Management Of Self-injurious Behavior Research Articles

Addressing Self-Injurious Behavior in the Medically Complex Child: Identifying the Root Cause vs Blocking Resulting Behavior.

Gillian is a 7-year-old nonverbal, internationally adopted girl with significant visual impairment (sees shadows and objects with high contrast), moderate-severe hearing loss, autism spectrum disorder, profound intellectual disability, and a seizure disorder. She resided in an orphanage until age 4 years when she was adopted by her mother. She is referred to the multidisciplinary team in developmental-behavioral pediatrics by her gastroenterologist, who is managing her constipation, for evaluation and management of self-injurious behavior that occurs before bowel movements.Gillian's adoptive mother reported that Gillian has a history of repetitive and self-injurious behavior including hitting her head with the palm of her hand and poking her eyes. The head-hitting behavior has resulted in consistent bruising to her forehead and nasal bridge. The eye poking is of significant concern because of the possibility of resultant injury including corneal abrasion or retinal detachment. Eye poking occurs exclusively during the hour before stooling, at home and school, and is accompanied by screaming, pacing, and increased aggression toward her mother/teachers. Mother typically responds by blocking the eye poking, redirecting Gillian to the toilet, providing prompts to use calming strategies (e.g., deep breathing), or providing sensory input by rubbing her arms/back. Teachers respond in a similar way at school. Gillian's mother has tried to place goggles over Gillian's eyes during eye poking, but this resulted in increased aggressive behaviors.Gillian is not fully bowel trained but will sit on the toilet to urinate when prompted. She completes toilet-sits at home/school 5 to 7 times daily. Gillian passes small, soft bowel movements 2 to 4 times daily on a bowel management regimen consisting of polyethylene glycol 3350 17 grams twice daily and liquid senna 8.8 mg daily. Seizures are reportedly well controlled with an antiepileptic medication managed by her neurologist. Previous medical evaluation by otolaryngology, ophthalmology, neurology, and gastroenterology did not identify a source of pain or other cause for the eye poking. Physical examination reveals normal bowel sounds and a mildly distended abdomen but is otherwise unremarkable. What are your next steps for evaluation and treatment?

14.1 Phenomenology and Management of Self-Injurious Behavior in ASD

Self-injurious behavior (SIB) in ASD is among the most difficult behaviors to manage. It occurs across a variety of comorbid diagnoses and genetic syndromes associated with ASD. The phenomenology of SIB for the individual can be remarkably stable and persistent across the life span. A functional behavioral analysis of symptoms is essential because sensory needs, communication abilities, social drive, and environmental circumstances are key to understanding the predisposing, precipitating, and perpetuating factors that are essential to developing a case formulation and intervention plan.

Management of self-injurious behaviour, reducing restrictive interventions and predictors of positive outcome in intellectual disability and/or autism

SUMMARYPerceptions of self-injurious behaviour as refractory to treatment, and of treatment outcomes as unpredictable, in children and adults with intellectual disabilities and/or autism may lead to treatment inertia or nihilism, restrictive practices and overuse of psychotropic medication in its management. Recent research suggests, however, that from infancy to young adulthood prospects for a positive outcome are fair, and markers predictive of treatment outcome have begun to be identified. In this clinical reflection we briefly describe this work, consider how it may contribute to case stratification, and outline current thinking on further functional differentiation of cases of SIB, promoting non-restrictive practices.

Risk factors and topographies for self-injurious behaviour in a sample of adults with intellectual developmental disorders.

Self-injurious behaviour (SIB) is a prevalent form of challenging behaviour in people with intellectual developmental disorders (IDD). Existing research has yielded conflicting findings concerning the major risk factors involved, and in addition, SIB shows multiple topographies and presentations. Although presence of autism spectrum disorders (ASD) and severity of intellectual disability (ID) are known risk factors for SIB, there are no studies comparing SIB topographies by severity degrees of ID and ASD. The purpose of the present paper has been to identify risk factors and topographies for SIB in a representative, stratified and randomised sample of adults with IDD. This study was conducted on the basis of data collected by the POMONA-ESP project, in a sample of 833 adults with IDD. Data concerning demographic and health information, ASD symptoms, psychopathology and ID, have been analysed to determine the presence of risk factors for SIB among participants and to explore the occurrence and topographies of SIB across different severity levels of ID and ASD symptoms. Self-injurious behaviour prevalence in the sample was 16.2%. Younger age, oral pain, greater severity of ID, presence of dual diagnosis, psychiatric medication intake and higher scores on Childhood Autism Rating Scale were risk factors for SIB among participants, whereas number of areas with functioning limitations, place of residence, diagnosis of epilepsy and sex were not. SIB was more frequent in participants with ASD symptoms regardless of its severity level, and they displayed a higher number of different topographies of SIB. People with profound ID without co-morbid ASD symptoms showed similar results concerning SIB prevalence and topographies. Knowledge on risk factors and topographies of SIB might play a vital role in the development of prevention strategies and management of SIB in people with IDD. The mere presence of ASD symptoms, regardless of its severity level, can be a crucial factor to be taken into account in assessing SIB. Accordingly, the presence of SIB in people with ID, especially when presented with a varied number of topographies, might provide guidance on ASD differential diagnosis.

29.2 Evaluation and Management of Self-Injurious Behavior in Autism Spectrum Disorder

29.2 Evaluation and Management of Self-Injurious Behavior in Autism Spectrum Disorder

A National Survey of Self-Injurious Behavior in American Prisons

This study sought information about the prevalence, epidemiology, and management of self-injurious behavior by inmates in U.S. prison systems. Although self-injurious behavior has long been the source of significant challenges in correctional settings, limited research is available on this topic. Mental health directors in all 51 state and federal prison systems were invited to respond to a 30-item questionnaire available online or in hard copy. Univariate statistics were used to describe significant aspects of the national experience with self-injurious behavior, and bivariate statistics were used to examine relationships between variables. Thirty-nine systems (77%) responded to the survey. Responses indicated that <2% of inmates per year engage in self-injurious behavior, but such events were reported to occur at least weekly in 85% of systems, with occurrences more than once daily in some systems, thus causing substantial disruptions to operations and draining resources. The highest rates of occurrence of these behaviors were in maximum-security and lockdown units and most often involved inmates with axis II disorders. Despite the seriousness of the problem, systems typically collect few, if any, data on self-injurious behaviors, and management approaches to dealing with them lack consistency within and across systems. Eighty-four percent of respondents expressed interest in participating in further studies on this topic. The survey responses indicated the disruptive effects of self-injurious behavior in the nation's prisons, a need for better epidemiologic monitoring and data on such behavior, and the importance of developing and widely using effective interventions. The high response rate and expressed interest in follow-up projects suggest that state and federal correctional mental health directors see a need for better information and management in this area.

A National Survey of Self-Injurious Behavior in American Prisons

Objective: This study sought information about the prevalence, epidemiology, and management of self-injurious behavior by inmates in U.S. prison systems. Although self-injurious behavior has long been the source of significant challenges in correctional settings, limited research is available on this topic. Methods: Mental health directors in all 51 state and federal prison systems were invited to respond to a 30-item questionnaire available online or in hard copy. Univariate statistics were used to describe significant aspects of the national experience with self-injurious behavior, and bivariate statistics were used to examine relationships between variables. Results: Thirty-nine systems (77%) responded to the survey. Responses indicated that <2% of inmates per year engage in self-injurious behavior, but such events were reported to occur at least weekly in 85% of systems, with occurrences more than once daily in some systems, thus causing substantial disruptions to operations and draining resources. The highest rates of occurrence of these behaviors were in maximum-security and lockdown units and most often involved inmates with axis II disorders. Despite the seriousness of the problem, systems typically collect few, if any, data on self-injurious behaviors, and management approaches to dealing with them lack consistency within and across systems. Eighty-four percent of respondents expressed interest in participating in further studies on this topic. Conclusions: The survey responses indicated the disruptive effects of self-injurious behavior in the nation's prisons, a need for better epidemiologic monitoring and data on such behavior, and the importance of developing and widely using effective interventions. The high response rate and expressed interest in follow-up projects suggest that state and federal correctional mental health directors see a need for better information and management in this area. (Psychiatric Services 62:285–290, 2011)

Gender differences in presentation and conceptualization of adolescent self-injurious behaviour: Implications for therapeutic practice

The UK is reported to have the highest rate of self-injurious behaviour (SIB) in Europe. It is no longer underrepresented in adolescent male populations, and further appears to correlate significantly with the increase in young male completed suicides. Early research suggested mental health professionals view males as being psychologically healthier than females. Gender differences in behavioural presentation and conceptual understanding of SIB may account for such disparity. The fields of counselling psychology and psychotherapy are in the advantageous position of embracing broader perspectives in which to challenge methodological and conceptual biases within existing medical frameworks. Differential gender biases in the nosology of comorbid conditions, psychodiagnosis, and treatment decisions are identified. Mental health workers across disciplines continue to find the management of SIB a challenge despite the wealth of theoretical models available to inform practice. Some techniques and promising therapies (dialectical behaviour therapy and problem-solving therapy) are highlighted as practicable approaches for counselling psychologists. Conclusions reveal future research may benefit from incorporating broader definitions of SIB expressed across the sexes. Further investigation into treatment efficacy with particular emphasis on the impact of gender role socialization is also indicated.

Self-injurious behavior in frontotemporal dementia

Frontotemporal dementia (FTD) may be one of the most common neurodegenerative dementias with onset before age 65. Investigators have only recently characterized FTD, which encompasses Pick's disease as well as non-specific degeneration of the frontal lobes. Neuropsychiatric symptoms are the main features of FTD and include disinhibition, apathy, obsessive-compulsive behavior, and the Kluver-Bucy syndrome. We report a patient with FTD who developed prominent self-injurious behavior (SIB) consisting of persistent self-biting and hair-pulling. Stereotypical, repetitive SIB usually occurs in patients with autism or mental retardation; SIB is rarely discussed in patients with dementia. This report extends the neuropsychiatric spectrum of FTD to encompass SIB and discusses the potential mechanisms for SIB in these patients. The most likely contributing source for their self-injury is the development of obsessive-compulsive behaviors in the presence of coincident self-directed behaviors. Hyperorality from anterior temporal Involvement and the release of primitive grooming behavior from frontal degeneration are self-directed behaviors that contribute to the specific manifestations of SIB among FTD patients. The pharmacological management of SIB emphasizes drugs that work through opioid, serotonergic, or dopaminergic systems.

Case Study: Paradoxical Response to Naltrexone Treatment of Self-Injurious Behavior

Opioid receptor antagonists have been studied in the management of self-injurious behavior (SIB) in developmentally disabled individuals. The authors present a case of a severely retarded, autistic man whose SIB increased dramatically during a trial of naltrexone. A paradoxical increase in SIB, attributed to the extinction burst phenomenon during the initial period of nonreward, is known to occur during treatment with naloxone, a short-acting parenteral opioid antagonist. It has only once been reported during treatment with naltrexone, a long-acting orally administered agent. Opioid analgesic effects and learning theory can explain both increases and decreases in SIB after opioid blockade.

The use of Overcorrection to Suppress Self-Injurious Behaviour

This paper reviews the application of overcorrection (OC) to management of self-injurious behaviour (SIB). A total of 32 studies are reviewed producing 47 discrete experiments. The literature supported the short-term efficacy of the procedure for the majority of subjects. However, findings on maintenance were less encouraging. Over 70% of experiments reporting durable response suppression continued a full OC regime. For the most part, the research considered did not yield clear indications on strategies that would enhance maintained suppression of responding. Generalization was subject to minimal investigation despite recognition of its importance in the management of SIB. Research comparing OC and other behavioural interventions is limited and difficult to interpret at this stage. Reservations regarding the use of OC include the intrusive and restrictive nature of the technique and limited data on maintenance, generalization and relative efficacy of OC and other behavioural interventions. These issues re...

Pharmacological Assessment and Comprehensive Behavioral Intervention in a Case of Pediatric Self-Injury

The present study evaluated the effects of psychotropic medication in concert with comprehensive behavioral intervention on multiple forms of self-injury in a deaf-blind child. Treatment consisted of a combination of reinforcement for noninjurious behaviors, plus brief, response-contingent interruption/immobilization. In addition, the study included programming for cross-setting generalization, training parents as home interventionists, and evaluating maintenance of intervention effects. Using a modified multiple-baseline design, treatment was demonstrated to be successful in reducing self-injurious behaviors to near-zero levels, with results maintained at a 6-month follow-up, Therapeutic effects were established across program settings and within the child's home. Psychotropic medication did not have a positive influence on the control of self-injury. issues relevant to the comprehensive assessment and management of self-injurious behavior are discussed.

In vivo desensitization in the management of self-injurious behavior

In vivo desensitization procedures were used successfully to manage self-injurious face slapping in a 10 yr old retarded boy. Face slapping had increased and persisted at self-injurious intensity following a surgical dental evaluation and had initially been prevented by the use of a hockey helmet. Parent's efforts to remove the helmet resulted in increased agitation, severe self-injurious behavior, and repeated efforts by the child to replace the helmet to restrain himself, or prompt adult restraint. An in vivo desensitization procedure involving increasingly extended periods without the helmet was introduced by the parents into a hierarchy of situations at home. Progress was monitored across four situations using a multiple baseline design with 6, 9, 12 and 15 month follow-up on each baseline. During treatment, self-injurious behavior was eliminated and the child developed a self-control response of wearing the helmet when agitated and spontaneously removing it when relaxed. Continued improvement was noted at 6, 9 and 12 month follow-ups. At the 15 month follow-up, no self-injurious behavior was observed and the use of the helmet was discontinued.