Running Head: CRITICAL REVIEW

Critical Review Jaylene Bettcher APSY 605 Research Design and Statistics Dr. David W. Nordstokke March 1, 2011

CRITICAL REVIEW Critical Review Gal, E., Dyck, M. J., & Passmore, A. (2009). The relationship between stereotyped movements and self-injurious behavior in children with developmental or sensory disabilities. Research in Developmental Disabilities, 30, 342- 352. doi: 10.1016/j.rdd.2008.06.003

Self-injurious behaviour (SIB) is a heterogeneous disorder whereby an individual initiates and directs self abuse, which often results in detrimental outcomes, and consequently, may diminish their quality of life. SIB is a perplexing puzzle in that it differs in frequency, intensity, function, and maintenance within each individual. Individuals with developmental or sensory impairments typically exhibit rhythmic, repetitive, and localized SIB, which often resembles stereotyped movements (SM). Although SM is fundamental component of autism, many individuals with developmental and sensory disorders may also display rocking, toe walking, hand or finger flapping, and whirling (Gal, Dyck, & Passmore, 2009). There are numerous theories why SIB is maintained in individuals with developmental or sensory disabilities. In accordance with Gal, Dyck, and Passmore (2009), SIB, when manifested by repetition, rigidity, and invariance in individuals with developmental and sensory disorders, may be better accounted for as severe SM, rather than a disconnected maladaptive behaviour. Purpose Gal et al. (2009) assessed whether SIB may be categorized as severe SM, and if children with autism and other developmental or sensory disorders exhibit distinct patterns of SIB and SM. Furthermore, Gal et al. (2009) examined if SIB and SM displayed by children with autism differs from SIB and SM displayed by children with other disorders. Gal et al. (2009) hypothesized that SIB items will be consistent with SM items, and that SIB will only be displayed in children who also demonstrate SM. If SIB is merely a more severe form of SM in

CRITICAL REVIEW children with developmental or sensory disabilities it may be plausible to infer that there is a continuum of stereotyped behaviours and SIB resides at the extreme end. Design Participants The participants in the study were 221 children (129 boys and 92 girls), age six through 13 years (mean= 9.40, S.D. = 1.81) that were recruited through a convenience sample. A convenience sample is the process of collecting data from participants that are easily accessible, and therefore, we must interpret the results of this study with extreme caution because they may not be a true representation of the population. The participants were separated into five groups according to diagnoses by physicians or psychologists. The groups consisted of typically developing children (n= 30), children with intellectual disabilities without sensory impairments

(n= 29), children with visual impairments (n=50), children with hearing impairments (n=51), and children with autism (n=56). There were a comparable number of girls and boys in all groups except for children with hearing impairments and children with autism, whereby there were 31 boys and 20 girls, and 42 boys and 14 girls respectively. Even though boys were overrepresented in these groups, the sex difference may accurately reflect the population as there is more males diagnosed with autism than females. However, neither gender nor age comparisons of SIB and SM were completed, and therefore, it is unknown whether an increase of SIB and SM in groups is attributed to the disability or to gender and/or hormonal differences. All of the participants lived at home with their families and attended school in the Haifa metropolitan area of Northern Israel. The typically developing children went to a state school, whilst the children with developmental or sensory disabilities went to a segregated school for children with disabilities where they were able to receive additional support. This may not be an

CRITICAL REVIEW accurate reflection of the population because not all children with developmental or sensory disabilities are enrolled in segregated schools. Thus, it may be reasonable to believe that the sample merely includes children with severe developmental or sensory disabilities that are more likely to engage in SIB and SM. The participants were excluded if they were diagnosed with developmental disorders other than intellectual disabilities or autism, or if they had received a

comorbid diagnosis. Criteria for exclusion included developmental disorders associated with SM such as Lech Nyhan Syndrome, Cornelia de Lange Syndrome, Fragile X Syndrome, and Rett Syndrome (etc.). Procedure The current study uses the Stereotyped and Self-Injurious Movement Interview to assess stereotyped movements, stereotyped manipulation of objects, and stereotyped SIB. The measure features 25 items, and for each item there are four possible scores based on different types of SM exhibited, frequency of SM, duration of SM, and intensity of SM. Since these scores are categorical, they may create an inaccurate representation of the results because of the large discrepancy in data. For instance, for the frequency of SM, the highest category is 30 or more times per week, this category may encompass both children who display SM 30 times per week and children who display SM 200 times per week. The interview was administered to the participants home room teacher. Although the teachers were briefed as to what constitutes as SIB and SM, the information accumulated from the interviews may be very subjective due to different beliefs and biases. Another limitation to only interviewing the participants teacher is that the results merely reflect the childrens behaviour at school, which may differ from their behaviour at home. Consequently, the results should not be generalized to all environments. Analysis

CRITICAL REVIEW In order to analyze the correlation between the four scores (different types of SM exhibited, frequency of SM, duration of SM, and intensity of SM), Pearson correlations were calculated. Gal et al. (2009) discovered that the correlations between scores were essentially interchangeable (children who exhibited many different types of SM also exhibited SM more

frequently and intensely over a longer period of time), so they only reported the frequency of SM for each item. As a result, the types, duration, and intensity of SM are unknown; these scores may have included insightful outliers and provided further insight about SIB and SM, however, they were simply disregarded. In order to investigate if SIB may be better accounted for as severe SM, Gal et al. (2009), assessed the probability of observing SIB in the absence of SM through a cross-tabulation of responses. Out of the 90 participants who displayed at least one incident of SIB, there were only three participants who did not display any type of SM. Furthermore, of the 170 participants who displayed SM, 83 participants displayed SM in the absence of SIB. Gal et al. (2009) also hypothesized that if SIB and SM are on the same continuum then group patterns of SIB should be analogous to group patterns of SM. The groups, from highest to lowest, of children who exhibited SIB were 64.3% (autism), 52.0% (vision impairment), 31% (intellectually disabled), 30.0% (hearing impairment) and 6.7% (typical). Similarly, the groups, from highest to lowest, of children who exhibited SM were 98.2% (autism), 86.0% (vision impairment), 79.3% (intellectually disabled), 67.9% (hearing impairment), and 36.7% (typical). Analysis of variance was used to evaluate between-group differences of SM. Groups differed significantly on 19 of the 25 items, for instance, children with autism displayed mouth/tongue and rocking SM more than any other group. Children with visual impairments tended to stare closely and operate switches, whilst children with hearing impairments tended to

CRITICAL REVIEW manipulate objects more than any other group. From these findings, Gal et al. (2009) attempted to categorize groups based on the most frequent type of SM, however, there was a great deal of within-group variation and the results were not reliable. Interpretation of results From their analysis, Gal et al. (2009) concluded that SIB, exhibited by children with developmental or sensory disabilities, is contingent on SM. Furthermore, SIB, when

characterized by repetition and rigidity, may be better accounted for as severe SM. Although the theory that SIB is a form of severe stereotypy may be credible, there are a couple limitations that need to be addressed. Firstly, SIB is a heterogeneous disorder whereby functions, symptoms, and outcomes of SIB may differ in each individual. For many children SIB may be considered severe stereotypy, however, for some children SIB may function as either a social/non-social mediated behaviour, or a way to relieve discomfort (e.g. hearing impairment). Secondly, there was a lot of between-group and within-group variation of SM in the present study that may be attributed to underlying impairments of the developmental and sensory disabilities. For example, eye gouging in children with visual impairments may not be a severe form of SM, but rather an attempt to improve their field of vision. Thus, it is important to identify the individuality of each case, instead of impetuously arriving at conclusions. Gal et al. (2009) also found that SIB and SM were displayed more frequently and in a greater portion of children with autism than in other children with developmental or sensory disabilities. Gal et al. (2009) believe that the implications of this finding may indicate that SIB is not only a challenging and destructive behaviour that is often comorbid with autism and other developmental and sensory disorders, but also a potential defining characteristic of autism. Once again, this conclusion may have been reached prematurely. If SIB is a severe form of a SM and

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a core component of autism, then we need to further investigate how the underlying impairments responsible for autism cause these destructive and damaging behaviours.

CRITICAL REVIEW Ludscher, P., Grreffrath, W., Schmahl, C., Kleindienst, N., Kraus A., Baumgrtner, U., Bohus, M. (2009). A cross-sectional investigation of discontinuation of self-injury and normalizing pain perception in patients with borderline personality disorder. Acta Psychiatrica Scandinavica, 120, 62-70. doi:10.1111/j.1600-0447.2008.01335.x According to Ludscher et al. (2009) approximately 60-90% of individuals with borderline personality disorder (BPD) engage in non-suicidal self injurious behaviour (SIB). SIB allows individuals with BPD to alleviate dysphoria, re-live painful experiences, which may be viewed as a method of punishing ones self, convey anger, and acquire social attention (Ludscher et al., 2009). It is believed that individuals with BPD have an attenuated pain perception, which may hinder both cognitive evaluations and emotional reactions to painful stimuli (Ludscher et al., 2009). Although there is a wealth of research on BPD and pain

perception, it is indefinite as to whether pain perception in individuals with BPD ever normalizes if SIB ceases. Purpose The intent of the current study was to assess whether pain perception in individuals with BDP who readily engage is SIB (BDP-SIB) differs from individuals with BDP who no longer engage in SIB (BDP-non-SIB), and furthermore, whether pain perception of those with BDP differs from healthy controls (HC). Ludscher et al. (2009) hypothesized that individuals with BDP-non-SIB may display an inclination for normal pain acuity, and that their pain thresholds will be situated between individuals with BDP-SIB and HC. Thus, it may be plausible that pain perception in individuals with BDP is negatively correlated with the severity of BDP symptoms (Ludscher et al., 2009). Design

CRITICAL REVIEW Participants The participants in the study were 24 female healthy controls (HC) and 24 females with

BDP; 13 of which currently engage in SIB (BDP-SIB) and 11 of which have not engaged in SIB for at least the past six months (BDP-non-SIB). Although the time of the most recent SIB was taken into account, frequency and method of SIB was not, which is unfortunate because it may have provided further insight into the results. The participants with BDP were diagnosed by psychiatrists who closely adhered to the criteria in the DSM-IV-TR. The mean age for HC was 25, while the mean age for BDP-SIB and BDP-non-SIB was 28 and 30, respectively. The sample size was quite small and consisted of all female participants, and therefore, results need to be interpreted with caution when applied to the general population and males with BDP. However, it is worth mentioning that according to the DSM-IV-TR, 75% of individuals diagnosed with BDP are female, and consequently it may have been difficult to recruit male participants with BDP. Participants with BDP were recruited from the Central Institute of Mental Health in Mannheim, Germany, and the Department of Psychiatry and Psychotherapeutic Medicine, University of Freiburg, Germany. 17 participants with BDP did not reside at a mental health care facility (8 BDP-SIB and 9 BDP-non-SIB), while seven participants with BDP did (5 BDPSIB and 2 BDP-non-SIB). The 24 HC were university students recruited from the Institute of Physiology and Pathophysiology at the University of Mainz, Germany. Exclusion criteria for participants with BDP included major depression, bipolar disorder, schizophrenia, alcohol or drug addiction, and consumption of psychotropic medication within the past two weeks. Excluding individuals who use psychotropic medication may have decreased external validity of the results because most individuals with BDP are routinely prescribed psychotropic medications

CRITICAL REVIEW to help with their symptoms. Exclusion criteria for the HC group were any axis I or axis II diagnoses from the DSM-IV-TR. Procedure In order to assess the participants sensory detection and pain thresholds a contact

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thermode was applied to the back of their hands. The baseline temperature of the thermode was 32C, and participants were required to push one of two buttons if the temperature either increased or decreased by 1C in order to assess their detection thresholds. The temperature steadily increased to 50 and steadily decreased to 0 (unless the participant requested to discontinue, whereby the temperature that they withstood was indicative of their pain threshold) in order to assess their pain threshold). In order to assess the participants pain perception, the participants were exposed to a laser beam that gave off radiant heat pulses. The participants were required to rate their perception of pain using a standard descriptor scale (nothing, touch, warm, pricking, stinging, burning, and miscellaneous). There was also a sensory discrimination task whereby participants were directed to complete an arithmetic problem (this served as a distraction) while determining the localization of a narrow (harder to discriminate) or wide (easier to discriminate) laser beam. A significant limitation of this study, regardless of standard descriptor scales and diverse measures of pain and perception, is that pain and self-reports are extremely subjective. What one perceives to be painful may be based on previous life experiences, for instance, a participant who had a baby may not believe that a radiant heat pulse is painful. Also, individuals with BPD often engage in attention seeking behaviours, and it may be plausible that they choose to withstand large amounts of pain in order to provoke a response from others, or vice versa, choose to overreact to miniscule amounts of pain in order to gain sympathy. Consequently, we must

CRITICAL REVIEW interpret the results with caution as they may not accurately reflect true pain acuity in participants with BDP. Analysis

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During the assessment there was a technical failure with the laser beam, and consequently data from three HC, one BDP-SIB, and one BDP-non-SIB could not be used in the results. Also, three participants with BDP-non-SIB requested to discontinue the assessment, thus, data from only seven participants with BDP-non-SIB could be used in the results, which may not be an adequate sample size to attain an accurate reflection of the population. One way ANOVAS were used to analyze group differences in pain measurement and all other psychometric data, and Shapriro Wilks was used to test normality. The Kruskal Wallis test was used when data were not normally distributed (sensory detection test) and the Pearsons coefficient test was used to calculate any correlations between BDP symptom severity and pain acuity. Each participants pain measurements were calculated into Z-scores, and accordingly, each participant received a mean score. This calculation was useful to discriminate how much and in what direction pain acuity in participants with BDP deviates from HC. Although Ludscher et al. (2009) claim that their sample sizes are large enough to attain adequate statistical power, it is my belief that the small sample sizes and the variance of participants in each group may decrease the reliability of the tests, and once again, results should be interpreted with caution. The analysis indicated that there were no group differences for non-painful thermal detection; however, there were significant differences for all other pain measurements, including laser detection thresholds, laser pain thresholds, and laser pain intensity ratings. As predicted, participants with BDP-SIB had the highest pain thresholds, followed by participants with BDP-

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non-SIB and then HC. The participants ability to discriminate the localization of the narrow and wide laser beams did not differ between groups. Interpretation of results From their analysis, Ludscher et al. (2009) found that the participants with BDP-SIB constantly scored higher than the participants with BDP-SIB and the HC, which was a consistent finding from all five pain measures. An interesting discovery was that there were no group differences on the sensory discrimination task and that each group completed the task with ease. According to Ludscher et al. (2009), this finding may implicate that the sensory discriminative pain component is indeed intact in individuals with BDP, and that this component is independent of SIB. Another significant finding was that there was a negative correlation between BPD symptom severity and pain intensity ratings. Ludscher et al. (2009) took into account numerous theories as to why there are betweengroup differences in pain acuity. These theories included differences in genetic and developmental factors whereby decreased pain sensitivity results in continuation of SIB, and difficulties with recalling pain intensity. In accordance with their hypothesis, Ludscher et al. (2009) also reasoned that the termination of SIB may lead to normalized pain acuity, which may be indicative of improved BDP symptomatology. Even though Ludscher et al. (2009) took numerous theorizations that may support their findings into consideration, they do not make assumptions or premature conclusions, which is a strength of the study. Rather, they state that in order to strengthen the causal attribution between BDP and pain acuity, longitudinal studies and studies on individuals with BDP who have never engaged in SIB need to be regarded. Until then, Ludscher et al. (2009) suggests that there is an association between the cessation of SIB and normalized pain acuity in individuals with BDP.