Bagaimana Bentuk Prilaku Menyakiti Diri Sendiri

Prilaku melukai dan menyakiti diri sendiri adalah salah satu perilaku yang paling sering ditunjukkan oleh para penyandang cacat perkembangan. Bentuk yang paling umum dari perilaku ini meliputi: head-banging, menggigit  tangan, dan berlebihan ketika menggosok dan menggaruk. Ada banyak kemungkinan mengapa seseorang memiliki perilaku yang merugikan diri sendiri, mulai dari alasan biokimia sampai dengan lingkungan sosial. Tulisan ini akan membahas banyak penyebab melukai diri sendiri dan intervensi berdasarkan penyebab yang mendasarinya.

Functional analysis

Awalnya, functional analysis harus dilakukan untuk memperoleh gambaran rinci tentang  perilaku  melukai diri sendiri seseorang dan untuk menentukan kemungkinan hubungan antara perilakunya dengan lingkungan fisik dan sosial (lihat Wacker, Northup & Lambert, 1997).

Informasi yang diperoleh dari functional analysis harus mencakup: Siapa? Apa yang terjadi sebelum, selama dan setelah perilaku? Kapan itu terjadi? Di mana terjadinya? Mudah-mudahan, jawaban atas pertanyaan-pertanyaan ini dapat membantu mengungkapkan alasan untuk perilaku.

Sebelum pengumpulan data, penting untuk menentukan perilaku yang menarik. Fokus dari functional analysis harus pada perilaku tertentu (misalnya, menggigit pergelangan tangan) ketimbang kategori perilaku (misalnya, melukai diri). Menggabungkan beberapa jenis melukai diri menjadi satu perilaku umum mungkin membuat sulit untuk menentukan alasan yang berbeda untuk perilaku masing-masing.

Sebagai contoh, jika seorang anak menggigit pergelangan tangan dan menggaruk berlebihan, mungkin ada alasan berbeda untuk perilaku masing-masing (lihat Edelson, Taubman dan Lovaas, 1983). Menggigit pergelangan tangan  mungkin reaksi terhadap frustrasi, sedangkan menggaruk berlebihan dapat menjadi cara untuk stimulasi.

Selama pengumpulan data, karakteristik menonjol dari perilaku yang merugikan diri sendiri harus dicatat, seperti, durasi, keparahan dan frekuensi. Pengumpulan data juga harus mencakup informasi tentang lingkungan seseorang baik fisik maupun sosial. Lingkungan fisik harus meliputi: pengaturan (misalnya, ruang kelas, kantin, taman bermain), pencahayaan (cahaya alami, neon, lampu pijar), dan suara (misalnya, mesin pemotong rumput, anak lain berteriak). Nama-nama (atau kode) setiap orang di lingkungan seseorang juga harus dicatat, seperti guru, orang tua, staf, pengunjung dan siswa. Faktor lain yang perlu dicatat adalah: waktu dan hari dalam seminggu.

Alasan Psikologis Prilaku Melukai Diri

Biokimia

Beberapa peneliti telah menggambarkan adanya tingkat neurotransmiter tertentu yang terkait dengan prilaku menyakiri diri sendiri. Beta-endorfin adalah endogenous opiate-seperti zat di otak, dan melukai diri dapat meningkatkan produksi dan / atau pelepasan endorfin.

Akibatnya, individu mengalami efek anestesi-seperti pura-pura tidak merasa sakit saat melakukannya (Sandman dkk., 1983). Selain itu, pelepasan endorfin dapat memberikan perasaan gembira pada individu (Herman et al, 1989).

Ujicoba pada hewan di laboratorium serta penelitian tentang pemberian obat untuk subyek manusia menungjukkan bahwa rendahnya serotonin atau tingginya dopamin berhubungan dengan prilaku melukai diri (DiChiara et al, 1971;. Mueller & Nyhan, 1982).

Dalam sebuah penelitian pada populasi cacat mental yang heterogen, Greenberg (1976) dan Coleman memberikan obat seperti reserpin dan clorpromazin untuk mengurangi kadar serotonin. Para peneliti mengamati peningkatan dramatis dalam perilaku agresif dan melukai diri sendiri. Obat yang meningkatkan kadar dopamin, seperti amfetamin dan apomorphine telah terbukti menstimulasi individu untuk merugikan diri sendiri (Mueller & Nyhan, 1982;. Mueller et al, 1982).

Menariknya, Coleman (1994) mempelajari sekelompok anak-anak autis yang memiliki tingkat kalsium yang rendah (yaitu, hypocalcinuria). Individu ini memiliki prilaku sering memelototkan mata. Ketika diberi suplemen kalsium, prilaku ini berkurang secara substansial. Selain itu, fungsi bahasa juga melngalami peningkatan..

Apa yang harus dilihat

Ketika prilaku melukai diri dikaitkan dengan ketidaknormalan biokimia, mungkin ada sedikit atau tidak ada hubungan sama sekali antara lingkungan fisik / sosial seseorang  dengan prilaku melukai diri. Dengan demikian, perilaku ini dapat terjadi di berbagai tempat dan sekitar orang yang berbeda. Namun, prilaku melukai diri dapat terjadi lebih sering pada situasi yang tidak sesuai seperti makan, bermain, dan bekerja pada tugas.

Intervensi

Intervensi gizi dan medis dapat diimplementasikan untuk menormalkan biokimia seseorang, hal ini pada gilirannya dapat mengurangi perilaku yang parah. Meskipun obat yang sering digunakan untuk meningkatkan kadar serotonin atau untuk mengurangi tingkat dopamin, Autism Research Institute di San Diego telah menerima laporan dari ribuan orangtua yang telah memberikan putra mereka / putri vitamin B6, kalsium dan / atau DMG. Para orangtua sering mengamati penurunan dramatis, dalam beberapa kasus, perilaku melukai diri yang merugikan. Orang tua juga melaporkan adanya penurunan setelah anak mereka melakukan diet terbatas, seperti bebas gluten / kasein, atau menghilangkan makanan tertentu yang mana anak mereka menunjukkan tanda-tanda reaksi alergi.

Kejang

Prilaku Merugikan Diri juga telah dikaitkan dengan aktivitas kejang di lobus frontal dan temporal (Gedye, 1989; Gedye, 1992). Perilaku ini sering dikaitkan dengan aktivitas kejang meliputi: telinga, headbanging, menampar, menggigit tangan, memukul dagu, menggaruk wajah atau lengan, dan dalam beberapa kasus kontak lutut ke muka. Karena perilaku ini bukan atas kemauan sendiri, beberapa individu mencari jalan keluar untuk pengendalian diri misalnya, dengan mengikat lenganya. Kejang mungkin mulai terlihat, ketika anak mencapai pubertas, mungkin karena perubahan hormon dalam tubuh.

Apa yang harus dicari

Kita tidak dapat mengamati hubungan antara prilaku melukai diri sendiri atau prilaku yang tidak disadari lainnya dengan lingkunganya. Namun stress memang dapat memicu kejang-kejang. Bisa jadi ada hubungan stress dengan lingkungan. Misalnya terlalu banyak stimulasi fisik seperti pencahayaan, kebisingan atau faktor stimulasi sosial seperti teguran, tuntutan dsb. Demikian halnya dengan makanan yang juga dapat memicu kejang (Rapp, 1991).

Jika perilaku dimulai atau kian memburuk selama masa pubertas, kita juga dapat mempertimbangkan kemungkinan munculnya aktivitas kejang. Sebaiknya orang tersebut menjalani pemeriksanaan EEG.

Intervensi

Meskipun obat yang digunakan untuk mengontrol aktivitas kejang seringkali dikaitkan dengan efek samping yang merugikan, namun cukup banyak bukti DMG akan mengurangi aktivitas efek kejang tanpa efek samping negatif (Roach & Carlin, 1982).

Genetik

Prilaku merugikan diri sendiri juga umum diantara penyandang kelainan genetik seperti Lesch-Nyhan Syndrome, Fragile X Syndrome, dan Cornelia de Lange Syndrome. Kelainan ini berhubungan dengan kerusakan struktural atau disfungsi biokimia sehingga mendorong orang tersebut untuk melukai diri sendiri.

Apa yang harus dilihat.

Orang syndrome Lesch-Nyhan sering menggigit area sekitar mulut dan jari-jari mereka; mereka dengan Syndrome Fragile X sering juga sering menggigit (termasuk bibir dan jari), dan mereka dengan Syndrome Cornelia de Lange sering menggigit dan memukul wajah.

Intervensi.

Intervensi biomedis seperti suplemen, nutrisi dan obat-obatan menjadi pilihan perawatan bagi orang dengan syndrome tersebut. Dan memungkinkan intervensi lainnya yang dibahas dalam makalah ini dapat membantu orang dengan syndrome yang disebutkan diatas. Misalnya memodifikasi prilaku untuk menghambat prilaku orang tersebut..

Gairah

Seringkali disebutkan bahwa prilaku yang merugikan berhubungan dengan gairah yang muncul. Para peneliti telah menemukan hubungan antara prilaku melukai diri sendiri dengan peningkatan atau penurunan gairah seseorang. Teorinya menyebutkan bahwa prilaku melukai diri sendiri ditujukan untuk menlampiaskan, menurunkan atau meningkatkan gairah mereka. (Edelson, 1984; Baumeister & Hollings, 1976). Dalam hal ini, melukai diri akan dianggap sebagai bentuk ekstrem untuk perangsangan diri sendiri. Prilaku ini juga digunakan untuk melepaskan ketegangan dan atau kecemasan. Tingkat gairah yang tinggi bisa jadi disebabkan oleh disfungsi fisiologis internal atau lingkungan yang merangsangnya.

Apa yang harus dilihat

Perlu diamati pada saat orang tersebut kurang gairah, prilaku yang mengarah pada sikap bosan atau kegiatan merangsang. Sedangkan pada tingkat gairah yang tinggi perlu dilihat pada intervensi lingkungan seperti pencahayaan, ruang yang bising atau interaksi sosial lainnya.

Intervention

If the person is under-aroused, an increase in activity level may be helpful. For example, an exercise program can be implemented (e.g., stationary bicycle). If the person is over-aroused, it is recommended that steps be taken, usually before the behavior begins, to reduce his/her arousal level. This may include: relaxation techniques (Cautela & Groden, 1978), deep pressure (Edelson et al. 1998), vestibular stimulation (King, 1991), and/or removing the person from a stimulating situation.  Exercise may also be used to reduce arousal level.

Pain

Another reason why an individual may engage in headbanging is to reduce pain such as pain from a middle ear infection or a migraine headache (de Lissovoy, 1963; Gualtieri, 1989). There is growing evidence that pain associated with gastrointestinal problems, such as acid reflux and gas, may be associated with self-injury. In addition, some autistic individuals report that certain sounds, such as a baby crying or a vacuum cleaner, can cause pain. In all of these instances, self-injury may release beta-endorphins which would dampen the pain. Conversely, these individuals may be ‘gating’ the pain. In this case, stimulating one area of the body (in this case by injuring oneself) may reduce or dampen the pain located in another area of the body.

What to look for

Self-injury behavior may occur sporadically. The person may show signs of illness or appear to be in pain on those days he/she exhibits self-injury. The person’s family history should be checked to see if migraines run in the family. If possible, the person should have his/her ears examined and body temperature measured to check for a middle ear infection.

Intervention

Consumption of dairy products are often associated with middle ear infections in many children. Certain foods in the person’s diet may be responsible for migraines. Additionally, magnesium deficiency is associated with an increase in sound sensitivity. Magnesium supplements are safe and can reduce sound sensitivity in some individuals. The recommended dosage is 3 to 4 milligrams per 10 pounds a day. Auditory integration training has also been shown to reduce sound sensitivity (Rimland & Edelson, 1994).

Sensory

Excessive self-rubbing or scratching may be an extreme form of self-stimulation. The person may not feel normal levels of physical stimulation; and as a result, he/she damages the skin in order to receive stimulation or increase arousal (Edelson, 1984).

What to look for

The person appears to be insensitive to pain and possibly touch. The behavior may decrease when the person is busy (e.g., playing, working on a task) because his/her attention is directed away from his/her body.

Intervention

The person may be encouraged to apply safe forms of physical stimulation to those parts of the body which he/she rubs and/or scratches excessively. This could include applying a massaging vibrator, rubbing textured objects against the skin (such as uncooked beans or macaroni), and rubbing a brush against the skin. There is also evidence that placing a topical anesthetic on the self-injured area may reduce the behavior.

Frustration

Caretakers and parents often report that the child’s self-injury is a result of frustration. This is consistent with the traditional Frustration è Aggression model proposed by Dollard and his colleagues (1939). Commonly reported scenarios include: a person with poor communication skills becomes frustrated because of his/her lack of understanding of what was said to him/her (poor receptive communication) or because the caretaker does not undestand what is said/requested; or an individual who has good communication skills but does not get what he/she wants. These reasons are discussed more in the next section.

Social Causes

Communication

Communication problems have often been associated with self-injurious behavior. If a person has poor receptive and/or has poor expressive language skills, then this may lead to frustration and escalate into self-injury.

What to look for

If the person has poor receptive skills, communication may be the problem if the behavior occurs after someone says something to him/her. Additionally, if a person has poor expressive skills, self-injurious behavior may occur after he/she tries to communicate, perhaps by gesture; and the caretaker does not understand or does not respond appropriately.

Intervention

With respect to expressive language, these individuals should be taught functional communication skills (Dyer & Larsson, 1997).  With respect to receptive communication skills, the person may be chronically ill (e.g., constant headache, nausea) and may not be able to clearly focus his/her attention to what was said.  This may be due to sensitivity to certain food items.  In addition, there is evidence that auditory integration training (AIT) may improve receptive language skills as a result of better retrieval of information from long-term memory (Edelson et al., 1999).

Social Attention

A great deal of research has investigated social contingencies of self-injury. Lovaas and his colleagues were able to control the frequency of self-injury by manipulating social consequences (Lovaas et al., 1965; Lovaas & Simmons, 1969). Basically, positive attention can increase the frequency of self-injury (i.e., positive reinforcement), whereas ignoring the behavior can decrease the frequency (i.e., extinction).

What to look for

Following an episode of self-injury, observe if/how the caretaker attends to the individual. This attention may be positive (e.g., “What do you want?”) or negative (“Don’t do that”). Note that the individual may interpret a negative comment in a positive manner; and consequently, the behavior may still be positively reinforced.

Interventions

If the person tends to receive attention following the behavior, especially if the attention is positive, then the caretaker should do his/her best to ignore the behavior. If this is not possible because the person may injure him-/herself, then the caretaker should minimize contact with the individual while displaying little facial expression (neither approving nor disapproving).

Consistency is very important because the behavior will continue if the individual receives intermittent reinforcement (i.e., attention) for the behavior. In fact, the behavior will be stronger and more resistant to extinction if intermittently reinforced. Since these individuals seek attention, which is quite normal for most people, they should receive attention, but it should not be contingent on self-injury. For example, the caretaker should give the person attention when he/she does not engage in self-injury (e.g., positive attention following 10 minutes without an episode of self-injury). There are numerous contingency strategies and schedules that can be implemented to provide attention to the individual (e.g., DRO–differential reinforcement of other behaviors).

Obtain Tangibles

Another reason why an individual may engage in self-injurious behavior is to obtain an object or event (Durand 1986; Durand & Cremmins, 1988). For instance, an individual may request something, not receive it, and then engage in self-injurious behavior. Additionally, the behavior may be reinforced positively if the individual should, on occasion, receive the desired object or event. A survey by Maisto et al. (1978) reported that 33% of the clients engaged in self-injury because “they wanted something.”

What to look for

Self-injury will typically occur after he/she requests something and does not get it.  The person occasionally does get what he/she wants during or soon after engaging in self-injury.

Interventions

In this situation, the person’s caretakers should not give anything to the person during or following an episode of self-injury. Consistency is also important because the behavior will continue even if the individual ‘gets what he wants’ on only some occasions. (See previous discussion on intermittent reinforcement.) A behavioral program can also be set up to allow the person to make requests to obtain what he/she wants, but this should occur in a controlled, systematic and non-violent manner (e.g., giving the person options at specific times of the day).

Avoidance/Escape

Some individuals engage in self-injury to avoid or escape an ‘aversive’ social encounter (Carr et al., 1976; Edelson et al., 1983). The individual may engage in self-injury just prior to the social interaction; and thus, he/she may avoid the social interaction before it begins. Alternatively, the individual may engage in self-injury to escape (or terminate) a social encounter that has already begun.

For example, a caretaker may ask a client to do something (e.g., to leave the play area); and if the person does not want to comply, he or she may then engage in self-injury. As a consequence, the caretaker’s initial request is dropped or forgotten, and the caretaker’s attention is then directed at stopping the behavior.

What to look for

In an ‘avoidance’ situation, the person may begin to self-injure soon after someone enters the room or approaches the person. In an ‘escape’ situation, the person may begin to self-injure during a social encounter. The caretaker’s requests (or demands) are often abandoned soon after the person engages in self-injury.

Concluding Remarks

It is important to understand that there are different reasons why individuals engage in self-injurious behavior. Edelson et al. (1983) observed three different forms of self-injury by the same individual. This client was observed for a total of five hours, and all antecedents and consequences of self-injury were recorded. The client banged his head against his knee and then received attention; pinched his stomach after the staff asked him to do something; and bit his wrist after he asked for something but did not receive it.

It is also possible that one form of self-injury may serve more than one function. For example, a person may engage in wrist-biting when he is unable to communicate his needs and when he does not get what he wants.

When conducting a functional analysis, the underlying reason for the self-injurious behavior may not be obvious in some cases. Based on observational data, the possible reasons for the behavior should be ranked ordered, from most likely to least likely. This rank ordering can then determine the order in which different interventions are implemented.

Research has also shown that aversives (i.e., punishment) may effectively reduce or eliminate self-injurious behavior by training the person to inhibit his/her behavior. If the behavior is severe and if numerous attempts have failed to reduce the behavior, then one may consider using an aversive to stop the behavior.

Visual screening (i.e., placing a cloth or piece of white paper in front of the person’s face) has been shown to be rather effective in reducing severe behaviors, such as self-injury and aggression (Jones et al. 1991). Other forms of aversives include: squirting lemon juice in the mouth, spraying the person’s face with a water mist, tilting the person backwards, and in some cases, using a mild electric shock. Great care should be taken when using an aversive strategy. For example, inconsistency should be avoided, generalization across different settings and caretakers should take place, and built-in safe-guards to protect against possible abuse should be incorporated.

Stephen M. Edelson, Ph.D

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