Many problem behaviors are caused by
pain or medical issues and cannot be successfully treated using only
a behavioral approach. But with children with autism who have little to no language,
it can be really challenging to figure out if a child is in pain or having some kind of medical
issues that are causing the problem behaviors. Today, this video blog is all about that.
Hi, I'm Dr. Mary Barbera, autism mom, Board Certified Behavior Analyst and bestselling author.
Each week I provide you with some of my ideas about turning autism around so if you haven't
subscribed to my YouTube channel, you can do that now. This week I am sharing a very short excerpt
with Dr. Tim Vollmer, an international ABA expert, and he discusses how we
can try to rule out medical issues and pain as the cause of problem behaviors.
To hear the whole podcast interview with Dr. Tim Vollmer, you can go to marybarbera.com/46,
or click the card on the screen right now. How can we do a better job of ruling out
medical issues in kids with moderate to severe autism, besides like my calendar,
you know, trying to have parents keep, keep some track.
So it's, it's like not going through this maze because when you have a, you know,
just say you see clients or patients one-to-one as a physician, I mean, it's really hard to tell,
especially if the kid is not conversational. I mean, we're lucky that Lucas can say head hurts
or neck hurts or knee hurts, but he can't give me like it's stabbing pain down here.
And it seems to be really sudden, uh, and really quick, like it goes away quickly too. Um, but like
how can we help physicians do a better job of ruling out medical issues? Well, as you know,
but maybe many, uh, parents in the audience might not know it's actually, um, an ethical requirement
for behavior analysts to rule out the possibility of medical involvement with severe behavior.
And I can't really imagine a case of, let's say self-injurious behavior that doesn't have some
level of medical involvement at the front end or at the backend, as I mentioned earlier. So,
uh, medical variables that make receiving instruction, uh, or aversive perhaps,
or, um, behavior that produces a medical outcome, like self-injury that needs medical treatment.
So I think it's incumbent, uh, behavior analyst to always with that type of severe behavior,
um, interact in some way with medical personnel. And when I look at the history of our field, uh,
and behavior analysis, I remember a time that behavior analytic services in general
were not widely accepted. Um, it was a very niche, um, approach.
Um, and very few people had access to those kinds of services and with board certification
and changes in insurance laws and things of that nature over the last 20 or so years,
we've seen a lot more accessibility, at least for children, um, accessing, uh, behavioral
analytic services. What I would hope to see over the next decade or so, um, is
a movement in the next direction where the accessibility is for those kinds of integrated
types of approaches and services. So that behavior analysts can work directly with medical personnel
on those types of problems and in a safe way so that we can ensure that, um, individuals are not
getting hurt in a way that is irreparable or, um, to make sure even that individuals working
with the, uh, that individual like teachers and parents and therapists are maybe perhaps
not getting hurt, uh, due to, uh, the behavior and medical variables that are contributing to.
Yeah. So in your talk at Penn State, you talked a little bit more after my question,
a little bit more about biting specifically as, as the behavior. And, and you said that that a lot of
animals, um, when they're stressed and, or in pain, they bite. And
so can you elaborate a little bit more on that? Yeah, the purpose of bringing that up
at t that point in the, in that discussion was that I was talking about some possible impediments
to behavioral treatment. And actually if I go back to the, that conference next year, I'm I
plan to elaborate on that a little bit more and maybe even have that as the, the full discussion,
not specifically about biting, but about impediments to effective behavioral treatment.
Um, but what I have found to be interesting about that biting phenomenon is that there was a
basic laboratory research that was done prior to like the mid 1970s. And it was with humans,
with animals and all kinds of different species showing that, as you said,
in response to some kind of aversive stimulation, so a painful stimulus or a noise, uh, aversive
noise, uh, humans and other animals will bite down and they'll bite down on whatever is available.
It might be if there's a bar in front of them, they'll bite on the bar. If there's nothing,
maybe they'll bite their hand. Uh, before the days of anesthesiology, uh, people would literally bite
on a towel or bite on some object during surgical procedures, or, you know, when a bullet was being
removed or something along those lines. So when you see that in the movies, that
that's what people did. Um, so biting down is a natural uman response. So what I'm wondering,
and some of my doctoral students are starting to wonder is why we've ignored that literature
for over 40 years now, because, uh, when we do behavioral assessments of biting self or others,
we often have a confound in our assessments. So for example, if we present an instruction
to someone and they bite their hand, or maybe they bite us. We then in our assessment,
give them a break and say, okay, nevermind. We're testing out whether that escape is the reinforcer
for the problem behavior or the biting but we've also presented that instructional demand.
So maybe if that is aversive the biting response is a kin to what we saw in those early studies.
And I think all of us who know individuals with autism and have um,
other individuals with autism have seen something like the following example where an individual is
sitting in a room, maybe even all by themselves. Maybe they don't know you're watching.
And some loud noise occurs like a fire alarm or a dump truck goes in reverse,
and they bring their hand to their mouth and bite down. Well, why is that? Uh, it appears
to be automatically reinforcing in some way. It's not that somebody turns off the fire alarm,
it's perhaps a natural response to biting. I keep saying perhaps because we don't, we haven't
ruled that out, but it's surprising to me that we haven't tested that over all of these years. So I
was suggesting it to the audience you were in, um, that maybe some of this resistance to treatment
that we're seeing when the behavior is hand or arm biting or when the behavior is biting others
relates to the fact that we don't have a complete handle on why the biting occurs.
Well and that's exactly what happened with Lucas. He, he, um, would bite his hand or
he would get aggressive. And it was usually related to pain or startle.
And, and I spent four years as a registered nurse, behavior analyst taking my data,
you know, trying to find some, I thought, was it a seizure? Like I never heard of being startled
and being aggressive or self-injurious, but that's when I went to Dr. Murray and he he's doing a lot
of work. He's at Hershey medical center. He's on podcast 28. And did a lot of work with individuals
with autonomic nervous system dysfunction. We talk a lot about that in, in that episode. And he
put Lucas on a cardiac med, uh, um, a beta blocker to settle his nervous system down.
And the way he explained it was like, Lucas was up here always kind of on edge. And so fire alarms,
somebody just kicked a trash can near him just suddenly sh you know, startled him. Um,
and he would either get self-injurious or aggressive, aggressive, and in pain at night
when he wakes up and he's saying head hurts as he's biting his hand or his finger.
Now we, with the Inderal dosage, we've managed to get aggression near zero. Um,
and self-injurious, you know, once a month. So we we've managed it through medication. I mean,
but this is what I'm saying, there's like, there's, there's not going to be like University
of Florida is not going to be able to catch that. It's the parents on the front lines who were like,
wait a second, or the teachers like, hey, the fire alarm goes off, he bites his hand and
it's like, um, it's just a lot of confounding variables that for each individual, I say like
each individual has like a hundred levers, some need to be up, some need to be down.
And it's like a complicated situation. Well, and I think in terms of, the role of
people like myself, the researchers, it's our job to start to explore the empirical basis for this
type of information. So parents may be seeing this and noting the correlation between, uh,
some physical illness or other medical problem. Um, but, uh, we need to provide the,
the research basis, uh, or set up models to demonstrate on a case by case basis,
what those variables are. I hope you enjoyed that short snippet from the podcast
if you want more content check out the podcast at marybarbera.com/podcast.
Wherever you’re watching this, I’d love it if you would leave me a comment, give me a thumbs up,
share this video with others who may benefit and for more information you can attend a free
online workshop at marybarbera.com/workshop and I’ll see you right here next week.