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RE S EARCH ART I C L E Protective procedures in functional analysis of self-injurious behavior: An updated scoping review Michelle A. Frank-Crawford1,2 | Drew E. Piersma1 | Nathalie Fernandez1,2 | Savannah A. Tate1,2 | Erik A. Bustamante1 1Department of Behavioral Psychology, Kennedy Krieger Institute, Baltimore, MD, USA 2Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD, USA Correspondence Michelle A. Frank-Crawford, Neurobehavioral Unit, Kennedy Krieger Institute, 707 N. Broadway, Baltimore, MD 21205. Email: crawfordm@kennedykrieger.org Funding information Eunice K. Shriver National Institute of Child Health and Human Development (NICHD), Grant/Award Number: GrantR01HD076653 Editor-in-Chief: John Borrero Handling Editor: Tara Fahmie Abstract Despite the efficacy of functional analyses in identifying the function of challenging behavior, clinicians report not always using them, partly due to safety concerns. Understanding how researchers employ safeguards to mitigate risks, particularly with dangerous topographies like self-injurious behavior (SIB), is important to guide research and practice. However, the results of a scoping review of functional analyses of self-injurious behavior conducted by Weeden et al. (2010) revealed that only 19.83% of publications included protections. We extended the work of Weeden et al. to determine whether reporting has improved. We observed increases in all but two types of protections reviewed by Weeden et al. Additionally, we included new protec- tions not reported by Weeden et al. In total, 69.52% of the studies included at least one protective procedure and 44.39% specified that the protections were used for safety. It appears that reporting has increased since Weeden et al. called for improved descriptions of participant protections. KEYWORDS functional analysis, protective procedures, safety, self-injurious behavior Self-injurious behavior (SIB) includes a variety of responses directed toward oneself that have the potential to cause or have a history of causing tissue damage. It is perhaps one of the most dangerous and debilitating forms of challenging behavior exhibited by individuals with intellectual and developmental disabilities. Although prevalence estimates vary, recent reports suggest that nearly 45% of individuals with autism spectrum disorder (Steenfeldt-Kristensen et al., 2020) and 58% of individuals with severe intellectual disabilities (Davies & Oliver, 2016) exhibit SIB. Further- more, SIB can emerge early in development (e.g., Fodstad et al., 2012), beginning as self-stimulatory stereotypy or proto-injurious behavior before developing into a topogra- phy that produces actual tissue damage (e.g., Berkson et al., 2001; Richman & Lindauer, 2005). Prevalent topographies of SIB include head-hitting, head-banging, self-biting, self-scratching, and self-hitting (Kahng et al., 2002; Shawler et al., 2019). Self-injurious behavior can cause serious harm, ranging from transient contusions and lacerations to permanent disfigurement and even vision loss (de Winter et al., 2011; Hyman et al., 1990; Rooker et al., 2018, 2020). For example, Hyman et al. (1990) conducted a retrospective chart review of SIB exhibited by 97 children admitted to an inpatient hospital unit for the assessment and treatment of challenging behavior. At the time of the study, physical injury was documented for 77% of the cases. Soft tissue damage, such as abrasions (observed on 49.5% of the chil- dren), was the most reported injury type. Approximately 2.1% of the children experienced skeletal fractures and 7% incurred injuries to the eye, such as corneal abrasions (3.1%) and retinal detachment (1%). The current standard of care in the assessment and treatment of SIB involves first identifying the causes of SIB through functional behavioral assessment, then using this information to guide the development of an individu- alized, function-based behavioral intervention. Func- tional analysis (Iwata et al., 1982/1994) is regarded as the most rigorous approach to functional behavior assess- ment of challenging behavior (Rooker et al., 2015). The functional analysis is a controlled assessment wherein antecedents and consequences hypothesized to evoke and maintain challenging behavior are manipulated in test conditions and their effects on challenging behavior are directly observed to determine its function. The causes of SIB are surmised when SIB occurs at a differentially Received: 19 November 2023 Accepted: 25 July 2024 DOI: 10.1002/jaba.2906 840 © 2024 Society for the Experimental Analysis of Behavior (SEAB). J Appl Behav Anal. 2024;57:840–858.wileyonlinelibrary.com/journal/jaba https://orcid.org/0000-0003-4319-6317 https://orcid.org/0009-0000-7122-1669 https://orcid.org/0000-0003-1180-6619 https://orcid.org/0000-0001-5197-2748 mailto:crawfordm@kennedykrieger.org http://wileyonlinelibrary.com/journal/jaba higher level in a test condition relative to the control con- dition of a functional analysis where the individual has noncontingent access to preferred items and attention, instructions are not issued, and challenging behavior pro- duces no programmed consequences (except when safety measures, such as response blocking, are necessary). Large-scale summaries of published (e.g., Melanson & Fahmie, 2023) and clinically derived (Hagopian et al., 2013) functional analyses reveal that they are highly effective in identifying the functions of SIB. However, due to repeated exposure to potentially evocative events, there is inherent risk in conducting a functional analysis of SIB despite modi- fications prioritizing precision and safety. To examine risk of injury in a retrospective chart review, Kahng et al. (2015) used the Self-Injury Trauma Scale (Iwata et al., 1990) to document the frequency and severity of injuries that occurred during the functional analysis and during the same period outside of it for 99 individuals admitted to an inpa- tient hospital. Results indicated that although the rate of injury may be higher during the functional analysis than outside of it, the severity of injuries was generally low across both contexts. The authors noted that many safeguards were in place to protect the patients in their study, and they concluded that functional analyses of SIB can be safe when conducted using the proper precautions. Several tactics can be employed to mitigate risks that are associated with SIB during assessment. In fact, Iwata et al. (1982/1994) outlined numerous safety precautions taken in their work with individuals with SIB. They excluded individ- uals whose SIB put them at imminent risk for injury based on medical exams conducted prior to initiating the study, sought approval from an ethics board, included individual- ized termination criteria, conducted medical examinations after terminated sessions and after every fourth session, and had medical personnel intermittently observe sessions. In addition to reporting on the safety precautions, Iwata et al. noted the types of injuries that occurred during the functional analyses as well as the number of times and for whom sessions were terminated. Following a terminated session, the medical team was consulted and either cleared the participant for continuation or recommended that sessions be temporarily paused. Furthermore, other researchers have reported using tactics such as protective equipment (Borrero et al., 2002), mechanical restraint (Silverman et al., 1984), padded session areas (Hall et al., 2018), and other protocols to emphasize safety (e.g., Betz & Fisher, 2011). For example, Betz and Fisher (2011) encouraged terminating session fol- lowing injury and taking session holidays until any affected areas had healed or an individual was medically cleared to continue. Regarding particularly severe topographies of chal- lenging behavior, Betz and Fisher also recommended the use of response blocking or protective equipment to prevent or interruptalso did not report on how protections, when used, were identified. Wiskirchen et al. (2017) noted that although the literature includes examples of protections used during functional analyses, there are no clear guidelines to aid practitioners in selecting the most appropriate procedures. Further- more, a survey by Deochand et al. (2020) suggested that most respondents wanted a risk-assessment tool that would allow them to gauge the risk associated with conducting a functional analysis. A risk assessment may serve to highlight safety considerations and guide deci- sion making for the selection of protections (Wiskirchen et al., 2017). This latter point is particularly important because selection of protections should be, to the extent possible, data driven; that is, one should not simply take a “more is better” stance when applying protections in assessment and treatment. Some protections may be det- rimental to the assessment process, such as when F I GURE 5 Percentage of studies reporting ethical protections across years. IRB = institutional review board. Inset panel: percentage of studies reporting each type of ethical protection. TABLE 7 Secondary analysis outcomes. Variable Studies that reported protections Studies that did not report protections Chi-square valuesn studies n with variable % n studies n with variable % SIB subject matter of study 130 31 23.85 57 15 26.32 0.7181 Prospective study 130 113 86.92 57 53 92.98 0.2271 Injury prior to functional analysis 130 29 22.31 57 10 17.54 0.4604 At least one participant head SIB 98a 82 83.67 49c 31 63.27 0.0096* At least one participant automatic function 120b 33 27.50 54d 15 27.78 0.9697 Note: SIB = self-injurious behavior. aOf the 130 studies that reported protections, 32 did not provide sufficient information to determine the topography for any participant. Thus, data on topography were extracted from 98 of these studies. bOf the 130 studies that reported protections, 10 did not provide sufficient information to determine the function for any participant. Thus, data on function were extracted from 120 of these studies. cOf the 57 studies that did not report protections, eight did not provide sufficient information to determine the topography for any participant. Thus, data on topography were extracted from 49 of these studies. dOf the 57 studies that did not report protections, three did not provide sufficient information to determine the function for any participant. Thus, data on function were extracted from 54 of these studies. *preflective of all protections in place. Some protections may go unreported, perhaps because they are ingrained in the clinical standard of care. For example, specialized treatment facilities and pro- viders who regularly serve individuals with severe SIB have likely developed several tactics for mitigating risks associated with SIB to allow it to be safely assessed and treated (e.g., Hagopian, Kurtz, et al., 2023). Thus, the outcomes of the current article may represent an underreporting of pro- tections that are used to mitigate risk of injury. We again encourage authors to continue reporting on protections employed during the functional analysis, to do so at the level of the individual participant, and to make the use of those protections explicit in the text or as supplemental materials (see Supporting Information I for a template). A third limitation is that we focused solely on SIB, protections for participants, and functional analysis. How- ever, individuals with challenging behavior often engage in topographies other than SIB, like aggression (Fitzpatrick et al., 2016; Hong et al., 2018). Protections for non- self-injurious behaviors may be distinct from those used for SIB; for example, safely managing aggression may require training in very specific techniques (e.g., Wine & Newcomb, 2024). Relatedly, protections for staff or care- givers who participate in the assessment and treatment process have not yet, to our knowledge, been sufficiently PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 855 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= examined. In addition, functional analysis is useful in that it can inform the development of behavioral interventions. Although it seems intuitive that risk of injury is reduced during intervention, we do not currently know whether this is true or whether risk of injury changes over the course of an evaluation. For example, injury may be more likely during baseline or generalization phases and perhaps less likely during initial treatment phases when schedules of reinforcement are relatively dense. Thus, additional research is warranted on risk of injury to staff, risk of injury during intervention, and how best to protect staff during the assessment and treatment process. In summary, the results of this scoping review are promising. In 2010, Weeden et al. asked, “Where are the descriptions of participant protections?” (p. 299). It appears that many researchers have responded to calls to improve protective-procedure reporting practices related to SIB. Importantly, we observed improvements in reporting for almost all types of protections included in Weeden et al. (2010). Although there is still progress to be made, we are encouraged to report that protections are finding their way into the literature, and we hope the trend continues in this positive direction. CONFLICT OF INTEREST STATEMENT The authors have no conflicts of interest to declare. DATA AVAILABILITY STATEMENT Supporting Information A includes the PRISMA-ScR checklist, Supporting Information B through G includes outcomes coded in this review for each study, and Sup- porting Information H includes the references for all studies that met inclusion criteria. Supporting Informa- tion I includes a checklist to aid in documenting and reporting on protections employed in research. ETHICS APPROVAL No human or animal subjects were used to produce this article. ORCID Michelle A. Frank-Crawford https://orcid.org/0000- 0003-4319-6317 Drew E. Piersma https://orcid.org/0009-0000-7122- 1669 Nathalie Fernandez https://orcid.org/0000-0003-1180- 6619 Savannah A. Tate https://orcid.org/0000-0001-5197- 2748 REFERENCES See Supporting Information H for studies included in this scoping review. Becraft, J. L., Hardesty, S. L., Goldman, K. J., Shawler, L. A., Edelstein, M. L., & Orchowitz, P. (2024). 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See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://doi.org/10.1177/1098214011426594 https://doi.org/10.1177/1098214011426594 https://doi.org/10.1002/jaba.27 https://doi.org/10.1002/jaba.27 https://doi.org/10.1002/jaba.601 https://doi.org/10.1002/jaba.1005 https://doi.org/10.1080/02739615.2021.1987237 https://doi.org/10.1002/jaba.25 https://doi.org/10.1002/jaba.25 https://doi.org/10.1002/jaba.236 https://doi.org/10.1111/jir.12489 https://doi.org/10.1111/jir.12489 https://doi.org/10.1016/j.ridd.2014.05.025 https://doi.org/10.1002/jaba.106 https://doi.org/10.1002/jaba.106 https://doi.org/10.1901/jaba.2009.42-697 https://doi.org/10.1007/s41252-018-0063-7 https://doi.org/10.1007/s41252-018-0063-7 https://doi.org/10.1542/peds.85.3.437 https://doi.org/10.1901/jaba.1994.27-197 https://doi.org/10.1901/jaba.1994.27-197 https://doi.org/10.1016/0270-4684(82)90003-9) https://doi.org/10.1016/0270-4684(82)90003-9) https://doi.org/10.1901/jaba.1990.23-99 https://doi.org/10.1901/jaba.1990.23-99 https://doi.org/10.1002/bin.1650 https://doi.org/10.1002/jaba.168 https://doi.org/10.1352/0895-8017(2002)107%3C0212:BTOSIT%3E2.0.CO;2 https://doi.org/10.1352/0895-8017(2002)107%3C0212:BTOSIT%3E2.0.CO;2 https://doi.org/10.1016/j.ridd.2009.10.020 https://doi.org/10.1016/j.ridd.2009.10.020 https://doi.org/10.1023/A:1016028522569 https://doi.org/10.1023/A:1016028522569 https://doi.org/10.1007/s40617-023-00838-5 https://doi.org/10.1002/jaba.983 https://doi.org/10.1002/jaba.849 https://doi.org/10.1901/jaba.2004.37-73 https://doi.org/10.1002/jaba.859 https://doi.org/10.1002/jaba.1063 https://doi.org/10.1002/jaba.1063 https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html https://doi.org/10.1901/jaba.1991.24-509 https://doi.org/10.1901/jaba.1991.24-509 https://doi.org/10.1007/978-1-4614-3037-7 https://doi.org/10.1007/978-1-4614-3037-7 https://doi.org/10.1352/0895-8017(2005)110%5B439:LAOSPA%5D2.0.CO;2 https://doi.org/10.1352/0895-8017(2005)110%5B439:LAOSPA%5D2.0.CO;2 https://doi.org/10.1002/bin.1400 https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= of self-injurious behavior. Journal of Applied Behavior Analysis, 53(2), 1042–1057. https://doi.org/10.1002/jaba.664 Rooker, G. W., Hausman, N. L., Fisher, A. B., Gregory, M. K., Lawell, J. L., & Hagopian, L. P. (2018). Classification of injuries observed in functional classes of self-injurious behaviour. Journal of Intellectual Disability Research, 62(12), 1086–1096. https://doi. org/10.1111/jir.12535 Schlichenmeyer, K. J., Roscoe, E. M., Rooker, G. W., Wheeler, E. M., & Dube, W. V. (2013). Idiosyncratic variables that affect functional analysis outcomes: A review (2001–2010). Journal of Applied Behavior Analysis, 46(1), 339–348. https://doi. org/10.1002/jaba.12 Shawler, L. A., Russo, S. R., Hilton, J. L., Kahng, S., Davis, C. J., & Dorsey, M. F. (2019). Behavioral treatment of self-injury: 2001– 2016. American Journal on Intellectual and Developmental Disabil- ity, 124(5), 450–469. https://doi.org/10.1352/1944-7558-124.5.450 Sigafoos, J., & Saggers, E. (1995). A discrete-trial approach to the func- tional analysis of aggressive behavior in two boys with autism. Australia and New Zealand Journal of Developmental Disabilities, 20(4), 287–297. https://doi.org/10.1080/07263869500035621 Silverman, K., Watanabe, K., Marshall, A. M., & Baer, D. M. (1984). Reducing self-injury and corresponding self-restraint through the strategic use of protective clothing. Journal of Applied Behavior Analysis, 17(4), 545–552. https://doi.org/10.1901/jaba.1984.17-545 Smith, R. G., & Churchill, R. M. (2002). Identification of environmen- tal determinants of behavior disorders through functional analysis of precursor behaviors. Journal of Applied Behavior Analysis, 35(2), 125–136. https://doi.org/10.1901/jaba.2002.35-125 Steenfeldt-Kristensen, C., Jones, C. A., & Richards, C. (2020). The prevalence of self-injurious behaviour in autism: A meta-analytic study. Journal of Autism and Developmental Disorders, 50(1), 3857–3873. https://doi.org/10.1007/s10803-020-04443-1 Thomason-Sassi, J. L., Iwata, B. A., Neidert, P. L., & Roscoe, E. M. (2011). Response latency as an index of response strength during functional analyses of problem behavior. Journal of Applied Behavior Analysis, 44(1), 51–67. https://doi.org/10.1901/jaba.2011. 44-51 Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., & Lewin, S. (2018). PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Annals of Internal Medicine, 169(7), 467–473. https://doi.org/10.7326/M18-0850 Weeden, M., Mahoney, A., & Poling, A. (2010). Self-injurious behavior and functional analysis: Where are the descriptions of participant protections? Research in Developmental Disabilities, 31(2), 299–303. https://doi.org/10.1016/j.ridd.2009.09.016 Wine, B., & Newcomb, E. T. (2024). A blocking and distance manage- ment staff training intervention for torso-and head-directed aggres- sion. Journal of Applied Behavior Analysis,57(3), 668–675. https:// doi.org/10.1002/jaba.1089 Wiskirchen, R. R., Deochand, N., & Peterson, S. M. (2017). Functional analysis: A need for clinical decision support tools to weigh risks and benefits. Behavior Analysis: Research and Practice, 17(4), 325–333. https://doi.org/10.1037/bar0000088 World Medical Association. (2013). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi. org/10.1001/jama.2013.281053 SUPPORTING INFORMATION Additional supporting information can be found online in the Supporting Information section at the end of this article. How to cite this article: Frank-Crawford, M. A., Piersma, D. E., Fernandez, N., Tate, S. A., & Bustamante, E. A. (2024). Protective procedures in functional analysis of self-injurious behavior: An updated scoping review. Journal of Applied Behavior Analysis, 57(4), 840–858. https://doi.org/ 10.1002/jaba.2906 858 FRANK-CRAWFORD ET AL. 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://doi.org/10.1002/jaba.664 https://doi.org/10.1111/jir.12535 https://doi.org/10.1111/jir.12535 https://doi.org/10.1002/jaba.12 https://doi.org/10.1002/jaba.12 https://doi.org/10.1352/1944-7558-124.5.450 https://doi.org/10.1080/07263869500035621 https://doi.org/10.1901/jaba.1984.17-545 https://doi.org/10.1901/jaba.2002.35-125 https://doi.org/10.1007/s10803-020-04443-1 https://doi.org/10.1901/jaba.2011.44-51 https://doi.org/10.1901/jaba.2011.44-51 https://doi.org/10.7326/M18-0850 https://doi.org/10.1016/j.ridd.2009.09.016 https://doi.org/10.1002/jaba.1089 https://doi.org/10.1002/jaba.1089 https://doi.org/10.1037/bar0000088 https://doi.org/10.1001/jama.2013.281053 https://doi.org/10.1001/jama.2013.281053 https://doi.org/10.1002/jaba.2906 https://doi.org/10.1002/jaba.2906 https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= Protective procedures in functional analysis of self‐injurious behavior: An updated scoping review METHOD Study identification and inclusion criteria Coding of participant data and data extraction Study characteristics Safety procedure characteristics Participant, setting, and functional analysis characteristics Intercoder agreement Data analysis Secondary data analysis RESULTS Study characteristics Participant and functional analysis characteristics Safety procedure characteristics Weeden et al. (2010) comparison Additional protections and categorical outcomes Secondary analysis findings DISCUSSION CONFLICT OF INTEREST STATEMENT DATA AVAILABILITY STATEMENT ETHICS APPROVAL ORCID REFERENCES SUPPORTING INFORMATIONbehavior directed toward vulnerable organs (e.g., eyes) as well as conducting a no-interaction condition rather than an alone condition when feasible such that the therapist is available to block instances of SIB when neces- sary. Since then, several published studies have referenced the procedures outlined by Betz and Fisher when conducting functional analyses of SIB (e.g., Fisher et al., 2016; Greer et al., 2020). Although some studies report on precautions used dur- ing the assessment process, this does not seem to be the standard. Weeden et al. (2010) conducted a scoping review of literature published between 1994 and 2008 wherein a functional analysis of SIB was conducted. The researchers examined whether the studies included individualized termi- nation criteria and nine safety precautions: response block- ing, institutional review board (IRB) approval, protective equipment, padded test areas, few and short sessions, medi- cal examination, mother in room, parent as therapist, and sessions monitored by medical personnel. Weeden et al. found that only 7.76% of the 116 publications reviewed included notations of termination criteria and 19.83% included at least one of the other nine protections evaluated. The authors noted that this was likely an underrepresenta- tion of the actual use of protections during functional analy- sis of SIB; however, they also noted the need for authors to report on this information so the use of protections can be evaluated and, when applicable, replicated. The safety precautions that Weeden et al. (2010) described in the literature were not exhaustive, and the authors did not delineate certain general categories of pro- tections. For example, although Weeden et al. reported on the use of protective equipment generally, they did not dif- ferentiate between types of equipment, such as mechanical restraint (e.g., arm splints), helmets, or protective clothing. Additionally, Weeden et al. did not describe whether self- restraint items were used or if consent or assent was obtained prior to participation. Finally, the only modifica- tion to the functional analysis reported to maximize safety was few and short sessions (i.e., a brief functional assess- ment; Northup et al., 1991). However, other modifications to the functional analysis have been proposed to increase both safety and efficiency (Poling et al., 2012). For example, conducting a precursor functional analysis (e.g., Borrero & Borrero, 2008; Fritz et al., 2013; Herscovitch et al., 2009; Smith & Churchill, 2002) in which consequences are deliv- ered following a precursor rather than challenging behavior can help reduce risk to the individual by limiting the amount of challenging behavior during the course of the assessment. Similarly, the interview-informed synthesized contingency analysis includes an open contingency class such that lower severity behaviors are reinforced, and it includes brief and relatively few test and control sessions (e.g., Hanley et al., 2014; Jessel et al., 2019).1 The occur- rence of challenging behavior may also be limited by using a latency-based functional analysis where sessions are termi- nated following the first instance of challenging behavior (e.g., Thomason-Sassi et al., 2011). In a trial-based func- tional analysis, antecedents and consequences are presented 1Many variations to the interview-informed synthesized contingency analysis have been designed to improve efficiency and, as a byproduct, safety. Metras and Jessel (2021) review such variations. PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 841 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= discreetly embedded in trials that are often conducted in the natural environment (e.g., Bloom et al., 2011; Sigafoos & Saggers, 1995). Trial-based functional analyses may mini- mize risk by using an occurrence measure that requires only one instance of challenging behavior to terminate the trial. Each of these modifications to the functional analysis of challenging behavior are important advancements, and researchers have suggested that they may improve both effi- ciency and safety in assessment.2 Most of these procedural modifications to the functional analysis occurred after the publication of Weeden et al. (2010). It is possible that researchers have heeded the calls of Weeden et al. to improve reporting practices; moreover, they may have done so by including some of these modified and, arguably, safer functional analyses. Thus, the purpose of this study was twofold. First, we replicated the scoping review conducted by Weeden et al. to provide an update on the percentage of studies in which researchers report partici- pant protections for functional analyses of SIB. Second, we extended the findings of Weeden et al. by expanding the types of protective procedures assessed throughout the course of the review and evaluating whether certain vari- ables, such as noted injuries or topography of SIB, were associated with notations of protections. METHOD Study identification and inclusion criteria We followed the guidelines described by the Preferred Reporting Items for Systematic Reviews and Meta- Analysis-Scoping Review (PRISMA-ScR; Tricco et al., 2018). Supporting Information A includes the PRISMA- ScR checklist, Supporting Information B through G includes outcomes coded in this review for each study, and Supporting Information H includes the references for all studies that met inclusion criteria. The inclusion criteria, adapted from Weeden et al. (2010), were as follows: (a) the article was a peer-reviewed empirical study (b) that described a functional analysis of SIB for at least one participant with an intellectual or developmental disability (c) where the data were not reported to have been published previously. Thus, we excluded (a) nonempirical or non-peer-reviewed articles such as reviews or commentaries and dissertations; (b) articles that did not include a functional analysis, articles that made reference to but did not describe a functional analysis (e.g., indicated that a functional analysis or functional assessment was completed but did not provide a description of the methods or supporting citation), or articles that included only an indirect or descriptive assessment; (c) articles where the challenging behavior targeted in the functional analysis did not include SIB for at least one partic- ipant; (d) articles where no participant had an intellectual or developmental disability; or (e) articles where data for any participant who otherwise would have met inclusion criteria were reported to have been published elsewhere (data were not original to the article). We also excluded articles that were published before 2009 or after 2022 and those that were published in a language other than English. If multiple topographies targeted within the functional analysis were col- lapsed into one reinforced class, the study was included if SIB was a member of that reinforced class. In some cases, articles included multiple participants but only some partici- pants met all criteria for inclusion; we extracted data from only those participants who met all inclusion criteria. As the first step of the review, we completed two searches to identify relevant studies. The first included a lit- erature search completed June 14, 2023, on the EBSCOhost research platform using the Scopus and PsychInfo data- bases. Specifically, we conducted a full-text search using the terms (“SIB” OR “self-injur*”) AND “functional analys*” between the years 2009 and 2022. This resulted in the identi- fication of 445 studies, 93 of which were duplicates.With duplicates removed, the initial database search resulted in 352 unique studies. However, we noted that many articles that should have been identified in this search were not among the 352 obtained results, including studies by authors of this scoping review.3 Therefore, as a second step of the review, we completed a search of each journal listed in Weeden et al. (2010; along with several relatively newer behaviorally oriented journals) using the same Boolean operators, search terms, and years used in the first step. This was completed on August 29, 2023. Step 2 yielded 1,080 studies, 202 of which were duplicates. Thus, we reviewed an additional 878 studies from the second search. In total, we identified 1,230 unique studies across the two search steps. Figure 1 includes a PRISMA flowchart for the review process. To identify as many studies with functional analyses targeting SIB as possible, studies were included in the full-text review if the abstract indicated that the study (a) targeted SIB specifically or challenging behavior more generally, without listing any particular topography, and the abstract noted that the study included (b) a functional analy- sis or functional behavioral assessment or (c) a behavioral intervention. That is, studies were included in the full-text review if the abstract noted generally that challenging behav- ior (or some variant thereof, such as “disruptive behavior” or “problem behavior”) was targeted; studies that specified that the target response was something other than SIB, such as elopement or stereotypy, were excluded. Also, we included studies in the full-text review if the abstract did not mention that a functional behavioral assessment was2It is important to note that although it makes intuitive sense that modifications that affect the assessment duration of the functional analysis may influence the safety of the assessment process (e.g., conducting fewer or shorter sessions will likely result in fewer instances of challenging behavior), there are no studies that we are aware of that present direct evidence to suggest that these modifications decrease injury rates. 3Becraft et al. (2024) noted a similar problem in an unrelated scoping review when they completed their initial search using electronic database searches. The authors also reported searching each journal separately and identifying substantially more relevant articles in the subsequent journal search. 842 FRANK-CRAWFORD ET AL. 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= completed but did note that a behavioral intervention was conducted because we hypothesized that the study authors likely reported on an assessment to inform the development of the intervention. Figure 1 denotes the number of studies excluded and reasons for exclusion. For the 10 studies that were published outside of 2009–2022, six were published before 2009 and the date was missed during the abstract search (simply due to human error); the correct date was noted during the full-text review, and the articles were thus excluded. The remaining four were published online during 2022 but in print during 2023 and were thus excluded. After review, 187 articles met inclusion criteria. Coding of participant data and data extraction A coding system was developed to synthesize data from various aspects of the studies. Generally, data were extracted for (a) study characteristics; (b) safety proce- dure characteristics; and (c) descriptive characteristics of the participants, settings, and functional analysis out- comes. The coding system was developed prior to initiat- ing the search and was then modified if additional protections were identified during the coding process that did not fit one of the previously established categories. If we identified a protection not in our initial coding sys- tem, we added it and recoded previously coded studies. Because the focus of our review was on SIB, we coded only participant, and not staff, protections. Study characteristics For each study, data collectors recorded the journal title, year of publication, and whether the study was prospective or retrospective. We differentiated between prospective and F I GURE 1 PRISMA flowchart. PRIMSA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; FA = functional analysis; SIB = self-injurious behavior. IDD = intellectual or developmental disability. PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 843 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= retrospective articles because we hypothesized that authors may be less likely to report safety procedures for retrospec- tively analyzed data, perhaps because the functional ana- lyses were completed by other clinicians or they had minimal information about the safety procedures used. We also hypothesized that researchers may be more likely to report on safety procedures when SIB was the primary sub- ject matter of the article than when SIB was not the focus. For example, SIB was considered the primary subject mat- ter for articles specifically examining functional analysis outcomes for SIB (e.g., Hall et al., 2014, examined func- tional analysis outcomes for skin picking by individuals with Prader–Willi syndrome) or for studies examining sub- types of automatically maintained SIB (e.g., Hagopian et al., 2015). We also characterized SIB as the primary sub- ject matter when researchers examined a particular type of treatment explicitly designed for use with SIB (e.g., Davis et al., 2013, examined the use of noncontingent matched stimuli in the treatment of automatically maintained SIB). Self-injury was classified as a secondary subject matter for articles in which SIB was just one of multiple topographies of challenging behavior for which assessment and treatment was conducted, such as a study comparing outcomes of different types of functional analyses without regard to the topographies of challenging behavior (e.g., LaRue et al., 2010, compared outcomes from traditional and trial-based functional analysis outcomes, and participant topography of challenging behavior was not essential to the purpose of the study). Thus, we coded a “yes” that SIB was the primary subject matter if SIB or some variant thereof (e.g., a specific self-injurious topography was noted, such as hand-mouthing or head-banging) was listed in the article title, study purpose statement, or keywords of the article. We coded “no” if SIB was not listed in any of those places. Safety procedure characteristics As previously noted, Weeden et al. (2010) evaluated the following protections: specific termination criteria, response blocking, IRB approval, protective equipment, padded test area, few and short sessions (brief functional analysis), medical exam, mother in the room, parent as therapist, and sessions monitored by medical personnel. It is possible that some of these procedures may not enhance safety or could even increase risk (e.g., caregiver as therapist or in the room). However, one goal was to replicate the procedures of Weeden et al.; therefore, we included the same protections as described in Weeden et al. even if the protections were perhaps not distinctly used to enhance safety. We extended the safetyproce- dures reported by Weeden et al. by including additional types of participant protections (e.g., different variations of functional analyses, participant assent). Furthermore, we categorized all protections as follows: environmental safety protocols, protective equipment, mechanical restraint, staffing protocols, session parameters, and ethi- cal protections. Table 1 includes a description and exam- ple of each category. Within each category, we specified the type of protections noted. TABLE 1 Protective procedure categories and examples. Category Description Examples Environmental safety Modifications made to the physical environment, to monitoring of sessions, or as a response to SIB to increase safety Padding within the environment (walls, floors, tables), use of mats, medical intervention (exams or monitoring), response blocking Protective equipment Protective equipment: Items that do not restrict movement and are worn by the participant to decrease the risk of injury caused by completion of the self-injurious response Helmets, arm or shin guards, padded gloves, protective dressings to cover wounds Self-restraint: Permitted self-restraint or provided self-restraint items that could be worn by the participant that were reported to be associated with reduced levels of self-injury Items could include (but were not limited to) sweaters wrapped around arms, airplane pillows Mechanical restraint Items that restrict movement to prevent the occurrence of a self-injurious response Arm restraints (with varying levels of flexion), Posey mitts, wrist guards Staffing protocols Procedures specific to therapists in session that could be associated with increased safety Training in functional analysis procedures, caregiver observing session, caregiver-conducted sessions, increased therapist proximity, additional staff in the vicinity Session parameters Procedures specific to conducting the functional analysis that could be associated with increased safety; modifications to the functional analysis methodology that minimize occurrence of self-injury Brief-FA, latency-FA, precursor-FA, trial-based FA, IISCA/ PFA, termination criteria, brief session durations (less than 5 min or if otherwise noted for safety) Ethical protections Procedures related to protections of human subjects in biomedical and behavioral research Approval by an ethics board or institutional review board, notations that the study was in compliance with ethical standards of research, caregiver consent, participant assent Note: SIB = self-injurious behavior; FA = functional analysis; IISCA/PFA = interview-informed synthesized contingency analysis/practical functional assessment. 844 FRANK-CRAWFORD ET AL. 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= Environmental safety included modifications to the physical environment, monitoring of sessions, or response to SIB in pursuit of safety (e.g., padded session area, ses- sions monitored by medical personnel, response blocking of SIB). Protective equipment included two types of pro- tections: protective gear worn by the participant and access to self-restraint or self-restraint items. Protective gear included items worn by the participant to protect the participant from injury but that did not restrict the par- ticipant’s movement (e.g., protective dressings to cover wounds, helmets, arm sleeves). The specific type of pro- tective gear was also noted when possible. Some individ- uals who engage in SIB may also engage in self-restraint, which includes responses such as sitting on one’s own hands or wrapping one’s hands in clothing (Hagopian et al., 2015). Thus, we also wanted to review whether self-restraint items were provided or self-restraint was permitted within session, as these items may decrease the overall level of, and therefore risk inflicted by, SIB. Self- restraint items were those that the individual could volun- tarily wear or place their arms or hands in or around that were reported to be associated with reduced levels of SIB. Permitting self-restraint or providing access to self- restraint items was included in the protective equipment category because (a) they served a protective function and (b) were voluntary responses (i.e., the participant could choose to engage in self-restraint or use self- restraint items). Mechanical restraint included items worn by the participant to protect them from injury but dif- fered from protective equipment in that (a) the items restricted movement such that the individual could not complete the SIB response to cause harm and (b) they were applied on the participant (e.g., arm restraints) rather than the participant electing to engage with them. Staffing protocols included procedures related to the ther- apists in session that could increase the safety of the func- tional analysis such as having the caregiver present in the room during the functional analysis or having them con- duct the session, increasing therapist proximity to the participant, or increasing the therapist-to-participant ratio (e.g., two therapists to increase the feasibility of response blocking). Session parameters included modify- ing the functional analysis methodology as a means of reducing risk during the functional analysis (i.e., brief, latency, trial-based, synthesized, or precursor functional analysis), using specific termination criteria, or conduct- ing an abbreviated analysis or using shorter session dura- tions. Functional analyses routinely range in duration. For example, in a review of functional analysis research conducted by Melanson and Fahmie (2023), 55.5% of studies included a maximum session duration of 5 min. Furthermore, of the 17.2% of studies that included a ses- sion duration other than 5, 10, or 15 min, the vast majority (79.7%) reported less than 5 min. These outcomes indi- cated that more than half of all functional analyses sum- marized by Melanson and Fahmie used short session durations, 5 min or less. Finally, ethical protections included obtaining approval from an ethics board or IRB, obtaining caregiver consent, or obtaining participant assent. Like Weeden et al. (2010), we also noted whether the authors reported having to terminate sessions. For each study, we reviewed the text and coded the presence of the safety procedures outlined above regard- less of whether the authors noted that the procedure was in place specifically for safety. That is, it was possible that a potential safety procedure was present in some articles but the authors did not explicitly acknowledge that it was included as a means of reducing risk. For example, response blocking was included in many studies identified in the current review but the study authors did not always note that they included it to protect the partic- ipant from injury. In the one exception to this rule, “short session duration” was only coded if the authors noted that the shorter durations were for safety or to reduce risk. We made this exception because so many studies include short session durations (see above) and we did not want to artificially inflate the outcomes of the current review by reporting every study that used a session dura- tion of less than 10 min as a participant protection. For the data analysis, we evaluated the general preva- lence of procedures commonly used for participant protec- tion as well as the prevalence of safety procedures that were specifically described as such. Therefore, for each study we coded whether it provided (a) specific or (b) general safety information. Specific safety was coded if the authors explic- itly noted that at leastone of the procedures was implemen- ted for safety (or using similar terms related to risk reduction or protection). General safety was coded if any potential safety procedure was included based on the cate- gories in Table 1 but the authors did not note that it was a specific safety procedure (see exception for the few and short sessions protection). Any reference to obtaining IRB or ethics board approval or conducting the study in accor- dance with the 1964 Helsinki Declaration (World Medical Association, 2013) and its later amendments anywhere in the body of the article or backmatter was categorized as “specific safety” because the guiding principles of ethics boards and the Helsinki Declaration include promoting the health, well-being, and rights of the patient or research par- ticipant. Safety is inextricably linked to these processes, as described in the Belmont Report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979) and the Helsinki Declaration (World Medical Association, 2013). Participant, setting, and functional analysis characteristics For each participant included in the study, data collectors recorded demographic information related to the partici- pant including the individual’s gender, age, race, ethnicity, and genetic or psychiatric diagnoses. We also recorded the presence or absence of autism spectrum disorder and PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 845 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= User Realce User Realce presence or absence of intellectual disability for each participant. For participants for whom an intellectual disability was described, we noted the level reported or “level not reported” if an intellectual disability was described but the level was not noted. In many cases, an intellectual disability or level was not explicitly noted but the researchers reported that the participant had limited to no communication skills or performed daily living skills at a level that was below expectations given their age. We classified these cases as having “reported deficits in com- munication or activities of daily living.” Data collectors recorded the topography of SIB targeted in the functional analysis and whether it was noted to have produced any injuries prior to or during the functional anal- ysis. Topographies of SIB were categorized in a manner similar to that in prior research on SIB (e.g., Hagopian, Falligant, et al., 2023) and included head-directed SIB, body-directed SIB, mouth-directed SIB, and skin-directed SIB. We also included ingestion-related SIB because a few topographies of SIB did not fit within the other four catego- ries.Head-directed SIB included any descriptions of the par- ticipant using any part of their body or an object to hit their head or poke their eyes (it excluded picking, pinching the head or face, and mouth-directed behavior). Body-directed SIB included descriptions of the participant using their hands, legs, mouth, or objects to hit or bite parts of their body (it excluded pinching, scratching, or behavior directed to the head and mouth). Mouth-directed SIB included descriptions of the participant using their hands or objects to hit, pinch, scratch, or pick at any portion of the mouth, including hand-mouthing. Skin-directed SIB included descriptions of the participant using their hands or objects to pinch or scratch the skin (it excluded self-biting, which was categorized as body-directed SIB). Additionally, we coded ingestion-related SIB for any descriptions of the par- ticipant inserting items into their nose, mouth, or ears or ingesting items. For injuries, we recorded data separately on whether the authors noted an injury prior to the func- tional analysis (by history) or during the functional analysis. Data collectors recorded “yes” if the authors explicitly noted that an injury had been reported or occurred, “no” if the authors explicitly noted that no injury had been reported or occurred, or “unknown” if the authors made no notation regarding injury. Finally, data collectors recorded the setting where the functional analysis was conducted and the functional analysis results. Settings included the participant’s home or residential placement, an outpatient or university- affiliated center or clinic, a school, or an inpatient hospi- tal. If multiple settings were used in the same study, this was reported as “multiple.” Functional analysis results were recorded based on the authors’ reports; we did not independently interpret functional analyses. Socially mediated functional analysis outcomes were coded as “attention” (which included attention or divided atten- tion), “tangible” (which included food or toys), “escape,” “synthesized” (which included two or more social tests in one condition), or “idiosyncratic” (e.g., mands function; see Schlichenmeyer et al., 2013, for a review of the litera- ture). When SIB was described as automatically main- tained, we categorized it as “automatic Subtype 1,” “automatic Subtype 2,” or “automatic Subtype 3” (e.g., Hagopian et al., 2015) if the subtype was reported by the authors; if the subtype was not reported, we categorized it as “automatic.” In some articles, the data were aggregated such that an individual’s demographic, setting, or functional analy- sis information could not be clearly determined. We retained those articles because they met inclusion criteria, and individual participant data for those cases was categorized as “unknown.” Intercoder agreement Throughout the screening process, a secondary coder assessed studies for inclusion or exclusion during both the abstract and full-text review steps. Intercoder agreement was calculated by dividing the total number of agree- ments by the total sum of agreements and disagreements and converting the quotient to a percentage. For the abstract review, agreement was calculated for 352 studies (28.62%); overall agreement equaled 92.90%. Agreement was calculated for 116 of the 362 studies (32.04%) that met criteria for the full-text review. Overall agreement for the full-text review was 91.38%. When disagreements occurred, the primary author met with either the second or third author to reread the abstract or text and dis- cussed the criteria until an agreement was obtained. All conflicts were resolved following discussion. After the final list of studies was identified, a pri- mary and secondary coder extracted data for 40 (of the 187) studies (21.39%) that met inclusion. Coding for some variables was restricted to a list of specific response options (e.g., age was restricted to specific age ranges) or “yes” or “no” (e.g., questions such as “Was a general protection included?”). Agreements in these cases included both coders selecting the same response option; disagreements included coders selecting different response options. Coding for other variables allowed for more than one response option. For example, participant diagnoses were open-ended it to allow data coders to include all reported psychiatric and genetic diagnoses; coders could also select from multiple protections within each participant protection category. For these variables, a proportional-agreement method was used to calculate agreement. For example, if the primary coder denoted the diagnoses of both autism spectrum dis- order and cerebral palsy for a participant, there would be two opportunities for the secondary coder to match. Thus, agreement for diagnosis for that individual would be 100% (2/2) if the secondary coder listed both diagnoses but only 50% (1/2) if they identified only one diagnosis. Studycharacteristics and safety procedures 846 FRANK-CRAWFORD ET AL. 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= were extracted at the study level (safety procedures were often not reported for individual participants and thus had to be extracted at the study level); participant demographics and functional analysis results were extracted at the individ- ual level for each participant that met inclusion criteria. On average, 49.38 opportunities for agreement (range: 30–264) occurred for each study. Overall agreement was calcu- lated by dividing the total sum of agreements across studies by the total sum of agreements and disagree- ments across studies and multiplying by 100 to obtain a percentage. Intercoder agreement during full-text data extraction was 95.70%. Following disagreements, the second and fourth authors met to resolve any conflicts by rereading the full text and discussing until an agree- ment was reached. Then, if necessary, the first author resolved any additional conflicts that may have persisted following this step. Using these procedures, a consensus was reached for all disagreements. Data analysis Participant characteristics were coded at the participant level and included sex, age, diagnoses (including level of intellectual disability when applicable), race, ethnicity, topography of SIB, and function of SIB. We collected information about functional analysis setting(s) at the study level because not all studies reported settings in a manner that would allow us to determine settings for each participant. All study and specific protection char- acteristics are described at the study level. We calculated the frequency of each coded item using Excel Pivot Tables and then calculated the percentages for all items. For items reported at the participant level, we divided the total number of response options within that variable (such as a given function) by the number of participants and multiplied the quotient by 100. For items reported at the study level, we divided the number of studies with a given response option by the total number of studies (N = 187) and multiplied the quotient by 100. Because we included the same nine specific protections and termination criteria evaluated by Weeden et al. (2010), we compared our results with theirs on these vari- ables. Weeden et al. reported the number of studies that included the specific protections and termination criteria; we converted these values to percentages and reported on the percentage of studies that included specific protection and termination criteria. We similarly calculated the num- ber and percentage of studies in our review that included the same nine protections and termination criteria. We also expanded Weeden et al. by including additional pro- tections and classified all of them (i.e., the nine from Weeden et al., the 26 new protections included in this review, and the notation of following the protocol outlined by Betz & Fisher, 2011) across six categories. Thus, we also report on the number and percentage of studies that included protections from each of the six categories. Secondary data analysis We were interested in identifying whether certain categor- ical variables were more likely to be reported when safety procedures were also reported. As previously noted, we hypothesized that authors may be more likely to report protections when SIB was the focus of the study and for prospective studies. We also hypothesized that authors may be more likely to report on protections if a prior injury was noted, if the participant targeted their head (given the high risk associated with head-directed injuries), and if SIB was automatically maintained, as prior research has demonstrated that SIB maintained by automatic rein- forcement is associated with a higher number and more severe injuries than socially maintained SIB (Rooker et al., 2018, 2020). Thus, we conducted a secondary analy- sis to examine the percentage of studies that reported on safety procedures for these variables. We supplemented the secondary analyses with chi-square tests of indepen- dence to determine whether any of these variables was associated with an increase in reporting safety procedures (see Franke et al., 2012) at a statistically significant level. RESULTS As noted, we were interested in identifying whether studies generally included protective procedures and whether the authors of those studies specifically designated safety as the purpose of the procedures. Figure 2 depicts the percentage of studies across years that reported on a protection and that specified it as such. Of the 187 studies that met inclu- sion criteria, 130 (69.52%) included at least one safety pro- cedure. Furthermore, 83 (44.39%) specifically reported it as a protective procedure. There appears to be a slight level change in the percentage of studies with reported protec- tions after 2013. Specifically, the mean percentage of studies for which a protection was reported from 2009–2013 was fairly stable and equaled 61.73% (range: 50%–70%); after 2014, the mean percentage of studies where a protection F I GURE 2 Percentage of studies reporting protections across years. The specific protections are reported from the 130 total studies that included at least one protection. PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 847 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= was reported increased to 78.18% (range: 66.67%–94.12%). When considering the 83 studies where the authors specifi- cally reported protective procedures, we observed a fairly steady increasing trend in the percentage of studies that included a protection and specified it as such across the 14 years examined in this study. Study characteristics Table 2 depicts the number and percentage of studies that met inclusion criteria, had general protections, and had specific protections across journals. Five of the 26 journals included 10 or more studies: Journal of Applied Behavior Analysis (n = 83; 44.39% of all studies), Behavioral Interventions (n = 15; 8.02%), Research in Developmental Disabilities (n = 14; 7.49%), Journal of Developmental and Physical Disabilities (n = 12; 6.42%), and Behavior Modifi- cation (n = 10; 5.35%). The remaining 21 journals included fewer than 10 studies, seven of which included only one study. The Journal of Applied Behavior Analysis had the largest number and greatest percentage of studies with general protections (n = 22; 46.81%) and specific pro- tections (n = 30; 36.14%). Table 3 depicts study information. Self-injury was the subject matter of the study for 46 (24.60%) studies. Most studies (n = 166; 88.77%) were prospective. Functional analyses were most commonly reported to have been TABLE 2 Number and percentage of studies, total protections, general protections, and specific protections. Journal title Studies Total protections General protections Specific protections n % n % n % n % Journal of Applied Behavior Analysis 83 44.39 52 40.00 22 46.81 30 36.14 Behavioral Interventions 15 8.02 11 8.46 3 6.38 8 9.64 Research in Developmental Disabilities 14 7.49 13 10.00 5 10.64 8 9.64 Journal of Developmental and Physical Disabilities 12 6.42 9 6.92 3 6.38 6 7.23 BehaviorModification 10 5.35 4 3.08 1 2.13 3 3.61 Behavior Analysis in Practice 7 3.74 4 3.08 1 2.13 3 3.61 Research in Autism Spectrum Disorders 6 3.21 6 4.62 1 2.13 5 6.02 Journal of Autism and Developmental Disorders 6 3.21 5 3.85 2 4.26 3 3.61 Developmental Neurorehabilitation 5 2.67 4 3.08 1 2.13 3 3.61 Advances in Neurodevelopmental Disorders 3 1.60 3 2.31 - - 3 3.61 Journal of Intellectual Disability Research 3 1.60 3 2.31 - - 3 3.61 American Journal on Intellectual and Developmental Disabilities 2 1.07 2 1.54 1 2.13 1 1.20 American Association on Intellectual and Developmental Disabilities 2 1.07 1 0.77 - - 1 1.20 Current Developmental Disorders Reports 2 1.07 1 0.77 - - 1 1.20 Education & Treatment of Children 2 1.07 2 1.54 2 4.26 - - International Journal of Developmental Disabilities 2 1.07 2 1.54 1 2.13 1 1.20 Journal of the Experimental Analysis of Behavior 2 1.07 1 0.77 1 2.13 - - Journal of Behavioral Education 2 1.07 2 1.54 1 2.13 1 1.20 Journal of Mental Health Research in Intellectual Disabilities 2 1.07 1 0.77 - - 1 1.20 Behavioral Development 1 0.53 - - - - - - Brain Injury 1 0.53 1 0.77 - - 1 1.20 Clinical Case Studies 1 0.53 1 0.77 1 2.13 - - Education and Training in Developmental Disabilities 1 0.53 - - - - - - Journal of Applied Research in Intellectual Disabilities 1 0.53 - - - - - - Psychological Reports: Disability and Trauma 1 0.53 1 0.77 - - 1 1.20 The Journal of Speech and Language Pathology and Applied Behavior Analysis 1 0.53 1 0.77 1 2.13 - - Total 187 130 47 83 848 FRANK-CRAWFORD ET AL. 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= completed in an outpatient clinic (n = 45; 24.06%), a school (n = 33; 17.65%), an inpatient hospital (n = 28; 14.97%), a university clinic or classroom (n = 24; 12.83%), or across multiple settings (n = 19; 10.16%). Regarding injuries, authors of 39 studies (20.86%) noted that injuries occurred prior to the functional analysis. An injury during the functional analysis was reported in only one study (0.53%); it was noted in two other studies (1.07%) that injuries occurred during the assessment period but not during the functional analysis. Authors of one study (0.53%) reported that they terminated a func- tional analysis session. Additionally, authors of only four studies (2.14%) explicitly reported that no injuries occurred during the functional analysis and authors of 10 studies (5.35%) explicitly noted that no functional analysis sessions had to be terminated. No other details on injuries were provided in the studies. Participant and functional analysis characteristics Table 4 depicts participant demographics, SIB topography, and functional analysis outcomes for 1,070 participants. When individual information could be extracted, most par- ticipants were identified as male (n = 534; 49.91% of partic- ipants), primarily ages 3–12 (n = 332; 31.01%) and 13–17 (n = 136; 12.71%). Race and ethnicity were reported for only 38 (3.55%) and 7 (0.65%) participants across studies, respectively. Additionally, 735 (68.69%) participants had an intellectual disability or a reported deficit in communication or activities of daily living, without a specified intellectual disability, and 539 (50.37%) had autism spectrum disorder. We also collected information on topography of SIB. Topography was unknown for 603 (56.36%) participants. When it was reported, participants could have engaged in more than one topography of SIB; thus, the total number of topographies reported for the 467 participants with a known topography equaled 729. Head-directed SIB was the most commonly reported (n = 288; 26.92% of participants), followed by body-directed SIB (n = 235; 21.96%), then skin-directed SIB (n = 120; 11.21%). Table 4 also includes information on the function(s) of SIB. The results for 292 individuals (27.29%) could not be discerned because only group data were reported. Thus, we report on functional analysis outcomes for 778 individuals. Some participants were reported to have more than one function for their SIB; thus, data were extracted for a total of 955 functions (of the 778 individ- uals that were included). We identified 635 social and synthesized functions (66.49% of the 955 known func- tions), 273 automatic functions (28.59% of known functions), and 10 idiosyncratic functions (1.05%); the remaining 37 (3.87%) were inconclusive. When automatic reinforcement was identified, we also examined whether subtype of SIB was reported. Self-injury was classified as Subtype 1 for 19 participants, Subtype 2 for 32 partici- pants, and Subtype 3 for 23 participants. Subtype was not reported or could not be determined for the remain- ing 199 participants. Safety procedure characteristics Weeden et al. (2010) comparison Table 5 depicts the outcomes of a direct comparison with the protections evaluated by Weeden et al. (2010). Since Weeden et al., the percentage of studies including protec- tions has increased for seven of the nine protections (albeit slightly for some). The largest changes were seen in reporting on the use of padded test areas, followed by caregivers functioning as therapists and obtaining IRB approval. Smaller changes were observed for few and short sessions, response blocking, protective equipment, and sessions monitored by medical personnel. Negligible changes were observed with the caregiver being in the room (perhaps because more were acting as therapists rather than mere observers) and medical exams (perhaps because many settings did not have access to such person- nel). When examining the use of specific termination TABLE 3 Study characteristics. Study information Response option n % Was SIB in the study title or keywords? Yes 46 24.60 No 141 75.40 Research type Prospective 166 88.77 Retrospective 21 11.23 FA setting Outpatient clinic 45 24.06 School 33 17.65 Inpatient hospital 28 14.97 University clinic/ classroom 24 12.83 Participant’s home 16 8.56 Residential program 7 3.74 Multiple settings 19 10.16 Unknown 15 8.02 Injuries reported before FA Yes 39 20.86 Not reported 148 79.14 Injuries reported during FA Yes 1 0.53 Yes, outside of FA sessions 2 1.07 No 4 2.14 Not reported 180 96.26 FA sessions terminated Yes 1 0.53 No 10 5.35 Not reported 176 94.12 Note: SIB = self-injurious behavior; FA = functional analysis. PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 849 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= criteria, we also saw a modest increase in reporting. Weeden et al. noted that only 7.76% of studies reported termination criteria; in the current review, we found that 12.30% of studies reported using termination criteria. Finally, when comparing the total percentage of studies that included any of these nine types of protections, Wee- den et al. found that at least one protection was noted in 19.83% of the studies they reviewed. In the current review, 54.01% of studies included at least one of these types of protections. Additional protections and categorical outcomes We extended Weeden et al. (2010) by including addi- tional protections, developing categories to organize all protections (those included by Weeden et al., 2010, and the new ones added in this review), and reportingon those categorical outcomes (for categories, see Table 1). Table 6 includes details on the number of studies that included each type of protection and the percentage of studies that included at least one protection from a given category. Studies could include more than one type of protection from one or more categories. The most com- mon protections were session parameters (n = 69; 36.90%), environmental safety (n = 63; 33.69%), ethical protections (n = 48; 25.67%), and staffing protections (n = 38; 20.32%). Protective equipment was reported in 14 (7.49%) studies, and mechanical restraint was reported in 10 (5.35%) studies. Of the 130 studies for which a protection was noted, 52 (40%) included only a single protection, whereas 78 (60%) included multiple protections. Furthermore, stud- ies including more than one protection could have noted (a) multiple protections from a single category, (b) a single protection from multiple categories, or (c) multiple protec- tions across multiple categories. Of the 78 studies with TABLE 4 Participant demographic information. Demographic information Response option n (of 1,070) % Sex Male 534 49.91 Female 191 17.85 Not reported 345 32.24 Age 17 108 10.09 Not reported 477 44.58 Race White 21 1.96 Black 14 1.31 Asian/Pacific Islander 3 0.28 Not reported 1,032 96.45 Ethnicity Hispanic 5 0.47 Not Hispanic 2 0.19 Not reported 1,063 99.35 Diagnosis ID (includes reported deficits in communication/ ADLs) 735 68.69 ASD 539 50.37 Other behavioral 265 24.77 Genetic/medical 164 15.33 Other communication 8 0.75 Vision/hearing 5 0.47 Unknown 194 18.13 Level of ID Severe 100 9.35 Moderate 77 7.20 Mild 61 5.70 Profound 43 4.02 Level not reported 276 25.79 Nonspecific- Reported deficits in communication/ ADLs 178 16.64 SIB topography Head-directed 288 26.92 Body-directed 235 21.96 Skin-directed 120 11.21 Mouth-directed 83 7.76 Ingestion-related 3 0.28 Unknown 603 56.36 Function of SIB Automatic 273 25.51 Subtype 1 19 1.78 Subtype 2 32 2.99 Subtype 3 23 2.15 Automatic (no subtype) 199 18.60 (Continues) TABLE 4 (Continued) Demographic information Response option n (of 1,070) % Escape 218 20.37 Tangible 198 18.50 Attention 118 11.03 Synthesized 56 5.23 Social (unspecified) 45 4.21 Inconclusive/ undifferentiated 37 3.46 Idiosyncratic 10 0.93 Unknown 292 27.29 Note: ID = intellectual disability; ASD = autism spectrum disorder; ADLs = activities of daily living; SIB = self-injurious behavior. 850 FRANK-CRAWFORD ET AL. 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= multiple protections noted, 15 (19.23%) included more than one protection within a single category, 24 (30.77%) included a single protection from multiple categories, and 39 (50%) included multiple protections across multiple cate- gories. Thus, it was most common for studies to include a variety of protections that spanned multiple categories. Figure 3 depicts the percentage of studies for which protections from each category were reported across the years. No discernable trends were observed in the percent- age of studies with reported staffing protocols and envi- ronmental protections between 2009 and 2022. The year 2015 appears to be an inflection point for many of the other categories. Few if any studies included reports of protective equipment or mechanical restraint prior to 2015 (protective equipment: M = 1.36%, range: 0%–4.17%; mechanical restraint: M = 0%). After 2015, the percentage of studies with reports of these categories increased, although reporting was variable across the remaining years (protective equipment: M = 12.16%, range: 0%–25%; mechanical restraint: M = 10.47%, range: 0%–37.50%). Except for the year 2010, the percentage of studies report- ing on session-parameter protections from 2009 to 2014 appears low and stable (M = 28.40%, range: 20%–50%). However, there is a notable upward shift in the percentage of studies reporting on session parameter protections from 2015 to 2022 (M = 46.19%, range: 35.71%–55.56%). Finally, there appears to be a steady increasing trend across the years in the percentage of studies where an ethical protection was reported. We further analyzed what types of protections contrib- uted to the changing levels and increasing trends observed in the session-parameter and ethical-protection categories, respectively. Figure 4 depicts outcomes for the three sub- categories that comprised session parameters: functional analysis type, termination criteria, and modification to the session or topography. For the most part (outside of the years 2020 and 2021), there is little change in the percent- age of studies that reported using specific termination criteria or that reported session or topography modifica- tion. On the other hand, the year 2015 appears to be an inflection point for functional analysis type where we observe an overall level change in the mean percentage of studies reporting on this type of protection (2009–2014: M = 13.08%, range: 0%–40%; 2015–2022: M = 34.51%, range: 25%–50%). The inset panel in Figure 4 depicts the percentage of studies where each specific type of functional analysis was reported; the change after 2015 appears to be attributable to increases in the use of the interview- informed synthesized contingency/practical functional assessment and latency functional analyses. Figure 5 depicts the percentage of studies with reports of ethical protections, and the inset panel shows data for relevant subcategories: caregiver consent, IRB approval, and participant assent. Between 2009 and 2013, ethical protections consisted almost exclusively of caregiver con- sent. After 2013, an increasing trend was observed with IRB approval and caregiver consent; the similar trend observed with these two protections intuitively makes sense because IRBs require consent for prospective research. Relatively few studies reported on assent proce- dures between 2009 and 2022. Secondary analysis findings We also evaluated whether studies were more likely to include protections when (a) SIB was the subject matter of the study, (b) the study was prospective, (c) injuries TABLE 5 Number and percentage of studies that reported protections described by Weeden et al. (2010). Type of protection n Weeden et al. % n Current Study % % Change (N = 116) (N = 187) Padded test areas 4 3.45 41 21.93 18.48 Institutional review board approval 6 5.17 29 15.51 10.34 Parent as therapist 1 0.86 27 14.44 13.58 Response blocking 6 5.17 24 12.83 7.66 Few and short sessions 4 3.45 21 11.23 7.78 Protective equipment 4 3.45 14 7.49 4.04 Medical exam 2 1.72 6 3.21 1.49 Sessions monitored by medical personnel 1 0.86 6 3.21 2.35 Parent in room 1 0.86 1 0.53 �0.33 Total n studies that included a protection (excluding specific termination criteria) 23 19.83a 101 54.01b 34.18 Specific termination criteria 9 7.76 23 12.30 4.54 aThe values in the column denoting the total data reported for Weeden et al. (2010) were derived from Table 1 in Weeden et al. and represent the number and percentage of studies that reported at least one type of protection (with the exclusion of specific termination criteria, which are reported separately). bThe values in the column denoting the total data for the current study were derived by calculating the total number and percentage of studies that reported at least one type of protection listed in this table (with the exclusion of specific termination criteria, which are reported separately). PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 851 19383703,2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= were reported prior to the functional analysis, (d) at least one participant had head SIB, and (e) at least one partici- pant had automatically maintained SIB. Table 7 depicts the outcomes from these secondary analyses. Overall, there were minimal differences in the percentage of studies that did and did not report a participant protection across most variables that were evaluated, with the exception of topography. Specifically, at least one participant engaged in head-directed SIB in 83.67% of the studies that included a participant protection versus 63.27% of studies where protections were not included. The chi-square test of inde- pendence determined that this difference was statistically significant, χ2(1) = 6.7, p = .00096, OR = 2.8, which indi- cated an association between participants engaging in head-directed SIB and reporting safety procedures. DISCUSSION Overall, the results of this review indicated that at least one safety procedure was noted in 69.52% (130/187) of studies that included a functional analysis of SIB. Furthermore, 54.01% (101/187) of studies included at least one of the nine types of participant protections that were also evaluated by Weeden et al. (2010). In comparison, Weeden et al. found that only 19.83% (23/116) of studies in their review TABLE 6 Number and percentage of studies that reported each type of protection. Category Type of protection n % Session parameters 69 36.90 FA modification 44 Few and short sessions/Brief FA 21 IISCA/PFA 13 Latency FA 7 Precursor FA 5 Trial-based FA 3 Session/topography modification 20 Alone not conducted/no interaction instead of alone 12 Special topography selection 4 Session pausing/breaks 2 Screened for automatic reinforcement 2 Specific termination criteria 23 Not reported 118 63.10 Environmental safety 63 33.69 Padding (test area or therapist) 41 Response blocking 24 Medical exam/clearance 6 Sessions monitored by medical personnel 6 Covert observation 1 Ingestion-resistant items 1 Sanitary procedures 1 Not reported 124 66.31 Ethical protections 48 25.67 Caregiver consent 43 Institutional review board approval 29 Participant assent 5 Not reported 139 74.33 Staffing protocols 38 20.32 Parent/Teacher as therapist 27 Staff in close proximity 4 Specific training in safety 3 Nonspecific – Cited Betz and Fisher (2011) 3 Parent/Teacher in room or observing session 1 Multiple therapists 1 Presession pairing 1 Reviewed cost–benefit analysis of FA with family 1 Not Reported 149 79.68 (Continues) TABLE 6 (Continued) Category Type of protection n % Protective equipment 14 7.49 Nonspecific – Cited Betz and Fisher (2011) 3 Arm sleeve(s) 2 Used self-restraint materials 2 Protective dressing 1 Permitted self-restraint 1 Unspecified 8 Not reported 173 92.51 Mechanical restraint 10 5.32 Arm splints 4 Nonspecific – Cited Betz and Fisher (2011) 4 Posey mitts 1 Unspecified 1 Not reported 177 94.65 Note: Studies may have included more than one type of protection within and across categories. Thus, the bolded number and percentage denoted for each category represent the total number and percentage of studies that included at least one of the types of protections noted within that category. The number denoted for each type of protection within a category represents the number of studies that included that type of protection. FA = functional analysis; IISCA/ PFA = interview-informed synthesized contingency analysis/practical functional assessment. 852 FRANK-CRAWFORD ET AL. 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= reported participant protections. We also determined how many studies reported on procedures that met our classifi- cation as a protection and where the study authors described at least one safety procedure as such; only 83 (44.39%) studies did both. We evaluated protections at the level of the study because, in most studies, protections were only reported generally and we could not always discern for which participant a given protection was used. Thus, we could not evaluate whether any patterns emerged with the use of specific types of protections aside from finding that protections were more commonly reported when a partic- ipant had head-directed SIB. Including information on the protective procedures used at the level of the individual could be particularly important as we seek to better under- stand how to select optimal protections. Protections, such as protective equipment, can sometimes suppress responding during the functional analysis (e.g., Borrero et al., 2002; Le & Smith, 2002; Moore et al., 2004), making the determi- nation of the causes of SIB difficult. Therefore, optimal protections will likely include those that allow for the occur- rence of SIB to the extent that it can be assessed and treat- ments can be evaluated while also minimizing risks of injury. We recommend that authors report specific protec- tions at the participant level. For example, Hagopian, Falligant, et al. (2023) included a table (Table 6, p. 584) that denoted the types of individually applied protections used during functional analyses for participants who engaged in SIB. They also described safeguards employed generally across all participants. Perhaps equally important to including information on individualized protections is information related to termi- nation of sessions and injuries that may have occurred during the assessment. In the current review, few studies reported on this information; only 11 studies explicitly noted whether a session was terminated, and only seven explicitly noted whether an injury occurred during the functional analysis. Information related to individualized F I GURE 3 Percentage of studies reporting each category of protection across years. F I GURE 4 Percentage of studies reporting session parameter protections across years. FA = functional analysis; Sess = session; IISCA/ PFA = interview-informed functional analysis/practical functional assessment. Inset panel: percentage of studies reporting each type of functional analysis; the y-axes for the graphs in the inset have been adjusted to 50% to more clearly depict the data associated with lower percentages. PROTECTIONS FOR SIB IN FUNCTIONAL ANALYSIS 853 19383703, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/jaba.2906 by C A PE S, W iley O nline L ibrary on [01/11/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fjaba.2906&mode= protections used and safety outcomes (e.g., termination of sessions, injuries) will be essential to future research directed at better assessing the degree to which protections are working. To that end, Supporting Information I includes a checklist that we developed to aid in document- ing and reporting on protections; this could be included as supporting information in future studies where SIB is a target response. Studies included in this scoping review
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