When the use of devices like SIBIS (Self-Injurious Behavior Inhibiting System) would be ethically justifiable?
Autor: Vinicius Garcia | Publicado: 2012-07-21T13:09:00-07:00




Linscheid and colleagues (1990) reported the empirical
testing of a device called SIBIS - (Self-Injurious Behavior Inhibiting System),
which provides a mild and brief electrical stimulation after each occurrence of
SIB [self-injurious behavior]. They presented the results of SIBIS in the
treatment of five cases of SIB, selected from the most severe in terms of
magnitude and frequency of self-injury, and that had proved refractory to other
treatment modalities. One of the participants was about to lose his sight due
to the chronicity of SIB. Another participant showed about three thousand self-injurious
responses per day. According to the authors, the effects were immediate, with
almost complete elimination of SIB. Both anecdotal information as follow-ups of
four of the five participants suggested the continuation of benefits and lack
of harmful side effects. It should be mentioned that the use of positive reinforcement procedures were associated with the
use of SIBIS. According to
the authors, the SIBIS should not be considered as a substitute for the
functional assessment or for programs of positive reinforcement for increasing
appropriate behaviors. The authors also pointed out explicitly that there is a
need for strict supervision of qualified professionals in the use of SIBIS.

Iwata (1988) reported in detail the contexts of the
emergence of SIBIS, and the reasons that led him to join the development project
of the device technology. The rudimentary precursor of the SIBIS was designed
by Leslie and Moosa Grant, parents of a girl with a severe autism spectrum
disorder in an attempt to get effective treatment for the intractable SIB of
their daughter, who was hitting head and face to the point of producing
lacerations that affected bone and came near to mutilate her ear. Her parents
had tried a lot of treatments with recognized professionals, without success.
After years of trying ineffective treatments, the Grant's came to know the
basics of what was then called behavior modification, and learned that the use
of contingent electric shock were an effective way to eliminate the SIB
refractory to any other form of treatment. They then built a device equipped
with an accelerometer that activated electrical stimulation automatically after
detecting rapid movements directed to the head. Although cumbersome and
impractical, the device quickly eliminated their daughter's SIB, which had been
ongoing so chronic for fifteen years.

Understandably, the Grant's wondered why they were,
for many years, subjecting&nbsp;their daughter to repeated ineffective treatments, and
why devices such as their own built device could not have been previously
available. They began to look for people who could build a better device for
their daughter, and also for others affected by similar problems. Then they made
​​contact with the Johns Hopkins Applied Physics Laboratory (APL), where they found
engineers who were able to build a prototype. These engineers realized they
would need the help of doctors and behavior analysts, and then asked Tom Linscheid,
who, in turn, invited Gary Pace, Michael Cataldo and Brian Iwata to join the
project.

For four years, the team of engineers, doctors and
behavior analysts worked on the development of the device, which was augmented
with response and stimulation provided counters, a tone that preceded
electrical stimulation, the possibility of activation via remote control, and
most importantly, the possibility of application of positive reinforcement
schedules through tones after specified periods without occurrence of SIB. The
use of electrical stimulation procedures of punishment is a very controversial
issue and there is very little recent work by behavior analysts about the
subject. Most current references have involved the treatment of SIB severe and
refractory to non-aversive interventions, and have been published sometimes in
journals not very significant&nbsp;in the field of applied behavior analysis
(Israel and colleagues, 2010; van Oorsouw and colleagues, 2008; Salvy and
colleagues, 2004; Linscheid and Rochenbach, 2002).

While devices like SIBIS proved to be very effective
in treating severe cases of SIB maintained by automatic reinforcement
refractory to all other treatment modalities available, it is important that
their use can be based on ethical perspectives and scientific research. Their use would be unthinkable in the treatment
of severe SIB, for example, exhibited by a person affected by a medical condition
related to pain, when this condition increases the frequency of SIB, as in some
cases of otitis media [ear infection] or other diseases involving pain.

Breau and colleagues (2003) indicated relationships
between pain and SIB in nonverbal children with severe disabilities, and
suggested that children affected by medical problems associated with chronic
pain may exhibit different topographies of SIB compared to those exhibited by children
without pain. In cases of SIB maintained by automatic negative reinforcement,
the use of devices like SIBIS could suppress the only possible ways to the
person to produce some relief of pain or discomfort. As much as these were
injurious ways of relieving, would be ethically very questionable to suppress the
only behavior able to bring some relief, without offering any other possibility
in this direction and, most importantly, without offering treatments for
actually resolving physical problems related to the etiology of discomfort or
pain. This argument may suggest that the use of devices such as SIBIS in cases
of SIB maintained by automatic negative reinforcement should be
contraindicated.

In cases of SIB maintained by automatic positive
reinforcement, topographies observed may be different from those observed in
cases of SIB maintained by automatic negative reinforcement, which also occurs
in the case of SIB precursor behaviors &nbsp;in both cases. Precursor behaviors are
behaviors whose occurrences can often be seen immediately before the occurrence
of a behavior which is the object of observation (Smith and Churchill, 2002).

Fahmie and Iwata (2011) pointed out recently in a
review of the research on SIB precursor behaviors that only in one patient among
34 of the total sample, could be identified a precursor of SIB maintained by
automatic reinforcement. The study found, however, various topographies and
functions of precursor behaviors of social maintained SIB. These results
suggest the need for more detailed studies focused on descriptions of precursors
of SIB maintained by automatic reinforcement. According to anecdotal accounts
provided by parents, teachers and rehabilitation professionals, while in SIB
maintained by automatic negative reinforcement, precursors are often facial
expressions of pain or discomfort, in cases of SIB maintained by automatic positive
reinforcement, precursors can include quiet facial expressions or even smiles,
which may continue to occur even during the period in which the person remains
engaged in SIB. For more such cases are generally included in one category,
called "SIB maintained by automatic reinforcement", it is plausible
to suppose that such cases are &nbsp;very
different, and should be treated in different ways as well.

In some cases of SIB maintained by automatic positive
reinforcement, it is hypothesized that neurobiological alterations may be
responsible for the anomalous sensitivities to harmful stimulation. The
hypothesis of the role of endogenous opioids (Cataldo and Harris, 1982; Ryan
and colleagues, 1989; Benjamin and colleagues, 1995)
would involve such alterations.

In such cases, the person self-stimulating in
self-injurious manners would produce a sensory response that would increase the
chances of self-stimulating again the same way. It is plausible that what that
person feels in response to harmful self- stimulation is quite different from
what he would feel if his organism were an neurobiologically typical organism,
with a typical sensitivity. If devices such as SIBIS can, immediately and contingently
to harmful self-stimulations, add an aversive stimulation that produces a sensory
response functionally equivalent to the sensory response that would actually
occur in a typical organism, it is plausible to assume that the intervention is
 ethically justified, because it represents an environmental adaptation that would allow
"correction" of a severe sensory impairment.



References:

- Linscheid, T. R., Iwata, B. A., Ricketts, R.
W., Williams, D. E., &amp; Griffin, J. C. (1990). Clinical evaluation of the
self-injurious behavior inhibiting system (SIBIS). Journal of Applied
Behavior Analysis, 23, 53-78.

- Iwata, B. A. (1988). The
development and adoption of controversial default technologies. Behavior Analyst,
11, 149–157.

- Israel,
M.L., Blenkush, N.A., von Heyn, R.E., &amp; Sands, C.C. (2010). Seven Case Studies of Individuals Expelled from
Positive-Only Programs. The Journal of
Behavior Analysis of Offender and Victim Treatment and Prevention, 2 (1),
20-36

- van Oorsouw, W.M.W.J., Israel, M. L., von Heyn, R. E., Duker, P. C.
(2008). Side effects of contingent shock treatment. Research in Developmental Disabilities, , 29(6), 513-523.

- Salvy, S., Mulick, J.A, Butter, E., Bartlett, R.K. &amp; 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.

- Linscheid, T.R. &amp; 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.

- Smith, R. G., &amp; Churchill, R. M. (2002).
Identification of environmental determinants of behavior disorders through
functional analysis of precursor behaviors. Journal of Applied Behavior
Analysis, 35, 125-136.

- Cataldo, M. F., &amp; Harris, J. (1982). 
The biological basis for self-injury in the mentally retarded. Analysis and 
Intervention in Developmental Disabilities, 2, 
21-39.

- Ryan E. P.; Helsel  W. J.; 
Lubetsky, M. J.; Miewald, B. K.; Hersen, M.; Bridge, J. (1989). Use of naltrexone in reducing self-injurious behavior: A 
single case analysis Journal of the multihandicapped person, 
2 (4), pg. 295-309.

- Benjamin, S.; Seek, A.; Tresise, L.; Price, E.; Gagnon, M. (1995). Case study: paradoxical response to naltrexone treatment of 
self-injurious behavior. J Am Acad Child Adolesc Psychiatry, 
Feb; 34(2):238-42.

- Fahmie,T.A. &amp; Iwata, B. A. (2011).
Topographical and functional properties of precursors to severe problem
behavior. Journal of Applied Behavior Analysis, 44, 993-997.