reduction of self-injurious behaviors of an individual

THERAPEUTIC RECREATION JOURNAL Vol. 35, No. 3, 207-219, 2001

Reduction of Self-Injurious Behaviorsof An Individual with Autism: Use ofA Leisure Communication Book

Rachelle Schneiter and Mary Ann Devine

The purpose of this case report is to discuss how a Leisure Communication Book (LCB) wasused with an individual with autism to increase his ability to express leisure preferences. Thegoal of the intervention was to reduce self-injurious behaviors in leisure environments when (a)the individual attempted to communicate a leisure preference but the staff could not understandhis choice; (b) the staff could not respond to leisure activity or equipment requests due toprogram, time, or supply constraints; and (c) various leisure activity options were offered, but notimmediately available for engagement. Results indicated that use of the LCB appeared to beeffective in reducing self-injurious behaviors in leisure contexts.

KEY WORDS: Autism, Hand-over-Hand, Leisure Communication Book, Leisure Preferences,Self-Determination, Self-Injurious Behaviors, Verbal Prompting

Autism is a lifelong, complex developmen- tism is primarily diagnosed through observa-tal disability that can present challenges to tions of atypical behaviors in these domainstherapeutic recreation specialists (TRSs) when (Carter, Van Andel, & Robb, 1985; Dattilo,responding to the leisure needs of individuals 1994). According to the DSM-IV (1994), awith this disabling condition (Hawkins, 1996). person with autism may exhibit behaviors suchCharacterized by severe limitations in commu- as an inability to develop typical, age appro-nication, social, and emotional behaviors, au- priate relationships with other people; a delay

Ms. Schneiter is a CTRS and graduate student at University of North Carolina at Chapel Hilland Dr. Mary Ann Devine is assistant professor at Kent State University. Correspondencemay be addressed to: Rachelle Schneiter, 306 McCauley St. #3, Chapel Hill, NC 27516.

Third Quarter 2001 207

in language development; an insistence onsameness; obsessive, ritualistic, and/or com-pulsive behaviors; self-stimulation; and/orself-destructive behaviors. While the cause ofautism is unknown, it is more common inmales and the behaviors usually appear beforethe person is three years old (Hawkins). Giventhe complexity of this disorder, it has oftenbeen difficult to determine the leisure needs,preferences, and choices of individuals withautism.

BackgroundTraditionally, caregivers and service pro-

viders have made decisions for people withcognitive disabilities (Guess, Benson, & Sie-gal-Causey, 1985). Only recently, profession-als have recognized the need to support per-sonal autonomy for all individuals (Lakin,Bruininks, & Larson, 1992). According toDattilo and St. Peter (1991), self-determina-tion includes the perception of freedom tomake choices and the ability to initiate chosenleisure activities. Self-determination is an im-portant consideration in facilitating autono-mous leisure opportunities for individuals withdevelopmental disabilities. Research has dem-onstrated that individuals with developmentaldisabilities can learn to make meaningfulchoices for their leisure, appreciate leisure,become aware of their own preferences, andacquire the skills necessary for independentleisure participation (Dattilo & St. Peter; Ni-etupski, Hamre-Nietupski, Green, Varnum-Teeter, LePera, Scebold, & Hanrahan, 1986).However, many individuals with autism havedifficulty maintaining and generalizing learnedleisure behaviors (Coleman & Whitman,1984). Previous research indicates a need todevelop techniques that transfer control of lei-sure behaviors and environments from the pro-fessional to the individual (Devine, Malley,Sheldon, Dattilo, & Gast, 1997; Nietupski etal., 1986).

Previous research has revealed that individ-uals with developmental disabilities can ac-quire skills that could benefit initiation of rec-reation and leisure participation. For example,

MacDuff, Krantz, and McClannahan (1993)reported a study in which photographic cueswere used to remind individuals with autism oftheir work and play schedules. They found thatby using photographic cues, individuals withautism could independently select and changeactivity choices as well as generalize activityselection skills to various contexts. Nietupskiet al. (1986) found that, given a consistent andconcrete method for self-initiating, studentswith developmental disabilities demonstratedchoice making skills for leisure participation.Stone, Ousley, Hepburn, Hogan, and Brown(1999) asserted that young children with au-tism can be taught various adaptive behaviors(e.g., choice making) using pictorial and ver-bal cues. Vicker (1996) argued that for indi-viduals who are nonverbal, establishing a two-way communication system using pictures canbe effective in establishing a communicationprocess.

While Hawkins (1996) indicated that indi-viduals with autism can be taught to makemeaningful choices during free time, there islimited research on the ability of these indi-viduals to identify leisure preferences. Thelack of ability to identify leisure preferencescontinues to be a barrier to the fulfillment ofself-determined behavior for people with de-velopmental disabilities (Mahon, 1994). Lim-ited opportunities to exhibit self-determinedbehavior have created a high incidence oflearned helplessness among individuals withautism (Jenkinson, 1999). Therefore, the pur-pose of this case report is to discuss how theuse of a Leisure Communication Book (LCB)increased the ability of a man with autism toexpress his leisure preferences. This case rep-resents a transdisciplinary intervention fromwhich results can be applied in therapeuticrecreation settings.

Biographical and DemographicInformation

Scott (pseudonym), a 21 year old man, wasdiagnosed at the age of 2 with Infantile AutismResidual State with Organic Mental Disorder.

208 Therapeutic Recreation Journal

He has a secondary diagnosis of mental retar-dation, but the degree to which mental retar-dation presented itself varied based on theevaluator and assessment tool used in the eval-uation.

His social, adaptive, motor, communica-tion, and cognitive functional levels were as-sessed in 1995 at age 16 using the BattelleDevelopmental Inventory (BDI; Newborg,Stock, & Whek, 1988) and the Vineland Adap-tive Behavior Scale (VABS; Sparrow, Bella,& Cicchetti, 1984). Scott did not display anyverbal or written communication skills, whichcreated difficulty in assessing his overall func-tional skills. The results of the BDI indicatedScott's functional level to be at that of aone-year old in social and communicationskills, a two-year old in cognitive skills, and athree-year old for adaptive and motor skills.The VABS was used to assess Scott's func-tional levels in the areas of communication,daily living skills, and social skills. Results ofthis assessment indicated Scott's functionallevel was approximately one year of age incommunication and social skills, and approx-imately two years of age in daily living skills.It should be noted that while the assessmentinstruments used to determine Scott's level ofskills indicated his functional age range to bebetween one and three years of age, individu-als with autism often exhibit skills and abilitiesthat indicate a much higher level of function-ing than measurements indicate (Hawkins,1996), as was the case with Scott.

Scott was not able to use words to verballyexpress himself, but instead used vocalizationssuch as a string of consonants, vowels, andvoice fluctuations. He had incredible receptivelanguage skills as he was able to understandand follow verbal directives. For example, ifScott was preparing to go on an outing with hisfamily, a staff member could prompt Scott toget his coat and use the rest room. He followedthese requests by doing the things asked ofhim with verbal prompting. He was also ableto find ways to express his needs to the staff.For instance, Scott used the signs for eatingand drinking to express hunger or thirst. Out-

side of the facility, Scott would tug on the armof a staff or family member to indicate hisneed to use the rest room. Another example ofScott's capacity to understand language was asituation where a staff member told Scott thathe could have a beverage from the soda popmachine at his facility if he cooperated at hisdentist appointment, a task which could bedifficult for Scott due to his fear of the dentist.He cooperated while visiting the dentist andupon his return to the facility he went inde-pendently to the staff member's office, wentinto her purse, and took a one-dollar bill. Hethen went to the soda pop machine indepen-dently, bought his beverage, and returned thechange to the staff member. This situationdemonstrated his ability to understand,through verbal prompting, the results of posi-tive behaviors. While Scott scored poorly ontests and assessments administered to deter-mine his abilities, he exhibited communicationand behavioral skills that appear to be at amuch higher functioning level. The exact ra-tionale for a person with autism functioning ata higher level than indicated by an assessmenttool can vary depending on the individual, butmost experts in the field of autism feel thisdiscrepancy is a function of the complexity ofthe disorder as well as a lack of specific testsfor people with this disorder (Freeman &Ritvo, 1981; Gilberg, 1989; Jenkinson, 1999).

Scott has shown a playful side to his per-sonality. He laughs in situations where he has"tested" the staff and they have "called him"on it. For example, he knew he was not sup-posed to unravel the toilet tissue from the roll,but would do it simply to get a surprisedreaction from the staff. Scott also enjoyedplaying practical jokes. Once, he removed allthe screws from a chair in his bedroom overthe course of several days. He hid all thescrews under his bed, and with the chair intactbut no hardware to hold it together, Scottwaited for his roommate to sit in the chair.When his roommate finally sat in the chair, itfell apart and he fell on the floor. Scott knew itwas wrong so he hid under a blanket on hisbed, but laughed at the situation.


Since age six, Scott has resided in an In-termediate Care Facility (ICF) with 40 otherindividuals with autism and/or mental retarda-tion. The facility has a home-like atmospherewhere residents share kitchen, living room,and bathroom facilities. The backyard has playequipment and a flower garden. The facilityhas a sensory integration room with lavalamps, slow-moving lights, soft music, andsoft pillows as well as an indoor swimmingpool. For the past five years Scott has shared abedroom with another male resident. He re-ceives educational services in the facility, of-fered by the local school board. In addition toeducational services, Scott receives a varietyof services such as art; occupational, music,and speech therapies; and leisure participation(i.e., community training and outings, facility-wide special events). While the facility doesnot employ a Certified Therapeutic RecreationSpecialist, they have a recreation director whoplans community outings, summer programs,and facility-wide special events. Scott'steacher, speech therapist, residential staff, andthe direct care staff assist him in his dailyleisure participation.

Case ContentThe problem addressed in this case report

is Scott's self-injurious behaviors (i.e., hittinghis right and left temple area and biting hishands/wrists) prior to and during leisure en-gagement. As part of his treatment, Scott hasbeen taking anti-psychotic medication twice aday for the past five years to help decrease theoccurrence of self-injurious behavior. For thepast two years, Scott has been taking anti-Parkinson's medication to combat side effectsof the anti-psychotic drug. The staff observedand noted that Scott often displayed self-inju-rious behaviors during leisure to (a) obtainpreferred leisure objects; (b) express his anger/frustration at not having his leisure preferencesresponded to immediately; or (c) obtain vari-ous leisure options that were offered, but notimmediately available for engagement.

Other situations appeared to occasionallytrigger Scott's self-injurious behaviors. If

Scott had a sinus headache due to pollen al-lergies, he sometimes displayed self-injuriousbehaviors. In this situation, the staff utilizedthe hand-over-hand technique to assist Scott inrubbing his temples to try to alleviate some ofthe pressure. On occasion, Scott self-injuredwhen he was frustrated or told that he couldnot do something, such as going outside ininclement weather. His self-injurious behav-iors were more prevalent at certain times of theyear, such as during the summer months and inDecember around the holidays. During thesetimes of the year there was less consistencyand structure in his schedule because schoolwas not in session, constituting a change in hisroutine. It is not uncommon for individualswith autism to exhibit negative behaviorswhen a change in a routine occurs (Hawkins,1996). However, the most prevalent time Scottself-injured was prior to and during recreation.

One type of situation where Scott woulddisplay self-injurious behavior was if hewanted to play with a specific object but thestaff could not understand him. For example, ifScott wanted to play with one of his favoritetoys, such as a yo-yo, and it was locked in acloset, he would stand next to the closet andbang on it. When the staff would not make hispreferred toy selection, Scott would bite hishand or hit himself in the head.

A second type of scenario that appeared totrigger self-injurious behavior was when staffcould not accommodate Scott's leisure re-quests. Some examples of this scenario werewhen Scott would grab the hand of a staffmember leading them to the front door andtrying to go outside because he wanted to gosomewhere in the van, or he would lead a staffmember to the door of the pool when hewanted to go swimming. Some of the reasonsthe staff were unable to respond to his leisurerequests were (a) lack of availability of sup-plies, (b) other program requirements being apriority at the same time he requested to en-gage in a certain leisure activity, or (c) pro-gram time constraints to carry out his preferredleisure activity. It appeared that Scott dis-played self-injurious behaviors on these occa-


sions as a way to object to not being able toengage in his preferred leisure activity. How-ever, staff would try to meet Scott's leisurerequests whenever possible. For example, ifScott grabbed the hand of a staff member totake a walk and no time or program constraintswere present, Scott would be able to take awalk.

Finally, self-injurious behaviors also man-ifested when Scott was offered various optionsfor leisure activity engagement that were notimmediately available. For example, if Scottindependently selected swimming as the lei-sure activity he wished to engage in, but thelifeguard was not available for another hour,Scott would become very agitated and engagein self-injurious behavior. Another examplewas when Scott chose an activity and the staffdelayed in responding to his request becausethey had to assist another resident before theycould meet Scott's expressed preference. Thisbehavior appeared to occur because he wasunable to immediately engage in his chosenleisure activity.

While the self-injurious behaviors were anindication that Scott was not having his leisurepreferences met, these behaviors often pre-vented him from successfully engaging in lei-sure activities. Frequently, as his frustrationand agitation escalated, Scott had to be re-moved from the room or area and restrained soas to not further injure himself.

AssessmentScott's self-injurious behaviors were first

noticed by various staff members in 1996.Specifically, staff noted that Scott was self-injuring an average of 20 times throughouteach day. Daily observations and notes weremade by staff across recreation, education, andresidential disciplines for one year to deter-mine the circumstances which triggered thesebehaviors and to obtain consistent informationover time. The time and duration of observa-tions varied according to when the behaviorsoccurred and the length of time Scott engagedin self-injurious behaviors. For example, ifScott bit himself five times during academic

activities, the teacher would attempt to deter-mine the antecedent to the behavior and notethe length of time Scott bit himself each timethis behavior occurred. Frequency of self-in-jurious behaviors were determined by thenumber of episodes each day.

After one year of observing and document-ing Scott's self-injurious behaviors, a patternof occurrence emerged that seemed to indicatethat he exhibited self-injurious behaviors whenhe was unable to engage in a preferred leisureactivity versus academic or self-care activity.Specifically, it appeared that the self-injuriousbehavior occurred when (a) Scott attempted tocommunicate a leisure preference but the staffcould not understand his choice; (b) the staffcould not respond to Scott's leisure activity orequipment requests; or (c) various leisure ac-tivity options were offered, but not immedi-ately available for engagement.

Scott's self-injurious behaviors were as-sessed and documented daily in staff notesthrough transdisciplinary staff observations.The staff observed that, when encounteringcertain situations discussed later in this report,Scott exhibited three primary self-injurious be-haviors: (a) hitting his head with his hand, (b)biting himself, and (c) on rare occasions bang-ing his head on walls and doors.

The recreation director completed an an-nual recreation survey to determine Scott'sleisure preferences. His preferences were de-termined by offering him a wide variety ofobjects and activities, observing his interest,and noting the duration of time his interest washeld. For example, if Scott was offered anobject to play with and he was not interested inthe object, he would leave it untouched. On theother hand, if Scott preferred an object, hewould play with it with great interest by ma-nipulating or holding the object for the dura-tion of the leisure time. Scott's interests inactivities were determined by his level of par-ticipation. Swimming was an activity Scottdemonstrated interest in by laughing and be-coming excited when told he was going to thepool. Scott did not appear interested in groupgames as he would walk away from the group


and sit by himself when these games tookplace. Scott's leisure interests included play-ing with toy cars, going hiking and to parks,swimming and aquatic activities, and objectmanipulation such as yo-yos. Other preferredtoys and activities included playing with nuts/bolts, beads, checkers, and dominoes.

PlanAnnual goals and objectives, including

those related to Scott's leisure functioning,were developed and included in his Individu-alized Education Plan (IEP). Also included inScott's IEP were goals and objectives relatedto domestic skills, vocational skills, and com-munity skills. Scott's leisure goals focused onincreasing his independent leisure functioningby teaching him choice making strategies. Thestaff of the ICF worked with Scott daily tohelp him attain the goals and objectives set forthat year.

After the assessment was conducted,Scott's transdisciplinary treatment goals wereto (a) learn ways to effectively communicatehis preferences for leisure activities and ob-jects and (b) select leisure activities and equip-ment that were readily available. The interven-tion selected to address the goals was the useof a Leisure Communication Book (LCB),which included pictures of his preferred lei-sure activities (i.e., swimming, attending com-munity events) and objects (i.e., yo-yos, dom-inos). The intent of the LCB was to reduceScott's self-injurious behaviors prior to leisureactivity engagement by teaching him to effec-tively communicate his leisure preferences andselect readily available leisure activities. Thisintervention was primarily chosen because itused a skill Scott currently possessed, to com-municate his needs by pointing to pictures.The LCB was also selected for use as a way toreduce Scott's frustration level by limitingpictures of leisure options to those that werereadily available. Lastly, this intervention wasselected because it could be used as a trans-disciplinary intervention particularly betweeneducational, residential, and recreational ser-vices.

Table 1.

Listing of Twenty Images in Scott'sLeisure Communication Book

DominosYo-yoCarSwimming PoolPersonal Radio

(i.e., Walkman)ComputerArt SuppliesPerson walkingMusical InstrumentsAssembly Toys

(i.e., Legos)

ParkFestivalStoreBeads

CheckersToolsMagazinesGym/Sport EquipmentWeighted Blanket

Nuts and Bolts

Scott's LCB was developed using a three-ring, 8.5 X 11 inch binder type of notebook.The LCB had five different pages in sheetprotectors, similar to photo album pages.Scott's LCB contained 20 pictures featuring acombination of computer-generated and pho-tographic pictures (see Table 1). Professionalsworking with individuals who have limitedcommunication skills have found that usingpictures and picture books is an effectivemethod for them to communicate a variety ofneeds and preferences (McDuff, Drantz, &McClannahan, 1993; Quill, 1995; Vicker,1996). The computer-generated pictures weredeveloped from a computer program that wasused throughout the facility to label rooms(e.g., classroom, bathroom, gymnasium,kitchen, etc.) and objects (e.g., water fountain,sink, table, wall, etc.). Each computer-gener-ated picture was 2 X 2 inches, displayed aleisure object or activity, and was labeled witha worded description beneath the picture.Computer-generated pictures were used to la-bel the item or action (e.g., dominos or walk-ing) and photographs were used to demon-strate use of the item or action (e.g., a personplaying dominos or a person walking). Thephotographs were taken with an instamaticcamera and were placed next to the computer


MUSIC GYM

RIDE IN CAR COOKING

WALKING MOVIES

FIGURE 1. REPRESENTED ACTIVITIES SIMILAR TO SCOTT'S LEISURE COMMUNICATIONBOOK.

pictures on each page. Representative graphicssimilar to those featured in Scott's LCB ofdifferent leisure activities or objects are fea-tured in Figure 1 because Scott's actual bookis too worn to reproduce.

All computer generated pictures and pho-tographs in Scott's LCB represented Scott's

preferences and included only items and activ-ities accessible in the ICF. The leisure picturesfrom which Scott made his selections repre-sented activities that he could engage in im-mediately; pictures could be added or removeddepending on the availability for engagement.When this intervention was implemented, the


facility owned the computer software andequipment used to create Scott's LCB, makingthe intervention easily accessible.

The LCB was to be used at least twice aday, seven days a week. On school days it wasused during free-time, structured recreation,and sensory tolerance periods. A sensory tol-erance period was a specific period of timeutilized to reduce Scott's response to overstimulation, as individuals with autism canexperience increased sensitivity to sensorystimuli. Scott was sensitive mainly to loudsounds (e.g., vacuum cleaners) and fast-mov-ing lights (e.g., strobe lights). During eveningsand weekends the LCB was used during struc-tured and unstructured recreation time periods.The effectiveness of the intervention was to beevaluated through use of a behavior log, de-signed specifically for this intervention, com-pleted by all staff who used the LCB withScott. Specifically, Scott would be observedeach time the LCB was used, for the durationof its use, and any occurrences of self-injuri-ous behaviors would be recorded. In addition,when the LCB was not in use, other instancesof self-injurious behaviors were documentedin a separate daily behavior log. Frequency,duration, and contexts under which all self-injurious behaviors occurred were noted inboth logs. By documenting the frequency, du-ration, and context of all self-injurious behav-iors and then analyzing the two logs, it washoped that the effectiveness of the interventioncould be evaluated.

ImplementationWhen the intervention was first imple-

mented, Scott had difficulty using the LCB toidentify his preferred leisure activity or objectprior to engagement. Specifically, he had dif-ficulty understanding that pointing to the pic-tures in the LCB was the way to communicatehis leisure preference prior to engagement. Forexample, instead of using his LCB, Scottwould just go get the object he wanted, engagein the activity, or engage in self-injurious be-havior as an attempt to communicate his dis-

pleasure of not having his leisure preferencemet.

Prior to implementing the intervention,staff working with Scott were trained in theuse of the LCB over a three-week period, for atotal of approximately 10 days of training. Thefacility's Qualified Mental Retardation Profes-sional (QMRP) served as the trainer. Staffobserved the trainer using the LCB with Scott,including documentation, for the first threedays of the training. Next, the staff practicedusing the LCB with Scott, while the trainermonitored the reliability and validity of its useand documentation. When a 95% reliabilityrating was achieved between each staff mem-ber and trainer, the LCB was used indepen-dently with Scott. The trainer monitored thedocumentation of self-injurious behaviorswhen using the LCB as well as the use of theLCB for accuracy and consistency for approx-imately three months following training.

To teach Scott to use the LCB to commu-nicate his selected leisure preferences prior toengagement, he was first presented with thebook. He was taught how to choose an activityfrom the book with verbal prompts and hand-over-hand technique. In using this technique,the staff member would place his/her hand ontop of Scott's hand and physically guide himto point to a picture. In addition to applying thehand-over-hand technique, staff memberswould verbally prompt Scott to point to hisactivity preference. For example, at the sametime the staff member would be physicallyguiding Scott's hand, they would be askinghim what he would like to do today during hisfree-time. The hand-over-hand technique andverbal prompting were implemented each timethe LCB was used for activity selection. Theuse of these techniques continued until Scottcould point independently 100% of the time tohis choice of activity with only verbal prompt-ing.

It took three months to teach Scott theprocess of using the hand-over-hand tech-nique, during which time staff members grad-ually decreased their physical guidance topoint to pictures. The decrease in physical


guidance to point to pictures was based onwhether Scott pointed to a leisure activityindependently. After Scott appeared to under-stand how to point to a picture, the staff beganleisure activity selection with only verbalprompts. If Scott did not point to a picture afterseveral verbal prompts, the staff would imple-ment the hand-over-hand technique to assisthim in selecting an activity picture. WhenScott pointed to a picture independently, thestaff would verbally praise him for doing so.

After Scott pointed to a picture of a pre-ferred leisure activity, the picture was verballyidentified by the staff member. Scott was thenverbally praised for communicating his pref-erence, for not exhibiting self-injurious behav-iors, and was immediately allowed to engagein the identified leisure activity. There wereoccasions when Scott would not point to apicture in the LCB, but instead would walk toa storage closet and bang on the closet or pointout the window at a car. On the rare occasionthis occurred the staff member would attemptto redirect him by explaining that the picturesin the book were the only activities that werereadily available. Then staff encouraged himto make a selection from the LCB.

When Scott exhibited self-injurious behav-iors during use of the LCB or prior to engage-ment in the leisure activity, he did not receivepreferred leisure objects or participation inleisure activities was discontinued until hestopped the behavior. When he exhibited self-injurious behaviors (i.e., hitting his head orbiting his hand) while participating in the lei-sure activity, the staff stopped the activity,verbally prompted Scott to terminate the be-havior, and resumed the activity only afterScott ceased the behavior.

Since the inception of the LCB, Scott hasbeen taught to use a voice communicationdevice to initiate use of the LCB. The voicecommunication device can be programmedwith 16 different phrases or activities. He hasbeen able to initiate the use of the LCB bypressing the button that states, "I want toplay." By utilizing this device, Scott has beenable to communicate leisure needs, answer

"yes" and "no" questions and have a variety ofpersonal needs met (e.g., eating, drinking).

EvaluationThe intent of the LCB was to decrease

Scott's self-injurious behaviors prior to andduring leisure participation by utilizing an ef-fective means of communicating his leisureneeds and preferences. A log of Scott's behav-ior was used to evaluate the effectiveness ofthe LCB. Scott's behavior was logged when heengaged in self-injurious behaviors during lei-sure time. When the behaviors occurred, theantecedent, frequency, duration, and contextwere recorded for the incidence of behavior.The QMRP reviewed all documentation forcompleteness and consistency. Figure 2 pro-vides a bar-graphed sample of Scott's behaviorlog used over the course of one year to docu-ment the frequency of his self-injurious behav-iors (i.e., hitting his head, biting his skin).

Prior to implementing the LCB to assistScott with expressing his leisure preferences,he self-injured an average of 20 times eachday. From its inception in February 1997 untilFebruary 1999, this intervention decreased theincidence of Scott's self-injurious behaviorsprior to and during leisure engagement. Spe-cifically, the staff noted a decrease of self-injurious behaviors from 20 to less than 5times a day. A decrease of self-injurious be-haviors was determined through a review ofdaily behavior logs by the QMRP. Logs werereviewed monthly by counting, averaging, andcomparing the frequency and context of occur-rence of self-injurious behaviors. In addition,the specific type of self-injurious behavior wasnoted. Then, the QMRP would average thefrequency of self-injurious behavior quarterlyand annually.

Figure 2 is a sample of Scott's annualbehavior log with monthly occurrences of spe-cific self-injurious behaviors documented. Thebehavior that had the most significant decreasewas Scott's biting of his hands. Specifically,over the two years in which this interventionwas documented, it was determined thatScott's hand biting decreased by 70%. Scott


70-

a Hitting Head• Biting Skin

January March July September NovemberTime

FIGURE 2. SCOTT'S ANNUAL BEHAVIOR LOG DEMONSTRATING MONTHLYINCIDENCE OF SELF-INJURIOUS BEHAVIOR.

frequently bit his hands in frustration or angerbefore he would hit himself in the head; thus,hand biting occurred more often than otherself-injurious behaviors.

The use of the LCB, as a method of com-municating leisure preferences, appeared to beeffective as it allowed Scott to communicatehis preferences in a positive way (by pointingto a preferred leisure object or activity), ratherthan displaying self-injurious behavior to havehis leisure needs met. Because Scott was of-fered only choices of leisure activities andobjects that were immediately available, oneof his sources of frustration was eliminated atthe onset of leisure participation.

Other factors were taken into considerationwhen determining the effectiveness of thisintervention. At the time the intervention wasimplemented, the context of Scott's daily rou-tine had been stable for more than three years.Scott has lived in the ICF for 13 years, hasbeen on an anti-psychotic medication for 5

years, has had the same daily routine includingacademic services and speech therapy for 10years, and has worked with the same staffmembers for more than 3 years. Two factorsthat may have contributed to the success ofthis intervention were the use of the LCBacross disciplines and the length of time it wasused. The LCB was used by staff in classroom,residential, recreation, and speech therapy set-ting consistently for two years.

Scott's self-injurious behaviors were ran-dom in that he may have exhibited none ofthese behaviors for 30 days and then self-injured five times in one day. The exact causefor the length of time between Scott's engage-ment in self-injurious behaviors was unknown,but in examining antecedents to his abusivebehaviors it can be speculated that boredom,change in routine, or exacerbation of allergiesmay be some of the causes. Thus, the staffcontinues to use the LCB, as well as docu-menting its use, so that circumstances sur-


rounding the self-injurious behavior can benoted and analyzed. For example, ongoingdocumentation allowed continuous evaluationof the intervention as well as Scott's behaviorin relation to self-injurious behaviors and cer-tain leisure activities, times of the day when heparticipated, and other circumstances that maytrigger self-injurious behaviors.

Authors' CommentsThe purpose of this case report was to

discuss effectiveness of a transdisciplinary in-tervention on the occurrence of self-injuriousbehaviors in a young man with autism. Theintervention provided an age-appropriate, ef-fective way for Scott to express his leisurepreferences. Using a book composed of pic-tures of his preferred leisure activities, Scottwas able to select an activity of choice bypointing to a picture. Choices offered in theLCB were limited to leisure activities andobjects that were immediately available to al-low Scott to decrease initiation of self-injuri-ous behaviors. In addition to using the LCB,Scott was able to develop his own methods ofcommunicating his leisure preferences. Forexample, instead of using his LCB, he wouldtake a staff person's hand and lead him or herto the object or activity he wanted. Being ableto develop and use his own system in conjunc-tion with the LCB appeared to increase Scott'sacceptance of not being able to immediatelyengage in a specified leisure activity and gavehim opportunities to be self-determined.

Use of the LCB appeared to promoteScott's self-determination by enabling him toidentify his leisure preferences, select an ac-tivity for participation, and immediately en-gage in the leisure activity. The possibility thatScott would feel more self-determined mayincrease the likelihood that he will initiateparticipation in leisure activities in the future.Devine and colleagues (1997) found that whenindividuals with developmental disabilitieswere provided opportunities to make choicesusing prompts, the initiation of leisure activi-ties increased.

During two years, this intervention was

successful in a 75% reduction of Scott's self-injurious behavior prior to and during engag-ing in his preferred leisure activities. Whilethis intervention was effective during the ma-jority of Scott's leisure time, self-injuriousbehaviors are a common characteristic of in-dividuals with autism. Studies have found itnearly impossible to completely eliminate self-injurious behaviors with individuals who havedevelopmental disabilities (cf. Logan & Keefe,1997; Scotti, Ujcich, Weigle, Holland, & Kirk,1996; Hanger, Butterworth, & Keith, 1995).This case report supports use of a choicemaking intervention, along with medications,to reduce self-injurious behaviors prior to andduring leisure engagement.

The LCB was practical to use with Scottbecause the staff working with him in theresidential unit, classroom, and recreation areacould use the book. It allowed staff to assistScott in choosing a leisure activity or object hepreferred, while maintaining control overthose choices by only giving him ones thatwere immediately available.

Recently, Scott has begun to learn to waitfor the signal to begin a preferred activity withthe use of an egg timer. For example, Scottwas told "we will go for a walk when the timerrings." His tolerance for waiting to commencean activity has increased from 0 to 60 seconds.When Scott has become conditioned to thetimer signaling the beginning of a preferredactivity, the timer can be used to give him anidea of when scheduled activities will begin.

Scott has also been taught to use commu-nication boards, which were similar to hisLCB, but instead of being in a book, thepictures of activities were placed on posterboard and hung on the wall. Scott has a com-munication board in his daily living area thathas choices of activities residents can partici-pate in for that area of the building. Scott'steacher also utilized a communication board todisplay classroom chores which students usedfor selection (e.g., emptying trash cans, pick-ing up trash, etc.).

Over the two years since the beginning of thisintervention, Scott appeared to mature a great


deal. Overall, he has become calmer and is moreeasily redirected at the onset of serf-injuriousbehaviors. When the intervention was firststarted, Scott sometimes had to have his armsheld by his sides to stop his self-injurious behav-ior, but at the end of the two years he coulddiscontinue the behavior with only verbalprompts. Also, the voice communication device,discussed previously, has allowed Scott to initi-ate the use of the LCB. He has been able toapproach staff and express his desire to choose aleisure activity from his LCB.

Individuals with disabilities have exhibitednegative responses, such as self-injurious be-haviors, to communicate expressed desiresduring leisure participation. This case reportdemonstrates one way to acknowledge posi-tive behaviors and and decrease negative ones.In relation to people with autism, therapeuticrecreation practitioners should identify inter-ventions that can contribute to decreasing oc-currences of self-injurious behavior and in-crease their ability to express choices duringleisure functioning. In addition, when individ-uals lack verbal or written communicationskills, it is imperative that facilitation tech-niques be examined, tested, and applied toenable them to express leisure needs and pref-erences.

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