................................................122.15 Minimizing Risk of Behavior-Change Interventions ...................122.16 Describing Behavior-Change Interventions Before Implementation ...........................................................................122.17 Collecting and Using Data ..................................................................122.18 Continual Evaluation of the Behavior-Change Intervention ....122.19 Addressing Conditions Interfering with Service Delivery ........12Section 3—Responsibility to Clients and Stakeholders ...............................133.01 Responsibility to Clients......................................................................133.02 Identifying Stakeholders ....................................................................133.03 Accepting Clients.................................................................................133.04 Service Agreement .............................................................................133.05 Financial Agreements ........................................................................133.06 Consulting with Other Providers .....................................................133.07 Third-Party Contracts for Services ..................................................133.08 Responsibility to the Client with Third-Party Contracts for Services .................................................................................................133.09 Communicating with Stakeholders About Third-Party Contracted Services ................................................................................143.10 Limitations of Confidentiality .............................................................143.11 Documenting Professional Activity ...................................................143.12 Advocating for Appropriate Services .............................................143.13 Referrals ...................................................................................................143.14 Facilitating Continuity of Services ....................................................143.15 Appropriately Discontinuing Services ............................................143.16 Appropriately Transitioning Services ..............................................14Section 4—Responsibility to Supervisees and Trainees .............................154.01 Compliance with Supervision Requirements ...............................154.02 Supervisory Competence .................................................................154.03 Supervisory Volume ...........................................................................154.04 Accountability in Supervision ...........................................................154.05 Maintaining Supervision Documentation .....................................154.06 Providing Supervision and Training ...............................................154.07 Incorporating and Addressing Diversity .......................................154.08 Performance Monitoring and Feedback ......................................154.09 Delegation of Tasks ............................................................................154.10 Evaluating Effects of Supervision and Training ...........................164.11 Facilitating Continuity of Supervision ...............................................164.12 Appropriately Terminating Supervision ..........................................16Section 5—Responsibility in Public Statements .............................................165.01 Protecting the Rights of Clients, Stakeholders, Supervisees, and Trainees ....................................................................165.02 Confidentiality in Public Statements ..............................................165.03 Public Statements by Behavior Analysts......................................165.04 Public Statements by Others ...........................................................165.05 Use of Intellectual Property ..............................................................165.06 Advertising Nonbehavioral Services ............................................165.07 Soliciting Testimonials from Current Clients for Advertising ...........................................................................................175.08 Using Testimonials from Former Clients for Advertising ........175.09 Using Testimonials for Nonadvertising Purposes .....................175.10 Social Media Channels and Websites ............................................175.11 Using Digital Content in Public Statements ...................................17Section 6—Responsibility in Research ..............................................................176.01 Conforming with Laws and Regulations in Research ................176.02 Research Review .................................................................................176.03 Research in Service Delivery ...........................................................176.04 Informed Consent in Research .......................................................186.05 Confidentiality in Research...............................................................186.06 Competence in Conducting Research .........................................186.07 Conflict of Interest in Research and Publication ........................186.08 Appropriate Credit ..............................................................................186.09 Plagiarism ...............................................................................................186.10 Documentation and Data Retention in Research .......................186.11 Accuracy and Use of Data ..................................................................18 Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 3Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.IntroductionAs a diverse group of professionals who work in a variety of practice areas, behavior analysts deliver applied behavior analysis (ABA) services to positively impact lives. The Behavior Analyst Certification Board® (BACB®) exists to meet the credentialing needs of these professionals and relevant stakeholders (e.g., licensure boards, funders) while protecting ABA consumers by establishing, disseminating, and managing professional standards. The BACB facilitates ethical behavior in the profession through its certification eligibility and maintenance requirements, by issuing the ethics standards described in this document, and by operating a system for addressing professional misconduct.The Ethics Code for Behavior Analysts (Code) guides the professional activities of behavior analysts over whom the BACB has jurisdiction (see Scope of the Code below). The Code also provides a means for behavior analysts to evaluate their own behavior and for others to assess whether a behavior analyst has violated their ethical obligations. An introduction section describes the scope and application of the Code, its core principles, and considerations for ethical decision making. The core principles are foundational concepts that should guide all aspects of a behavior analyst’s work. The introduction is followed by a glossary that includes definitions of technical terms used in the Code. The final section includes the ethics standards, which are informed by the core principles. The standards are organized into six sections: 1) Responsibility as a Professional, 2) Responsibility in Practice, 3) Responsibility to Clients and Stakeholders, 4) Responsibility to Supervisees and Trainees, 5) Responsibility in Public Statements, and 6) Responsibility in Research.Scope of the CodeThe Code applies to all individuals who hold Board Certified Behavior Analyst® (BCBA®) or Board Certified Assistant Behavior Analyst® (BCaBA®) certification and all individuals who have completed an application for BCBA or BCaBA certification. For the sake of efficiency, the term “behavior analyst” is used throughout this document to refer to those who must act in accordance with the Code. The BACB does not have separate jurisdiction over organizations or corporations. The Code applies to behavior analysts in all of their professional activities, including direct service delivery, consultation, supervision, training, management, editorial and peer-review activities, research, and any other activity within the ABA profession. The Code applies to behavior analysts’ professional activities across settings and delivery modes (e.g., in person; in writing; via phone, email, text message, video conferencing). Application of the Code does not extend to behavior analysts’ personal behavior unless it is determined that the behavior clearly poses a potential risk to the health and safety of clients, stakeholders, supervisees, or trainees. Specific terms are defined in the Glossary section; however, two definitions are provided here because they are frequently used in the Core Principles section. Client: The direct recipient of the behavior analyst’s services. At various times during service provision, one or more stakeholders may simultaneously meet the definition of client (e.g., the point at which they receive direct training or consultation). In some contexts, the client might be a group of individuals (e.g., with organizational behavior management services). Stakeholder: An individual, other than the client, who is impacted by and invested in the behavior analyst’s services (e.g., parent, caregiver, relative, legally authorized representative, collaborator, employer, agency or institutional representative, licensure board, funder, third-party contractor for services). Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 4Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.Core Principles Four foundational principles, which all behavior analysts should strive to embody, serve as the framework for the ethics standards. Behavior analysts should use these principles to interpret and apply the standards in the Code. The four core principles are that behavior analysts should: benefit others; treat others with compassion, dignity, and respect; behave with integrity; and ensure their own competence.1. Benefit Others. Behavior analysts work to maximize benefits and do no harm by:• Protecting the welfare and rights of clients above all others• Protecting the welfare and rights of other individuals with whom they interact in a professional capacity• Focusing on the short- and long-term effects of their professional activities• Actively identifying and addressing the potential negative impacts of their own physical and mental health on their professional activities• Actively identifying potential and actual conflicts of interest and working to resolve them in a manner that avoids or minimizes harm• Actively identifying and addressing factors (e.g., personal, financial, institutional, political, religious, cultural) that might lead to conflicts of interest, misuse of their position, or negative impacts on their professional activities• Effectively and respectfully collaborating with others in the best interest of those with whom they work and always placing clients’ interests first2. Treat Others with Compassion, Dignity, and Respect. Behavior analysts behave toward others with compassion, dignity, and respect by:• Treating others equitably, regardless of factors such as age, disability, ethnicity, gender expression/identity, immigration status, marital/relationship status, national origin, race, religion, sexual orientation, socioeconomic status, or any other basis proscribed by law• Respecting others’ privacy and confidentiality• Respecting and actively promoting clients’ self-determination to the best of their abilities, particularly when providing services to vulnerable populations• Acknowledging that personal choice in service delivery is important by providing clients and stakeholders with needed information to make informed choices about services3. Behave with Integrity. Behavior analysts fulfill responsibilities to their scientific and professional communities, to society in general, and to the communities they serve by:• Behaving in an honest and trustworthy manner• Not misrepresenting themselves, misrepresenting their work or others’ work, or engaging in fraud• Following through on obligations• Holding themselves accountable for their work and the work of their supervisees and trainees, and correcting errors in a timely manner• Being knowledgeable about and upholding BACB and other regulatory requirements• Actively working to create professional environments that uphold the core principles and standards of the Code • Respectfully educating others about the ethics requirements of behavior analysts and the mechanisms for addressing professional misconduct4. Ensure their Competence. Behavior analysts ensure their competence by: • Remaining within the profession’s scope of practice• Remaining current and increasing their knowledge of best practices and advances in ABA and participating in professional development activities• Remaining knowledgeable and current about interventions (including pseudoscience) that may exist in their practice areas and pose a risk of harm to clients• Being aware of, working within, and continually evaluating the boundaries of their competence• Working to continually increase their knowledge and skills related to cultural responsiveness and service delivery to diverse groups Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 5Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.Application of the CodeBehavior analysts are expected to be knowledgeable about and comply with the Code and Code-Enforcement Procedures. Lack of awareness or misunderstanding of an ethics standard is not a defense against an alleged ethics violation. When appropriate, behavior analysts should inform others about the Code and Code-Enforcement Procedures and create conditions that foster adherence to the Code. When addressing potential code violations by themselves or others, behavior analysts document the steps taken and the resulting outcomes. Behavior analysts should address concerns about the professional misconduct of others directly with them when, after assessing the situation, it seems possible that doing so will resolve the issue and not place the behavior analyst or others at undue risk.The BACB recognizes that behavior analysts may have different professional roles. As such, behavior analysts are required to comply with all applicable laws, licensure requirements, codes of conduct/ethics, reporting requirements (e.g., mandated reporting, reporting to funding sources or licensure board, self-reporting to the BACB, reporting instances of misrepresentation by others), and professional practice requirements related to their various roles. In some instances, behavior analysts may need to report serious concerns to relevant authorities or agencies that can provide more immediate relief or protection before reporting to the BACB (e.g., criminal activity or behavior that places clients or others at risk for direct and immediate harm should immediately be reported to the relevant authorities before reporting to the BACB or a licensure board).The standards included in the Code are not meant to be exhaustive, as it is impossible to predict every situation that might constitute an ethics violation. Therefore, the absence of a particular behavior or type of conduct from the Code standards does not indicate that such behavior or conduct is ethical or unethical. When interpreting and applying a standard, it is critical to attend to its specific wording and function, as well as the core principles. Additionally, standards must be applied to a situation using a functional, contextualized approach that accounts for factors relevant to that situation, such as variables related to diversity (e.g., age, disability, ethnicity, gender expression/identity, immigration status, marital/relationship status, national origin, race, religion, sexual orientation, socioeconomic status) and possible imbalances in power. In all instances of interpreting and applying the Code, behavior analysts should put compliance with the law and clients’ interests first by actively working to maximize desired outcomes and minimize risk. Ethical decision making. Behavior analysts will likely encounter complex and multifaceted ethical dilemmas. When faced with such a dilemma, behavior analysts should identify problems and solutions with care and deliberation. In resolving an ethical dilemma, behavior analysts should follow the spirit and letter of the Code’s core principles and specific standards. Behavior analysts should address ethical dilemmas through a structured decision-making process that considers the full context of the situation and the function of relevant ethics standards. Although no single ethical decision-making process will be equally effective in all situations, the process below illustrates a systematic approach behavior analysts can take to document and address potential ethical concerns.1. Clearly define the issue and consider potential risk of harm to relevant individuals.2. Identify all relevant individuals.3. Gather relevant supporting documentation and follow-up on second-hand information to confirm that there is an actual ethical concern.4. Consider your personal learning history and biases in the context of the relevant individuals.5. Identify the relevant core principles and Code standards.6. Consult available resources (e.g., research, decision-making models, trusted colleagues).7. Develop several possible actions to reduce or remove risk of harm, prioritizing the best interests of clients in accordance with the Code and applicable laws.Throughout all of the following steps, document information that may be essential to decision making or for communicating the steps taken and outcomes (e.g., to the BACB, licensure boards, or other governing agencies). For example, consider documenting: dates, times, locations, and relevant individuals; summaries of observations, meetings, or information reported by others. Take care to protect confidentiality in the preparation and storage of all documentation. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 6Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.8. Critically evaluate each possible action by considering its alignment with the “letter and spirit” of the Code, its potential impact on the client and stakeholders, the likelihood of it immediately resolving the ethical concern, as well as variables such as client preference, social acceptability, degree of restrictiveness, and likelihood of maintenance.9. Select the action that seems most likely to resolve the specific ethical concern and reduce the likelihood of similar issues arising in the future.10. Take the selected action in collaboration with relevant individuals affected by the issue and document specific actions taken, agreed-upon next steps, names of relevant individuals, and due dates.11. Evaluate the outcomes to ensure that the action successfully addressed the issue.Enforcement of the CodeThe BACB enforces the Code to protect clients and stakeholders, BCBA and BCaBA certificants and applicants, and the ABA profession. Complaints are received and processed according to the processes outlined in the BACB’s Code-Enforcement Procedures document. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 7Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.GlossaryAssentVocal or nonvocal verbal behavior that can be taken to indicate willingness to participate in research or behavioral services by individuals who cannot provide informed consent (e.g., because of age or intellectual impairments). Assent may be required by a research review committee or a service organization. In such instances, those entities will provide parameters for assessing assent.Behavior AnalystAn individual who holds BCBA or BCaBA certification or who has submitted a complete application for BCBA or BCaBA certification.Behavior-Change InterventionThe full set of behavioral procedures designed to improve the client’s wellbeing. Behavioral ServicesServices that are explicitly based on the principles and procedures of behavior analysis and are designed to change behavior in meaningful ways. These services include, but are not limited to, assessment, behavior-change interventions, training, consultation, managing and supervising others, and delivering continuing education.Client The direct recipient of the behavior analyst’s services. At various times during service provision, one or more stakeholders may simultaneously meet the definition of client (e.g., the point at which they receive direct training or consultation). In some contexts, the client might be a group of individuals (e.g., with organizational behavior management services). Clients’ RightsHuman rights, legal rights, rights codified within behavior analysis, and organization rules designed to benefit the client.Conflict of InterestAn incompatibility between a behavior analysts’ private and professional interests resulting in risk or potential risk to services provided to, or the professional relationship with, a client, stakeholder, supervisee, trainee, or research participant. Conflicts may result in a situation in which personal, financial, or professional considerations have the potential to influence or compromise professional judgment in the delivery of behavioral services, research, consultation, supervision, training, or any other professional activity.Digital ContentInformation that is made available for online consumption, downloading, or distribution through an electronic medium (e.g., television, radio, ebook, website, social media, videogame, application, computer, smart device). Common digital content includes documents, pictures, videos, and audio files.Informed ConsentThe permission given by an individual with the legal right to consent before participating in services or research, or allowing their information to be used or shared.Service/Research: Providing the opportunity for an individual to give informed consent for services or research involves communicating about and taking appropriate steps to confirm understanding of: 1) the purpose of the services or research; 2) the expected time commitment and procedures involved; 3) the right to decline to participate or withdraw at any time without adverse consequences; 4) potential benefits, risks, discomfort, or adverse effects; 5) any limits to confidentiality or privacy; 6) any incentives for research participation; 7) whom to contact for questions or concerns at any time; and 8) the opportunity to ask questions and receive answers.Information Use/Sharing: Providing the opportunity for an individual to give informed consent to share or use their information involves communicating about: 1) the purpose and intended use; 2) the audience; 3) the expected duration; 4) the right to decline or withdraw consent at any time; 5) potential risks or benefits; 6) any limitations to confidentiality or privacy; 7) whom to contact for questions or concerns at any time; and 8) the opportunity to ask questions and receive answers.Legally Authorized RepresentativeAny individual authorized under law to provide consent on behalf of an individual who cannot provide consent to receive services or participate in research. Multiple RelationshipA comingling of two or more of a behavior analyst’s roles (e.g., behavioral and personal) with a client, stakeholder, supervisee, trainee, research participant, or someone closely associated with or related to the client. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 8Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.Public StatementsDelivery of information (digital or otherwise) in a public forum for the purpose of either better informing that audience or providing a call-to-action. This includes paid or unpaid advertising, brochures, printed material, directory listings, personal resumes or curriculum vitae, interviews, or comments for use in media (e.g., print, statements in legal proceedings, lectures and public presentations, social media, published materials).ResearchAny data-based activity, including analysis of preexisting data, designed to generate generalizable knowledge for the discipline. The use of an experimental design does not by itself constitute research. Research ParticipantAny individual participating in a defined research study for whom informed consent has been obtained.Research Review CommitteeA group of professionals whose stated purpose is to review research proposals to ensure the ethical treatment of human research participants. This committee might be an official entity of a government or university (e.g., Institutional Review Board, Research Ethics Board), an independent committee within a service organization, or an independent organization created for this purpose.Scope of CompetenceThe professional activities a behavior analyst can consistently perform with proficiency.Social Media ChannelA digital platform, either found through a web browser or through an application, where users (individuals and/or businesses) can consume, create, copy, download, share, or comment on posts or advertisements. Both posts and advertisements would be considered digital content. Stakeholder An individual, other than the client, who is impacted by and invested in the behavior analyst’s services (e.g., parent, caregiver, relative, legally authorized representative, collaborator, employer, agency or institutional representatives, licensure board, funder, third-party contractor for services).SuperviseeAny individual whose behavioral service delivery is overseen by a behavior analyst within the context of a defined, agreed-upon relationship. Supervisees may include RBTs, BCaBAs, and BCBAs, as well as other professionals carrying out supervised behavioral services.TestimonialAny solicited or unsolicited recommendation, in any form, from a client, stakeholder, supervisee, or trainee affirming the benefits received from a behavior analyst’s product or service. From the point at which a behavior analyst asks an individual for a recommendation it is considered solicited.Third PartyAny individual, group of individuals, or entity, other than the direct recipient of services, the primary caregiver, the legally authorized representative, or the behavior analyst, who requests and funds services on behalf of a client or group of clients. Some examples include a school district, governmental entity, mental health agency, among others. TraineeAny individual accruing fieldwork/experience toward fulfilling eligibility requirements for BCaBA or BCBA certification. Website A digital platform found through a web browser where an entity (individual and/or organization) produces and distributes digital content for the consumption of users online. Depending on the functionality, users can consume, create, copy, download, share, or comment on the provided digital content. Note: Terms defined in the glossary are italicized the first time they appear in a standard in each section of the Code. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 9Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.Ethics StandardsSection 1—Responsibility as a Professional1.01 Being TruthfulBehavior analysts are truthful and arrange the professional environment to promote truthful behavior in others. They do not create professional situations that result in others engaging in behavior that is fraudulent or illegal or that violates the Code. They also provide truthful and accurate information to all required entities (e.g., BACB, licensure boards, funders) and individuals (e.g., clients, stakeholders, supervisees, trainees), and they correct instances of untruthful or inaccurate submissions as soon as they become aware of them.1.02 Conforming with Legal and Professional RequirementsBehavior analysts follow the law and the requirements of their professional community (e.g., BACB, licensure board).1.03 AccountabilityBehavior analysts are accountable for their actions and professional services and follow through on work commitments. When errors occur or commitments cannot be met, behavior analysts take all appropriate actions to directly address them, first in the best interest of clients, and then in the best interest of relevant parties.1.04 Practicing within a Defined RoleBehavior analysts provide services only after defining and documenting their professional role with relevant parties in writing.1.05 Practicing within Scope of CompetenceBehavior analysts practice only within their identified scope of competence. They engage in professional activities in new areas (e.g., populations, procedures) only after accessing and documenting appropriate study, training, supervised experience, consultation, and/or co-treatment from professionals competent in the new area. Otherwise, they refer or transition services to an appropriate professional. 1.06 Maintaining CompetenceBehavior analysts actively engage in professional development activities to maintain and further their professional competence. Professional development activities include reading relevant literature; attending conferences and conventions; participating in workshops and other training opportunities; obtaining additional coursework; receiving coaching, consultation, supervision, or mentorship; and obtaining and maintaining appropriate professional credentials. 1.07 Cultural Responsiveness and DiversityBehavior analysts actively engage in professional development activities to acquire knowledge and skills related to cultural responsiveness and diversity. They evaluate their own biases and ability to address the needs of individuals with diverse needs/backgrounds (e.g., age, disability, ethnicity, gender expression/identity, immigration status, marital/relationship status, national origin, race, religion, sexual orientation, socioeconomic status). Behavior analysts also evaluate biases of their supervisees and trainees, as well as their supervisees’ and trainees’ ability to address the needs of individuals with diverse needs/backgrounds.1.08 NondiscriminationBehavior analysts do not discriminate against others. They behave toward others in an equitable and inclusive manner regardless of age, disability, ethnicity, gender expression/identity, immigration status, marital/relationship status, national origin, race, religion, sexual orientation, socioeconomic status, or any other basis proscribed by law.1.09 NonharassmentBehavior analysts do not engage in behavior that is harassing or hostile toward others.1.10 Awareness of Personal Biases and ChallengesBehavior analysts maintain awareness that their personal biases or challenges (e.g., mental or physical health conditions; legal, financial, marital/relationship challenges) may interfere with the effectiveness of their professional work. Behavior analysts take appropriate steps to resolve interference, ensure that their professional work is not compromised, and document all actions taken in this circumstance and the eventual outcomes. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 10Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.1.11 Multiple RelationshipsBecause multiple relationships may result in a conflict of interest that might harm one or more parties, behavior analysts avoid entering into or creating multiple relationships, including professional, personal, and familial relationships with clients and colleagues. Behavior analysts communicate the risks of multiple relationships to relevant individuals and continually monitor for the development of multiple relationships. If multiple relationships arise, behavior analysts take appropriate steps to resolve them. When immediately resolving a multiple relationship is not possible, behavior analysts develop appropriate safeguards to identify and avoid conflicts of interest in compliance with the Code and develop a plan to eventually resolve the multiple relationship. Behavior analysts document all actions taken in this circumstance and the eventual outcomes.1.12 Giving and Receiving GiftsBecause the exchange of gifts can invite conflicts of interest and multiple relationships, behavior analysts do not give gifts to or accept gifts from clients, stakeholders, supervisees, or trainees with a monetary value of more than $10 US dollars (or the equivalent purchasing power in another currency). Behavior analysts make clients and stakeholders aware of this requirement at the onset of the professional relationship. A gift is acceptable if it functions as an infrequent expression of gratitude and does not result in financial benefit to the recipient. Instances of giving or accepting ongoing or cumulative gifts may rise to the level of a violation of this standard if the gifts become a regularly expected source of income or value to the recipient.1.13 Coercive and Exploitative RelationshipsBehavior analysts do not abuse their power or authority by coercing or exploiting persons over whom they have authority (e.g., evaluative, supervisory).1.14 Romantic and Sexual RelationshipsBehavior analysts do not engage in romantic or sexual relationships with current clients, stakeholders, trainees, or supervisees because such relationships pose a substantial risk of conflicts of interest and impaired judgment. Behavior analysts do not engage in romantic or sexual relationships with former clients or stakeholders for a minimum of two years from the date the professional relationship ended. Behavior analysts do not engage in romantic or sexual relationships with former supervisees or trainees until the parties can document that the professional relationship has ended (i.e., completion of all professional duties). Behavior analysts do not accept as supervisees or trainees individuals with whom they have had a past romantic or sexual relationship until at least six months after the relationship has ended. 1.15 Responding to RequestsBehavior analysts make appropriate efforts to respond to requests for information from and comply with deadlines of relevant individuals (e.g., clients, stakeholders, supervisees, trainees) and entities (e.g., BACB, licensure boards, funders). They also comply with practice requirements (e.g., attestations, criminal background checks) imposed by the BACB, employers, or governmental entities. 1.16 Self-Reporting Critical InformationBehavior analysts remain knowledgeable about and comply with all self-reporting requirements of relevant entities (e.g., BACB, licensure boards, funders). Section 2—Responsibility in Practice2.01 Providing Effective TreatmentBehavior analysts prioritize clients’ rights and needs in service delivery. They provide services that are conceptually consistent with behavioral principles, based on scientific evidence, and designed to maximize desired outcomes for and protect all clients, stakeholders, supervisees, trainees, and research participants from harm. Behavior analysts implement nonbehavioral services with clients only if they have the required education, formal training, and professional credentials to deliver such services. 2.02 TimelinessBehavior analysts deliver services and carry out necessary service-related administrative responsibilities in a timely manner.2.03 Protecting Confidential InformationBehavior analysts take appropriate steps to protect the confidentiality of clients, stakeholders, supervisees, trainees, and research participants; prevent the accidental or inadvertent sharing of confidential information; and comply with applicable Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 11Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.confidentiality requirements (e.g., laws, regulations, organization policies). The scope of confidentiality includes service delivery (e.g., live, teleservices, recorded sessions); documentation and data; and verbal, written, or electronic communication. 2.04 Disclosing Confidential InformationBehavior analysts only share confidential information about clients, stakeholders, supervisees, trainees, or research participants: (1) when informed consent is obtained; (2) when attempting to protect the client or others from harm; (3) when attempting to resolve contractual issues; (4) when attempting to prevent a crime that is reasonably likely to cause physical, mental, or financial harm to another; or (5) when compelled to do so by law or court order. When behavior analysts are authorized to discuss confidential information with a third party, they only share information critical to the purpose of the communication.2.05 Documentation Protection and RetentionBehavior analysts are knowledgeable about and comply with all applicable requirements (e.g., BACB rules, laws, regulations, contracts, funder and organization requirements) for storing, transporting, retaining, and destroying physical and electronic documentation related to their professional activities. They destroy physical documentation after making electronic copies or summaries of data (e.g., reports and graphs) only when allowed by applicable requirements. When a behavior analyst leaves an organization these responsibilities remain with the organization.2.06 Accuracy in Service Billing and ReportingBehavior analysts identify their services accurately and include all required information on reports, bills, invoices, requests for reimbursement, and receipts. They do not implement or bill nonbehavioral services under an authorization or contract for behavioral services. If inaccuracies in reporting or billing are discovered, they inform all relevant parties (e.g., organizations, licensure boards, funders), correct the inaccuracy in a timely manner, and document all actions taken in this circumstance and the eventual outcomes. 2.07 FeesBehavior analysts implement fee practices and share fee information in compliance with applicable laws and regulations. They do not misrepresent their fees. In situations where behavior analysts are not directly responsible for fees, they must communicate these requirements to the responsible party and take steps to resolve any inaccuracy or conflict. They document all actions taken in this circumstance and the eventual outcomes.2.08 Communicating About ServicesBehavior analysts use understandable language in, and ensure comprehension of, all communications with clients, stakeholders, supervisees, trainees, and research participants. Before providing services, they clearly describe the scope of services and specify the conditions under which services will end. They explain all assessment and behavior-change intervention procedures before implementing them and explain assessment and intervention results when they are available. They provide an accurate and current set of their credentials and a description of their area of competence upon request.2.09 Involving Clients and StakeholdersBehavior analysts make appropriate efforts to involve clients and relevant stakeholders throughout the service relationship, including selecting goals, selecting and designing assessments and behavior-change interventions, and conducting continual progress monitoring.2.10 Collaborating with ColleaguesBehavior analysts collaborate with colleagues from their own and other professions in the best interest of clients and stakeholders. Behavior analysts address conflicts by compromising when possible and always prioritizing the best interest of the client. Behavior analysts document all actions taken in these circumstances and their eventual outcomes.2.11 Obtaining Informed ConsentBehavior analysts are responsible for knowing about and complying with all conditions under which they are required to obtain informed consent from clients, stakeholders, and research participants (e.g., before initial implementation of assessments or behavior-change interventions, when making substantial changes to interventions, when exchanging or releasing confidential information or records). They are responsible for explaining, obtaining, reobtaining, and documenting required informed consent. They are responsible for obtaining assent from clients when applicable. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 12Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.2.12 Considering Medical NeedsBehavior analysts ensure, to the best of their ability, that medical needs are assessed and addressed if there is any reasonable likelihood that a referred behavior is influenced by medical or biological variables. They document referrals made to a medical professional and follow up with the client after making the referral.2.13 Selecting, Designing, and Implementing AssessmentsBefore selecting or designing behavior-change interventions behavior analysts select and design assessments that are conceptually consistent with behavioral principles; that are based on scientific evidence; and that best meet the diverse needs, context, and resources of the client and stakeholders. They select, design, and implement assessments with a focus on maximizing benefits and minimizing risk of harm to the client and stakeholders. They summarize the procedures and results in writing.2.14 Selecting, Designing, and Implementing Behavior-Change InterventionsBehavior analysts select, design, and implement behavior-change interventions that: (1) are conceptually consistent with behavioral principles; (2) are based on scientific evidence; (3) are based on assessment results; (4) prioritize positive reinforcement procedures; and (5) best meet the diverse needs, context, and resources of the client and stakeholders. Behavior analysts also consider relevant factors (e.g., risks, benefits, and side effects; client and stakeholder preference; implementation efficiency; cost effectiveness) and design and implement behavior-change interventions to produce outcomes likely to maintain under naturalistic conditions. They summarize the behavior-change intervention procedures in writing (e.g., a behavior plan).2.15 Minimizing Risk of Behavior-Change InterventionsBehavior analysts select, design, and implement behavior-change interventions (including the selection and use of consequences) with a focus on minimizing risk of harm to the client and stakeholders. They recommend and implement restrictive or punishment-based procedures only after demonstrating that desired results have not been obtained using less intrusive means, or when it is determined by an existing intervention team that the risk of harm to the client outweighs the risk associated with the behavior-change intervention. When recommending and implementing restrictive or punishment-based procedures, behavior analysts comply with any required review processes (e.g., a human rights review committee). Behavior analysts must continually evaluate and document the effectiveness of restrictive or punishment-based procedures and modify or discontinue the behavior-change intervention in a timely manner if it is ineffective.2.16 Describing Behavior-Change Interventions Before ImplementationBefore implementation, behavior analysts describe in writing the objectives and procedures of the behavior-change intervention, any projected timelines, and the schedule of ongoing review. They provide this information and explain the environmental conditions necessary for effective implementation of the behavior-change intervention to the stakeholders and client (when appropriate). They also provide explanations when modifying existing or introducing new behavior-change interventions and obtain informed consent when appropriate.2.17 Collecting and Using DataBehavior analysts actively ensure the appropriate selection and correct implementation of data collection procedures. They graphically display, summarize, and use the data to make decisions about continuing, modifying, or terminating services.2.18 Continual Evaluation of the Behavior-Change InterventionBehavior analysts engage in continual monitoring and evaluation of behavior-change interventions. If data indicate that desired outcomes are not being realized, they actively assess the situation and take appropriate corrective action. When a behavior analyst is concerned that services concurrently delivered by another professional are negatively impacting the behavior-change intervention, the behavior analyst takes appropriate steps to review and address the issue with the other professional.2.19 Addressing Conditions Interfering with Service DeliveryBehavior analysts actively identify and address environmental conditions (e.g., the behavior of others, hazards to the client or staff, disruptions) that may interfere with or prevent service delivery. In such situations, behavior analysts remove or minimize the conditions, identify effective modifications to the intervention, and/or consider obtaining or recommending assistance from other professionals. Behavior analysts document the conditions, all actions taken, and the eventual outcomes. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 13Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.Section 3—Responsibility to Clients and Stakeholders3.01 Responsibility to Clients (see 1.03, 2.01)Behavior analysts act in the best interest of clients, taking appropriate steps to support clients’ rights, maximize benefits, and do no harm. They are also knowledgeable about and comply with applicable laws and regulations related to mandated reporting requirements.3.02 Identifying StakeholdersBehavior analysts identify stakeholders when providing services. When multiple stakeholders (e.g., parent or legally authorized representative, teacher, principal) are involved, the behavior analyst identifies their relative obligations to each stakeholder. They document and communicate those obligations to stakeholders at the outset of the professional relationship. 3.03 Accepting Clients (see 1.05, 1.06)Behavior analysts only accept clients whose requested services are within their identified scope of competence and available resources (e.g., time and capacity for case supervision, staffing). When behavior analysts are directed to accept clients outside of their identified scope of competence and available resources, they take appropriate steps to discuss and resolve the concern with relevant parties. Behavior analysts document all actions taken in this circumstance and the eventual outcomes.3.04 Service Agreement (see 1.04)Before implementing services, behavior analysts ensure that there is a signed service agreement with the client and/or relevant stakeholders outlining the responsibilities of all parties, the scope of behavioral services to be provided, the behavior analyst’s obligations under the Code, and procedures for submitting complaints about a behavior analyst’s professional practices to relevant entities (e.g., BACB, service organization, licensure board, funder). They update service agreements as needed or as required by relevant parties (e.g., service organizations, licensure boards, funders). Updated service agreements must be reviewed with and signed by the client and/or relevant stakeholders.3.05 Financial Agreements (see 1.04, 2.07)Before beginning services, behavior analysts document agreed-upon compensation and billing practices with their clients, relevant stakeholders, and/or funders. When funding circumstances change, they must be revisited with these parties. Pro bono and bartered services are only provided under a specific service agreement and in compliance with the Code. 3.06 Consulting with Other Providers (see 1.05, 2.04, 2.10, 2.11, 2.12)Behavior analysts arrange for appropriate consultation with and referrals to other providers in the best interests of their clients, with appropriate informed consent, and in compliance with applicable requirements (e.g., laws, regulations, contracts, organization and funder policies).3.07 Third-Party Contracts for Services (see 1.04, 1.11, 2.04, 2.07)When behavior analysts enter into a signed contract to provide services to a client at the request of a third party (e.g., school district, governmental entity), they clarify the nature of the relationship with each party and assess any potential conflicts before services begin. They ensure that the contract outlines (1) the responsibilities of all parties, (2) the scope of behavioral services to be provided, (3) the likely use of the information obtained, (4) the behavior analysts’ obligations under the Code, and (5) any limits about maintaining confidentiality. Behavior analysts are responsible for amending contracts as needed and reviewing them with the relevant parties at that time. 3.08 Responsibility to the Client with Third-Party Contracts for Services (see 1.05, 1.11, 2.01)Behavior analysts place the client’s care and welfare above all others. If the third party requests services from the behavior analyst that are incompatible with the behavior analyst’s recommendations, that are outside of the behavior analyst’s scope of competence, or that could result in a multiple relationship, behavior analysts resolve such conflicts in the best interest of the client. If a conflict cannot be resolved, the behavior analyst may obtain additional training or consultation, discontinue services following appropriate transition measures, or refer the client to another behavior analyst. Behavior analysts document all actions taken in this circumstance and the eventual outcomes. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 14Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.3.09 Communicating with Stakeholders About Third-Party Contracted Services (2.04, 2.08, 2.09, 2.11)When providing services at the request of a third party to a minor or individual who does not have the legal right to make personal decisions, behavior analysts ensure that the parent or legally authorized representative is informed of the rationale for and scope of services to be provided, as well as their right to receive copies of all service documentation and data. Behavior analysts are knowledgeable about and comply with all requirements related to informed consent, regardless of who requested the services.3.10 Limitations of Confidentiality (see 1.02, 2.03, 2.04)Behavior analysts inform clients and stakeholders of the limitations of confidentiality at the outset of the professional relationship and when information disclosures are required. 3.11 Documenting Professional Activity (see 1.04, 2.03, 2.05, 2.06, 2.10)Throughout the service relationship, behavior analysts create and maintain detailed and high-quality documentation of their professional activities to facilitate provision of services by them or by other professionals, to ensure accountability, and to meet applicable requirements (e.g., laws, regulations, funder and organization policies). Documentation must be created and maintained in a manner that allows for timely communication and transition of services, should the need arise.3.12 Advocating for Appropriate Services (1.04, 1.05, 2.01, 2.08)Behavior analysts advocate for and educate clients and stakeholders about evidence-based assessment and behavior-change intervention procedures. They also advocate for the appropriate amount and level of behavioral service provision and oversight required to meet defined client goals.3.13 Referrals (see 1.05, 1.11, 2.01, 2.04, 2.10)Behavior analysts make referrals based on the needs of the client and/or relevant stakeholders and include multiple providers when available. Behavior analysts disclose to the client and relevant stakeholders any relationships they have with potential providers and any fees or incentives they may receive for the referrals. They document any referrals made, including relevant relationships and fees or incentives received, and make appropriate efforts to follow up with the client and/or relevant stakeholders.3.14 Facilitating Continuity of Services (see 1.03, 2.02, 2.05, 2,08, 2.10)Behavior analysts act in the best interests of the client to avoid interruption or disruption of services. They make appropriate and timely efforts to facilitate the continuation of behavioral services in the event of planned interruptions (e.g., relocation, temporary leave of absence) and unplanned interruptions (e.g., illness, funding disruption, parent request, emergencies). They ensure that service agreements or contracts include a general plan of action for service interruptions. When a service interruption occurs, they communicate to all relevant parties the steps being taken to facilitate continuity of services. Behavior analysts document all actions taken in this circumstance and the eventual outcomes.3.15 Appropriately Discontinuing Services (see 1.03, 2.02, 2.05. 2.10, 2.19)Behavior analysts include the circumstances for discontinuing services in their service agreement. They consider discontinuing services when: (1) the client has met all behavior-change goals, (2) the client is not benefiting from the service, (3) the behavior analyst and/or their supervisees or trainees are exposed to potentially harmful conditions that cannot be reasonably resolved, (4) the client and/or relevant stakeholder requests discontinuation, (5) the relevant stakeholders are not complying with the behavior-change intervention despite appropriate efforts to address barriers, or (6) services are no longer funded. Behavior analysts provide the client and/or relevant stakeholders with a written plan for discontinuing services, document acknowledgment of the plan, review the plan throughout the discharge process, and document all steps taken.3.16 Appropriately Transitioning Services (see 1.03, 2.02, 2.05. 2.10)Behavior analysts include in their service agreement the circumstances for transitioning the client to another behavior analyst within or outside of their organization. They make appropriate efforts to effectively manage transitions; provide a written plan that includes target dates, transition activities, and responsible parties; and review the plan throughout the transition. When relevant, they take appropriate steps to minimize disruptions to services during the transition by collaborating with relevant service providers. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 15Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.Section 4—Responsibility to Supervisees and Trainees4.01 Compliance with Supervision Requirements (see 1.02)Behavior analysts are knowledgeable about and comply with all applicable supervisory requirements (e.g., BACB rules, licensure requirements, funder and organization policies), including those related to supervision modalities and structure (e.g., in person, video conference, individual, group).4.02 Supervisory Competence (see 1.05, 1.06)Behavior analysts supervise and train others only within their identified scope of competence. They provide supervision only after obtaining knowledge and skills in effective supervisory practices, and they continually evaluate and improve their supervisory repertoires through professional development.4.03 Supervisory Volume (see 1.02, 1.05, 2.01) Behavior analysts take on only the number of supervisees or trainees that allows them to provide effective supervision and training. They are knowledgeable about and comply with any relevant requirements (e.g., BACB rules, licensure requirements, funder and organization policies). They consider relevant factors (e.g., their current client demands, their current supervisee or trainee caseload, time and logistical resources) on an ongoing basis and when deciding to add a supervisee or trainee. When behavior analysts determine that they have met their threshold volume for providing effective supervision, they document this self-assessment and communicate the results to their employer or other relevant parties.4.04 Accountability in Supervision (see 1.03)Behavior analysts are accountable for their supervisory practices. They are also accountable for the professional activities (e.g., client services, supervision, training, research activity, public statements) of their supervisees or trainees that occur as part of the supervisory relationship.4.05 Maintaining Supervision Documentation (1.01, 1.02, 1.04, 2.03, 2.05, 3.11)Behavior analysts create, update, store, and dispose of documentation related to their supervisees or trainees by following all applicable requirements (e.g., BACB rules, licensure requirements, funder and organization policies), including those relating to confidentiality. They ensure that their documentation, and the documentation of their supervisees or trainees, is accurate and complete. They maintain documentation in a manner that allows for the effective transition of supervisory oversight if necessary. They retain their supervision documentation for at least 7 years and as otherwise required by law and other relevant parties and instruct their supervisees or trainees to do the same.4.06 Providing Supervision and Training (see 1.02, 1.13 2.01)Behavior analysts deliver supervision and training in compliance with applicable requirements (e.g., BACB rules, licensure requirements, funder and organization policies). They design and implement supervision and training procedures that are evidence based, focus on positive reinforcement, and are individualized for each supervisee or trainee and their circumstances. 4.07 Incorporating and Addressing Diversity (see 1.05, 1.06, 1.07, 1.10)During supervision and training, behavior analysts actively incorporate and address topics related to diversity (e.g., age, disability, ethnicity, gender expression/identity, immigration status, marital/relationship status, national origin, race, religion, sexual orientation, socioeconomic status).4.08 Performance Monitoring and Feedback (see 2.02, 2.05, 2.17, 2.18)Behavior analysts engage in and document ongoing, evidence-based data collection and performance monitoring (e.g., observations, structured evaluations) of supervisees or trainees. They provide timely informal and formal praise and feedback designed to improve performance and document formal feedback delivered. When performance problems arise, behavior analysts develop, communicate, implement, and evaluate an improvement plan with clearly identified procedures for addressing the problem.4.09 Delegation of Tasks (see 1.03)Behavior analysts delegate tasks to their supervisees or trainees only after confirming that they can competently perform the tasks and that the delegation complies with applicable requirements (e.g., BACB rules, licensure requirements, funder and organization policies). Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 16Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.4.10 Evaluating Effects of Supervision and Training (see 1.03, 2.17, 2.18)Behavior analysts actively engage in continual evaluation of their own supervisory practices using feedback from others and client and supervisee or trainee outcomes. Behavior analysts document those self-evaluations and make timely adjustments to their supervisory and training practices as indicated.4.11 Facilitating Continuity of Supervision (see 1.03, 2.02, 3.14)Behavior analysts minimize interruption or disruption of supervision and make appropriate and timely efforts to facilitate the continuation of supervision in the event of planned interruptions (e.g., temporary leave) or unplanned interruptions (e.g., illness, emergencies). When an interruption or disruption occurs, they communicate to all relevant parties the steps being taken to facilitate continuity of supervision.4.12 Appropriately Terminating Supervision (see 1.03, 2.02, 3.15)When behavior analysts determine, for any reason, to terminate supervision or other services that include supervision, they work with all relevant parties to develop a plan for terminating supervision that minimizes negative impacts to the supervisee or trainee. They document all actions taken in this circumstance and the eventual outcomes.Section 5—Responsibility in Public Statements5.01 Protecting the Rights of Clients, Stakeholders, Supervisees, and Trainees (see 1.03, 3.01)Behavior analysts take appropriate steps to protect the rights of their clients, stakeholders, supervisees, and trainees in all public statements. Behavior analysts prioritize the rights of their clients in all public statements. 5.02 Confidentiality in Public Statements (see 2.03, 2.04, 3.10)In all public statements, behavior analysts protect the confidentiality of their clients, supervisees, and trainees, except when allowed. They make appropriate efforts to prevent accidental or inadvertent sharing of confidential or identifying information. 5.03 Public Statements by Behavior Analysts (see 1.01, 1.02)When providing public statements about their professional activities, or those of others with whom they are affiliated, behavior analysts take reasonable precautions to ensure that the statements are truthful and do not mislead or exaggerate either because of what they state, convey, suggest, or omit; and are based on existing research and a behavioral conceptualization. Behavior analysts do not provide specific advice related to a client’s needs in public forums.5.04 Public Statements by Others (see 1.03)Behavior analysts are responsible for public statements that promote their professional activities or products, regardless of who creates or publishes the statements. Behavior analysts make reasonable efforts to prevent others (e.g., employers, marketers, clients, stakeholders) from making deceptive statements concerning their professional activities or products. If behavior analysts learn of such statements, they make reasonable efforts to correct them. Behavior analysts document all actions taken in this circumstance and the eventual outcomes.5.05 Use of Intellectual Property (see 1.01, 1.02, 1.03)Behavior analysts are knowledgeable about and comply with intellectual property laws, including obtaining permission to use materials that have been trademarked or copyrighted or can otherwise be claimed as another’s intellectual property as defined by law. Appropriate use of such materials includes providing citations, attributions, and/or trademark or copyright symbols. Behavior analysts do not unlawfully obtain or disclose proprietary information, regardless of how it became known to them.5.06 Advertising Nonbehavioral Services (see 1.01, 1.02, 2.01)Behavior analysts do not advertise nonbehavioral services as behavioral services. If behavior analysts provide nonbehavioral services, those services must be clearly distinguished from their behavioral services and BACB certification with the following disclaimer: “These interventions are not behavioral in nature and are not covered by my BACB certification.” This disclaimer is placed alongside the names and descriptions of all nonbehavioral interventions. If a behavior analyst is employed by an organization that violates this Code standard, the behavior analyst makes reasonable efforts to remediate the situation, documenting all actions taken and the eventual outcomes. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 17Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.5.07 Soliciting Testimonials from Current Clients for Advertising (see 1.11, 1.13, 2.11, 3.01, 3.10)Because of the possibility of undue influence and implicit coercion, behavior analysts do not solicit testimonials from current clients or stakeholders for use in advertisements designed to obtain new clients. This does not include unsolicited reviews on websites where behavior analysts cannot control content, but such content should not be used or shared by the behavior analyst. If a behavior analyst is employed by an organization that violates this Code standard, the behavior analyst makes reasonable efforts to remediate the situation, documenting all actions taken and the eventual outcomes.5.08 Using Testimonials from Former Clients for Advertising (see 2.03, 2.04, 2.11, 3.01, 3.10)When soliciting testimonials from former clients or stakeholders for use in advertisements designed to obtain new clients, behavior analysts consider the possibility that former clients may re-enter services. These testimonials must be identified as solicited or unsolicited, include an accurate statement of the relationship between the behavior analyst and the testimonial author, and comply with all applicable privacy and confidentiality laws. When soliciting testimonials from former clients or stakeholders, behavior analysts provide them with clear and thorough descriptions about where and how the testimonial will appear, make them aware of any risks associated with the disclosure of their private information, and inform them that they can rescind the testimonial at any time. If a behavior analyst is employed by an organization that violates this Code standard, the behavior analyst makes reasonable efforts to remediate the situation, documenting all actions taken and the eventual outcomes.5.09 Using Testimonials for Nonadvertising Purposes (see 1.02, 2.03. 2.04, 2.11, 3.01, 3.10)Behavior analysts may use testimonials from former or current clients and stakeholders for nonadvertising purposes (e.g., fundraising, grant applications, dissemination of information about ABA) in accordance with applicable laws. If a behavior analyst is employed by an organization that violates this Code standard, the behavior analyst makes reasonable efforts to remediate the situation, documenting all actions taken and the eventual outcomes.5.10 Social Media Channels and Websites (see 1.02, 2.03, 2.04, 2.11, 3.01, 3.10)Behavior analysts are knowledgeable about the risks to privacy and confidentiality associated with the use of social media channels and websites and they use their respective professional and personal accounts accordingly. They do not publish information and/or digital content of clients on their personal social media accounts and websites. When publishing information and/or digital content of clients on their professional social media accounts and websites, behavior analysts ensure that for each publication they (1) obtain informed consent before publishing, (2) include a disclaimer that informed consent was obtained and that the information should not be captured and reused without express permission, (3) publish on social media channels in a manner that reduces the potential for sharing, and (4) make appropriate efforts to prevent and correct misuse of the shared information, documenting all actions taken and the eventual outcomes. Behavior analysts frequently monitor their social media accounts and websites to ensure the accuracy and appropriateness of shared information.5.11 Using Digital Content in Public Statements (see 1.02, 1.03, 2.03, 2.04, 2.11, 3.01, 3.10)Before publicly sharing information about clients using digital content, behavior analysts ensure confidentiality, obtain informed consent before sharing, and only use the content for the intended purpose and audience. They ensure that all shared media is accompanied by a disclaimer indicating that informed consent was obtained. If a behavior analyst is employed by an organization that violates this Code standard, the behavior analyst makes reasonable efforts to remediate the situation, documenting all actions taken and the eventual outcomes. Section 6—Responsibility in Research6.01 Conforming with Laws and Regulations in Research (see 1.02)Behavior analysts plan and conduct research in a manner consistent with all applicable laws and regulations, as well as requirements by organizations and institutions governing research activity.6.02 Research Review (see 1.02, 1.04, 3.01)Behavior analysts conduct research, whether independent of or in the context of service delivery, only after approval by a formal research review committee. 6.03 Research in Service Delivery (see 1.02, 1.04, 2.01, 3.01)Behavior analysts conducting research in the context of service delivery must arrange research activities such that client services and client welfare are prioritized. In these situations, behavior analysts must comply with all ethics requirements for both Behavior Analyst Certification Board | Ethics Code for Behavior Analysts | 18Updated 03/2022, Copyright © 2020, BACB® | All rights reserved.service delivery and research within the Code. When professional services are offered as an incentive for research participation, behavior analysts clarify the nature of the services, and any potential risks, obligations, and limitations for all parties. 6.04 Informed Consent in Research (see 1.04, 2.08, 2.11)Behavior analysts are responsible for obtaining informed consent (and assent when relevant) from potential research participants under the conditions required by the research review committee. When behavior analysts become aware that data obtained from past or current clients, stakeholders, supervisees, and/or trainees during typical service delivery might be disseminated to the scientific community, they obtain informed consent for use of the data before dissemination, specify that services will not be impacted by providing or withholding consent, and make available the right to withdraw consent at any time without penalty. 6.05 Confidentiality in Research (see 2.03, 2.04, 2.05)Behavior analysts prioritize the confidentiality of their research participants except under conditions where it may not be possible. They make appropriate efforts to prevent accidental or inadvertent sharing of confidential or identifying information while conducting research and in any dissemination activity related to the research (e.g., disguising or removing confidential or identifying information).6.06 Competence in Conducting Research (see 1.04, 1.05, 1.06, 3.01)Behavior analysts only conduct research independently after they have successfully conducted research under a supervisor in a defined relationship (e.g., thesis, dissertation, mentored research project). Behavior analysts and their assistants are permitted to perform only those research activities for which they are appropriately trained and prepared. Before engaging in research activities for which a behavior analyst has not received training, they seek the appropriate training and become demonstrably competent or they collaborate with other professionals who have the required competence. Behavior analysts are responsible for the ethical conduct of all personnel assigned to the research project.6.07 Conflict of Interest in Research and Publication (see 1.01, 1.11, 1.13)When conducting research, behavior analysts identify, disclose, and address conflicts of interest (e.g., personal, financial, organization related, service related). They also identify, disclose, and address conflicts of interest in their publication and editorial activities. 6.08 Appropriate Credit (see 1.01, 1.11, 1.13)Behavior analysts give appropriate credit (e.g., authorship, author-note acknowledgment) to research contributors in all dissemination activities. Authorship and other publication acknowledgments accurately reflect the relative scientific or professional contributions of the individuals involved, regardless of their professional status (e.g., professor, student). 6.09 Plagiarism (see 1.01)Behavior analysts do not present portions or elements of another’s work or data as their own. Behavior analysts only republish their previously published data or text when accompanied by proper disclosure.6.10 Documentation and Data Retention in Research (see 2.03, 2.05, 3.11, 4.05)Behavior analysts must be knowledgeable about and comply with all applicable standards (e.g., BACB rules, laws, research review committee requirements) for storing, transporting, retaining, and destroying physical and electronic documentation related to research. They retain identifying documentation and data for the longest required duration. Behavior analysts destroy physical documentation after making deidentified digital copies or summaries of data (e.g., reports and graphs) when permitted by relevant entities. 6.11 Accuracy and Use of Data (see 1.01, 2.17, 5.03)Behavior analysts do not fabricate data or falsify results in their research, publications, and presentations. They plan and carry out their research and describe their procedures and findings to minimize the possibility that their research and results will be misleading or misinterpreted. If they discover errors in their published data they take steps to correct them by following publisher policy. Data from research projects are presented to the public and scientific community in their entirety whenever possible. When that is not possible, behavior analysts take caution and explain the exclusion of data (whether single data points, or partial or whole data sets) from presentations or manuscripts submitted for publication by providing a rationale and description of what was excluded. TheSellDecision:ImplicationsforPsychologicalAssessmentandTreatmentRichardH.HunterClinicalOutcomesGroupandSouthernIllinoisUniversitySchoolofMedicineA.JocelynRitchieandWilliamD.SpauldingUniversityofNebraskaThisarticledescribes2importantpracticeconsiderationsaffirmedintheU.S.SupremeCourt’sSellv.UnitedStates(2002)decision:(a)theimportanceofprovidingleastrestrictiveservicespriortointerventionsthatviolatepatients’libertyinterests,and(b)contextualandenvironmentalfactorsmaybeconsideredinclinicaldeterminationsofdangerousness.Thepsychologicaltreatmentofbehaviordisor-dersfallwithinthepurviewofleastrestrictiveorintrusiveinterventionscomparedwiththeinvoluntaryadministrationofpsychoactivemedications.Tolegitimatelycomplywiththeleastrestrictivecriterion,theprovisionofpsychologicalservicesisessential.Thislong-heldcriterionisrarelyacknowledgedtodayasprovidersuserestrictedservicearraysandattempttoresolvecomplexandco-occurringbehaviorproblemswithmedicationsandrestraints.Lessrestrictivepsychologicalinterventionsarerequiredforeffectivetreatmentofchallengingbehaviors.A2ndsignificantimplicationliesinthecourt’saffirmationthatitislegitimatetoconsidercontextualfactorssuchashistoryandcurrentenvironmentalconditionsindeterminingdangerousness.Keywords:leastrestrictivetreatment,involuntarytreatment,U.S.SupremeCourt,psychotropicdrugs,functionalbehavioranalysisTheU.S.SupremeCourt’sSellv.UnitedStates(2002)decisionisprimarilyaboutwhetherpsychotropicdrugsmaybeusedagainstanondangerousperson’swilltorestorecompetencytostandtrial.Sellwasapatientinapsychiatrichospitalandhadlegalchargespendingagainsthim.Hewasrefusingpsychiatricmedication,whichwasbelievedtobenecessarytorestorehiscompetencytostandtrial.Alowercourthadagreedtoinvoluntaryadministrationofmedicationforthatpurpose.TheSupremeCourt’srulingva-catesthelowercourt’sauthorizationtoforcemedicationsbecausethelowercourtfailedtoappropriatelyaddressthecriterionofdangerousnessandthestate’sinterestinbringingthedefendanttotrialassufficientprerequisitesforforcingtheadministrationofdrugs.Thecourtnotesthatitsspecificrulingwillprobablyapplyonlytorarecasesinwhichcompetencytostandtrialisatissuefornondangerousdefendantsdeterminedcompetenttoconsenttotreatment.Dangerousnessandcompetencetoconsenttotreatmentgenerallyrepresentmoreestablishedlegalcriteriaforinvoluntarydrugadministrationthanforcingmedicationssolelyforthepur-poseofmakinganunwillingdefendantfittostandtrial.Thecourtreasonedthatmostpeoplerequiringforcedmedicationswouldmeeteitherthedangerousnesscriterionorbedeterminedunabletoconsenttotreatmentandwouldconsequentlyreceivecourtordersforforcedmedications.Thismakesirrelevantthequestionofinvoluntarymedicationforthesolepurposeofrestoringcompe-tencetostandtrial.Involuntarytreatment(usingmedicationsagainsttheperson’swill)wouldproceedifthepersonweredeter-mineddangerousorotherwiseincompetenttomakedecisionsconcerninghisorherownbehalf.ItremainstobeseenwhethertheRICHARDH.HUNTERreceivedhisPhDineducationalpsychologyin1982fromSouthernIllinoisUniversityatCarbondale.Hehasover40yearsexperienceworkingwithpeoplewithseriousmentalillness.Heoperatesaconsultingfirm,ClinicalOutcomesGroup,specializingincomprehensiveservicestoindividualsthatdonotrespondtotypicalinterventionsandthosewithco-occurringbehavioraldisorders.Heusesthemultimodalfunctionalmodelandfunctionalbehavioralassessmentsinhisconsultingworkandservesasanexpertwitnessinfederalcourtright-to-treatmentcases.HeisaclinicalassociateprofessorintheDepartmentofPsychiatry,SouthernIllinoisUniversitySchoolofMedicine,andpastchairoftheAmericanPsychologicalAssociationandCommitteeontheAdvancementofProfessionalPracticeTaskForceonSeriousMentalIllnessandSevereEmotionalDisturbance.HunterisboardcertifiedinclinicalpsychologybytheAmericanBoardofProfessionalPsychologyandinmedicalpsycho-therapybytheAmericanBoardofMedicalPsychotherapists.A.JOCELYNRITCHIEcompletedtheUniversityofNebraskaLawandPsychologyGraduateTrainingProgram,earningherJDin1985andherPhDinexperimentalpsychologyin1990.Afterworkingasanattorney,sheretrainedasaclinicianandcompleteda2-yearpostdoctoralfellowshipinneuropsychologyatYaleUniversity.Herinterestsremaininthecivilandcriminalforensicarena.SheiscurrentlyaresearchassistantprofessorwiththeUniversityofNebraska—LincolnandaconsultingpsychologistalongwithWilliamD.Spauldinginanintensivepsychiatricrehabilitationunitatthestatehospital,workingwithindividualswithsevereandpersistentmentalillnesses.WILLIAMD.SPAULDINGreceivedhisPhDinclinicalpsychologyin1976fromtheUniversityofArizona.HewasapostdoctoralfellowinmentalhealthresearchandteachingintheUniversityofRochesterDepartmentofPsychiatry.HejoinedthefacultyoftheUniversityofNebraska—Lincolnin1979andisnowaprofessorofpsychologyanddirectoroftheClinicalPsychologyTrainingProgramthere.CORRESPONDENCECONCERNINGTHISARTICLEshouldbeaddressedtoRich-ardH.Hunter,PhD,ClinicalOutcomesGroup,10202BriggsRoad,Marion,IL62959.E-mail:rich.hunter@clinicaloutcomes.usProfessionalPsychology:ResearchandPracticeCopyright2005bytheAmericanPsychologicalAssociation2005,Vol.36,No.5,467–4750735-7028/05/$12.00DOI:10.1037/0735-7028.36.5.467467 courtiscorrectinpredictingthatastuteuseofcriteriafordanger-ousnessandcompetencetoconsenttotreatmentwillmaketheSellrulingapplicableonlytorarecases.Thecourt’sdiscussioninSelladdressesconceptsandcaselawthatgobeyondthisexceptionalcase.Inadditiontothestrictlylegalimplications,theprinciplesaffirmedintheSelldecisionhavefar-reachingimplicationsformentalhealthpolicy,andforhospitalpractice.Inparticular,thecourt’sfindingsanddiscussionaddresstwokeycriteriaforforcingmedications:(a)determineddanger-ousnessand(b)theleastrestrictivecriterion.Thisarticleaddressestheimportanceofthesetwocriteriainpsychologicalassessmentandinprovidingpsychologicalservicesthatreducetheneedformorerestrictivealternatives.TheDangerousnessCriterion:AssessingDangerousnessTheimportanceofassessingdangerousnessincasesinvolvinginvoluntarymedicationusewasemphasizedinSell.ThecourtreasonedthatifSellhadbeenfounddangerous,theforceduseofdrugswouldhavebeenjustifiedonthatbasis.Thecourthowevernotedthatkeycontextualconsiderationswerenotaddressedinassessingthedefendant’sdangerousness.Inparticular,thecourtcriticizedthepreviousrulingforitsnarrowfocusonimmediatedangerousness.Sellhadengagedininterpersonalbehaviorthat,althoughnotimmediatelydangerousinthepsychiatrichospital,indicatedasignificantriskoutsidethatsetting.ThecourtsuggestedthatamoreinsightfuldeterminationwouldhavefoundSelltobedangerous.Thecourtnotedthatthepreviousrulinghadlimiteditsdeter-minationtoSell’s“dangerousnessatthistimetohimselfandtothosearoundhiminhisinstitutionalcontext.”Thecourtdidnotreversethepreviousrulingondangerousness,butonlybecauseneitherpartytotheconflicthadchallengeditorbasedanargumentonit.Thecourtdidnotethatthetreatingclinicianshadmadethedeterminationofdangerousnessbasedinpartonthedefendant’sinfatuationwithanurseandhisfailuretodesistfrommakingadvances.Althoughsuchbehaviorwouldnotinitselfmeetcriteriafordangerousness,itmightinthecontextofthedefendant’shistory,whichincludedcriminalbehaviorandactingondelusions.InSell,thecourtclearlystatedthatitconsideredcontextualcir-cumstancessuchashistoryandcurrentenvironmentalconditionslegitimatefactorsindeterminingdangerousness.Thecourt’saffirmationofthelegitimacyandimportanceofconsideringcontextualfactorsindeterminingdangerousnessre-futeshighlyrestrictiveinterpretationsthatmanyclinicianshaveencounteredinmanyclinicalcontexts.ThemostextremeexampleinWilliamD.Spaulding’sexperiencewasamanagedcaredeter-minationthatapatientfailedtomeetdangerousnesscriteriaforinpatienttreatmentbecausethepatientwasinrestraintsandcouldnotattackanyonewhileinrestraints.Morecommonly,courts,mentalhealthboards,orevencliniciansmaydeterminethatapersondoesnotmeetcriteriaforinvoluntarytreatmentbecausedangerisnotimmediateorimminent,eventhoughthatperson’shistoryrevealshighriskundercomparableconditions.Behaviorthatdoesnotdenotedangerousnessinonepersonmayindicatesignificantdangerousnessinanother.Similarly,apersonmaybequitedangerousinanormalenvironmentbutnotsoinastructuredtherapeuticenvironment.Therefore,determinationofdangerous-nessrequiresmorethansimplyanappraisalofwhetherapersonisimminentlydangerousattheparticulartimeandunderthepartic-ularconditionsoftheassessment.Itrequiresanassessmentinthecontextofnotonlytheperson’shistorybutalsotheenvironmental(andother)contextsinwhichthepersonwillbeintheforeseeablefuture.1Thecourt’sperspectiveondangerousnessconvergeswithcon-temporarypsychologicalconceptsofriskassessmentandriskmanagement.Lessthanthreedecadesago,clinicians’abilitytodeterminedangerousnesswasdubious,basedasitwasonmea-suresofpersonalityandrelatedtraitcharacteristics.Inmorerecentyears,predictionofdangerousnesshasimproved,inlargepartbecauseofdevelopmentofmoreactuariallybasedmeasuresoftraitcharacteristics,andtheincorporationoffunctionalassess-mentsthatidentifysituationsassociatedwithhighriskandthelikelihoodthatthepersoninquestionwillencountersuchsitua-tionsintheforeseeablefuture(Bauer,Rosca,Khawalled,Gruzniewski,&Grinshpoon,2003;Borum,1996;Steadman,2000).Today,riskassessmentandmanagementarerapidlydevel-opingtechnologies.ClinicalapplicationisfarmoreroutinethantheexoticcircumstancesofSell.Everyday,peoplearesubjectedtocivilcommitmentdeterminationsinwhichriskanddangerousnessarethekeyissues.Thedicta(i.e.,commentsanddiscussionbe-yondwhatisdirectlypertinenttotherulings)inSellclearlyindicatethecourt’spresumptionthatsuchdeterminationsshouldnotbebasedonasimplisticdeterminationofwhethertheindivid-ualisdangerous“righthereandrightnow”butonbroaderassess-mentsofthecontextoftheperson’sbehavior.Withtheadventofoutpatientcivilcommitment(Petrila,Ridgely,&Borum,2003;Ridgely,Borum,&Petrila,2001;Schopp,2003),thesedetermi-nationswillnotonlybecomemoreroutinebutthecontextsandcircumstancesthatmustbeaddressedwillbecomemorecomplex(e.g.,communitylivingvs.institutions).Forclinicalpsychologists,thewritingisonthewall.Riskassessmentandmanagementandmoregenerallyfunctionalassessmentofbehaviorarebecomingprerequisiteskills,especiallyforthosewhoservepeoplewithseriousmentalillnessorpracticeinthepublicsector.TheLeastRestrictiveCriterionLeastRestrictiveorIntrusiveInterventionsTheconceptofprovidingservicestopeoplediagnosedwithmentalillnessormentalretardationalongacontinuumfromlessrestrictivetomorerestrictivehasalonghistoryandgenerallyreferstorestrictionsonliberty,asotherwiseguaranteedbythe14thAmendment.Theleastrestrictivealternativestandardwasestab-lishedinfederalmentalhealthlawaspartofthelandmarkWyattv.Stickney(1972)right-to-treatmentcaseandsubsequentrulingsthatestablishedminimumconstitutionalstandards.ThislandmarkcaseresultedinanumberofrulingsandwasnotfinallysettleduntilDecember5,2003.Sincethe1970s,conceptssuchastherighttotreatment,therighttoservicesintheleastrestrictivesettingpossible,andtherighttoprivacyanddignityhavebeenincorporatedinfederalregulationsandstatelawsacrossthecoun-trytovariousdegrees.1Theclinicaldeterminationof“immediate”or“imminent”stillapplies,however,inregardtoimposingemergencycontrolinterventionssuchasrestraintsandseclusion.468HUNTER,RITCHIE,ANDSPAULDING Theconceptsofleastrestrictiveandleastintrusivesometimesappeartobeusedinterchangeably,particularlyinearliercases.However,adifferencearisesinmorerecentcasessuchasWash-ingtonv.Harper(1990),Rigginsv.Nevada(1992),andSellwherethetermintrusiveisgenerallyusedindiscussionsofforcedmed-ications.TheSelldecisionusesthetermintrusiveexclusively,withtheexceptionofasinglequotefromthelowercourtindescribingthebackgroundofthecase.AftercitingtheAmericanPsycholog-icalAssociation’ssuggestionthatnondrugtherapiesmaybemoreeffectiveinbringingapsychoticpatienttocompetence,thecourtinSellrecommendeditsownbehaviormodificationapproach,suggesting“acourtordertothedefendantbackedbythecontemptpower,beforeconsideringmoreintrusivemethods.”InHarper,thetermrestrictiveisnotusedregardingforcedmedicationatall,andthetermintrusiveisusedtorefertotheuseofinvoluntarymedication.2Totheextentthatthe14thAmendmentprohibitsforcedintrusionuponthephysicalintegrityofthebodyandthemind,aswellasarbitraryimprisonment,thetermsintrusiveandrestrictiveareinthatsensefunctionallyequivalentyetdifferentlyapplicabletoforcedmedication.Thetermrestrictivebetterde-scribestreatmentcontinua,incarceration,andphysicalrestraint,whereasthetermintrusivebetterdescribesforcedmedicationanditspsychotropicandphysiologicaleffectsonone’sbody.Thiscouldhaveimportantimplicationsforweighingtherelativemeritsofforcedmedicationagainstothertreatments,especiallypsycho-logicaltreatments.ArePsychologicalTreatmentsLessIntrusiveand/orLessRestrictiveAlternatives?Thepast30yearshaveseendevelopmentofeffectivepsycho-logicaltreatmentandrehabilitationapproachestoseriousanddisablingmentalillness(seeAPAandCAPP,2005;Bedell,Hunter,&Corrigan,1997;Paul&Menditto,1992;Spaulding,Sullivan,&Poland,2003;Wallace,Liberman,Kopelowicz,&Yaeger,2001).Inadditiontopromotingfunctionalrecoveryfromdisability,theseapproachesreduceaggressionandotherdimen-sionsofdangerousness,sotheyshouldbeconsideredalternativestoinvoluntarydrugadministration.Infact,theydecreaserelianceonbothchemicalandmechanicalrestraintandseclusion(Donat,1998,2002a,2002b,2003;Donat&McKeegan,2003;Hunter,2000;Wilkniss,Silverstein,&Hunter,2004).Psychologicalandpsychosocialinterventionsforaggressioninvolvecomprehensive,multimodalcaseformulationstrategiesthatincludeassessmentofthecontextualfactorsandfunctionalpropertiessurroundingthebehaviorsthemselves.Often,thesein-terventionsincludeskill-basedlearningprotocolsandtheteachingoffunctionallyequivalentreplacementbehaviors.Psychologicalandpsychosocialinterventionsareoftensupplementedbymilieumanagement,levelsystems,tokeneconomies,orotherenviron-mentalsupportsthatprovideincentivesforprosocialchoicesandbehaviors.Thereareavarietyofcognitiveandbehavioraltech-niquesthatareintegratedintoeffectivetreatmentregimens,in-cludingredirection,modeling,behavioralcontracting,cognitiverehearsal,structureddifferentialreinforcementschedules,positivepractice,self-monitoring,self-control,andexclusionaryandnon-exclusionarytime-outfromreinforcement,onacase-by-casebasis.Thenatureofpsychologicaltreatmentsmakestheminherentlylessintrusivethanforcedmedication.Whenacourtapprovesforcedmedication,itisauthorizingpractitionerstousephysicalforcetoadministerthetreatmentifnecessary.Thepsychologicaltreatmentsmosteffectiveforcontrollingdangerousnessdonotinvolvephysicalforce.3Whetherpsychologicaltreatmentsarealsolessrestrictivemaybedifficultorimpossibletodetermine,asthismaydependonindividualresponsestoforcedmedication,thenatureofthepsychologicalinterventionnecessarytocontroltheaggression,anduniquecontextualfactors.Certainly,psychologicaltreatmentsarepotentiallylessrestrictive.Inanycase,however,theinherentlylessintrusivenatureofpsychologicaltreatmentstypi-callymakesthemthepreferablealternativeforcontrollingaggres-sion,especiallyforindividualswhowouldotherwiserequireforcedmedication,regardlessofrestrictiveness.Useofpsychologicaltechniquesforpeoplewithseverementalillnessanddevelopmentaldisabilityhaslongbeenguidedbyasubstantialbodyofclinicalresearchandlegalscholarship(e.g.,Roos,1974;Stepleton,1975;Tryon,1976;Wexler,1973;White&Morse,1988)thataddresseswhatinstitutionalcontingenciesmaybeappliedtoanyindividuals,includingthosewhochoosenottoconsentorparticipateintreatmentatanyparticulartime.Thereareuniversallyacceptedprohibitionsagainstmakingnutrition,cloth-ing,orabedcontingentonanybehaviorandagainstpunitive,threatening,intimidating,orphysicalconsequencesofanykind.Whensuchprohibitionsarefollowed,psychologicalinterventionsthatusecontingencymanagementareclearlylessintrusiveandusuallylessrestrictivethanforcedmedication.InSell,thecourtrecognizedsucharoleofcontingencymanagementbysuggestingthatacourtorderbackedbythreatofacontemptcitationbeusedtogainSell’scompliancebeforeapplyingmoreintrusiveoptions.InthestandardsoftheJointCommissiononAccreditationofHealthcareOrganizations(JCAHO),psychologicalandpsychoso-cialapproachesareconsideredlessrestrictiveandintrusivethanphysicalalternatives,includingforcedmedication,restraint,andseclusion.JCAHO(2004)stated,“Nonphysicaltechniquesarethepreferredinterventioninbehaviormanagement”(p.155),andindescribingtheelementsofperformance,stated,“Nonphysicaltechniquesarealwaysthepreferredintervention”(p.155).Theempiricallyestablishedeffectivenessofpsychologicaltreat-mentsandtheirstatusasbeinglessrestrictiveorintrusivethanforcedmedicationwouldrequirethattheybedeterminedtobeineffectiveinaparticularcasebeforeinvoluntarydrugadminis-trationisjustified.Similarly,thesameprinciplewouldrequirethatwhenforcedmedicationisused,psychologicaltreatmentmustalso2Harperdoesnotrequirealeastrestrictiveorintrusivemeanstest,becauseHarperinvolvesaprisonerandprisonsecurityratherthanapretrialdetaineeasinRigginsorSell.InSell,thecourtaffirmsakeydistinctionbetweencorrectionalandmentalhealthsettingsinthisregard.3Someextremelyrarepsychologicaltreatmentsmayarguablyinvolvephysicalforce,atleastpotentially(e.g.,faradicaversionconditioningtostopself-injuryinpeoplewithseveredevelopmentaldisabilitiesortoreducethelong-termdangerousnessofsexoffenders).Suchuseswouldbemorecomparabletoforcedmedicationbutareseldomusedtocontroldangerousnessinthesamesituationsinwhichdrugsmightbeused.Evenwhentheyare,concomitantcontingencymanagementmayreducetheneedforforcedadministrationoftheaversiveprocedure.Further,theseproce-duresarerarelyimplementedwithouttheapprovalandoversightofoutsideexperts,consentoftheclientorguardian,andapprovalbyahumanrightscommitteeandabehaviormanagementcommittee.469SPECIALSECTION:IMPLICATIONSOFSELL beusedtominimizeitsamount,frequency,orduration.However,therehasneverbeenalegalchallengetoinvoluntarydrugadmin-istrationonthegroundsthatpsychologicalalternativeshavenotbeendeterminedtobeineffective.Inpractice,courtsgenerallyacceptthetestimonyoftheprescribingpsychiatristthatthereisnoalternativetodrugtreatment.Suchtestimonyismadevulnerabletochallengebytheoutcomeliteratureonpsychologicaltreatmentofseriousmentalillnessandtheavailabilityofexpertwitnessesinthatarea.InalltherelevantrulingsfromWyatttoSell,thecourtsubiquitouslycitelackofevidence(e.g.,experttestimony)ofalessrestrictiveorintrusivealternativethanmedication.Thisinviteschallengesinfuturecasesthatlessintrusiveandrestrictivealter-nativeshavenotbeenadequatelyconsidered.Ajustificationthatlessrestrictiveandintrusivealternativesaresimplyunavail-ableinaparticularsettingwouldlikelynotbeconstitutionallyacceptable.4Apossiblecounterargumenttoaleastintrusiveandrestrictivechallengewouldbethatpsychologicaltreatmentsforseriousmen-talillnessalmostalwaysareprovidedwithconcomitantpsycho-tropicdrugsandcannotbeexpectedtoprovidetherequiredben-efitsbythemselves.However,thereisnoevidencethatdrugsareanecessaryconcomitanttopsychologicaltreatment,especiallyforthespecificpurposeofcontrollingaggressionorotherwisereduc-ingdangerousness(e.g.,Mendittoetal.,1996).Theresearchdatadonotprovidenormativestatisticsthatreflectthelikelihoodthatagivenindividualwillrespondtopsychologicaltreatmentalone,butneitheristhereanyreasontoexpectforcedmedicationalonewouldhaveagreaterorlesserlikelihood.Evenifsomeindividualsgainsuchbenefitsofpsychologicaltreatmentonlywithmedica-tion,forthepurposeofforcedmedication,itisnecessarytodeterminethattheparticularpersoninquestionisnotoneofthoseindividuals.Noassessmentortestcanpredictthat.Areliabledeterminationcanbemadeonlythroughasufficientclinicaltrial.Unfortunately,thisisrarelytheexperienceforpeopleconsidereddangerousandsubjectedtoforcedmedication.Arelatedcounterargumenttoaleastrestrictiveandintrusivechallengeisthatthereisevidencethatuntreatedpsychosispro-ducesapoorerultimateoutcome,possiblymediatedbyirreversiblebraindamage.Drugtreatmentmayproduceaquickerandmorereliableresolutionofacutepsychosisandthusismorelikelytopreventharm.Thedangerousnessbeingtreatedhereisthedanger-ousnesstooneselfcreatedbydisregardoftheneedfordrugtreatmenttopreventlastingharm.Themainpremiseofthiscoun-terargumentisweak.Despitesubstantialresearch,thequestionofwhetherdrugtreatmentofactivepsychosispreventsdeteriorationinthechroniccourseremainscontroversial.Butevenifscienceresolvesthiscontroversyinfavorofdrugtreatment,itwillremainunclearwhethertheriskforlong-termdeteriorationfulfillstheconstitutionalcriterionforpreventionofharmtotheparticularindividualinquestion.Forboththeabovecounterarguments,itisalsorelevantthatinadditiontocontrollingaggressionanddan-gerousness,psychologicaltreatmentsincreasevoluntaryadherencetotreatmentingeneral,includingdrugtreatment.InSell,thecourtexplicitlypointedoutthatalternativemeanstosecuringvoluntaryadherencemaybelessrestrictiveorintrusivethanphysicalforce.Thecourtcitedtheexampleofthethreatofcontemptofcourtactions,ajudicialformofcontingencymanagement.However,clinicalcontingencymanagementandpsychoeducationinterven-tionsinformedbypsychologicalprinciplesareevenlessrestrictiveorintrusiveandprobablymoreeffectiveinpromotingvoluntaryadherencetoadrugregimen.Evenwhencourtsupholdinvoluntaryadministrationofdrugs,concomitantapplicationofpsychologicaltreatmentmaybere-quiredtomeetconstitutionalrequirements.Thisisespeciallyap-plicableforthosepeoplewhorepeatedlyexhibitdangerousbehav-iorsdespitemultipletrialsofmedicationsandthosewhoseaggressionsometimesrequiresseclusionorrestraint.Insuchcases,medicationpluspsychologicaltreatmentmaywellbelessrestric-tiveandintrusiveandmoreeffectivethanmedicationalone.Ifuntreatedpsychosisdoesindeedcreateariskforbraindamage,long-termadherencesustainedbypsychologicaltreatmentwillbemoreimportantforpreventingthatconsequencethanshort-termemergencyuseofmedicationtocontrolimmediatedangerousness.EmpiricalVerificationofEffectivenessInSell,thecourtcitedanamicusbrieffromtheAmericanPsychiatricAssociationclaimingthatdrugtreatmentisgenerallymoreeffectivethanalternativetreatmentsforrestoringcompe-tence.Inthesamecontext,thecourtcitedanamicusbrieffromtheAmericanPsychologicalAssociationclaimingnondrugtherapiesmayalsobeeffective.Therelevantcriterionislikelihoodoftherapeuticbenefit,notcertainty.ThusSellremainssomewhatambiguousastowhetherdrugsmustbeafirst-recoursetreatmentwithoutconsiderationoflessintrusivealternatives.Apotentialtoolforresolvingthisambiguity,atleastinpart,mightbefoundinsystematicallydevelopingasufficientscientificbasistosupporttestimonyfortheuseoflessrestrictivealternativesandtochal-lengetheadmissibilityorweightgivenbycourtstoopinion4Evenincasesrequiringsignificanttransitioncostsacrosslargegroupsofplaintiffs,thecourthasrequiredeventualactionanddemonstrablemovementtowardthedesiredend.Forexample,thecourtorderedschooldesegregation“withalldeliberatespeed”inBrownv.BoardofEducation(1954).Similarly,thecourtacknowledgedgroupvs.individualconcernsinOlmsteadv.LC(1999),anAmericanswithDisabilitiesActcase,indicatingthatthestatecouldavoidunlimitedexpenditurestoaccommodateindivid-ualplaintiffsattheexpenseofallcitizensinthestate’scareifthestatechosetodevelopacomprehensive,effectivelyworkingplanforplacingqualifiedpersonswithmentaldisabilitiesinlessrestrictivesettingsanddemonstrateawaitinglistthatmovedatareasonablepace.InWyattv.Stickney(1972),JudgeJohnsonstated,“Intheevent,though,thattheLegislaturefailstosatisfyitswell-definedconstitutionalobligation,andtheMentalHealthBoard,becauseoflackoffundingoranyotherlegallyinsufficientreason,failstoimplementfullythestandardshereinordered,itwillbenecessaryfortheCourttotakeaffirmativesteps,includingappoint-ingamaster,toensurethatproperfundingisrealizedandthatadequatetreatmentisavailableforthementallyillofAlabama”(p.626).Currently,theuseofappropriatepsychologicaltreatmentswouldmostlikelyrequireashiftinhowfundsareusedratherthananincreaseinoverallcost,inpartbecauseoflowerstaffingcostsachievedbyincreasingpatientcomplianceanddecreasingtheuseofrestraintandseclusion,aswellasdecreasingthedirectandindirectcostsassociatedwithforcedmedications.Thecost-effectivenessofthePaulandLentz(1977)program,comparedwithpsy-chiatrictreatmentasusual,wassubstantial.TheCommunityTransitionProgramattheNebraskastatehospitalinLincolnwhereA.JocelynRitchieandWilliamD.Spauldingprovideserviceshasbeenfoundtocostlessthanotherstatehospitalprogramsprovidingsimilarlevelsofsecurecareandhasbeenfoundtoproduceacostoffsetwithinfouryearsafterdischargeduetolowerrelapseandrehospitalizationrates.470HUNTER,RITCHIE,ANDSPAULDING testimonybasedonpersonalorprofessionalexperience,orothernonscientific(orlessscientific)sources.InDaubertv.MerrellDowPharmaceuticals,Inc.(1993),5theSupremeCourtruledthat“anexpert’stestimonybothrestsonareliablefoundationandisrelevanttothetaskathand”(p.597).Thecourtfurtherstated,“inordertoqualifyas‘scientificknowl-edge,”aninferenceorassertionmustbederivedbythescientificmethod.”(Daubertv.MerrellDowPharmaceuticals,Inc.,1993,p.590).Daubertprovidedsomeguidelinestocourtsastohowtodeterminereliability6althoughthecriteriaespousedbyDaubertareneitherexhaustivenorexclusiveandhavebeenmademoreflexibleinsubsequentcases.7Post-DaubertdecisionssuchasKumhoTireCo.v.Carmichael(1999)andGeneralElectricCo.v.Joiner(1997)havearticulatedthattrialcourtshavebroadlatitudeinreliabilitydeterminationsandadmissibilityofexperts.ThecourtinKumhorecognizedthat“Daubert’slistofspecificfactorsnei-thernecessarilynorexclusivelyappliestoallexpertsorineverycase”(KumhoTireCo.v.Carmichael,1999,p.142).Thecourtindicatedthatalthough“engineeringtestimonyrestsuponscien-tificfoundations,thereliabilityofwhichwillbeatissueinsomecases....Inothercases,therelevantreliabilityconcernsmayfocusuponpersonalknowledgeorexperience....ThefactorsidentifiedinDaubertmayormaynotbepertinentinassessingreliability,dependingonthenatureofthecase,theexpert’spar-ticularexpertise,andthesubjectofhistestimony”(KumhoTireCo.v.Carmichael,1999,p.150).However,thecourtinWeisgramv.MarleyCo.(2000)agreedwiththeEighthCircuitCourtofAppealsthatappellatecourtshavethepower,underFederalRuleofCivilProcedure50(a),todirectadistrictcourttoenterjudgmentnotwithstandingtheverdictagainstawinningplaintiffiftheap-pellatecourtdeterminesthatadmittedexperttestimonywasunre-liableandinadmissibleunderDaubert,ratherthanreturnthecaseforretrial.Inlightofthecourt’spost-Daubertdecisionsonexperttesti-monyandthedisparatetreatmentofRule702oftheFederalRulesofEvidencebythedistrictcourts,therulewasamendedin2000.“Ifscientific,technical,orotherspecializedknowledgewillassistthetrieroffacttounderstandtheevidenceortodetermineafactinissue,awitnessqualifiedasanexpertbyknowledge,skill,experience,training,oreducationmaytestifytheretointheformofanopinionorotherwiseif(1)thetestimonyisbaseduponsufficientfactsordata,(2)thetestimonyistheproductofreliableprinciplesandmethods,and(3)thewitnesshasappliedtheprinciplesandmethodsreliablytothefactsofthecase[italicsadded]”(Fed.R.Evid.702,2000)Inthewakeofthesedevelopments,lawyersarebeingadvisedthat“litigatorsmustpreparetheircaseswithanunderstandingthatheightenedscrutinyofallbutthemostnoncon-troversialexperttestimonyislikely”(Ollanik,1999,p.30).Ifanotionhaswidespreadacceptanceandthereisevidenceofferedtosupportthis,itmaybeadmissibleevenwithoutothermorerigor-ousmarkersofthescientificmethod.However,itwillbecomeincreasinglynecessaryforthelitigatingmembersofthebartobecomemoreeducatedregardingthescientificbasesformakinganddefendingagainstsuchchallenges;psychologistsandotherbehavioralhealthprofessionalshaveanimportantroletoplayinthisregard.RegardingtheimpactofthisdiscussiononSellandtheotherforcedmedicationcases,itiswellknownthatdrugsarenotalwayseffectiveatcontrollingorevenreducingaggressivebehavior,muchlessrestoringcompetencetostandtrial.Itispredictablethatreliableandvalidclinicaldataonaggressivebehaviororcompe-tencetostandtrialwouldoftenrevealthatinvoluntarilyadminis-tereddrugshavenoeffectonthepertinentbehaviors.ItisatleastarguablethatthecombinationofSellandothercaselawregardingforcedmedications,alongwiththeDaubertlineofcasesandthe2000amendmentstotheFederalRulesofEvidence,wouldneces-sitatereliableandvalidclinicaldatatojustifynotonlytheinitia-tionbutalsothecontinuationofinvoluntarilyadministereddrugs.Themostcompellingdataforthispurposewouldbesystematicobservationandrecordingtodeterminefrequencyandintensityofaggressionorotherdangerousbehaviororcompetencetostandtrial,beforeandafteradministrationofdrugsorothertreatment.ThustheSellandHarperrulingsandagrowingnumberofstatecourtvariations,takeninthecontextofDaubertandtheFederalRulesofEvidence,couldpotentiallyrequiretheproponentofforcedtreatmenttosystematicallydemonstratewhynolessintru-sivealternativesareavailableratherthansimplystatinganopin-ion.Intheabsenceofcontrolledstudies,thiscouldconceivablyrequirethatanindividualizedassessmentwithasufficienttrialofpsychologicaltreatment—completewithcredibleobservational5SeealsoGeneralElectricCo.v.Joiner(1997),UnitedStatesv.Scheffer(1998),KumhoTireCo.v.Carmichael(1999),andWeisgramv.MarleyCo.(2000).Also,anumberoflowercourtcaseshaveappliedDauberttopsychologists’,psychiatrists’,andothermentalhealthprofes-sionals’testimony.ForlatercasesdiscussingDaubert,seealsoGeneralElectricCo.v.Joiner(1997),UnitedStatesv.Scheffer(1998),andKumhoTireCo.v.Carmichael(1999).6TheDaubertandpost-Daubertguidelinesapplytothefederalcourtsandmanystatecourtsthathaveadoptedsimilarstandards.TheU.S.SupremeCourtinDaubertwasaskediftheFederalRulesofEvidencerevisionsin1973supersededthepriorFryetest,namedaftera1923decisionbytheDistrictofColumbiaCourtofAppealsthatfirstarticulatedthatexpertscientificevidencewasadmissibleonlyiftheprinciplesonwhichitwasbasedhadgainedgeneralacceptanceinthescientificcom-munity(Fryev.UnitedStates,1923).DespiteitswidespreadadoptionbystateandfederalcourtspriortoDaubert,thisgeneral-acceptancestandardwasviewedbymanyasundulyrestrictive,becauseitsometimesbarredtestimonybasedonintellectuallycrediblebutsomewhatnovelscientificapproaches.Underthe1973FederalRulesofEvidence,experttestimonymustactuallybefoundedonscientificknowledgetobeadmissible.Thisimplied,accordingtothecourtinDaubert,thatthetestimonymustbegroundedinthemethodsandproceduresofscience(i.e.,thescientificmethod).Evidencethusgrounded,saidthecourt,wouldpossessthereq-uisitescientificvaliditytoestablishevidentiaryreliability.TheDaubertcourtindicatedtherewasnochecklistbutthatadmissibilityoftestimonycouldbesupportedbyevidencethatindicates(e.g.)whetherthetheoriesandtechniquesusedbythescientificexperthavebeentested,whethertheyhavebeensubjectedtopeerreviewandpublication,whetherthetechniquesusedbytheexperthaveaknownerrorrate,whetherthetechniquesaresubjecttostandardsgoverningtheirapplication,andwhetherthetheoriesandtechniquesusedbytheexpertenjoywidespreadacceptance.Bywayofofferingfurtherguidance,thecourtemphasizedthattheadmissibilityinquiry(astotestimony)mustfocus“solely”ontheexpert’s“principlesandmethodology,”and“notontheconclusionsthattheygenerate”(Dau-bertv.MerrellDowPharmaceuticals,Inc.,1993,p.593–595).Theweightultimatelygiventoadmissibleevidenceisuptothetrieroffact,thejudgeorjury,whetherunderDaubertanditsprogeny,theFederalRulesofEvidenceassubsequentlyamendedin2000,orFrye.7Foramoredetaileddiscussion,seeSalesandShuman(2005).471SPECIALSECTION:IMPLICATIONSOFSELL datashowinganinsufficienttreatmenteffect—mustprecedein-voluntaryadministrationofdrugsandmustbeconductedagaintojustifyitscontinuationafterward.Ofcourse,ongoingtreatmentresponseisnotthesolesourceofvalidclinicaldata.8Inindividualcases,data-basedexperttesti-monycouldproduceacompellingargument,forexample,usinghistoricaldatafromsocialhistoriesandclinicalrecords,thateitherpsychologicalorpharmacologicalinterventionhasagreaterorlesserlikelihoodofsuccessatonepointintimefortheparticularindividual.Thisshouldmeanthatonacase-by-casebasis,courtswillweighevidenceforcompetinghypothesesonanongoingbasisandapproveforcedmedicationwhentheevidenceweighsinfavorofitsclinicalnecessity(inSell,thecourt’scommentthatclinicalcircumstancesaresubjecttochangeishelpfulinthisregard).WehopeDaubertwillhelptransformthenotorious“battleofexperts”inlitigationintoa“battleofdata.”Aslitigationconcerningforcedmedicationproceeds,psychologicalinterventionsprovidethemostlogicalinterimstrategyformanagingriskanddangerousness.Moreover,psychologicalinterventionsaretheonlytreatmental-ternativesthatuncoverthemeaningandfunctionalpropertiesassociatedwithdangerousbehaviors,teachangermanagementandcontroltechniques,providefortheteachingofsociallyappropriatereplacementbehaviors,andteachclientsself-monitoringandcon-trolsskillstoreduceriskforaggressioninthefuture.Inthissense,theprimaryquestionaboutforcedmedicationshouldalwaysbe,Whenshoulditbeaddedtoaregimenofpreviouslyinitiatedpsychologicaland/orbehavioraltreatment?ImplicationsforPsychologicalPracticeThecriteriaforforcedmedicationasarticulatedinSell,com-binedwiththerequirementsfordata-supportedassessmentinDaubert,poseconditionsthatareeffectivelyaddressedinatreat-mentsettinginwhichfunctionalbehavioralanalysisandmilieu-basedpsychologicaltreatmentareroutinelyavailabletogetherwithothertreatmentmethods.Withoutsuchresources,itwouldbeexceedinglydifficulttodemonstratethattheleastrestrictiveandintrusivestandardsaffirmedinSellorHarperhavebeenmetwhilealsomeetingthestandardsofevidenceofDaubertastheypertaintotheindividualinquestion.Functionalbehavioralanalysis(FBA)isatechniquefordeter-miningwhatfactorscontrolaspecificbehaviorofinterest(Iwata,Kahng,Wallace,&Lindberg,2000;O’Brian&Haynes,1993;O’Neilletal.,1997).Itoriginatedinthe1960sasatechnologicalapplicationoflearningtheory.Bythe1980s,ithadincorporatedthecognitiveperspectiveofsociallearningtheory.FBAinvolvesidentifyingthetemporalantecedentsandconsequencesofspecificbehaviors.Initsoperant–respondentconditioningversion,thesetermsmeantenvironmentaleventsthatoccurconsistentlybeforeorafterthebehaviorofinterest.Initssociallearningversion,thisalsoincludesorganismiccognitiveandemotionalevents(thoughtsandfeelings)relevanttothebehaviorofinterest,associatedeithertemporallyorthroughcognitiverelationships(e.g.,aperson’sbeliefthataparticularbehaviorisassociatedwithaparticularemotionalstate).Systematicobservationandanalysisrevealwhichbehaviorsarecontrolledbyenvironmentalandorganismicante-cedentsandconsequences.Thisinformationcanthenbeusedtotherapeuticallymanipulatetheenvironmenttoinfluenceexpres-sionofthebehaviorofinterest.Insettingswheredangerousnessandforcedmedicationsareatissue,multimodalcaseformulationstrategiesthatincludeFBAprovidesthemostcredibledataforshowingwhatinterventionsdoordonoteffectivelycontrolanybehaviorofinterest(Wilknissetal.,2004).Specifictreatmentinterventionscanactaseitherante-cedentsorconsequencestodangerousbehaviors.Effectivemodelsoftreatmentinvolveongoingprogressandoutcomedatathatinformclinicaldecisions.Reductionandeventualeliminationofdangerousbehavioraftertheintroductionoftherapeuticanteced-entsorconsequenceswouldprovideacompellingdemonstrationofeffectiveness.Similarly,failureofspecifictreatmentstopro-ducesucheffectswouldbeequallyclear.FBAshouldthusbeexpectedtofigureatbothkeypointsintheprocessofdeterminingwhetherthecriteriaforforcedmedicationhavebeenmet(i.e.,thedeterminationthatlessrestrictivealternativesmayormaynotcontroldangerousnessandthedeterminationthatmedicationmayormaynotcontroldangerousness).Comprehensive,multimodalcaseformulationstrategiesin-cludingFBAareprerequisitestothemilieu-basedpsychologi-calinterventionsknowntobemosteffectiveforcontrollingaggressionandotherdangerousbehavior.Thoseinterventionsgenerallyinvolveidentificationandcontrolofantecedentsandconsequencestothedangerousbehavior,asidentifiedinaformalFBAandcaseformulationplan.BecauseFBAisacentralcomponentoftheapproach,empiricaldatapertinenttoleastrestrictiveandintrusiveconsiderationsarecollectedinthecourseoftreatment.Unfortunatelytoday,settingsthatsupportFBAandmilieu-basedpsychologicaltreatmentaretheexception,nottherule.9ItisobvioustoobserversoftheAmericanpublicmentalhealthsystemthatcomprehensivetreatmentalternativesareoftenunavailableorareextremelylimited(Hunter,2000,2001).Thisreflects,amongotherthings,apervasiveproblemindisseminationofnewtreat-menttechnologytoenvironmentswherepeoplewithserious8Accordingtothedraftersofthe2000amendmentstoRule702oftheFederalRulesofEvidence,“Nothinginthisamendmentisintendedtosuggestthatexperiencealone—orexperienceinconjunctionwithotherknowledge,skill,trainingoreducation—maynotprovideasufficientfoundationforexperttestimony.Tothecontrary,thetextofRule702expresslycontemplatesthatanexpertmaybequalifiedonthebasisofexperience.Incertainfields,experienceisthepredominant,ifnotsole,basisforagreatdealofreliableexperttestimony....Ifthewitnessisrelyingsolelyorprimarilyonexperience,thenthewitnessmustexplainhowthatexperienceleadstotheconclusionreached,whythatexperienceisasufficientbasisfortheopinion,andhowthatexperienceisreliablyappliedtothefacts.Thetrialcourt’sgatekeepingfunctionrequiresmorethansimply‘takingtheexpert’swordforit’....Themoresubjectiveandcontroversialtheexpert’sinquiry,themorelikelythetestimonyshouldbeexcludedasunreliable”(Fed.R.Evid702AdvisoryCommittee’sNote,2001).SeealsoKumhoTireCo.v.Carmichael(1999):“Itwillattimesbeusefultoaskevenofawitnesswhoseexpertiseisbasedpurelyonexperience,say,aperfumetesterabletodistinguishamong140odorsatasniff,whetherhispreparationisofakindthatothersinthefieldwouldrecognizeasacceptable”(p.150).9RichardH.Hunter,A.JocelynRitchie,andWilliamD.Spauldinghavehadthegoodfortunetopracticeintwosuchenvironments,inNebraskaandIllinois.472HUNTER,RITCHIE,ANDSPAULDING mentalillnessareserved(Lehmanetal.,1998).Theproblemisespeciallyapplicabletopsychologicaltreatment.Advancesineffectivepsychologicaltreatmentsoccurredatatimeofmajoroverhaulofpsychiatricservicesinanenvironmentofrestriction,cutbacks,andcostshiftingonthepartofstates,managedcareorganizations,andHMOs.Forpeoplerequiringinpatienttreatment,manyofthesecost-savingandcost-shiftingdecisionsledtoreducedtreatmentoptions,anarrowingofstrate-giesandinterventions,constrictedcaseformulationdecisions,andreductionsinthetypeofstaffneededfortheprovisionofcom-prehensiveservices(Hunter,2000).Assystemsconstricted,theavailabilityofcomprehensivearraysofassessmentandtreatmentcapabilitieswereofteneliminated.Withcutbacksofinpatientservicesthroughhospitalclosings,bedreductions,andvarioustypesofdiversionprograms,theproportionofinvoluntarytovoluntarypatientsinmanystatesystemshasgrowndramatically.Thecriteriainmoststatesforinvoluntaryadmissionarethepresenceofamentalillnessandadeterminationthatthepersonisadangertohim-orherselforothers,reflectingthekeyprinciplesaffirmedinSell.Itiswidelyknownthatasubstantialproportionofpeoplewithseriousmentalillnessexperiencebothseveresymptomsofamentaldisorderandsignificantbehaviordysfunctionthatleavethepersonatriskforinvoluntarytreatment,includingforcedmedication.Cutbacksanddownsizingofinpatientservicesystemsoverthepastseveralyearshaveledtothelayoffsorattritionofprofessionalscapableoftreatingbehaviordysfunction.Communitymentalhealthprovidershavenotbeenimmunetothesecutbacks,yetwiththeincreasinguseofcourt-orderedcommunity-basedtreatment(outpatientcivilcommitment),demandsoncommunityprovidersarealsoincreas-ing.Asaresult,inmostsettingsthereislittletonopossibilityofdata-basedcaseformulationandassessmentorcomprehensive,leastrestrictivepsychologicalandbehavioraltreatmentalterna-tives.EvenasSupremeCourtrulingsandbest-practicesstandardshaveconvergedonthenecessityofdata-basedassessmentandpsychologicaltreatmentinsettingsinwhichpeoplewithseriousmentalillnessareserved,mentalhealthsystemshavegrownlesscapableofprovidingthoseservices.Psychologicalandsociologicalfactorsamongpractitionersalsoservetoperpetuatetheproblem.Advancesinpsychopharmacol-ogy,coupledwithoverlyoptimisticexpectationsabouttheeffec-tivenessofpsychotropicdrugs,leadtooverdependenceondrugsastheprimaryandalltoooftenonlytreatmentprovidedpeopleinbothinpatientandoutpatientsettings(Glenmullen,2000;Hunter,2000,2001;Valenstein,1998).Thereisacommonbutunfoundedbeliefthatmedicationsbeneficialinsuppressingtheacutesymp-tomsofmentalillnessalsoeffectivelyaddressotherbehaviordysfunctions(e.g.,aggression).Suchbeliefsmightbemoderatedbyinterdisciplinarytreatmentteamsthatformulateandimplementcomprehensiveinterventionsstrategies,butfartoomanyproviderslackclinicianswithexpertiseinpsychologicaltreatments,andthesecliniciansareinshortsupplyinthesettingsinwhichpeoplewithseriousmentalillnessaretreated.Despitethisbleakscenario,theimplicationsofSellandrelatedcases,especiallyinthecontextoftheproceduralrequirementsofDaubert,shouldputrenewedpressureonmentalhealthsystemstoprovidehighqualityempiricallyinformedpsychologicalassess-mentandtreatment.Clinicianswhoworkinthesesettingsshouldbepreparedtorespondtothechallengescreatedbythejudicialmandatetoempiricallyverifythataparticularindividual’sdan-gerousbehaviorisunderstoodandtreatedwiththeleastintrusiveandrestrictivealternative(s).Thekeytoolsformeetingthischal-lengewillbeacombinationofmultimodalcaseformulationstrat-egiesandfunctionalbehavioralanalysisassociatedwithcognitiveandbehavioralinterventionsknowntodirectlyreduceaggressionandotherdangerousbehaviors.Further,theseapproachespromoteadherencetoothertreatmentsdemonstratingimprovedoutcomes,includingbothpsychologicalandpharmacologicaltreatments.TheimplicationsforclinicalpracticeofSell,Harper,andre-lateddecisionshavedirectimpactontherolesthatpsychologistsperformintreatmentsettingsandinthelegalarena.Thepsychol-ogististypicallythetreatmentteammemberwiththemostback-groundandexperienceinmultimodalcaseformulation,FBA,andmilieu-basedpsychologicaltreatment.Arguably,casessuchasSellandHarper,intheproceduralcontextofDaubert,representnewandpressingreasonsforpsychologiststousetheirindependentpractitionerstatusinallthesettingsinwhichpeoplewithseriousmentalillnessareservedtoprovidetheirexpertisetothetreatmentteamsinwhichtheyparticipate.Oneproblem(andastrength)withmultimodalcaseformulation,FBA,andmilieu-basedtreatmentisthattheyrequirespecificstafftrainingandprogramwideinterdisciplinarycollaboration.Thisre-quires,inturn,anadministrativecommitmenttodeveloptherequiredtrainingcapabilities,datamanagementsystems,regula-tionsandpolicies,andthediversearrayofprofessionalstaff.Theprofessionalandscientificliteratureonpsychologicaltreatmentofaggressionisakeyresourceforcliniciansinpursuitofbestpracticesrelevanttoforcedmedicationandleastrestrictivealternatives.Psychologistscanalsodrawonestablishedmethodsandinstru-mentstodevelopfunctionalassessmentandpsychologicaltreat-mentcapabilitiesinthesettingsinwhichtheypractice.Oneexampleistherecordreviewprotocol(RRP)developedbyRich-ardH.Hunter(Hunter,2001).Thechecklistprovidespromptsofvarioustypesofinterventions,fromlessrestrictiveinterventionstorestraintsandseclusion.Thisprotocolhasbeenusedtoreviewinterventionstrategiesforpeoplewhoareregularlyrestrained,putinseclusion,orassaultstafforotherpatients.Staffcaneffectivelybetaughttoauditaclinicalrecordandnotethepresenceorabsenceofrelevantinformationandinterventionsalongacontin-uumofrestrictiveness.ExamplesofthetypesofassessmentsandleastrestrictiveinterventionsarelistedontheRRP,andstaffcaneasilyassesswhethertheselessintrusiveinterventionshavebeentriedpriortoamorerestrictiveand/ormoreintrusiveintervention.Numerousself-surveysandreviewsbyRichardH.Hunterhaverevealedthatinmostcasesinwhichclientscontinuetoexhibitdangerousbehaviorsleadingtorestraintsandseclusion,lessre-strictiveandlessintrusiveinterventionswerenotattempted;func-tionalassessmentsofthespecificoffendingbehaviorswerenotconducted;relevantantecedentandconsequenceconditionswerenotstudied;andtreatmentstrategiesimmediatelyincludedmedi-cationtrials(usuallymultiplemedicationtrials)andproceededtoevenmorerestrictiveandcontrollinginterventionssuchaschem-icalrestraints,mechanicalrestraints,and/orseclusion.Further,typicaltreatmentprotocolsdonotinvolvetheclientintheassess-mentofantecedentsnordotheyimproveeitherthetreatingclini-cian’sortheclient’sunderstandingofthemeaningandcommu-nicativeintentoftheunwantedbehaviors.Rarelydothetreatment473SPECIALSECTION:IMPLICATIONSOFSELL protocolsinvolveteachingoffunctionallyequivalentreplacementbehaviors,alternativecopingskills(e.g.,angermanagementtrain-ing,interpersonalproblem-solvingskillbuilding),improvedcom-municationandnegotiationskills,orotherstrategiesthatmaybuildimmunitiesandoffertheclientalternativewaystocopewithchallengesorexpressneedsintothefuture.TheRRPcouldbeusedasapreliminarysurveyinstrumentfordetermininglessrestrictiveassessmentandinterventionprotocols.TheSellrulinganditspredecessorsreinforcetheneedforclearandstrictstandardsforinvoluntarydrugadministrationintreatingindividualswithseverementalillness.Applicationofthesestan-dardsshouldpromotenotonlymoreresponsibleuseofdrugtreatmentbutmorereliableandvalidclinicalassessmentofdan-gerousnessandtreatmenteffectivenessandgreateravailabilityoflessrestrictiveandlessintrusivepsychologicaltreatments.ReferencesAmericanPsychologicalAssociation&CommitteefortheAdvancementofProfessionalPracticeTaskForceonSeriousMentalIllness.(2005).Traininggridoutliningbestpracticesforrecoveryandimprovedout-comesforpeoplewithseriousmentalillness.RetrievedMay11,2005,fromhttp://www.apa.org/practice/grid.htmlBauer,A.,Rosca,P.,Khawalled,R.,Gruzniewski,A.,&Grinshpoon,A.(2003).Dangerousnessandriskassessment:Thestateoftheart.IsraeliJournalofPsychiatryandRelatedSciences,40(3),182–190.Bedell,J.R.,Hunter,R.H.,&Corrigan,P.W.(1997).Currentapproachestoassessmentandtreatmentofpersonswithseriousmentalillness.ProfessionalPsychology:ResearchandPractice,28,217–228.Borum,R.(1996).Improvingtheclinicalpracticeofviolenceriskassess-ment:Technology,guidelines,andtraining.AmericanPsychologist,51,945–956.Brownv.BoardofEducation,347U.S.483(1954).Daubertv.MerrellDowPharmaceuticals,Inc.,509U.S.579(1993).Donat,D.C.(1998).Impactofamandatorybehavioralconsultationonseclusion/restraintutilizationinapsychiatrichospital.JournalofBe-haviorTherapyandExperimentalPsychiatry,29,13–19.Donat,D.C.(2002a).Employingbehavioralmethodstoimprovethecontextofcareinapublicpsychiatrichospital:Reducinghospitalrelianceonseclusion/restraintandpsychotropicPRNmedication.Cog-nitiveandBehavioralPractice,9,28–37.Donat,D.C.(2002b).Impactofimprovedstaffingonseclusion/restraintrelianceinapublicpsychiatrichospital.PsychiatricRehabilitationJour-nal,25,413–416.Donat,D.C.(2003).Aregressionanalysisofsuccessfulseclusion/restraintreductioneffortsatapublicpsychiatrichospital.PsychiatricServices,54,1119–1123.Donat,D.C.,&McKeegan,G.F.(2003).Employingbehavioralmethodstoimprovethecontextofcareinapublicpsychiatrichospital:Realizingimprovementsintheinterpersonalbehaviorofdirectcareproviders.CognitiveandBehavioralPractice,10,178–187.Fed.R.Evid.702(2000).FedR.Evid.702advisorycommittee’snote,28U.S.C.A.43(2001).Fryev.UnitedStates,54App.D.C.46,293F.1013(1923).GeneralElectricCo.v.Joiner,522U.S.136(1997).Glenmullen,J.(2000).Prozacbacklash:OvercomingthedangersofProzac,Zoloft,Paxil,andotherantidepressantswithsafe,effectivealternatives.NewYork:Simon&Schuster.Hunter,R.H.(2000).Treatment,management,andcontrol:Improvingoutcomesthroughmoretreatmentandlesscontrol.InH.R.Lamb(SeriesEd.)&F.J.Frese,III(Vol.Ed.),Newdirectionsformentalhealthservices:Theroleoforganizedpsychologyintreatmentoftheseriouslymentallyill(pp.5–15).SanFrancisco:Jossey-Bass.Hunter,R.H.(2001).Improvingoutcomesrequiresmore,notless,frompsychology.TheBehaviorAnalystToday,2,4–13.Iwata,B.,Kahng,S.,Wallace,M.,&Lindberg,J.(2000).Thefunctionalanalysismodelofbehavioralassessment.InJ.Austin&J.Carr(Eds.),Handbookofappliedbehavioranalysis(pp.61–89).Reno,NV:ContextPress.JointCommissiononAccreditationofHealthcareOrganizations.(2004).Hospitalaccreditationstandards.OakbrookTerrace,IL:Author.KumhoTireCo.v.Carmichael,526U.S.137(1999).Lehman,A.,Steinwachs,D.,Dixon,L.,Goldman,H.,Osher,F.,Postrado,L.,etal.(1998).Translatingresearchintopractice:TheSchizophreniaPatientOutcomesResearchTeam(PORT)treatmentrecommendations.SchizophreniaBulletin,24,1–10.Menditto,A.,Beck,N.,Stuve,P.,Fisher,J.,Stacy,M.,Logue,M.,&Baldwin,L.(1996).Effectivenessofclozapineandasociallearningprogramforseverelydisabledpsychiatricinpatients.PsychiatricSer-vices,47,46–51.O’Brian,W.,&Haynes,S.N.(1993).Behavioralassessmentinthepsychiatricsetting.InA.Bellak&M.Hersen(Eds.),Handbookofbehaviortherapyinthepsychiatricsetting(pp.39–71).NewYork:PlenumPress.Ollanik,S.A.(1999,November).Experttestimony:DefeatingtheKumhochallenge.Trial,35,28–35.Olmsteadv.LC,527U.S.581,607(1999).O’Neill,R.F.,Horner,R.H.,Albin,R.W.,Sprague,J.R.,Storey,K.,&Newton,J.S.(1997).Functionalassessmentandprogramdevelopmentforproblembehavior:Apracticalhandbook(2nded.).PacificGrove,CA:Brooks/Cole.Paul,G.L.,&Lentz,R.J.(1977).Psychosocialtreatmentofchronicmentalpatients:Milieuversussocial-learningprograms.Cambridge,MA:HarvardUniversityPress.Paul,G.L.,&Menditto,A.A.(1992).Effectivenessofinpatienttreatmentprogramsformentallyilladultsinpublicpsychiatricfacilities.AppliedandPreventivePsychology,1,41–63.Petrila,J.,Ridgely,M.S.,&Borum,R.(2003).Debatingoutpatientcommitment:Controversy,trendsandempiricaldata.CrimeandDelin-quency,49,157–172.Ridgely,M.S.,Borum,R.,&Petrila,J.(2001).Theeffectivenessofinvoluntaryoutpatienttreatment:Empiricalevidenceandtheexperienceofeightstates.SantaMonica,CA:RAND.Rigginsv.Nevada,504U.S.127(1992).Roos,P.(1974).Humanrightsandbehaviormodification.MentalRetar-dation,12,3–6.Sales,B.D.,&Shuman,D.W.(2005).Expertsincourt:Reconcilinglaw,science,andprofessionalknowledge.Washington,DC:AmericanPsy-chologicalAssociation.Schopp,R.F.(2003).Outpatientcivilcommitment:Adangerouscharadeoracomponentofacomprehensiveinstitutionofcivilcommitment?Psychology,PublicPolicy,andLaw,9,33–69.Sellv.UnitedStates,123S.Ct.512(2002).Spaulding,W.,Sullivan,M.,&Poland,J.(2003).Treatmentandrehabil-itationofseverementalillness.NewYork:GuilfordPress.Steadman,H.J.(2000).Fromdangerousnesstoriskassessmentofcom-munityviolence:Takingstockattheturnofthecentury.JournaloftheAmericanAcademyofPsychiatryandLaw,28,265–271.Stepleton,J.(1975).Legalissuesconfrontingbehaviormodification.Be-havioralEngineering,2,35–43.Tryon,W.(1976).Behaviormodificationtherapyandthelaw.ProfessionalPsychology:ResearchandPractice,7,468–474.474HUNTER,RITCHIE,ANDSPAULDING UnitedStatesv.Scheffer,523U.S.303(1998).Valenstein,E.S.(1998).Blamingthebrain:Thetruthaboutdrugsandmentalhealth.NewYork:FreePress.Wallace,C.J.,Liberman,R.P.,Kopelowicz,A.,&Yaeger,D.(2001).Psychiatricrehabilitation.InG.Gabbard(Ed.),Treatmentsofpsychiat-ricdisorders(3rded.,pp.1093–1112).Washington,DC:AmericanPsychiatricPublishing.Washingtonv.Harper,494U.S.210(1990).Weisgramv.MarleyCo.,528U.S.440(2000).Wexler,D.(1973).Tokenandtaboo:Behaviormodification,tokenecon-omies,andthelaw.Behaviorism,1,1–24.White,L.,&Morse,L.(1988).Behaviormodificationininstitutions:Thedevelopmentoflegalprotectionsofpatients’rights.BehavioralResi-dentialTreatment,3,287–314.Wilkniss,S.M.,Silverstein,S.M.,&Hunter,R.H.(2004).Nonpharma-cologictreatmentofaggressionandviolenceinindividualswithpsy-chosis.ContemporaryPsychiatry,3(2),1–8.Wyattv.Stickney,344F.Supp.373(M.D.Ala.1972).ReceivedMay11,2004RevisionreceivedJune1,2005AcceptedJune10,2005475SPECIALSECTION:IMPLICATIONSOFSELL 105Restraint and self-injury inpeople with intellectualdisabilitiesA reviewEDWIN JONESSpecial Projects team,Bro Morgannwg NHS Trust,Wales and Unit for Development in Intellectual Disability,University of Glamorgan,WalesDAVID ALLENSpecial Projects team,Bro Morgannwg NHS Trust,Wales and Unit for Development in Intellectual Disability,University of Glamorgan,WalesKATE MOORESpecial Projects team,Bro Morgannwg NHS Trust,WalesBETHAN PHILLIPSSpecial Projects team,Bro Morgannwg NHS Trust,Wales and Unit for Development in Intellectual Disability,University of Glamorgan,WalesKATHY LOWESpecial Projects team,Bro Morgannwg NHS Trust,Wales and Unit for Development in Intellectual Disability,University of Glamorgan,WalesAbstractMost of the recent debate concerning the ethics ofphysical interventions has focused on the management ofaggressive and destructive behaviours,neglecting the managementof self-injurious behaviour.This is an important omission,giventhe extremely serious consequences that can arise from this formof challenging behaviour.The present article reviews types ofrestraint used to manage self-injury,prevalence of use,and mainand side effects of restraint use.It describes some good practicestandards and highlights the need for further research and debatein this complex area.Keywordsrestraint;self-injuryarticleJournal of Intellectual Disabilities©2007sagepublicationsLondon,Los Angeles,New Delhi and Singaporevol11(1) 105‒118issn1744-6295(074006)11:1doi: 10.1177⁄1744629507074006 IntroductionMurphy (1999) has deÞned self-injurious behaviour (SIB) as any behaviourinitiated by the individual that directly results in physical harm to that indi-vidual.Self-injury in people with intellectual disabilities is a heterogeneousclass of responses that have multiple topographies with numerous causesand effects (Schroeder et al.,1980).Its common characteristics includerepetitive movements of various body parts that produce physical damageor potential damage if repeated frequently.Thompson and Caruso (2002)have suggested that this behaviour occurs in two principal forms.First,itmay present in discrete,brief bouts lasting no longer than a few seconds;it is proposed that brief episodes of this type are environmentally deter-mined.Alternatively,it may consist of very protracted episodes lasting forseveral hours with only very brief pauses;whilst SIB of this type may beprecipitated by environmental events,once started,it is maintained byneurological factors.Oliver et al.(1998) have stated that between 4and 14percent of peoplewith intellectual disabilities self-injure.SIB is often persistent,difÞcult totreat and,when untreated,has serious consequences.The latter can includemajor injury that can result in permanent tissue damage and secondaryproblems such as infection,sensory and neurological impairment and evendeath (Emerson,1992).Therapeutic interventions for SIB have most typically employed eitherpharmacological or behavioural methods,although more psychodynamicinterventions have also been undertaken (Simpson and Miller,2004).Someforms of psychotropic medication,notably the typical neuroleptics,havebeen used to treat SIB but with little evidence of therapeutic effectiveness,other than general sedation affecting all forms of behaviour (Brylewski andDuggan,2001;DeLeon et al.,2002).A potentially promising developmentin recent years has been the use of opiate antagonists,such as naloxone ornaltrexone,to block the effect of endogenous opiates that are produced byrepeated self-injury,thereby effectively reducing the behaviour itself(Emerson,1992;Murphy,1999;Oliver et al.,1987;Thompson and Caruso,2002).Whilst this form of pharmacological intervention appears effectivefor some,interventions based on applied behaviour analysis are stillgenerally considered the most proven treatments for self-injury,especiallywhen based on detailed functional analysis (Carr et al.,1990a;1990b;Emerson,1992;Horner and Carr,1997;Kahng et al.,2002a;2002b;Schroeder et al.,2002;Scotti et al.,1996;Thompson and Caruso,2002).Optimum intervention may well involve combined bio-behavioural treat-ment where,for example,opiate antagonists are used functionally in directresponse to the results of behavioural analysis of SIB (DeLeon et al.,2002;JOURNALOFINTELLECTUALDISABILITIES11(1)106 Thompson et al.,1994).However,despite the continued promise ofeffective intervention,available data suggest that most people with SIB (andindeed challenging behaviour in general) in the UK are unlikely to receiveeffective evidence-based treatment (Emerson et al.,2000;Harris andRussell,1989;Oliver et al.,1987;Qureshi,1994;Robertson et al.,2005).Even with successful intervention,complete elimination of self-injuryis a rare phenomenon.Given the risks that this behaviour poses,there is aclear need therefore to devise effective reactive strategies to manage self-injurious episodes in combination with proactive strategies for behaviourchange.Over the last decade,virtually all of the ethical debate,policydevelopment and staff training concerning reactive strategies has focusedon managing externally directed behaviour,most notably aggression(Allen,2001,2002;British Institute of Learning Disabilities,2001;Depart-ment of Health and Department for Education and Skills,2002;Harris etal.,1996).In contrast,very little attention has been paid to the reactivemanagement of self-injury.The present article is therefore devoted to thistopic.The existing literature is reviewed,and information on the types ofrestraint employed to manage self-injury,their frequency of use,andprimary and secondary effects are described.Some good practice points arethen identiÞed and future research issues discussed.MethodPreliminary electronic literature searches were conducted in the Medlineand PsycINFO databases using various combinations of search terms.PsycINFO proved to be the most productive:a search using the termsÔmental retardation and self-injurious behaviour and restraintÕ,limited topeer review journals,identiÞed 52papers.Similar combinations substitut-ing ÔrestraintÕwith Ôbehavioural managementÕidentiÞed one unpublisheddissertation;substitutions using Ôreactive strategiesÕand Ôreactive manage-ment strategiesÕidentiÞed no papers.Searches using the terms Ômentalretardation and autism and self injurious behaviourÕyielded four papersthat were all included in the list of 52papers previously identiÞed.Sub-stituting Ôlearning disabilitiesÕ,Ôintellectual disabilitiesÕ,Ôself-harm,ÕÔautisticspectrum disorderÕ,Ôtriad of social impairmentÕand testing differentcombinations did not identify any additional papers.In a number of thesepapers,restraint was employed as a punitive consequence in a behaviouralintervention rather than as a reactive strategy per se.A total of 34papers wereÞnally included in the review.JONESETAL.:RESTRAINTANDSELF-INJURY107 Types of restraint employed to manage self-injuryThere is clearly great variation in the type of restraint used to manage self-injury.Mechanical restraints,for example,can range in their form of re-strictiveness and degree of restrictiveness from almost completeimmobilization using objects such as beds (Tate,1972) or chairs,to the useof wrist cuffs that bring the SIB under stimulus control but which do notrestrict movement (Oliver et al.,1998).The way in which terminology isused can also be confusing.Although the term Ômechanical restraintÕimpliesa greater degree of restriction than the term Ôprotective deviceÕ,they areoften used interchangeably,which makes differentiating between protectionand restraint problematic.For example,the joint guidance from the Depart-ment of Health and Department for Education and Skills (2002,p.10)brießy mentions mechanical restraint and deÞnes the use of a protectivehelmet to prevent self-injury as non-restrictive and the use of arm cuffs orsplints to prevent self-injury as restrictive.However,some forms of Ôpro-tective deviceÕ,such as orthotic helmets that cover the entire face,could bemore restrictive than some forms of mechanical restraint,such as wrist cuffsthat allow a considerable degree of movement.Further,some forms ofphysical restraint (for example,having your hands held at your side by acarer),although applied for short periods,could conceivably be moreintrusive and restrictive than protective devices such as wrist cuffs that allowconsiderable movement but are worn continuously.The degree of restrictiveness is a complex issue and a more objectiveand reliable means of measuring and describing this would clearly beuseful.Duker and Seys (1997) developed the Imposed MechanicalRestraint Inventory (IMRI) to directly address some of these issues andmeasure restrictiveness as a dependent variable when evaluating treat-ment.The IMRI measures a number of dimensions in considerable detailsuch as:whether restraint is applied when the person is ambulant,sittingin a chair or lying in bed;the parts of the body that may be restrained;the degree of restraint applied to each body part;and a timescale tomeasure the duration of restraint.The IMRI is notable because it appearsto be one of the only scales designed to directly address this issue;it hasbeen found to be reliable and could be adapted to gather useful data infuture studies.Figure 1shows responsive strategies for self-injury cited in the litera-ture organized into a general continuum from least to most restrictive.Thiscontinuum can only be described in very general terms because the degreeof restriction can vary considerably depending on the speciÞc details ofhow the strategy is designed and applied in practice.Unfortunately,manystudies do not describe the approach used in sufÞcient detail to make aprecise assessment of the degree of restriction involved.JOURNALOFINTELLECTUALDISABILITIES11(1)108 The strategies have been classiÞed into three levels of intrusiveness.The least intrusive strategies consist primarily of distraction/defusiontechniques,although a low level of physical prompting may also besufÞcient to interrupt early stages of self-injury for some service users.Restrictive strategies include alterations to the physical environment,personal restraint and speciÞc mechanical restraint devices that do not havea major impact on restricting the wearerÕs movement.Finally,the mostrestrictive devices are those which both inhibit self-injury and place majorrestrictions on the wearerÕs freedom of movement.Prevalence of useData are sparse regarding the extent to which reactive strategies are usedto manage SIB in practice and this may be related to the fact that writtenplans are only found in very few service settings (Oliver et al.,1987).However,despite this,it can be assumed that staff are likely to adoptvarious ad hocreactive approaches,as they,quite understandably,feel guiltyif they do nothing in response to SIB.Hastings (1996) investigated staffresponses to a hypothetical situation involving severe SIB and found staffciting a range of strategies consistent with the continuum of restrictive-ness previously described.However,notably,staff reported that they were much more likely to use physical and mechanical restraint becausethey needed to take immediate action to prevent service users harmingthemselves.JONESETAL.:RESTRAINTANDSELF-INJURY109Least ¥Distraction (Hastings, 1996)Restrictive¥Diversion to a reinforcing/compelling event, strategic capitulation(LaVigna and Willis, 2002)¥Verbal commands to stop or other forms of communication such asattempts to reassure and calm the person, touching the person (e.g.Hastings, 1996)¥Adaptations to physical environment Ð padding furniture and Þxtures,using a cushion to prevent injury, e.g. when hitting head against hardsurfaces (e.g. Hastings, 1996; Spain et al., 1984)¥Physical or personal restraint, i.e. holding the person in some way(e.g. Harris, 1996; Hastings, 1996)¥Protective devices designed to prevent or reduce injury but notrestrain individuals such as helmets (e.g. Dorsey et al., 1982; Dukerand Seys, 1997; Murphy et al., 1993; Spain et al., 1984)Most Restrictive¥Various types of appliances designed to mechanically restrainindividuals to prevent the occurrence of SIB such as arm splints, bedor chair ties (e.g. Dorsey et al., 1982; Duker and Seys, 1997; Murphyet al., 1993; Spain et al., 1984)Figure 1A continuum of management strategies for self-injurious behaviour Mechanical forms of restraint have received the greatest attention in theliterature on self-injury and some epidemiological studies report on theprevalence of use.A total population study of people with intellectualdisabilities and challenging behaviour in one health region in the UK inthe early to mid 1980s (Murphy et al.,1993;Oliver et al.,1987) showedthat approximately 13percent (75individuals) of people with intellectualdisabilities who self-injured wore protective devices or mechanicalrestraints.Arm splints were the most commonly used device.These peoplehad severe SIB,were generally younger,and had greater sensory,cognitiveand physical impairments than other people with SIB.They also tended topresent multiple forms of challenging behaviour.Emerson (2002) reported on a series of studies conducted over theperiod 1994Ð2000that showed that 5percent of children with intellectualdisabilities who self-injured were ÔusuallyÕor ÔsometimesÕmanaged bymechanical restraint.The equivalent Þgures for adults in two separatestudies were 7and 17percent.Although comparisons are difÞcult,takenoverall,these Þgures suggest little change in the rate of mechanical restraintfor self-injury in the UK over the last two decades.Given the lack of avail-ability of effective therapeutic support alluded to earlier,this wouldperhaps be expected.Although not directly related to the present article,it is important tonote that it has been estimated that between 12and 50percent of peoplewith intellectual impairments and SIB also engage in self-restraint.This mayoccur via service users folding their arms,sitting on their hands or legs,entangling themselves in clothing,requesting or positioning themselves inmechanical restraints,holding or wearing particular items (Forman et al.,2002).Whilst this is generally viewed as an attempt to prevent or escapefrom SIB,the precise functional relationship between SIB and self-restraintis likely to be more complex.Main and side effectsThere is no doubt that restraint can be very effective in reducing self-injurywhilst in use,and there is also some evidence to suggest that brief personalrestraint (i.e.when the person is held by others) is at least as effective aslonger-term application (Harris,1996).Mechanical restraint can also have a number of detrimental side effects.A major concern is that the social attention that is delivered during theapplication can serve to positively reinforce and therefore increase rates ofSIB in individuals whose behaviour is maintained by this contingency(Hastings,1996;Spain et al.,1984).In the absence of a clear frameworkof guidance,training and monitoring,physical restraint may also riskinjury to the client or staff involved,as well as providing contingentJOURNALOFINTELLECTUALDISABILITIES11(1)110 attention (Harris,1996).Harris also suggests that mechanical restraintmay be safer than personal restraint,although evidence from the greyliterature would appear to question this assertion (Allen,in press).Mechanical or protective devices may themselves serve to reinforce andmaintain SIB,thus making the person dependent on wearing them forlong periods of time (Fisher et al.,1997;Foxx and Dufrense,1984;Spainet al.,1984).In this sense,the restraint itself assumes reinforcing proper-ties,possibly because it represents a means of escaping compulsive self-injury.Under these circumstances,it is not unusual to see self-injuryoccurring at high rates in order to ÔearnÕaccess to restraints,and uponrestraint removal in an attempt to secure reapplication.Mechanicalrestraint may also result in the development of other,alternative types of SIB,that replace those controlled or eliminated through usingmechanical restraints (Emerson,1992;Fisher et al.,1997;Kahng et al.,2001;Lerman et al.,1994).A not uncommon outcome is that controllingone form of self-injury (e.g.Þst to head hitting) via restraint may simplyresult in other forms (e.g.damaging knees by hitting objects or headbutting).Muscular atrophy,demineralization of bones,shortening oftendons,arrested motor development and disuse of limbs may also occurbecause of long-term restriction (Emerson,1992;Fisher et al.,1997).Mechanical restraint and protective devices are also associated withdisruption or prevention of opportunities to engage in activities associ-ated with daily living,education,leisure and reduced levels of interactionwith carers (Emerson,1992;Spain et al.,1984).Good practice guidelinesJust as has been the case with the reactive management of aggression(Harris et al.,1996),a set of good practice guidelinesthat could form thebasis for clear standards regarding the management of SIB would be usefulin improving service provision.This section will list some of the keypoints that emerged from the literature that could form the basis of a setof more comprehensive guidelines informed by further research anddebate.First,given that SIB is a heterogeneous class of responses that havemultiple topographies which may be maintained by social,environmentaland biological factors,all interventions should be based on functionalanalysis of SIB and follow the least restrictive alternative approach.Thereshould be clear written behavioural management plans and treatmentprogrammes in place,and their implementation regularly monitored andreviewed (Emerson,1992;Hamad et al.,1983;Kahng et al.,2002a;2002b;Spain et al.,1984).Multifaceted interventions should involve strategies bothfor behaviour change and for situational behaviour management;whereJONESETAL.:RESTRAINTANDSELF-INJURY111 appropriate,the former should consist of combined pharmacological andbehavioural intervention as described above.The clearest and most comprehensive good practice guidelines regard-ing the management of SIB were set out by Spain et al.(1984)and thesecontinue to be relevant,especially concerning the use of protective devices.The enduring relevance of these guidelines highlights the lack of focusedattention given to this issue over the last two decades.Spain et al.(1984)emphasize that protective appliances may be of considerable value in themanagement and treatment of SIB,but that they should be used withcaution and only as part of a general behavioural programme aimed to treatSIB and replace it with alternative behaviour.They recognized the need tobalance the danger of a person becoming dependent on the protectivedevice against the possible detrimental effects of the unprotected severe SIB.They suggested that the following type of key question should always beasked:Is there any alternative way of preventing damage;which would be non-reinforcing of the SIB;whichwould allow the person to engage in other activities;and which would be feasible in practice,givenactual stafÞng levels?If the answer to this question is ÔNoÕ,then protection may be the onlyalternative to prevent tissue damage,and they make a series of straight-forward recommendations:¥Protection could include physical holding (depending on stafÞnglevels).However,it may be preferable to use material restraints sincephysical contact may,in itself,be a powerful reinforcer in maintainingSIB.Appliances should also be easy to put on and take off,avoidingprolonged physical contact,for the same reason.¥No one should be left unattended when wearing an appliance.1¥There are no standard appliances as such;suitably skilled and experi-enced therapists need to adapt and make them according to individualneeds.¥Attempts should always be made to make the appliance look as ordinaryand as pleasing as possible to promote social acceptability and positiveself-image.Adapting ordinary clothing should always be considered Ðe.g.wearing a hat over a helmet.¥Shorter periods of use of appliance are found to be generally moreeffective than longer periods.(However,there are notable exceptions tothis,such as people with LeschÐNyhan syndrome).¥It may be justiÞable to provide a suitable mechanical protective applianceto be only used in emergencies,mainly to allay staff anxiety.This isbecause staff may be more willing to implement reinforcement-basedJOURNALOFINTELLECTUALDISABILITIES11(1)112 behavioural treatment programmes in the knowledge that they can usean appliance if the SIB becomes too severe.¥Ideally,it should always be possible for the person wearing the applianceto engage in other activities for a large part of the day and be stronglyrewarded.¥Consideration should be given from the outset as to how the use of theappliance can be gradually faded over time.Studies that are more recent conÞrm and suggest some further develop-ments in line with these recommendations.Coaching staff in positivebehavioural support strategies can reduce levels of personal and mechanicalrestraint (Sturmey,2002).Similarly,the possible counter-therapeutic effectof restraint application acting as a social reinforcer can be reduced byensuring that high densities of social reinforcement are delivered non-contingently throughout the personÕs day (LaVigna and Willis,2002).Where restraints are impractical (for example,the person refuses to wear adevice),altering the environment to make it safer (by removing sharpcorners,padding targeted areas,etc.:Harris et al.,1996;Mental WelfareCommission for Scotland,2002) may represent a better option.Oliver et al.(1998) highlight as good practice that reduction strategies for fadingmechanical restraints should be based on a functional analysis wheneverpossible,otherwise SIB or self-restraint may be inadvertently reinforced,causing physical and emotional distress to service users.However,in somecases,functional analysis using experimental analogue conditions may notbe possible because the SIB may not vary in line with manipulations,or freeresponding is too dangerous to allow.In these cases,they recommend thatmechanical restraints be designed so that they can be easily faded in morethan one way or parameter,e.g.size,pressure,and degree of ßexion.Armsplints were faded in experimental evaluation with very positive results fortwo out of three participants including both a signiÞcant reduction in SIB,a reduction in overall restriction,no increase in distress and no detrimen-tal effect on social contact and engagement in activities.The results showedthat stimulus control over the absence of SIB could be maintained afterrestraints were faded in size,and so that 100percent ßexion was allowed.The arm splint used provided a considerable degree of control over ßexionand had a modular design so it could be faded in size easily by removingsections.Thus,if stimulus control was lost,resulting in a return of SIB,itcould quickly and easily be restored to optimum size,avoiding the risk ofhigh frequency SIB returning whilst waiting for a new splint to be made.The need for an individualized approach is clear in the literature andhighlighted by the repeated emphasis on functional assessment.Oliver et al.(1998) suggested that the parameters of stimulus control are likely to varyJONESETAL.:RESTRAINTANDSELF-INJURY113 between individuals,and their approach could support the point made byMurphy (1999) that the use of interview/questionnaire-based functionalanalysis (e.g.OÕNeill et al.,1997) in combination with natural observationsmay play a useful part in deciding the most appropriate managementapproach.Although less robust and reliable than the type of experimentalanalogue functional assessment approaches described by Iwata et al.(1982),they may be appropriate when either practical constraints,or the nature ofSIB itself,prevent or severely limit analogue assessment.ConclusionsWhilst many positive changes may have occurred over the last two decadesin the management and treatment of challenging behaviour,the reactivemanagement of SIB seems to have received little attention.In the mid1980s,several authors argued that the management of SIB should be givengreater attention because restraint appeared to be quite frequently used inpractice and that people with SIB were at risk because treatment was eitherunavailable or ineffective (GrifÞn et al.,1986;Richmond et al.,1986;Spainet al.,1984).These key things appear not to have changed and the provisionof this attention is now long overdue.Treatment and management are both necessary components of positivebehavioural support.The provision of any kind of reactive intervention tochallenging behaviour is ultimately indefensible on ethical grounds in theabsence of parallel,proactive intervention strategies.The ÔsolutionÕto self-injury amongst people with learning disability lies in the latter rather thanthe former.However,as previously stated,even when treatment is effective,complete elimination of SIB may be elusive.It is therefore equally unethi-cal not to consider ways of making service users safe,and in ways thatmaximize their opportunities for living a full life whilst limiting potentiallynegative side effects.A clear set of guidelines and standards reßecting some of the advancesmade in the positive behavioural management of aggressive and destruc-tive behaviours would be very helpful in relation to SIB.Spain et al.Õs (1984)account is useful because it contains detailed descriptions and illustrationsof the types of devices that are discussed,making it understandable,relevant and of practical use to practitioners;any future guidelines shouldshare these characteristics.Good practice guidelines,in themselves,will notsolve the issues,and indeed are likely to raise questions of service deÞcitsin many areas,such as access to specialists who can make bespokeappliances,the general absence of behavioural inputs and the need for staffto be effectively managed as well as trained.However,debating andagreeing standards is a useful Þrst step in improving quality.Standards areJOURNALOFINTELLECTUALDISABILITIES11(1)114 more likely to be valid if the debate engages those key stakeholders (e.g.researchers,service providers,staff,the various multidisciplinaryprofessionals,relatives and people with SIB themselves) who,despite thelack of academic attention given to the issue in recent years,have beencontinually dealing with the reality of managing SIB in practice.Note1This is particularly critical,as many deaths in restraint with other user groupshave occurred when people have asphyxiated as a result of being entangled intheir restraints.ReferencesALLEN,D.(2001) Training Carers in Physical Interventions:Research Towards Evidence Based Practice.Kidderminster:BILD.ALLEN,D.(ed.) (2002) Ethical Approaches to Physical Intervention.Responding to ChallengingBehaviour in People with Intellectual Disabilities.Kidderminster:BILD.ALLEN,D.(in press) ÔRisk and Prone Restraint:Reviewing the EvidenceÕ,in M.NUNNOETAL.(eds) Ensuring the Safety of High-risk Interventions.New York:ChildWelfare League of America.BRITISHINSTITUTEOFLEARNINGDISABILITIES(2001) Code of Practice for Trainers in theUse of Physical Interventions.Kidderminster:BILD.BRYLEWSKI,J.& DUGGAN,L.(2001) ÔAnti Psychotic Medication for ChallengingBehaviour in People with Learning Disability (Cochrane Review)Õ.The CochraneLibrary,Issue 4,2002.Oxford:Update Software.CARR,E.G.,ROBINSON,S.& PALUMBO,L.W.(1990a) ÔThe Wrong Issue:Aversiveversus Nonaversive Treatment.The Right Issue:Functional versus Non FunctionalTreatmentÕ,in A.C.REPP& N.SINGH(eds) Current Perspectives in the Use of Nonaversiveand Aversive Interventions with Developmentally Disabled Persons.Sycamore,IL:Sycamore.CARR,E.G.,ROBINSON,S.,TAYLOR,J.C.& CARLSON,J.I.(1990b) PositiveApproaches to the Treatment of Severe Behavior Problems in Persons with Developmental Disabilities.Washington,DC:Association for Persons with Severe Handicaps.DELEON,I.G.,RODRIGUEZ-CATTER,V.& CATALDO,M.F.(2002) ÔTreatment:Current Standards of Care and Their Research ImplicationsÕ,in STEPHENR.SCHROEDER,MARYLOUOSTERKER& TRAVISTHOMPSON(eds) Self InjuriousBehavior:GeneÐBrainÐBehavior Relationships.Washington,DC:American PsychologicalAssociation.DEPARTMENTOFHEALTH& DEPARTMENTFOREDUCATIONANDSKILLS(2002)Guidance for Restrictive Physical Interventions.Valuing People:A New Strategy for Learning Disability forthe 21st Century.London:Department of Health.DORSEY,M.F.,IWATA,B.A.,REID,D.H.& DAVIS,P.A.(1982) ÔProtectiveEquipment:Continuous and Contingent Application in the Treatment of Self-injurious BehaviourÕ,Journal of Applied Behavioral Analysis15(2):217Ð30.DUKER,P.& SEYS,D.(1997) ÔAn Inventory Method for Assessing the Degree ofRestraint Imposed by OthersÕ,Journal of Behaviour Therapy and Experimental Psychiatry28(2):113Ð21.EMERSON,E.(1992) ÔSelf-Injurious Behaviour:An Overview of Recent Trends inEpidemiological and Behavioural ResearchÕ,Mental Handicap Research5:49Ð81.EMERSON,E.(2002) ÔThe Prevalence of Use of Reactive Management Strategies inJONESETAL.:RESTRAINTANDSELF-INJURY115 Community-Based Services in the UKÕ,in D.ALLEN(ed.) Ethical Approaches to PhysicalIntervention.Kidderminster:BILD.EMERSON,E.,ROBERTSON,J.,GREGORY,N.,HATTON,C.,KESSISSOGLOU,S.,HALLAM,A.& HILLERY,J.(2000) ÔTreatment and Management of ChallengingBehaviours in Residential SettingsÕ,Journal of Applied Research in Intellectual Disabilities13:197Ð213.FISHER,W.W.,PIAZZA,C.C.,BOWMAN,L.G.,HANLEY,G.P.& ADELINISJ.D.(1997) ÔDirect and Collateral Effects of Restraint and Restraint FadingÕ,Journal ofApplied Behaviour Analysis30:105Ð20.FORMAN,D.,HALL,S.& OLIVER,C.(2002) ÔDescriptive Analysis of Self-InjuriousBehaviour and Self-RestraintÕ,Journal of Applied Research in Intellectual Disabilities15:1Ð7.FOXX,R.M.& DUFRENSE,D.(1984) ÔÒHarryÓ:The Use of Physical Restraint as aReinforcer,Time-Out from Restraint,and Fading Restraint in Treating a Self-Injurious ManÕ,Analysis and Intervention in Developmental Disabilities4:1Ð14.GRIFFIN,J.C.,WILLIAMS,D.E.,STARK.M.T.,ALTMEYER,B.K.& MASON,M.(1986) ÔSelf-injurious Behaviour:A State-wide Prevalence Survey of the Extent andCircumstancesÕ,Applied Research in Mental Retardation7:105Ð16.HAMAD,C.D.,ISLEY,E.& LOWRY,M.(1983) ÔThe Use of Mechanical Restraint andResponse Incompatibility to Modify Self-Injurious Behaviour:A Case StudyÕ,MentalRetardation21(5):213Ð17.HARRIS,J.(1996) ÔPhysical Restraint Procedures for Managing ChallengingBehaviours Presented by Mentally Retarded Adults and ChildrenÕ,Research inDevelopmental Disabilities17(2):99Ð134.HARRIS,J.,ALLEN,D.,CORNICK,M.,JEFFERSON,A.& MILLS,R.(1996) PhysicalInterventions:A Policy Framework.Kidderminster:BILD.HARRIS,P.& RUSSELL,O.(1989) ÔThe Prevalence of Aggressive Behaviour amongPeople with Learning DifÞculties (Mental Handicap) in a Single Health DistrictÕ,Bristol:Norah Fry Research Centre,University of Bristol.HASTINGS,R.P.(1996) ÔStaff Strategies and Explanations for Intervening withChallenging BehavioursÕ,Journal of Intellectual Disability Research40:166Ð75.HORNER,R.H.& CARR,E.G.(1997) ÔBehavioral Support for Students with SevereDisabilities:Functional Assessment and Comprehensive InterventionÕ,The Journal ofSpecial Education31:88Ð104.IWATA,B.A.,DORSEY,M.F.,SILFER,K.J.,BAUMAN,K.E.& RICHMAN,G.S.(1982) ÔToward a Functional Analysis of Self-InjuryÕ,Analysis and Intervention inDevelopmental Disabilities2:3Ð30.KAHNG,S.,ABT,K.A.& WILDER,D.A.(2001) ÔTreatment of Self-Injury Correlatedwith Mechanical RestraintsÕ,Behavioural Interventions16:105Ð10.KAHNG,S.,IWATA,B.A.& LEWIN,A.B.(2002a) ÔBehavioural Treatment of Self-Injury,1964to 2000Õ,American Journal on Mental Retardation107(3):212Ð21.KAHNG,S.,IWATA,B.A.& LEWIN,A.B.(2002b) ÔThe Impact of FunctionalAssessment on the Treatment of Self-Injurious BehaviourÕ,in STEPHENR.SCHROEDER,MARYLOUOSTERKER& TRAVISTHOMPSON(eds) Self InjuriousBehavior:GeneÐBrainÐBehavior Relationships.Washington,DC:American PsychologicalAssociation.LAVIGNA,G.W.& WILLIS,T.(2002) ÔCounter-Intuitive Strategies for CrisisManagement within a Non-Aversive FrameworkÕ,in D.ALLEN(ed.) Ethical Approachesto Physical Interventions.Responding to Challenging Behaviour in People with Intellectual Disabilities.Kidderminster:BILD.JOURNALOFINTELLECTUALDISABILITIES11(1)116 LERMAN,D.C.,IWATA,B.A.,SMITH,R.G.& VOLLMER,T.R.(1994) ÔRestraintFading and the Development of Alternative Behviour in the Treatment of SelfRestraint and Self InjuryÕ,Journal of Intellectual Disability Research38:135Ð48.MENTALWELFARECOMMISSIONFORSCOTLAND(2002) Rights,Risks and Limits toFreedom:Principles and Guidance on Good Practice in Caring for Residents with Dementia and RelatedDisorders and Residents with Learning Disabilities Where Consideration Is Being Given to the Use ofPhysical Restraint and Other Limits to Freedom.Edinburgh:MWCS.MURPHY,G.(1999) ÔSelf-Injurious Behaviour:What Do We Know and Where Are WeGoing?Õ,Tizard Learning Disability Review4(1):5Ð11.MURPHY,G.,OLIVER,C.,CORBETT,J.,CRAYTON,L.,HALES,J.,HEAD,D.&HALL,S.(1993) ÔEpidemiology of Self Injury,Characteristics of People with SevereSelf Injury and Initial Treatment OutcomeÕ,in C.KIERNAN(ed.) Research into Practice?Implications of Research on the Challenging Behaviour of People with Learning Disability,pp.1Ð35.Kidderminster:BILD.OLIVER,C.,MURPHY,G.H.& CORBETT,J.A.(1987) ÔSelf-Injurious Behaviour inPeople with Mental Handicap:A Total Population StudyÕ,Journal of Mental DeÞciencyResearch31:147Ð62.OLIVER,C.,HALL,S.,HALES,J.,MURPHY,G.& WATTS,D.(1998) ÔThe Treatmentof Severe Self-Injurious Behavior by the Systematic Fading of Restraints:Effects onSelf-Injury,Self-Restraint,Adaptive Behavior and Behavioral Correlates of AffectÕ,Research in Developmental Disabilities19(2):143Ð65.OÕNEILL,R.E.,HORNER,R.H.,ALBIN,R.W.,SPRAGUE,J.R.,STOREY,K.&NEWTON,J.S.(1997) Functional Assessment and Program Development for Problem Behaviour:A Practical Handbook.PaciÞc Grove,CA:Brooks/Cole.QURESHI,H.(1994) Parents Caring for Young Adults with Mental Handicap and Behaviour Problems.Manchester:Hester Adrian Research Centre.RICHMOND,G.,SCHROEDER,S.R.& BICKEL,W.(1986) ÔTertiary Prevention ofAttrition Related to Self Injurious BehaviorsÕ,in K.D.GADOW(ed.) Advances inLearning and Behavioral Disabilities,vol 5.London:JAI Press.ROBERTSON,J.,EMERSON,E.,PINKNEY,L.,CEASAR,E.,FELCE,D.,MEEK,A.,CARR,D.,LOWE,K.,KNAPP,M.& HALLAM,A.(2005) ÔTreatment andManagement of Challenging Behaviours in Congregate and Non-CongregateCommunity-Based Supported AccommodationÕ,Journal of Intellectual Disability Research49(1):63Ð72.SCHROEDER,S.R.,MULICK,J.A.& ROJAHN,J.(1980) ÔThe DeÞnition,Taxonomy,Epidemiology,and Ecology of Self-Injurious BehaviourÕ,Journal of Autism andDevelopment Disorder10:417Ð32.SCHROEDER,S.R.,OSTERKER,M.L.& THOMPSON,T.(eds) (2002) Self-InjuriousBehaviour:GeneÐBrainÐBehaviour Relationships.Washington,DC:American PsychologicalAssociation.SCOTTI,R.J.,UJCICH,K.J.,WEIGLE,K.L.,HOLLAND,C.M.& KIRK,K.S.(1996) ÔInterventions with Challenging Behavior of Persons with DevelopmentalDisabilities:A Review of Current Research PracticesÕ,Journal of the Association for Personswith Severe Handicaps21(3):123Ð34.SIMPSON,D.& MILLER,L.(2004) Unexpected Gains:Psychotherapy and People with LearningDisability.London:Karnac.SPAIN,B.,HART,S.A.& CORBETT,J.(1984) ÔThe Use of Appliances in theTreatment of Severe Self-Injurious BehaviourÕ,in GLYNISMURPHY& BARBARAJONESETAL.:RESTRAINTANDSELF-INJURY117 WILSON(eds) Self-Injurious Behaviour:A Collection of Published Papers on Prevalence,Causes,andTreatment in People Who Are Mentally Handicapped or Autistic.Kidderminster:BIMH.STURMEY,P.(2002) ÔRestraint ReductionÕ,in D.ALLEN(ed.) Ethical Approaches toPhysical Intervention:Responding to Challenging Behaviour in People with Intellectual Disabilities.Kidderminster:BILD.TATE,B.G.(1972) ÔCase Study:Control of Chronic Self-Injurious Behavior byConditioning ProceduresÕ,Behaviour Therapy3:72Ð83.THOMPSON,T.& CARUSO,M.(2002) ÔSelf-Injury:What WeÕre Looking ForÕ,inSTEPHENR.SCHROEDER,MARYLOUOSTERKER& TRAVISTHOMPSON(eds) Self Injurious Behavior:GeneÐBrainÐBehavior Relationships.Washington,DC:AmericanPsychological Association.THOMPSON,T.,EGLI,M.,SYMONS,F.& DELANEY,D.(1994) ÔNeurobehavioralMechanisms of Drug Action on Developmental DisabilitiesÕ,in T.THOMPSON& D.B.GRAY(eds) Destructive Behaviour in Developmental Disabilities:Diagnosis and Treatment.Thousand Oaks,CA:Sage.Correspondenceshould be addressed to:EDWINJONES,Special Projects Team,Unit 3,Cowbridge Court,56Ð58CowbridgeRoad West,Cardiff,Wales CF55BS,UK.e-mail:edwin.jones@bromor-tr.wales.nhs.ukDate accepted23/07/06JOURNALOFINTELLECTUALDISABILITIES11(1)118 APPLIEDPSYCHOLOGY|REVIEWARTICLETreatingself-injuriousbehaviorsinautismspectrumdisorderGaryShkedy2,DaliaShkedy3andAileenH.Sandoval-Norton1*Abstract:Self-injuriousbehaviors(SIBs)are“aclassofbehaviors,oftenhighlyrepetitiveandrhythmic,thatresultinphysicalharmtotheindividualdisplayingthebehavior.”Intheautisticpopulation,SIBsareconsiderednon-suicidalself-injuriousbehaviors,duetonoapparentintentorwillfulself-harm.SIBsarehighlyprevalentinpeoplewithAutismSpectrumDisorder(ASD).TherearefewhypothesesforwhypeoplewithASDself-harm;onewidelyacceptedmethodforassessingself-harm;andnorealconsensusfortreat-ment.However,acomprehensivereviewofliteratureonSIBsmakeitevidenttheetiologyofSIBsmaylieinaspecificdeficit,similarlytohowpsychologistsviewSIBsinnon-autisticpersons;andthataneffectivetreatmentoptionexists,yetisnotusedonASDpatients.SIBsintheautisticpopulationshouldbeconceptualizedthesamewaytheyarecon-ceptualizedinneurotypicalindividuals,andshouldbetreatedwiththesamegoalscurrentlyusedinCognitiveBehavioralTherapiesevenwhentheindividualisnonverbalorminimallyverbal.Subjects:Self-HarminChildrenandAdolescents;Autism&AspergersinChildren&Adolescents;Autism;CommunicationDisordersKeywords:autism;self-injuriousbehaviors;functionalcommunication;treatment;dialecticalbehaviortherapyABOUTTHEAUTHORAlternativeTeachingStrategyCenter(ATSC)isanon-profitorganizationlocatedinSanDiego,Californiadedicatedtoprovidingservicestofamilieswithchildrenandadultswithautismandothercognitiveandlearningdisabilities.ATSCworksdirectlywithparents,insurancecompanies,schooldistricts,andotherStateagencies,andprovidesone-on-onetreatmentservicestochildrenandadultsfromallovertheworld.ATSCisdedicatedtoresearchingtreat-mentsandinterventionsprimarilyinautismandrelateddisorderswithaprimaryfocusonsevereautism,duetoasparselypopulatedresearchbase.Thegroup’sworkincludestopicsrelatedtotheeffectiveoveralltreatmentoptionsandmethods,theuseoftechnologyintreatment,implementationofspecialeducationespeciallyinpublicschools,socialization,andethicalprac-tice,withagoalofimprovingthequalityoflifefortheaforementionedpopulations.PUBLICINTERESTSTATEMENTSelf-injuriousbehaviors(SIBs)are“aclassofbehaviors,oftenhighlyrepetitiveandrhythmic,thatresultinphysicalharmtotheindividualdis-playingthebehavior.”Intheautisticpopulation,SIBsarehighlyprevalent,andareconsiderednon-suicidalself-injuriousbehaviors,duetonoapparentintentorwillfulself-harm.TheaimofthispaperistoreviewtheliteratureonSIBsandtohighlighttheetiologyofSIBsinAutismSpectrumDisorder(ASD)sinceitissimilartothewaypsychologistsviewSIBsinnon-autisticpersons.Thisisnoteworthyaspsychologistshavesuccess-fullytreatedSIBsformanyyears,yetthistreatmentoptionandthetheoriesbehindithaveneverbeenappliedtotheunderstandingSIBsinpersonswithASD.Furthermore,currentapproachestoSIBsinpersonswithASDareactuallycounter-intuitiveandcanperpetuateabuseandlearnedhelplessness.Theseresearcherscalluponprofessionalstousethesameapproachesusedinthenon-autisticpopula-tionandtodiscontinueunscientificapproachestoSIBSinthisvulnerablepopulation.Shkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766©2019TheAuthor(s).ThisopenaccessarticleisdistributedunderaCreativeCommonsAttribution(CC-BY)4.0license.Received:29July2019Accepted:10October2019FirstPublished:22October2019*Correspondingauthor:AileenH.Sandoval-Norton,ClinicalDirector,AlternativeTeachingStrategyCenter,10640ScrippsRanchBlvdSuite200,SanDiego,CA92131,USAE-mail:aherlindasandoval@gmail.comReviewingeditor:LucaCerniglia,Uninettunouniver-sity,ItalyAdditionalinformationisavailableattheendofthearticlePage1of9 1.Self-injuriousbehaviorsinautismcomparedtootherpopulationsSelf-injuriousbehaviors(SIB)aredescribedas“aclassofbehaviours,oftenhighlyrepetitiveandrhythmic,thatresultinphysicalharmtotheindividualdisplayingthebehaviour(Fee&Matson,1992,p.4).”Whenthesebehaviorsoccurintheautisticpopulationtheyareconsideredwhatpsychologistsrefertoasnon-suicidalself-injuriousbehaviors,asthereisnoapparentintentorwillfulself-harm.Thesebehaviorsincludebutarenotlimitedtobiting,hairpulling,head-banging,andskinpicking/scratching(Minshawietal.,2014).Diagnostically,self-injuriousbehaviorsaretypicallyassociatedwithBorderlinePersonalityDisorder(BPD),butresearchhasidentifiedthesebehaviorstobehighlyprevalentinchildrenwithAutismSpectrumDisorder(ASD)aswell(AmericanPsychiatricAssociation[APA],2013;Sokeetal.,1971).Infact,researchsuggests30%ofchildrenwithAutismSpectrumDisorderinclinic-basedstudiesengageinSIB.Additionally,SIBsaremorecommoninchildrenwithASDthanintheirtypicallydevelopingpeers(Minshawietal.,2014;Sokeetal.,1971).WhileASDisdiagnosticallycategorizedaspersistentdeficitsinsocialcommunicationandinteraction,aswellasrestrictedorrepetitivepatternsofbehaviors,interestsoractivities,butinadditiontothesecoresymptoms,ASDhasalsobeenstronglyassociatedwithsensoryprocessingissuesandself-injuriousbehaviors(Baghdadli,Pascal,Grisi,&Aussilloux,2003;Duerdenetal.,2012;Rattaz,Michelon,&Baghdadli,2015;Richards,Oliver,Nelson,&Moss,2012).PsychologistsobserveSIBsinchildrenandadultsinthetypicalpopulationandhaveconceptua-lizedSIBsasaresultofdifficultyregulatingextremenegativeemotions,andphysicaland/orpsychologicalpain(Skegg,2005).Meaning,manyoftheseindividualsdonothavetheskillstoregulateorcommunicateandthereforeitistheironlywaytocope.ThisisalsowhySIBsaretypicallyassociatedwithhopelessnessandlowself-esteem.Inthefieldofpsychology,SIBsareoftenconceptualizedasa“cryforhelp”,meaningthatthepersonneedsandmaybetryingtoobtainhelp,butisunabletodosoinanadaptivemanner.SIBscanbeviewedasanonverbalmeanstocryforhelpwhenthelanguageandcopingskillsarenotavailable,and/orthepainisunbearable.InpersonswithoutASD,thecommunicationdeficitisnotreferringtospeechabilitybutisreferringtoeffectivecommunicationandinterpersonaleffectiveness.Thatis,onecanhavefullverbalabilitiesbutisunabletoexpressthemselvesinanadaptiveandeffectivemanner,ortheydonothaveasupportiveenvironmenttodoso.Forexample,someindividualswhoengageinSIBsmaytheoreticallybeabletocommunicateeffectivelybuttheyareoppressedbytheirenvironmentandsotheyarenotfreetodoso.TheresultsarethattheindividualcannotopenlyaskforhelpandresortstoSIBs-asilentcryforhelp.ThisconceptualizationofSIBsandthevariablesthatcontributetoSIBsisnotbreakingnews.Infact,a“cryforhelp”hasevenbeenimplementedinvariousstandardizedassessmentssuchastheMinnesotaMultiphasicPersonalityInventory(MMPI)(Hathaway&McKinley,1943).TheMMPIandotherassessmentshelppsychologistsreadilyidentifysuchpsychologicaldistressandpersonalitycharacteristicsinordertoinformtreatment.OncepsychologistsareawareofanySIBstheyactimmediatelytohelpidentifypain,amelioratethepain,andimprovetheclient’scopingandcommunicationskills.DialecticalBehaviorTherapy(DBT)isthemostwidelyused,evidence-basedtreatmentforSIBs.DialecticalBehaviorTherapyisamodifiedformofCognitiveBehaviorTherapy(CBT),whichemphasizestheinterconnectednessofone’sphysiology,thoughts,emotionsandbehavior.DialecticalBehaviorTherapy(DBT)usesthisfoundationandfocusesoninterpersonaleffectiveness,distresstolerance/realityacceptance,emotionregulation,andmindfulness(Linehan,1993).Trainedpsychologistsincorporateclinicaljudgment,empathyandrapportastheyimple-mentinterventionstoimprovecommunication,increasefrustrationtolerance,andimproveemo-tionregulationinindividualswhoself-injure.ThehallmarkofDBTistohelptheindividualwithSIBslearnskillstocommunicate,regulatetheiremotions,andtodevelopfrustrationtolerance.DBTandothersimilarCognitiveBehavioralTherapieshaveworkedwondersforindividualswhosufferandengageinSIBs.However,thisconceptualizationofSIBsingeneral,hasnotbeenappliedtochildrenwithASD.Shkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page2of9 Whileitmaybesurprisingtosome,thereasonswhysomeonewithASDmayengageinSIBsarethesamereasonswhyanindividualwithoutASDmayengageinSIBsmentionedabove(i.e.pain,inabilitytocommunicate).Researchfromvariousfieldsindicatesthatcommunicationand/or“adaptiveskills”canbetriggersfor,andveryoftendirectlycorrelatewithSIBsinpeoplewithASD(Baghdadlietal.,2003;Chiang,2008;Matson,Boisjoli,&Mahan,2009;Murphyetal.,2005;Richardsetal.,2012;Weiss,2003).Researchershaveconsistentlyfoundthatself-injuriousbehaviorsinindividualswithASDarehighlyassociatedwithlowerlevelsofadaptiveand/orexpressivelanguageskills(Baghdadlietal.,2003;Chiang,2008;Matsonetal.,2009;Murphyetal.,2005;Richardsetal.,2012;Weiss,2003).Interestingly,thereisastrongassociationbetweenchallengingbehaviorsandlearningdisabilities,butthechildrenwithASDwhomanifestSIBsaretypicallythosewithnoexpressivelanguageatall(Mossetal.,2000).ChildrenwithASDwhoarenonverbalorhavelowerlevelsofexpressivelanguagehavehigherincidenceofSIB(Baghdadlietal.,2003;Chiang,2008;Foxx&Livesay,1984;Mossetal.,2000;Rattazetal.,2015;Talkingtonetal.,1971).ResearchhasbeenfairlytransparentthatahighproportionofchildrenwithASDwithsevereimpairmentsusechallengingbehaviorasaformofexpression,andevenifthebehaviorisignored,thechildwillstillengageinSIBinordertotrytocommunicate(Chiang,2008).Aspreviouslymentioned,thisisconsistentwithwhatmanypsychologistsunderstandtobeaskillsdeficitand/orcryforhelp.ResearchhascontinuedtofindahighprevalenceofchallengingbehaviorinchildrenwithASDwhohavelimitedspokenlanguage,andadecreaseinthesebehaviorswhenteachingfunctionalcommunication,againsupportingtherelationshipbetweenexpressivelanguageskillsandchallengingorself-injuriousbehaviors(e.g.Baghdadlietal.,2003;Chiang,2008;Murphyetal.,2005;Saloviita,2000).Sometherapistsandresearchershavebeguntorealizethatchallengingbehaviorsareareflectionofdeficitsthatcanbeamelioratedbyteachingcommunicativeskills,orwhatissometimescalledfunctionalcommunicativetraining(Carr&Durand,1985;Durand,1990;Murphyetal.,2005).However,itappearsthatdespitetheconsistencyinresearchindicatingpoorexpressivelanguageorcommunicationskillsaresignificantlycorrelatedwithSIB,theapplicationofthisresearchislacking(Matsonetal.,2009;Rattazetal.,2015;Shodell&Reiter,1968;Talkingtonetal.,1971).Evenresearchinotherfieldsoutsideoftraditionalapproachestopsychologyhaveattemptedtostudypossibleneurochemicalimplicationsthatcouldhelpexplainthesebehaviors,inordertoinformtreatment.Thehypothesesdevelopedfromaneurochemicalperspectivehavebeengenerallyunremarkablebutareincludedhereforcomprehensiveness.ResearchhasgenerallyfoundinconsistentassociationsorlinksbetweenanymajorneurochemicalissuesaswellasinconsistenteffectivenessoftreatmentsforSIBs.However,someofthecommonhypothesesindicatetheroleofnaturalopiatesorendor-phins,aswellasadeficitinspecificneurotransmitters.DopamineandserotoninhavebeenlinkedtoSIBsinAutismSpectrumDisorderbasedonanimalstudies(Goldstein,1989)aswellastheuseofdopamineandserotoninantagonistssuchasHaloperidolandRisperidone(Weiss,2003).Researcherssuggestthatperhapsadeficiencyinserotoninmaybetheculpritofincreasedratesofself-aggression(Cohen,Ihrig,Lott,&Kerrick,1998;VandenBorreetal.,1993).However,thereisnoempiricalevidencetosupporttheideathattheserotoninsystemaloneunderliesself-injury(Rothenberger,1993b).Theopiateor“addictionhypothesis”suggeststhatthereleaseofopiatesafterthepainproducedbySIBisreinforcinginitofitself.Thisandsimilarhypothesessuggestthatsomeonewhoself-injurescanbecomeaddictivetotheopiatesorendorphinsreleasedandwillsubsequentlyengageinself-injuryevenmore(Rothenberger,1993a,1993b;Sandman,1990;Sandman&Hetrick,1995).Opiatesareaddictiveforeveryone,andsobythesamelogiconecouldarguethatthosewithBPDalsoengageinSIBbecausetheyareaddictedtothereleaseofopiatesafterthepainproducedbySIBs.However,empiricalevidenceandgeneralsupportforthesehypothesesdonotexistinordertoapplythisresearchtoSIBsinanypopulation(includingtheautisticpopulation)withanyreliability(Rothenberger,1993a,1993b).Additionally,whilemostresearchinthisareahasfocusedonwhetherornotphysiologyorneurochemicalprocessescanbeconsideredtheetiologyforSIB,otherstudieshaveviewedSIBasmerelyasymptomandthephysiologicalcomponentasapartofamaladaptivecopingstrategy(Groschwitz&Plener,2012;Kartzinel,2018).ThesestudieshaveindicatedthattheShkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page3of9 physiologicalresponsesresultinginpainfromnon-suicidalself-injurycanbeanattempttohealpsychologicalpainorotherpain,especiallyforindividualswithaninsufficientstressresponse.Thishypothesisismoreconsistentwiththewaymostpsychologistsconceptualizeself-injuriousbehaviors,particularlythosepsychologistswhouseevidence-basedtreatmentsuchasCognitiveBehavioralTherapyorDialecticalBehaviorTherapy(DBT)(Linehan,1993).SinceneurochemicalorphysiologicalhypothesesconsistofaverysmallportionofresearchregardingSIBandhasnotproducedanyconsistentresults,manyparaprofessionalsarestillsearchingforanswersevidentlywithouttheknowledgeoftwothings:firstly,thatpsychologistsalreadyknowhowtoappropriatelytreatSIB,andsecondly,thatresearchindicatesSIBsinASDhasthesameorsimilaretiology(e.g.painand/orcommunicationdeficits)asSIBsinthenon-autisticpopulation,indicatingthatexistingtreatmentmethodsarelikelyadequate.WhyisitwhenindividualswithASDengageinSIB,theresearch,knowledge,andexpertiseregardingSIBanditstreatmentareignored?WhenneurotypicalindividualsengageinSIB,theyareapproachedwithempathy,competencyandtheapplicationofresearchandevidence-basedpractices(e.g.,DBT,CBT),whileanequivalentautisticindividualengaginginSIBgoeswithoutanyofthese.ThismaybeinpartbecausethemajorityofchildrenwithASDwhoengageinSIBshaveminimalexpressivelanguage,sotraditionaltalktherapiesandinterventionsarenotappropriate.Whilethetreatmentmayhavetobeadjusted,thequestionstillstandsastowhythegeneralconceptualizationofSIBsisignored?ItislikelyduetoadisconnectbetweenthosewhoareexpertsinhumanpsychologyandthosewhodeliverservicestotheASD,aswellasthecurrentapproachtoSIBsintheASDpopulation.2.Thecurrentunscientificapproachofassessingself-injuriousbehaviorsDespitethecurrentresearchandknowledgeregardingself-injuriousbehaviorsandawell-establishedevidence-basedtreatment,manyprofessionalsandparaprofessionalsneglectbestpracticesandattempttodifferentiateSIBintheautisticpopulation,asifitwasanentirelydifferentsymptomorpsychosis.Currently,themostpopular“go-to”assessmentforSIBsintheautisticpopulationisaFunctionalBehavioralAssessmentorAnalysis(FBA).AnFBAisintendedtodevelopandthentestvarioushypothesesinordertoeventuallydeterminethe“function”ofabehavior,inthiscaseself-injuriousbehaviors(Maurice,Green,&Luce,1996).AFunctionalBehaviorAssessmentorAnalysisisamethodthatiswidelyusedinAppliedBehavioralAnalysis(ABA)therapyandistypicallyconductedbyaBoardCertifiedBehavioralAnalyst(BCBA),inordertoassumethefunctionofabehavior.AppliedBehavioralAnalysisutilizesoneverysmallsubsetofpsychologycalledbehavioralpsychologyorbehaviorismasthepremiseforitstreatmentpractices.ThebehavioristmovementbeganpredominantlywithJohnB.WatsonandB.F.Skinnerintheearly1900s.Behavioristsbelievethatallbehaviorissimplyareflexorreactiontoouroutsideenvironment.Theseearlybehavioralpsychologistsinsistedthatwhatcannotbeobservedcannotbescientificallystudiedandmeasured,especiallyintangiblessuchassensa-tions,emotions,andthoughts(Myers&DeWall,2017).Theimportanceofthoughts,emotions,andinternalprocessesbecameevidentwiththeriseofcognitivepsychology,whichbecamemorewidelyacknowledgedinthemid-1900s.Asaresult,theprinciplesofbehaviorismthatareimplementedthroughABAtherapydonottakeintoaccountinternalprocesses.Consequently,theFBAwasdesignedtodeterminethefunctionorcauseofexternalbehaviorsbyidentifyingexternaltriggersorstimuli.ABAusesanFBAtotrytodeterminethefunctionofthebehaviorbyusingwhatiscalled“ABC”-antecedents,behavior,andconsequences(Martin&Pear,2011).Anantecedentisstimulithatexistsrightbeforeabehavior,andtheconsequenceiswhatoccursafterabehavior.Forexample,achildseeshisfriend(antecedent),thechildrunstohisfriendandfallsdown(behavior),thechildbeginstocry(consequence).Inthisscenario,youcanclearlydetermineoneexternalfunctionforwhythechildiscrying-heisphysicallyhurt.Nowconsideranactualcasefromclinicalpracticewhenanonverbalchildwasaskedtomatchphotosofhisfamilymembers.Everytimehewasshownaphotoofhisfather(antecedent),hewouldthrowtheiPad(behavior)andthushedidnothavetomatchthephotoofhisfather(consequence).However,therealreasonforthebehaviorwashisparentsweregettingdivorcedandthefatherShkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page4of9 hadjustmovedoutofthehouse.Continuingwiththechainofbehaviors,thechildavoidsthetask(antecedent),thebehavioristusesrewardorpunishmenttomakethechilddothetaskagain(behavior),andthenthechildthrowstheiPadagainandbecomespsychologicallydis-tressed(consequence).Thecyclecontinuesandasaresult,thetherapistcontinuestoinvalidatethechildandexacerbatethechild’semotionalandpsychologicaldistressrelatingtohisparents’separation.Nowrecallthefirstexample,thechildwhofallsasherunstohisfriendmayalsobecryingduetoembarssmentorshame,butthiswouldnotbeanexternal,measureablefactoranditnolongerfitswithintherealmofbehaviorism.Behavioristsmightrealizethattheobservablebehaviorisanexpressionofaninternalprocess,buttheunderstandingandtreatmentofthebehaviorisnowbeyondthescopeofabehaviorist.ABAtherapistsuseanFBAtolookatboththeantecedentandtheconsequenceofSIBsinordertohypothesizethefunctionofSIBs.Itisunclearwhyonewouldassumesuchanassessment/analysiswouldalsobeappropriatetoassessthethoughts,feelings,andotherinternalprocessesthatoftendeterminethefunctionofself-injuriousbehaviors(especiallysinceweknowthisisthecaseforSIBsinthenon-autisticpopulation).InsteadofapproachingtheseSIBsandunderstand-ingthemthewayweunderstandSIBsinotherpopulations,wehavemisappliedanFBAinanattempttomeasureSIBsdespitethefactthatitcannotmeasuresuchaconstruct.Thismakestheassessmentunscientificandmethodologicallyflawed.Consequently,themisappliedFBAhassometimesobtainedthesameinformationandobservationasthepreviouslymentionedresearch(communicationdifficultiescorrelatedwithSIB),buttheconclusionsforthefunctionsofSIBreachedarevaried,inconsistent,andwithoutanyscientificbasis.Therefore,anytreatmentrecommendationsthatarederivedfromanFBAshouldbeconsideredunreliablesincetheassessmentmethodinitofitselfisunscientific,asitattemptstomeasureanunobservableconstruct,whichisoutsideofthesphereofbehaviorismandshouldonlybeperformedbysome-onetrainedinpsychology.3.Attemptsmadetoexplainanddifferentiateself-injuriousbehaviorsinautismMosthypothesesandresearchsurroundingSIBintheAutismpopulationhavebeenderivedfromAppliedBehavioralAnalysis(ABA),specificallythroughtheapplicationofaFunctionalBehavioralAnalysis(FBA),previouslydescribed.AlthoughtheFBAwasinventedtoassessexternalbehaviorsandstimuli,ithasbeeninappropriatelyappliedtoaddressSIBtodevelophypothesesastotheinternal,invisibleprocesseswithinachildinordertodeterminewhytheyareengaginginSIB.Asaresult,variousbehavioralhypothesesandtreatmentrecommendationshavearisenfromtheseFBA,despitetheinappropriateuseofthisassessmenttoolanditsinherentmethodologicalflaws.ThesehypotheseshaveignoredtheevidentlycommontriggerforSIBacrossamultitudeofstudiesperhapsduetothedivisionofprofessionalfields,confirmationbias,andalackofcross-disciplinaryeducation.SomecommonhypothesesderivedfromtheapplicationofanFBAsuggestthefunctionofSIBislikelysocialattention,accesstotangiblerewards,toescapeoravoidcertainactivitiesorsituations,orduetointernalself-stimulation(Minshawietal.,2014).ForanunderstandingofwhytheFBAisinappropriate,letusexaminetheconclusionthatSIBisusedfortaskavoidance.Considerastudentwhohitshisownheadwhenthetherapistgiveshimadifficulttasktoperform.OneassumptionwouldbethatthestudentdidnotwanttodothetasksotheSIBisanexpressionoftaskavoidance.Anotherassumptioncouldbethatthepresentationofthedifficulttasktriggeredastressresponseand/orapainresponse.Inthiscase,theSIBisanexpressionofpainrelief.Yetanotherassumptioncouldbethestudenthadaheadacheandbypresentingatasktobeperformed,thetherapistwasnotacknowledgingthepain,andsotheSIBisanexpressionoffrustrationandhelplessness.Atthispoint,itshouldbeapparentthateachoftheseassumptionsarejustassumptionsandcannotbevalidatedwithoutsophisticatedequipment(e.g.anFMRI)orexpertiseinhumanpsychology,andthereforearenotscientificallyreliableandcannotformthebasisforanytreatmentprotocol.Moreover,anFBAattemptingtoidentifyinternalprocessesandmotivationsforSIBiscontradictorytoBehaviorism,andproducesonlyassumptionsthatcannotbeconsideredscientificallyreliable.Shkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page5of9 SinceanFBAcannotadequatelyassessthechild’sintentionsormotives,researchershavemanipu-latedvarioussettingsandresponsestoSIBinordertobetterpinpointtheetiologyforSIB.SomeoftheresponsestoachildwhoisengaginginSIBasinthepriorexamplearepunishment-basedsuchasmistingthechildinthefacewithwaterortakingawaydesiredobjects.Otherresponsesincludewithholdingattentionfromthechild,ignoringthechild,orremovingthechildfromthesituation(Carr,1977;Minshawietal.,2014;Weiss,2003).ItisunclearwhyonewouldthinktheseresponsesareappropriateforsomeonewhoisengaginginSIBsincetheseresponsesdonotfollowanyevidenced-basedtreatmentortheoreticalorientation.ApsychologistortherapistwouldnotrespondtoanyclientthiswayafterdiscoveringtheirclienthasbeenorisengaginginSIB.4.DonoharmManyparaprofessionalsandprofessionalscontinuetouseFunctionalBehavioralAnalysis(FBA)repeatedly,oftencompletelyineffectively,withthesamechild,perhapswiththehopesofeventuallyidentifyingthefunctionofSIBassomethingexternalorsomekindofbehaviorthatcanbemodified.Thiskindofconfirmationbiasmaybepartlytoblameforwhyafocustowardfunctionalcommunica-tionhasnotbeenwidelyestablished.Instead,childrenwhoengageinself-injuriousbehaviorsareignored,forcedtoengageinanactivitytheycannotcompleteordonotunderstand,arepunishedwithdog-trainingtechniquessuchaselectricalshockorwatermisting,areforcedtowearhelmets,forcedintorestraints,areleftinpaddedrooms,etc.(Carr,1977;Minshawietal.,2014;Weiss,2003).InadditiontothefactthattheseresponsestoSIBareabusiveandcontraindicatedinalmosteverytheoreticalorientationandevidence-basedpractice,theseresponseshavealsobeenidentifiedwithinMarshaLinehan’sBiosocialTheoryasthecausesofBorderlinePersonalityDisorder(1993).Theinvalidatingandignoringofachild,aswellaspunishingtocontrolbehavior,andnottakingseriouslythechild’sneedsareallcommonandevenrecommendedresponsestoSIBintheautisticpopulation,despitetheseresponsesbeinglinkedtothedevelopmentofBorderlinePersonalityDisorder.Infact,researchindicatesco-morbiditiesandcommonalitiesinsymptomsofBPDandASDsuchasinterpersonalinstability,SIBs,socialimpairments,irregularfacialemotionrecognition,andadysfunctionalpatternofempathiccapacity(Dell’Ossoetal.,2018;Fertucketal.,2009;Harari,Shamay-Tsoory,Ravid,&Levkovitz,2010).Fertuckandcolleaguesfound“MentalstatediscriminationbasedontheeyeregionofthefaceisenhancedinBPD.AnenhancedsensitivitytothementalstatesofothersmaybeabasisforsocialimpairmentsinBPD.”(Fertucketal.,2009,p.1)Thisresearchisnotdissimilartowhatweknowabouttheautisticbrain.InAutismresearch,the“hyperarousalmodel”isamuchsupportedmodelwhichstatesthatgazeavoidanceisanadaptive(appropriate)responsebecausethefaceandeyesarestronglyaversivetothosewithASD(Corden,Chilvers,&Skuse,2008;Daltonetal.,2005;Richer&Coss,1976;Senju&Johnson,2009).Researchalsoindicatesageneralhyperactivityinvariousareasoftheautisticbrainresultinginoverstimulationwhichcanexplainanumberofsymptoms,inadditiontojustaversiveresponsestoeye-gaze(Dichter,Felder,&Bodfish,2009;Markram&Markram,2010;Martineau,Andersson,Barthélémy,Cottier,&Destrieux,2010).Anotherstudyexploringco-morbiditiesfound15%offemalepatientswithaverifieddiagnosiswithBPDalsometfullcriteriaforASD(Rydén,Rydén,&Hetta,2008).Inaddition,thesepatientshadmorefrequentsuicideattemptsandmorenegativeself-image.WhenlookingatAsperger’s,Autismandacontrolgroup,researchersfoundtheAsperger’sandAutismgroupsweresignificantlyelevatedontheBorderlinePersonalityDisorderscalewhencomparedtothecontrolgroup(Thede&Coolidge,2007).ResearchevensuggeststhatBPDandASDmight“bevariantpresentationsofempathicimbalancethediagnosticoutcomeinfluencedbytheseverityoftheimbalanceandthepresenceorabsenceofchildhoodmaltreatment”(Smith,2013,p.1).Yet,ABAtherapistsandotherparaprofessionalswithevidentlynotraininginhumanpsychologyorchilddevelopmentareengagingthekindofmaltreatmentidentifiedinBPDresearch.ThiscurrentresponsetoSIBsintheAutismpopulationisincompatiblewithanyformaleducationorknowledgeregardingcurrentresearchandappropriatewaystoaddressSIB.AtherapistisdutyboundtoDoNoHarm,andyetbytheseveryactionswearecausingmoreharmandmayevenbeaffectingthechild’spropensityforthedevelopmentofBPD.Shkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page6of9 5.CommunicationiskeyRegardlessoftheinappropriatenatureofthecurrentattemptat“treating”orunderstandingSIBsinASD,manypatternsandexistingresearchhavebeenblatantlyignored.Forexample,researchershavefoundthatinterspersingsimpledemandsamongstmoredifficultdemandsinsteadofforcingachildtositandengageinaverydifficulttask,lowersphysicalaggression(Horner,Day,Sprague,O’Brien,&Heathfield,1991).Thiswouldappeartobecommonsense,asforcinganyonetoengageinsomethingtheyareunabletodowouldnaturallycreatestress,anxiety,andfrustration;thedifferencebeingthatmostpeopleorchildrencanverballyexpresstheirdissatisfactionandcanaskforabreak,orhavetheautonomytotakeabreakwhenneeded.Similarly,themostprominentpatternfoundisthatSIBsignificantlydecreaseswhenthechildistaughthowtocommunicate.CoxandSchopler(1993)usedanicebergmetaphordescribingSIBasthetipoftheiceberg,onthesurfaceandeasilyvisible;butunderlyingarevariousdeficits,especiallycommunicativedeficits.AreviewoftheresearchpreviouslymentionedsuggestsCoxandSchopler’smetaphormayhavebeenspoton,yetithasbeensystematicallyignored.Onestudyinparticularevenstates“Asmentioned,teachingcommunicativebehaviorsthatresultinaccesstotangiblesorescapefromaversivesituationscanreplacethefunctionalpropertiesoftheSIB,strippingtheproblematicbehaviorsoftheiradaptivequalities”(Weiss,2003,p.137).Yetinclinicalsettings,expressivecommunicationisstillnotviewedasanetiologyorhypothesisforSIBintheASDpopulation.6.ConclusionAlthoughDBTcannotbeusedwithmanychildrenwithASDwhoexhibitSIB,wecanneverthelesslearnfromtheDBTapproachandapplysimilarstrategiesforchildrenwithASD.Thefirststepistotreatthemwithempathyandacknowledgetheircryforhelp.SinceoneofthemajorcausesofSIBisphysicalpain,andsomechildrenwithASDcannotcommunicatethatpain,weneedtobediligentintherecognitionandtreatmentofthatpain.ThehallmarkofDBTistohelptheindividualwithSIBlearntocommunicate,regulatetheiremotions,andtodevelopfrustrationtolerance.ForchildrenwithASDweneedtofocusonteachingthemfunctionalcommunication,andslowlybuildtheirtoleranceforfrustrationandteachthemtoregulatetheiremotions.TodoanythingelsewouldviolatetheHippocraticOath.FundingTheauthorsreceivednodirectfundingforthisresearch.AuthordetailsGaryShkedy2E-mail:gary@altteaching.orgORCIDID:http://orcid.org/0000-0002-5422-9885DaliaShkedy3E-mail:dalia@altteaching.orgORCIDID:http://orcid.org/0000-0003-1185-0054AileenH.Sandoval-Norton1E-mail:aherlindasandoval@gmail.comORCIDID:http://orcid.org/0000-0002-7066-70411ClinicalDirector,AlternativeTeachingStrategyCenter,10640ScrippsRanchBlvdSuite200,SanDiego,CA92131,USA.2DirectorofResearch,AlternativeTeachingStrategyCenter,10640ScrippsRanchBlvdSuite200,SanDiego,CA92131,USA.3ExecutiveDirector,AlternativeTeachingStrategyCenter10640ScrippsRanchBlvdSuite200,SanDiego,CA92131,USA.CompetinginterestsOnbehalfofallauthors,thecorrespondingauthorstatesthatthereisnoconflictofinterest.CitationinformationCitethisarticleas:Treatingself-injuriousbehaviorsinautismspectrumdisorder,GaryShkedy,DaliaShkedy&AileenH.Sandoval-Norton,CogentPsychology(2019),6:1682766.ReferencesAmericanPsychiatricAssociation.(2013).Diagnosticandstatisticalmanualofmentaldisorders(5thed.).Washington,DC:Author.Baghdadli,A.,Pascal,C.,Grisi,S.,&Aussilloux,C.(2003).Riskfactorsforself-injuriousbehavioursamong222youngchildrenwithautisticdisorders.JournalofIntellectualDisabilityResearch,47(8),622–627.doi:10.1046/j.1365-2788.2003.00507.xCarr,E.G.(1977).Themotivationofself-injuriousbeha-vior:Areviewofsomehypotheses.PsychologicalBulletin,84(4),800.doi:10.1037/0033-2909.84.4.800Carr,E.G.,&Durand,V.M.(1985).Reducingbehaviorproblemsthroughfunctionalcommunicationtraining.JournalofAppliedBehaviorAnalysis,18(2),111–126.doi:10.1901/jaba.1985.18-111Chiang,H.M.(2008).Expressivecommunicationofchil-drenwithautism:Theuseofchallengingbehaviour.JournalofIntellectualDisabilityResearch,52(11),966–972.doi:10.1111/j.1365-2788.2008.01042.xCohen,S.A.,Ihrig,K.,Lott,R.S.,&Kerrick,J.M.(1998).Risperidoneforaggressionandself-injuriousbeha-viorinadultswithmentalretardation.JournalofAutismandDevelopmentalDisorders,28(3),229–233.doi:10.1023/A:1026069421988Corden,B.,Chilvers,R.,&Skuse,D.(2008).Avoidanceofemotionallyarousingstimulipredictssocial–PerceptualimpairmentinAsperger’ssyndrome.Neuropsychologia,46(1),137–147.doi:10.1016/j.neuropsychologia.2007.08.005Cox,R.D.,&Schopler,E.(1993).Aggressionandself-injuriousbehaviorsinpersonswithautism:TheShkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page7of9 TEACCHapproach.ActaPaedopsychiatrica:InternationalJournalofChild&AdolescentPsychiatry.Dalton,K.M.,Nacewicz,B.M.,Johnstone,T.,Schaefer,H.S.,Gernsbacher,M.A.,Goldsmith,H.H.,…Davidson,R.J.(2005).Gazefixationandtheneuralcircuitryoffaceprocessinginautism.NatureNeuroscience,8(4),519.doi:10.1038/nn1421Dell’Osso,L.,Cremone,I.M.,Carpita,B.,Fagiolini,A.,Massimetti,G.,Bossini,L.,…Gesi,C.(2018).Correlatesofautistictraitsamongpatientswithborderlinepersonalitydisorder.ComprehensivePsychiatry,83,7–11.doi:10.1016/j.comppsych.2018.01.002Dichter,G.S.,Felder,J.N.,&Bodfish,J.W.(2009).Autismischaracterizedbydorsalanteriorcingulatehyper-activationduringsocialtargetdetection.SocialCognitiveandAffectiveNeuroscience,4(3),215–226.doi:10.1093/scan/nsp017Duerden,E.G.,Oatley,H.K.,Mak-Fan,K.M.,McGrath,P.A.,Taylor,M.J.,Szatmari,P.,&Roberts,S.W.(2012).Riskfactorsassociatedwithself-injuriousbehaviorsinchil-drenandadolescentswithautismspectrumdisorders.JournalofAutismandDevelopmentalDisorders,42(11),2460–2470.doi:10.1007/s10803-012-1497-9Durand,V.M.(1990).Severebehaviorproblems:Afunctionalcommunicationtrainingapproach.AdivisionofGuilfordPublications,Inc.Fee,V.E.,&Matson,J.L.(1992).Definition,classification,andtaxonomy.InJ.K.Luiselli,J.L.Matson,&N.N.Singh(Eds.),Self-injuriousbehavior:Analysis,assessment,andtreatment(pp.3–20).NewYork,NY:Springer-Verlag.Fertuck,E.A.,Jekal,A.,Song,I.,Wyman,B.,Morris,M.C.,Wilson,S.T.,…Stanley,B.(2009).Enhanced‘readingthemindintheeyes’inborderlinepersonalitydis-ordercomparedtohealthycontrols.PsychologicalMedicine,39(12),1979–1988.doi:10.1017/S003329170900600XFoxx,R.M.,&Livesay,J.(1984).Maintenanceofresponsesuppressionfollowingovercorrection:A10-yearret-rospectiveexaminationofeightcases.AnalysisandInterventioninDevelopmentalDisabilities,4(1),65–79.doi:10.1016/0270-4684(84)90019-3Goldstein,M.(1989).Dopaminergicmechanismsinself-inflictingbitingbehavior.PsychopharmacologyBulletin(0048-5764),25(3),349.Groschwitz,R.C.,&Plener,P.L.(2012).Theneurobiologyofnon-suicidalself-injury(NSSI):Areview.SuicidologyOnline,3(1),24–32.Harari,H.,Shamay-Tsoory,S.G.,Ravid,M.,&Levkovitz,Y.(2010).Doubledissociationbetweencognitiveandaffectiveempathyinborderlinepersonalitydisorder.PsychiatryResearch,175(3),277–279.doi:10.1016/j.psychres.2009.03.002Hathaway,S.R.,&McKinley,J.C.(1943).TheMinnesotamultiphasicpersonalityinventory.Minneapolis,MN:UniversityofMinnesotaPress.Horner,R.H.,Day,H.M.,Sprague,J.R.,O’Brien,M.,&Heathfield,L.T.(1991).Interspersedrequests:Anonaversiveprocedureforreducingaggressionandself-injuryduringinstruction.JournalofAppliedBehaviorAnalysis,24(2),265–278.doi:10.1901/jaba.1991.24-265Kartzinel,D.(2018,March13).Let’stalkaboutselfinjur-iousbehaviors.Retrievedfromhttps://www.mendingnaturally.com/lets-talk-self-injurious-behaviors/Linehan,M.(1993).Skillstrainingmanualfortreatingborderlinepersonalitydisorder(Vol.29).NewYork:GuilfordPress.Markram,K.,&Markram,H.(2010).Theintenseworldtheory–Aunifyingtheoryoftheneurobiologyofautism.FrontiersinHumanNeuroscience,4,224.doi:10.3389/fnhum.2010.00224Martin,G.,&Pear,J.J.(2011).Behaviormodification:Whatitisandhowtodoit.PsychologyPress.PearsonEducation.Martineau,J.,Andersson,F.,Barthélémy,C.,Cottier,J.P.,&Destrieux,C.(2010).Atypicalactivationofthemirrorneuronsystemduringperceptionofhandmotioninautism.BrainResearch,1320,168–175.doi:10.1016/j.brainres.2010.01.035Matson,J.L.,Boisjoli,J.,&Mahan,S.(2009).Therelationofcommunicationandchallengingbehaviorsininfantsandtoddlerswithautismspectrumdisorders.JournalofDevelopmentalandPhysicalDisabilities,21(4),253–261.doi:10.1007/s10882-009-9140-1Maurice,C.E.,Green,G.E.,&Luce,S.C.(1996).Behavioralinterventionforyoungchildrenwithautism:Amanualforparentsandprofessionals.Austin,TX:PRO-ED.Minshawi,N.F.,Hurwitz,S.,Fodstad,J.C.,Biebl,S.,Morriss,D.H.,&McDougle,C.J.(2014).Theassocia-tionbetweenself-injuriousbehaviorsandautismspectrumdisorders.PsychologyResearchandBehaviorManagement,7,125.doi:10.2147/PRBMMoss,S.,Emerson,E.,Kiernan,C.,Turner,S.,Hatton,C.,&Alborz,A.(2000).Psychiatricsymptomsinadultswithlearningdisabilityandchallengingbehaviour.TheBritishJournalofPsychiatry,177(5),452–456.doi:10.1192/bjp.177.5.452Murphy,G.H.,Beadle-Brown,J.,Wing,L.,Gould,J.,Shah,A.,&Holmes,N.(2005).Chronicityofchallen-gingbehavioursinpeoplewithsevereintellectualdisabilitiesand/orautism:Atotalpopulationsample.JournalofAutismandDevelopmentalDisorders,35(4),405–418.doi:10.1007/s10803-005-5030-2Myers,D.G.,&DeWall,C.N.(2017).Psychologyinevery-daylife.NewYork,NY:Worth,MacmillanLearning.Rattaz,C.,Michelon,C.,&Baghdadli,A.(2015).Symptomseverityasariskfactorforself-injuriousbehavioursinadolescentswithautismspectrumdisorders.JournalofIntellectualDisabilityResearch,59(8),730–741.doi:10.1111/jir.12177Richards,C.,Oliver,C.,Nelson,L.,&Moss,J.(2012).Self-injuriousbehaviourinindividualswithautismspec-trumdisorderandintellectualdisability.JournalofIntellectualDisabilityResearch,56(5),476–489.doi:10.1111/j.1365-2788.2012.01537.xRicher,J.M.,&Coss,R.G.(1976).Gazeaversioninautisticandnormalchildren.ActaPsychiatricaScandinavica,53(3),193–210.doi:10.1111/acp.1976.53.issue-3Rothenberger,A.(1993a).Self-injuriousbehaviour(SIB)–Fromdefinitiontohumanrights.ActaPaedopsychiatrica,56(2),65–67.Rothenberger,A.(1993b).Psychopharmacologicaltreat-mentofself-injuriousbehaviorinindividualswithautism.ActaPaedopsychiatrica:InternationalJournalofChild&AdolescentPsychiatry.56(2),99-104.Rydén,G.,Rydén,E.,&Hetta,J.(2008).Borderlineper-sonalitydisorderandautismspectrumdisorderinfemales:Across-sectionalstudy.ClinicalNeuropsychiatry,5(1),22–30.Saloviita,T.(2000).Thestructureandcorrelatesofself-injuriousbehaviorinaninstitutionalsetting.ResearchinDevelopmentalDisabilities,21(6),501–511.doi:10.1016/S0891-4222(00)00055-XSandman,C.A.(1990).Theopiatehypothesisinautismandself-injury.JournalofChildandAdolescentPsychopharmacology,1(3),237–248.doi:10.1089/cap.1990.1.237Sandman,C.A.,&Hetrick,W.P.(1995).Opiatemechan-ismsinself-injury.MentalRetardationandShkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page8of9 DevelopmentalDisabilitiesResearchReviews,1(2),130–136.doi:10.1002/(ISSN)1098-2779Senju,A.,&Johnson,M.H.(2009).Theeyecontacteffect:Mechanismsanddevelopment.TrendsinCognitiveSciences,13(3),127–134.doi:10.1016/j.tics.2008.11.009Shodell,M.J.,&Reiter,H.H.(1968).Self-mutilativebehaviorinverbalandnonverbalschizophrenicchildren.ArchivesofGeneralPsychiatry,19(4),453–455.doi:10.1001/archpsyc.1968.01740100069010Skegg,K.(2005).Self-harm.Lancet,366,1471–1483.doi:10.1016/S0140-6736(05)67600-3Smith,A.(2013,April).Autism,borderlinepersonalitydisorder,andempathy.EmotionReview,5,223–224.doi:10.1177/1754073912469685Soke,G.N.,Rosenberg,S.A.,Hamman,R.F.,Fingerlin,T.,Robinson,C.,Carpenter,L.,&Talkington,L.W.(1971).Communicationdeficitsandaggressioninthementallyretarded.AmericanJournalofMentalDeficiency,76(2),235–237.Talkington,L.W.(1971).Communicationdeficitsandaggressioninthementallyretarded.AmericanJournalofMentalDeficiency,76(2),235–237.Thede,L.L.,&Coolidge,F.L.(2007).PsychologicalandneurobehavioralcomparisonsofchildrenwithAsperger’sdisorderversushigh-functioningaut-ism.JournalofAutismandDevelopmentalDisorders,37(5),847–854.doi:10.1007/s10803-006-0212-0VandenBorre,R.,Vermote,R.,Buttiens,M.,Thiry,P.,Dierick,G.,Geutjens,J.,…Heylen,S.(1993).Risperidoneasadd-ontherapyinbehaviouraldistur-bancesinmentalretardation:Adoubleblindplacebo-controlledcross-overstudy.ActaPsychiatricaScandinavica,87,237–245.doi:10.1111/j.1600-0447.1993.tb03364.xWeiss,J.A.(2003).Self-injuriousbehavioursinautism:Aliteraturereview.JournalonDevelopmentalDisabilities,9,127–144©2019TheAuthor(s).ThisopenaccessarticleisdistributedunderaCreativeCommonsAttribution(CC-BY)4.0license.Youarefreeto:Share—copyandredistributethematerialinanymediumorformat.Adapt—remix,transform,andbuilduponthematerialforanypurpose,evencommercially.Thelicensorcannotrevokethesefreedomsaslongasyoufollowthelicenseterms.Underthefollowingterms:Attribution—Youmustgiveappropriatecredit,providealinktothelicense,andindicateifchangesweremade.Youmaydosoinanyreasonablemanner,butnotinanywaythatsuggeststhelicensorendorsesyouoryouruse.NoadditionalrestrictionsYoumaynotapplylegaltermsortechnologicalmeasuresthatlegallyrestrictothersfromdoinganythingthelicensepermits.CogentPsychology(ISSN:2331-1908)ispublishedbyCogentOA,partofTaylor&FrancisGroup.PublishingwithCogentOAensures:Immediate,universalaccesstoyourarticleonpublicationHighvisibilityanddiscoverabilityviatheCogentOAwebsiteaswellasTaylor&FrancisOnlineDownloadandcitationstatisticsforyourarticleRapidonlinepublicationInputfrom,anddialogwith,experteditorsandeditorialboardsRetentionoffullcopyrightofyourarticleGuaranteedlegacypreservationofyourarticleDiscountsandwaiversforauthorsindevelopingregionsSubmityourmanuscripttoaCogentOAjournalatwww.CogentOA.comShkedyetal.,CogentPsychology(2019),6:1682766https://doi.org/10.1080/23311908.2019.1682766Page9of9 CopyrightofCogentPsychologyisthepropertyofTaylor&FrancisLtdanditscontentmaynotbecopiedoremailedtomultiplesitesorpostedtoalistservwithoutthecopyrightholder'sexpresswrittenpermission.However,usersmayprint,download,oremailarticlesforindividualuse.