sábado, 21 de julho de 2012

When the use of devices like SIBIS (Self-Injurious Behavior Inhibiting System) would be ethically justifiable?

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 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 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  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  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.

- Linscheid, T. R., Iwata, B. A., Ricketts, R. W., Williams, D. E., & 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., & 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. & 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. & 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., & 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., & 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. & Iwata, B. A. (2011). Topographical and functional properties of precursors to severe problem behavior. Journal of Applied Behavior Analysis, 44, 993-997.

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