BCBA seeking advice
I’m a BCBA looking for guidance regarding a 13-year-old client engaging in severe self-injurious behavior. Approximately one week ago, the client engaged in SIB by extracting one of her permanent teeth during the night. Parent reported the client had been perseverating on the “tooth fairy” and repeatedly discussing losing teeth. The client was evaluated by a dentist afterward, and parent reported the teeth were healthy.
Four days later, the client extracted another permanent tooth adjacent to the first tooth. Parent has appointments scheduled with a dentist and neurologist next week; however, today the client extracted a third permanent tooth.
At this time, the behavior does not appear to have contacted the tangible reinforcement of receiving money from the “tooth fairy,” although the client continues to perseverate on the topic. The behavior appears compulsive/obsessive in nature and presents significant medical and safety concerns. Parent also reported the client made statements about “pulling her eye out,” which raises concern for escalation of SIB severity.
I have discussed with parent the importance of psychiatric evaluation and medication management, as this presentation appears beyond the scope of behavioral intervention alone and may require urgent psychiatric involvement. Parent follow-through with psychiatric services has been limited thus far. Parent also reported sleep medication have not been effective, as episodes continue occurring overnight.
In the meantime, I recommended environmental and response prevention strategies to reduce access/opportunity during nighttime hours (increased supervision, protective clothing/gloves, etc.) while awaiting medical follow-up.
For those who have managed similar presentations:
- Would you consider this an indication for higher level of care/crisis psychiatric intervention?
- At what point would you consider behavioral services inappropriate to continue without psychiatric stabilization?
- Any recommendations regarding immediate risk mitigation strategies in the home environment?
I’m extremely concerned regarding risk of permanent injury and escalation of SIB severity.