Competing with the Urge to Pick
By: Elizabeth Zeppernick, M.Ed., BCBA, LBA
Skin picking can be defined as the repetitive scratching, pulling or digging of the body with the absence of an underlying cause such as a dermatological condition. Behavior Analysts working in the field of Intellectual and Developmental Disabilities are often familiar with this problem behavior and it is estimated that nearly 10% of individuals with Autism Spectrum Disorder (ASD) exhibit this type of self injury (Gulsrud et al. 2018). The intensity of skin picking can range from relatively mild with little to no injury, to much more severe tissue damage which presents a risk to the individual’s health.
The majority of research regarding skin picking addresses and provides treatment possibilities for children and adolescents and in tightly controlled environments such as a clinic. Fewer studies look at interventions for adults and even fewer present data on treatment for adults in natural settings such as the home and community.
In the study, “Using Competing Stimuli with an Adult with Stereotypic Skin Picking: A Case Study of Assessment, Treatment, and Generalization,” researchers Jeglum et al. (2022) worked with a woman in her 20’s diagnosed with ASD and intellectual disability. The participants' parents reported that her skin picking was nearly constant and could often escalate to cause severe injury in the form of bleeding, and damage to the skin and nails. They determined that the behavior was maintained by automatic reinforcement which means it was self-stimulating and not happening because of social or environmental factors like attention from others.
In an outpatient clinic, the researchers used a Competing Stimulus Assessment (CSA), in sessions lasting 5-minutes each, to find out which stimuli or activities would successfully compete with the skin picking in order to reduce this problem behavior. Stimuli or engaging activities were chosen based on a preference assessment to find out which stimuli (beads, animal puppets, stuffed animals, slinky, keyboard, squishy and stress toys etc.) were most preferred by the participant. Researchers measured the duration of engagement with each item while also measuring the duration or percentage of engagement in skin picking. During this portion of the study, evaluators found that the larger stimuli which required two hands to manipulate, led to a greater reduction in skin picking.
Measurements prior to treatment (the baseline) showed skin picking was happening for an average duration of 52.5% of the sessions. When they simply presented the items, they found that free access to the stimuli led to a reduction to an average of 19.3% of the sessions. Treatment then included using free access plus Response Promotion and Response Disruption (RPRD) which means that the skin picking was disrupted by the parent who then prompted her to engage with the stimuli that were proven to effectively ‘compete’ with the skin picking. The caregivers then praised their daughter for engaging with the competing toy or activity. They would provide a descriptive comment like, “I love how you’re stirring the spoon in the teacup!” By the end of the trial phase, levels of skin picking were reduced by 80% from the pre-treatment levels.
Follow up sessions occurred about once per month, first in the clinic but then in the family’s home via telehealth. During this telehealth post-treatment follow up, it was found that both low rates of skin picking and high rates of engagement in the competing stimuli were still present. The successful generalization of treatment to the home setting with caregivers is a key component of this study as staff and therapists may come and go but caregivers are typically the constant in an individual’s life, responsible for maintaining safety and supporting positive behaviors.
When clinicians and parents consider common alternative interventions for self injury, they may consider response blocking which physically prevents the individual from engaging in the problem behavior. Response blocking is typically more invasive and can lead to the escalation of behaviors when compared to the treatment used in this study. On the other hand and as presented in the study outlined above, response promotion in the form of presenting a preferred activity and providing verbal praise may be an intervention worth exploring for its practicality and less invasive approach to the problem of skin picking.
Sources:
Gulsrud, A., Lin, C. E., Park, M. N., Hellemann, G., & McCracken, J. (2018). Self-injurious behaviours in children and adults with autism spectrum disorder (ASD). Journal of Intellectual Disability Research, 62(12), 1030-1042. https://doi.org/10.1111/
Jeglum, S. R., Luehring, M. C., & Kurtz, P. F. (2022). Using competing stimuli with an adult with stertypic skin picking: A case study of assessment, treatment, and generalization. Behavior Interventions, 1-11, https://doi.org/10.1002/bin.1870
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