Reducing self-injurious behavior through functional communication training in cerebral palsy

Teaching Manding Through Functional Communication

Teaching Manding Thorugh Functional Communication Training To A 53-year-old Man With Cerebral Palsy

Self-injurious behavior (SIB) usually occurs in mentally retarded persons. There are certain genetic syndromes which are more likely to cause self-injury as part of the behavioral phenotype of the condition. SIB can be quite devastating since it is a characteristic of several mental disorders. About 5-17% of all people who have intellectual disabilities and developmental disabilities usually engage in self-injurious behavior in a repetitive nature with some having the number of incidences of self-injurious behavior being quite high. The incidence of self-injurious behavior in those who are mentally retarded can exceed 50%. SIB is a chronic problem Mikhail & King, 2001.

Emerson (1995)

found that out of 95 individuals who were mentally retarded, about 71% of them still showed signs of self-injurious behavior up to 7 years later. Functional communication is one of the methods of reduction of occurrence of self-injurious behavior.

SIB in cerebral palsy patients

A good number of patients with cerebral palsy usually have developmental and intellectual disabilities which causes them to have severe cognitive impairment. For this reason, they are unable to understand their environment well and thus they exhibit self-injurious behavior especially when they are unable to communicate with ease. There are three major risk factors which act as indicators of self-injurious behaviors in cerebral palsy patients. These are the damage to the nervous system, epilepsy and their learning disability. Other risk factors include age - research has shown that the incidence of SIB is at peak in patients between 15-34years, gender -- research has shown that men exhibit more incidence of SIB than women. Other factors include communication difficulties and multiple impairments Scope ()

Functional communication

Lingraphica News (2006)

states that functional communication is a term which refers to the capability of a person to receive a message or convey it regardless of the mode used to pass the message in order to make sure communication is effective and independent of the environment. This is the definition of functional communication as given by the American Speech-Language-Hearing Association. In simpler terms, functional communication is basically making oneself understood by whatever means possible even though it may include the use of aid devices such as communications boards or speech generators. It also involves the person being able to communication in this way without being assisted. Simply responding to a question using yes or no does not include functional communication Schieltz et al., 2010()

Functional communication has been recognized in the field of psychology as one of the methods that has been used to help individuals who have behavioral problems. It is used to prevent the escalation of wild behavior such as self-injury or aggression from previously mild behaviors. It is often an intervention measure taken by the people in charge of the care of the patient. All that needs to be done is to educate them on this method. Functional communication has come to be praised greatly by both practitioners and researchers because of its huge success Sternberg, 1991()

Functional communication and extinction

Extinction is an important variable in the use of functional communication in the treatment of self-injurious behavior. Extinction means that functional communication is combined with time-out.

In a research study conducted by Shirley, Iwata, Kahng, Mazaleski, and Lerman (1997)

it was found that when functional communication was combined with extinction or time-out, it was more effective in decreasing the occurrence of self-injurious behavior. The study was conducted on two participants, Rick and Sue. The former was used to test the use of extinction while the latter was testing functional communication without extinction. For Rick's case, it was found that when functional communication was combined with extinction, the incidence of self-injurious behavior increased at the initial stage but this decreased thereafter. At the beginning of the experiment, the average number of responses of self-injurious behavior was 2.54 per minute which then reduced to 0.08 per minute during the last five sessions which were combined with extinction. At this point, when extinction was removed, the number of responses continued to reduce to 0.02 per minute. For Sue who did not have time-out, the initial number of responses increased before decreasing to 0.19 responses per minute during the last five sessions. This goes to show that extinction is quite important in the reduction of incidences and treatment of self-injurious behavior Shirley et al., 1997()

Manding

Manding is a form of functional communication that is mostly used by adults to teach their children. It basically is asking a question which requires more than a simple yes or no answer. When the teacher uses mands, it gives them a leading role in the learning opportunity so presented and when they offer a mand, they expect a response from the other person. Because of this back and forth nature of manding, the teacher is easily able to find out whether the student understands them and whether they are capable of performing the request Murphy & Barnes-Holmes, 2010()

In a situation where the student understands the mands, they are able to do as they asked and when they are not capable of understanding it, two things can be assumed. First is that the mand was not understood or second is that the task was too difficult for the student. If either of these two assumptions comes to be true, then it is possible to change the request to make it more understandable and easier to perform by the student.

Use of functional communication to intervene in self-injurious behaviors

Manding

Functional communication and especially manding has been known to be most effective in autistic children. In autistic researches, functional communication training was essentially found to be a way to replace the inappropriate behaviors with more effective and appropriate modes of communication and skills

ADDIN EN.CITE

(Padilla Dalmau et al., 2011; Reichow, Volkmar, Doehring, & Cicchetti, 2010; Yamamoto & Mochizuki, 1988)

Functional communication was essentially found to be most effective with children without any discrimination on their level of cognition or their communication abilities regarding expressions. In the many researches that have been conducted on manding, it was found that it is most effective in the early childhood stages and at the elementary levels. However, an assumption is made that functional communication and manding can also be used for older learners Howlett, Sidener, Progar, & Sidener, 2011()

Experiments and studies regarding functional communication and manding are essentially conducted in clinical, home and school-based environments. Though research has not yet indicate the use of manding in the community, it may be ideal for teaching in community settings where inappropriate or self-injurious behaviors are common Harding et al., 2009()

Manding has also been used severally in the treatment of various psychological and behavioral disorders mostly those involving self-injurious behaviors. In one of the studies, three students who were suffering from autism were trained to make requests for specific objects from an adult who they referred to as the supplier using a sentence that began with 'give me ____.' They were then to give the object to another different adult who they referred to as 'the director'. The degree to which the 'give me ____' was controlled by the supplier when they gave the student an object other than the one which they had asked for Yamamoto & Mochizuki, 1988()

At first, the students did not know the names of all objects and thus would pass the object on to the director though it was not the object they asked for. The students were then trained the names of the object and to refuse taking a wrong object by saying 'that's not it. Give me ____.' This exhibited a characteristic of a mand since the students were now able to control the 'give me ____' response by the object requested. Without the students being able to identify the variables which control the response, this cannot be considered a mand but since the student were now able to relate the object to the required response, this became a mand Yamamoto & Mochizuki, 1988()

In another different study, two individuals who did not previously acquire picture exchange communication despite intensive efforts being put in place were evaluated to establish the effectiveness of using representative objects to teach mands for their preferred items. Each of the 2 participants was involved in self-injurious behavior but was trained to exhibit a communicative response which functioned to solicit for reinforcement to help them refrain from these self-injurious behaviors. For the two participants of the study, they had consequences for inappropriate behavior. These consequences included graduated guidance or time-outs. The training of functional communication was done till the participants were found to emit the communicative response in an independent fashion and there was no occurrence of the self-injurious behavior for at least two sessions Wacker et al., 1990()

Results of this study showed that both the training on functional communication and the intervention regarding the self-injurious behavior was necessary to be able to gain maximum control over this behavioral problem. This study is also another example of the effectiveness of manding in the control of self-injurious behavior Wacker et al., 1990()

In yet another separate study, six children between the ages of 7 and 11 who were institutionalized were trained to use manding to request for food items under the natural situation where snacks were presented. The appropriate terminology for this study when food was presented by and adult was 'I want a ____'. 'Out' was the appropriate term when the items were placed in the hallway which was across a half-door barrier Simic & Bucher, 1980 ()

Through the setting of natural condition and using cues, the sequence of steps for this functional communication was trained. The two mands were not trained concurrently rather in sequence. To encourage productions that were 'spontaneous', no vocal cues were provided by the adult. After the children were able to perform according to the criteria required for each step, there were several probe session which were conducted using various adults, cuing conditions and settings. In probes sessions that were held after imitation training, there was no spontaneous manding which was not due to difficulties in production rather was due to the children not showing transfer to the natural cues. This implied that training regarding the specific appropriate cues was often required Simic & Bucher, 1980 ()

Probe sessions also showed that the children had mastered which mand to use in which situation. Thus they did not mix up the mand with the situation. This was important in showing that the training of the children to learn a second mand, generally did not in any way disrupt the use of the first mand. However, for two children, there was significant disruption. At the end of the training, the trainers did some extinction training regarding one particular mand which did not affect the other mand Simic & Bucher, 1980 ()

Generally the results of this study showed that the appropriate form of a mand depended specifically on the setting characteristics and specific stimulus. These specific setting characteristics had to be put into consideration during training Simic & Bucher, 1980 ()

Advantages of using manding

From the studies that have been conducted on the use of manding to intervene in certain psychological conditions, there are many advantages of the use of manding that can be seen. One is that manding helps in reducing the occurrence of the particular inappropriate or self-injurious behavior since it enables the subject to be able to replace this inappropriate behavior with appropriate communicative responses.

Secondly, manding helps the subject to be able to express themselves in a way which other people can understand them other than the use of yes and no responses which may not be adequate in responding to the question or situation at hand.

Manding helps the subjects to be able to carry out activities which they would not have otherwise been able to participate in majorly because their behavior is considered inappropriate in the community or society. Since they are able to reduce the incidence of these inappropriate or self-injurious behaviors, they are able to be more socially acceptable in the community or society at large Winborn-Kemmerer et al., 2010()