The use of punishment in the modification of behavior has been used for a long time. However, it has attracted different views with some people being against the use of punishment especially in the management of self-injurious behavior due to the severe injuries associated with the practice. This essay will discuss the use of self-injurious behavior inhibiting system in the management of self-injurious behavior and the ethical issues surrounding the process.
Introduction
Punishment is defined as a change in the environmental change depending on behavior, which results to a reduction in responding over time (Lerman & Vorndran, 2002). Other ways of reducing the response include extinction, satiation, and change of stimulus. There are several punishment procedures that have been developed and are used in applied settings. These procedures have been categorized into three groups such as aversive stimuli, work and penalty procedures and removal from the reinforcing events. The aversive stimuli include slaps, unpleasant cognitive images, cold baths, noise and contingent electric shock. The work and penalty procedures include overcorrection, response cost, contingent exercise lute, and negative practice. Removal from reinforcing events includes time out, social isolation, loss of television time, physical restraint, and facial screening (Matson, 1981).
Use of punishment may heighten the level of efficacy when reinforcement is used in the establishment of appropriate behavior, which is meant to either, competes with inappropriate behavior or replace them. This means that once the results are attained, there a likelihood that the punishment is withdrawn. Where the effects resulting from the punishment are primary effects, there is no good reason to expect that punishment belonging to one response is capable of increasing reinforcement efficacy in the establishment of other responses. However, in situations that punishment effects are secondary to avoidance and escape, there is a second reinforcement source that is provided for responses that are not compatible with the response being punished. This is referred to as negative reinforcement (Spradlin, 2002).
The Self-Injurious Behavior
Head-hitting is one of the self-injurious behaviors (SIB) that is most common and occurs in people with developmental disabilities or mental retardation (Linscheid, Pejeau, Cohen, & Footo-Lenz, 1994; Holz & Azrin, 1963). This is a serious and a chronic problem that affects about 10% to 14% of those people having mental retardation. The negative effects of SIB have an increased impact as the patient is approaching adolescence or adulthood. Some of the consequences that are experienced at this time include health problems and ongoing injuries, increased social isolation, restricted l vocational and educational opportunities, and high cost in medical and residential care. The main problem that is common in SIB situations includes head banging in small children although the condition is a transient problem. The prevalence of the condition in children aged 9-18 months is 15%, while in children who are 2 years old is about 9% (Kurtz, et al., 2003).
Operant punishments have been considered to be very critical in the success of the treatment of SIB especially in cases where the variables that maintain the problem behavior are hard to identify or control. It is also important in situations where there is a need to suppress the problem behavior immediately in order to prevent serious injury. The Self-injurious behavior is also displayed by those suffering from autism and involves the appearance of behaviors that lead to patients causing physical injury to their bodies. In some of the most severe cases, SIB has lead to breaking bones, brain injury, bleeding, and even death. There has been resistance in the treatment of SIB through the use of only the non-aversive means (Salvy, Mulick, Butter, Bartlett, & Linscheid, 2004).
The use of response contingent electrical stimulations is considered to be behavior intervention that is most intrusive. The intervention is also superior to other punishment techniques and has a good safety record. A number of factors contribute to the effectiveness of electrical stimulation. Some of the factors include the immediacy of delivery the subject is incapable of avoiding or escaping the punishing stimulus, and the close contiguity that exists between the punishing consequence and the target behavior. Even with these advantages, punishment does not always lead to maintenance of the benefits behind it over time. There is thus the need to use neutral stimuli in combination with the punishing ones in order to come up with conditioned properties. The application of punishers that are conditioned may help in the reduction of the primary aversive intervention exposure and reduction of the factors that are related to the inconsistency of the program in case there is an extension of the treatment (Salvy, Mulick, Butter, Bartlett, & Linscheid, 2004).
Self-Injurious Behavior Inhibiting System
One of the most successful ways that have been employed in the treatment of SIB is the Self-injurious behavior inhibiting system (SIBIS). The system was specifically designed to be used with humans. SIBIS are made up of a sensor module that is worn on the head and has the capability of detecting blows directed to the head. SIBIS also has a radio transmitter which sends a radio signal to the stimulus module that is usually worn on the leg. The transmitter then administers a 200 ms electric shock that has a minimum current of 3.5mA. In the system, there is a hand-held remote activator, which is a wireless device and is used in the activation of stimulus module in order to deliver a shock (Linscheid & Reichenbach, 2002).
The level of shock that is applied is mainly dependent on the severity of SIB with the less severe conditions using contingent shock that is relative. The use SIBIS together with differential reinforcement as well self-injurious escape behavior extinction resulted in minimal SIB reductions. When there is a combination of Hot Shot, self-injurious escape behavior extinction and compliance reinforcement lead to an immediate and great reductions in SIB (Williams & Kirkpatrick-Sanchez, 1993).
Withdraw of SIBIS has been shown to reverse the SIB condition in several cases. Individuals who were treated with SIBIS and had shown great reduction in the SIB severity gradually increased the rate of SIB until the levels returned to pre-treatment levels. There are number factors that may lead to the return of the SIB. These factors include the treatment being conducted only during day time and the treatment is not done daily. Those cases where contingent electrical stimulation has successfully suppressed SIB include those treatments where behavioral and psychopharmacological interventions were combined with the contingent electric shock (Linscheid & Reichenbach, 2002).
In a study conducted by Thompson et al (1999), individual as well a combined effect of punishment and reinforcement were accessed. The study revealed that use of reinforcement alone does not lead to a large reduction in SIB in any of the participants examined. When punishment was used alone, there was a noticeable decrease in the level of SIB in some of the participants. However, combination of punishment with reinforcements resulted in an effective decrease in SIB (Thompson, Iwata, Conners, & Roscoe, 1999).
These findings have indicated that there is an interaction between behavioral, medical, and social factors with the contingent electric shock effectiveness. The relative influence resulting from these factors may undergo changes over time in a way that the modifications that occur in the electric shock program, environmental and medical treatment may be necessary in order to have suppression that is clinically meaningful (Linscheid & Reichenbach, 2002). The use of functional communication training together with punishment has also been indicated as an effective measure rather than using functional communication training alone (Kurtz, et al., 2003).
Positive Side Effects of SIBIS
The use of SIBIS is associated with a number of positive side effects including self-initiated interactions, smiling, vocalizations, hand clapping, reduced crying, and distressed vocalizations. The onset of some of these positive side effects occurs almost after the medication was started (Linscheid, Pejeau, Cohen, & Footo-Lenz, 1994). Other positive side effects include improvement in social behavior by the participant, increased activity levels and increased eye contact. Other positive side effects that have been reported in other studies include cases where the participants became happier, calmer, and were less clingy to people at the time of treatment as compared to baseline (van Oorsouw, Israel, von Heyn, & Duker, 2008).
Just like any other type of reinforcement and punishment, there is a high possibility that use of shock may be misused. There is, therefore, need to regulate and limit contingent shock use in the management of severely destructive behavior. There is, however, reduced consequences of SIBIS misuse due to the lack of any physical risk that is associated with SIBIS. As a default technology, the use of SIBIS is appropriate for only very few or aggressive behavior or severe self-injurious cases. In cases where behavioral interventions that are less restrictive can produce results that are comparable to the results attained using the more restrictive, then the use of SIBIS treatment or other restrictive treatments may be unnecessary. When evaluation of the procedure’s restrictiveness is done, there is a need to consider the amount of time that is necessary to give effective treatment as well as the consequences that may rise when there is a delayed treatment (Williams, Kirkpatrick-Sanchez, & Cracker, 1994).
Ethical Considerations
One of the major ways through which punishment interacts with ethical issues lies in the power to define intersects with ethics is in its power for the punishment to define as well prioritizing the cultural value. This has resulted into numerous misconceptions about punishment where people have referred punishment as a way of brainwashing, and cross manipulating the subject. One of the major factors that have maintained the negative image about punishment and those who use it need to consider the ethical concerns. However, most of the procedures that are employed by most of the behavior therapists are similar to any other intervention and they are made up with an aim of changing the behavior of the individual or a group of people (Guydish & Kramer, 1982).
There are various concerns that are raised as procedures involving behavior modification continue to be used. The public, as well as mental health professionals are more concerned on whether the procedures of behavior modification have been demonstrated in a sufficient manner through research for them to be recommended in general terms. The level at which the procedures are disseminated is also worrying (Braun, 1975). The onset of behavior modification has been as a conceptual lightning rod that has come up middle of stormy controversies concerning the ethical problems that are linked to attempts at social influence. The procedure draws to the highly charged issues including the fear of controlling the mind or even concerns about the treatment of individuals that are institutionalized against what they would wish. The actual or apparent rights infringement and the abuse of the behavioral procedures have resulted in the litigation as well as calls for the curbs on the utilization of behavior modification (Guydish & Kramer, 1982).
There are some people who fear the modification and control of behavior because of the prevalent contemporary attitudes of skepticism and distrust of authority generally and in particular of mind control. There are others who have specific concerns that are related to the use of behavior modification, misconceptions or myths concerning the use of behavior modification (Guydish & Kramer, 1982).
One of the procedures that have been seriously misused is the aversive procedures. This has become the means through which the people in power are exercising control over the ones who are under these people. These people may then go ahead and try to justify the use of the abusive treatment where they refer to it as a therapeutic procedure and labeling it punishment. In the recent past, there have been an increased number of people who have expressed their concerns that there is a need for the people conducting the programs on punishment to take special care. This is to ensure that the methods are ethical, and the person who is going through the behavior change program is protected (Stolz, Wienckowski, & Brown, 1975).
There are many researchers as well as therapists who use the methods of punishment and exercise the normal caution. However, there are some aspects of the situation that do not get the attention that is deserved. One of the main challenges in the establishment of ethical standards to be used while using punishment in behavior modification has been the fact that the issues, as well as problems, are different in different populations as well as in different settings. For instance, it is clearly meaningful in a situation where a normal adult goes to an outpatient clinic and seeks for guidance on how to alter a specific behavior that needs to be changed. However, it is not clear that a prisoner can give his consent voluntarily when they are offered with an opportunity to go through a punishment that may help in behavior modification (Stolz, Wienckowski, & Brown, 1975).
In conclusion, the question by Kazdin (2001) on whether some behavioral procedure should be used in the elimination of behavior is justified since some of the punishments have negative effects to the subject. However, the use of punishment especially SIBIS has been shown to be an effective method in behavior modification. There is, however, need to combine the procedures with other interventions such as medication in order to produce the desired results. There is also need to have ethical considerations and the level of restrictiveness when choosing a behavior modification procedure.
Reference List
Braun, S. H. (1975). Ethical Issues in Behavior Modification. Behavior Therapy, 6, 51--62.
Guydish, J., & Kramer, J. J. (1982). Behavior modification: doing battle in the ethical arena. Journal of behavior therapy and experimental psychiatry, 13(4), 315-320.
Holz, W. C., & Azrin, N. H. (1963). A Comparison of Several Procedures For Eliminating Behavior. Journal of the Experimental Analysis of Behavior, 6(3), 399-406.
Kazdin, A. (2001). Behavior Modification in Applied Settings. Belmont, CA: Brooks/Cole
Kurtz, P., Chin, M. D., Huete, J., Tarbox, R. F., O’connor, J., & Paclaw. (2003). Functional Analysis and Treatment of Self-Injurious Behavior in Young Children: A Summary of 30 Cases. Journal of Applied Behavior Analysis, 36(2), 205–219.
Lerman, D. C., & Vorndran, C. (2002). On the Status of Knowledge for Using Punishment: Implications for Treating Behavior Disorders. Journal of Applied Behavior Analysis, 35(4), 431–464.
Linscheid, T. R., & Reichenbach, H. (2002). Multiple factors in the long-term effectiveness of contingent electric shock treatment for self-injurious behavior: a case example. Research in Developmental Disabilities, 23, 161-177.
Linscheid, T. R., Pejeau, C., Cohen, S., & Footo-Lenz, M. (1994). Positive Side Effects in the Treatment of SIB Using the Self-Injurious Behavior Inhibiting System (SIBIS): Implications for Operant and Biochemical Explanations of SIB. Research in developmental Disabilities, 15(1), 81-90.
Matson, L. (1981). Punishment in Behavior Modification: Pragmatic, Ethical, and Legal Issues. Clinical Psychology, 1, 197-210.
Salvy, S.-J., Mulick, J. A., Butter, E., Bartlett, R. K., & Linscheid, T. R. (2004). Contingent Electric Shock (Sibis) and A Conditioned Punisher Eliminate Severe Head Banging In A Preschool Child. Behavioral Interventions, 19, 59–72.
Spradlin, J. (2002). Punishment: A Primary Process? . Journal of Applied Behavior Analysis, 35(4), 475–477.
Stolz, S., Wienckowski, L., & Brown, B. S. (1975). Behavior Modification: A Perspective on Critical Issues. American Psychologist, 30(11), 1027-1048.
Thompson, R., Iwata, B., Conners, J., & Roscoe, A. M. (1999). Effects of Reinforcement for Alternative Behavior during Punishment of Self-Injury. Journal of Applied Behavior Analysis, 32(3), 317–328.
van Oorsouw, W., Israel, M., von Heyn, R., & Duker, P. (2008). Side effects of contingent shock treatment. Research in Developmental Disabilities, 29, 513–523.
Williams, D. E., & Kirkpatrick-Sanchez, S. (1993). A Comparison of Shock Intensity in the Treatment of Longstanding and Severe Self-Injurious Behavior. Research in Developmental Disabilities, 14, 207-219.
Williams, D. E., Kirkpatrick-Sanchez, S., & Cracker, W. T. (1994). A Long-Term Follow-Up of Treatment for Severe Self-Injury. Research in Developmental Disabilities, 15(6), 487-501.
