Reductions In Self-injurious Behavior Research Articles

Using Functional Communication Training to Reduce Self-Injurious Behavior for Individuals with Autism Spectrum Disorder.

Children with autism spectrum disorders (ASD) have a high risk of developing self-injurious behavior (SIB), which is often a result of deficits in communication skills. The use of functional communication training (FCT) to address SIB maintained by negative reinforcement among children with ASD is supported by an emerging trend of behavioral research. The purpose of this study was to examine the effects of FCT on the SIB of children with ASD and to find out if the results would be maintained during periods of nonreinforcement. The results indicated significant reduction in SIB for all three participants and maintained for over two weeks following the withdrawal of the intervention. However, resurgence of SIB occurred when extinction was implemented for all participants.

Physical Exercise as Medicine for Self-Injurious Behavior

Self-injurious behavior is one of the leading causes of death worldwide. Anxiety, substance abuse, posttraumatic stress disorder, trauma, depression, and personality disorders are commonly reported in patients with self-injurious behavior. The primary purpose of this article is to present a summary of research examining the effectiveness of exercise to reduce self-injurious behavior and to recommend directions for further research. Major research databases including PubMed, Scopus, Science Direct, Taylor & Francis, Google Scholar, PsycINFO, MEDLINE, and ERIC were searched for published work. Only five studies were found relevant to the topic of our interest: one retrospective case study, two cross-sectional studies, and two interventional/experimental studies. The results of interventional studies found beneficial effects of aerobic exercise for reduction in self-injurious behavior. In addition, cross-sectional studies found effectiveness of moderate to vigorous exercise for self-injury. The findings also showed that exercise appeared to reduce negative psychological conditions and improve overall psychological states in people with self-injurious behavior. [ Psychiatr Ann . 2020;50(4):167–177.]

Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key.

Self-injurious behaviour (SIB) is a devastating condition frequently encountered in autism spectrum disorders (ASDs) that can lead to dangerous tissue injury and profound psychosocial difficulty. An increasing number of reports over the past decade have demonstrated the swift and well tolerated resolution of intractable SIB with electroconvulsive therapy (ECT) when psychopharmacological and behavioural interventions are ineffective. The current article provides a review of the salient literature, including the conceptualization of repetitive self-injury along the catatonia spectrum, and further clarifies the critical distinction between ECT and contingent electric shock. We searched electronically for literature regarding ECT for self-injurious behaviour from 1982 to present, as the first known report was published in 1982. Eleven reports were identified that presented ECT in the resolution of self-injury in autistic or intellectually disabled patients, and another five reports discussed such in typically developing individuals. These reports and related literature present such self-injury along the spectrum of agitated catatonia, with subsequent implications for ECT. Intractable self-injury remains a significant challenge in ASDs, especially when patients do not respond adequately to behavioural and psychopharmacological interventions. ECT is well tolerated and efficacious treatment for catatonia, and can confer marked reduction in SIB along the agitated catatonia spectrum.

A double-blind, placebo-controlled, crossover trial of the selective dopamine D1 receptor antagonist ecopipam in patients with Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is a genetic disorder that has characteristic metabolic, neurologic, and behavioral features. There are multiple behavioral problems including impulsivity, aggressiveness, and severe recurrent self-injurious behavior (SIB). This last behavior varies considerably across subjects and may encompass self-biting, self-hitting, scratching, head banging, and other injurious actions. Current treatments for SIB involve behavioral extinction, sedatives, physical restraints, and removal of teeth. Because these interventions do not reliably control SIB, better treatments are urgently needed. Animal studies have suggested that D1-dopamine receptor antagonists such as ecopipam may suppress SIB. These observations have led to proposals that such drugs might provide effective treatment for in LND. The current study describes the results of a double-blind, three-period, crossover trial of a single dose of ecopipam in subjects with LND. The study was designed for 20 patients, but it was terminated after recruitment of only 10 patients, because interim analysis revealed unanticipated side effects. These side effects were most likely related to starting with a single large dose without any titration phase. Despite the limited data due to early termination, the drug appeared to reduce SIB in most cases. Subjects who completed the trial were eligible to continue the drug in an open-label extension phase lasting a year, and one patient who elected to continue has maintained a striking reduction in SIB for more than a year with no apparent side effects. These results suggest ecopipam could be a useful treatment for SIB in, but further studies are needed to establish an appropriate dosing regimen.

Effects of arm-splint rigidity on self-injury and adaptive behavior.

The current study replicated and extended previous research on the use of a rapid assessment to identify effective arm-splint rigidity with 2 participants who had been diagnosed with autism and who engaged in self-injurious behavior (SIB). We varied rigidity levels within a multielement design across several adaptive tasks and identified the most effective rigidity level in terms of reductions in SIB and levels of compliance.

Naltrexone use for self-injurious behavior in patients with developmental disabilities

Self-injurious behavior (SIB) is a serious problem seen in individuals with developmental disabilities (DD). Evidence-based options for the treatment of SIB in patients with DD are limited and no medication is approved for this indication. Non-pharmacotherapeutic options including environmental change and behavioral therapy are generally recommended for use as first line therapy. However, these options are sometimes inadequate. Despite lack of strong evidence, a variety of medications are used for SIB in DD. These include: antipsychotics (typical and atypical), antiepileptic drugs (e.g. divalproex, carbamazepine, etc.), lithium, and antidepressants (particularly selective serotonin reuptake inhibitors). First line agents include atypical antipsychotics (e.g. risperidone, olanzapine) and mood stabilizers (e.g. divalproex, carbamazepine). However, if a patient fails to respond to these agents or has contraindications to these options, other agents may occasionally be utilized. One such agent is the opioid antagonist naltrexone. Using naltrexone for the treatment of SIB comes from the theory that SIB is influenced by the release of endogenous opioids. Therefore, blocking the effects of these opioids could attenuate these behaviors. This article briefly summarizes the evidence for safety and efficacy of naltrexone for SIB in DD.

Opioid Antagonists May Reverse Endogenous Opiate “Dependence” in the Treatment of Self-Injurious Behavior

Self-injurious behavior (SIB) is a primary reason that individuals with neurodevelopmental disabilities (NDD) are either retained in restrictive environments or are administered psychotropic medication. There are no known causes and no universally accepted treatments for this complex behavior among individuals with NDD. There is developing evidence, however, that individuals exhibiting SIB have a disturbance of the opiate-mediated pain and pleasure system. One hypothesis is that SIB reflects insensitivity to pain and general sensory depression (hypoalgesia), perhaps related to chronic elevation of endogenous opiates. For instance, many self-injurious individuals do not exhibit the usual signs of pain after their “injurious” behavior. Moreover, for some individuals the addictive properties of elevated endogenous opiates (euphoria) may be responsible for maintaining their SIB. In this perspective, SIB may be viewed as an addiction because it supplies the “fix” for tolerant, down-regulated opiate receptors. Reports that levels of endogenous opiates at rest and after SIB episodes predict positive responses to opiate blockers (e.g., naltrexone) provide further support for opiate-mediated SIB and form the basis for a rational treatment strategy. Although the long term effects of opiate blockers on SIB are unknown, reduction in SIB following acute treatment provides support that a specific biological system may be dysregulated in a subgroup of patients. It is concluded that naltrexone produces a clinically significant reduction in the serious and life-threatening behavior of self injury for individuals who have not been responsive to any other type of treatment. Several suggestions and cautions are provided for regimens of naltrexone treatment of SIB.

Sequential Modification and the Identification of Instructional Components Occasioning Self-Injurious Behavior

The present study describes a case of a 9-year-old girl diagnosed on the autism spectrum who averaged nearly 1200 hand-to-head self-injuries (+attempts) per school day. Given the resources of the school and the significance of the self-injurious behavior (SIB), analog functional analysis is not possible. Moreover, functional assessment results were inconclusive. Subsequent analyses suggested a relationship between SIB and instructional conditions, which we evaluated in an alternating treatments design that manipulated task difficulty, rate, interspersal, novelty, and order of presentation. This sequential modification of instructional components ultimately produced a methodology that is associated with an approximately 90% reduction in SIB. The study illustrates a strategy for treatment decision making in cases of serious problem behavior and when traditional functional behavioral assessment and functional analysis are inconclusive.

Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial

Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre–post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson’s criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Stability of the recovery after one month following discharge, however, was not evaluated and requires further study.

Possibilities and limits of treatment of aggressive behavior in patients with mental retardation with risperidone

Despite definite indication for psychopharmacologic intervention, severe and persistent symptoms of aggressive and self-injurious behaviour still remain a therapeutic challenge. As recent research has demonstrated, not only the dopaminergic and serotonergic but also the endogenous opiate system plays a role in the pathogenesis of self-injurious behaviour. Nevertheless, the efficacy of classical neuroleptics as well as opiate antagonists is questioned. In open and controlled studies, the administration of the atypical neuroleptic risperidone (a serotonin 2A-dopamine D2 antagonist) was associated with a long-term effect in reducing self-injuries. In our clinical trial, 20 mentally retarded adults presenting with severe self-injurious and aggressive behaviour were administered risperidone over a follow-up period of 35 months. Clinical efficacy was measured with the Disability Assessment Schedule (DAS), conducted in a home for people with mental retardation. In 17 patients, a significant reduction in self-injurious behaviour is shown. Besides, there was a significant overall clinical improvement in behaviour.

Multiple factors in the long-term effectiveness of contingent electric shock treatment for self-injurious behavior: a case example

This report describes the effective treatment of self-injurious behavior (SIB) using contingent electric shock in an adolescent. Data are presented to document the initial dramatic reduction in SIB and the ongoing effectiveness of the treatment over a 5-year period. Positive side effects of the intervention are documented, as is information on the interaction of a medical condition (e.g., ear infections, fever), psychoactive medication status, and staff changes that served to effect the rate of SIB across 4 years of treatment. Recognizing and attending to these various factors has served to insure the success of the aversive intervention with very low rates of SIB and, consequently, very low rates of the administration of electric shock. Keeping the rate of administration of shock low serves to decrease the chances of habituation to the shock thereby emphasizing the importance of attending to the individual’s total medical, social, and administrative environments.

Self-Injurious Behavior Is Decreased by Cyproterone Acetate in Adult Male Rhesus (Macaca mulatta)

Self-injurious behavior (SIB) presents a serious problem in laboratory macaques that cannot be socially housed for scientific reasons and among institutionalized children and adults where it is often associated with different forms of brain dysfunction. We have experienced limited success in reducing SIB in macaques by enhancing their environment with enrichment devices. Psychotropic drugs also help, but problems are associated with their use. Because sexual and aggressive behavioral problems in men have been treated with progestational drugs, we tested the efficacy of cyproterone acetate (CA, 5–10 mg/kg/week) on reducing SIB in 8 singly housed, adult male rhesus macaques. The main findings were: (1) SIB and other atypical behaviors were significantly reduced during CA treatment; (2) serum testosterone was significantly reduced during CA treatment; (3) cerebral spinal fluid (CSF) levels of 5HIAA and HVA, metabolites of serotonin and dopamine, respectively, declined significantly during CA treatment; (4) the duration of SIB positively correlated with levels of 5HIAA in CSF; but (5) sperm counts were not reduced during treatment. Thus, CA was a partially effective treatment (3 months) for adult male macaques whose behavioral problems include SIB. In summary, CA reduced SIB, overall aggression, serum testosterone, CSF 5HIAA, and CSF HVA. We hypothesized that the progestin activity of CA represses the hypothalamic gonadal axis and decreases testosterone, which in turn decreases SIB. In addition, we speculate that the decrease in 5HIAA and HVA in CSF may have been caused by progestins decreasing the activity of MAO. Therefore, the reduction of SIB may also be related to an increase in the availability of active monoamines in the CNS.

Using analog baselines to assess the effects of naltrexone on self-injurious behavior

Naltrexone (NLTX), an opiate receptor antagonist, has been prescribed as a pharmacological intervention for the treatment of self-injurious behavior (SIB). Previous research has investigated NLTX’s effects in the absence of information about the role of environmental events related to SIB. This study extended previous analyses by administering NLTX on analog baselines using a double-blind, placebo-controlled reversal design. Pretreatment functional analysis results showed that the SIB of the two participants occurred in more that one assessment condition. For one participant NLTX produced slight reductions in SIB across baseline conditions. The second participant’s results showed that NLTX reduced head-slapping occurring during demand sessions, but had no apparent effect on head-banging occurring during alone and demand sessions. These outcomes suggest that NLTX may have function- and/or response-specific treatment effects. The potential utility of this model as a general method for assessing pharmacological interventions, as well as other implications and limitations, are discussed.

Case Report: The Effects of Selective Serotonergic Reuptake Inhibitors Combined with Behavioral Treatment on Self-Injury Associated with Lesch-Nyhan Syndrome

A 6-year-old African-American male child with Lesch-Nyhan syndrome participated. Because of the occurrence of unmanageable self-injurious behavior (SIB) in a group home, “James” at the age of 3.5 years was admitted to a large residential facility for persons with mental retardation. A behavior treatment program was implemented soon after admission and produced a large decrease in SIB; however, rates of SIB remained clinically unacceptable and a danger to him. The program consisted of differential reinforcement, extinction, and noncontingent protective restraint. Because SIB may be caused by decreased serotonergic activity, open trials of serotonergic drugs in combination with a serotonergic diet were conducted. The use of a serotonergic diet alone resulted in no change in SIB. Dose-dependent reductions in SIB occurred during paroxetine and sertraline phases, suggesting some benefit in the use of serotonergic drugs.

Effects of haloperidol, alone and combined with DRO, on the self-injurious behavior in a woman with profound mental retardation and atypical psychosis

The effects of haloperidol, alone and combined with differential reinforcement of other behavior (DRO) on self-injurious behavior (SIB) of a woman with profound mental retardation and atypical psychosis were evaluated. Haloperidol, alone and combined with DRO, produced large reductions in SIB and injuries resulting from SIB. Response to environmental stimuli improved, meal refusal decreased significantly, her weight increased to an acceptable range, and sleep stabilized. SIB, meal refusal, sleep difficulties, weight loss, and inconsistent response to environmental stimuli appeared to be components of atypical psychosis that was responsive to low-dose haloperidol in combination with DRO. Treatment effects were maintained at a 27-month follow-up.

125]RTI-55, a high affinity cocaine analog, labels two binding sites in human caudate membranes possibly related to the 5-HT transporter

rocking, head rolling, hand flapping) that occur without eliciting stimuli and have no clear function. SIB typically includes head banging, eye poking, and other repetitive self-injurious acts. As these behavior disorders have important similarities to compulsions, we examined the prevalence and co-morbidity of SBD, SIB, and compulsive behavior disorder (CBD) in a state residential facility for the mentally retarded, in severely mentally retarded adults, CBD typically consists of compulsive activities (e.g., arranging, checking, hoarding) as well as intricate personal routines (e.g., eating, drinking, or dressing rituals). Our sample included all ambulatory and medically stable individuals at the facility (n-234). All subjects were severely or profoundly mentally retarded. The caseload psychologist for each subject completed a structured survey, which included a symptom checklist. SBD was reported in 59% of the subjects, SIB in 48.7%, and CBD in 38.5¢t. in comparing subjects with CBD (n-90) to those without (n-144), we found a significant association of compulsive behavior with SBD (!)<.05) and SIB (p<.05). in addition, after excluding potential subjects who were taking medication known to affect appetite and/or weight, we found that subjects with CBD and SBD were significantly shorter and weighed less than matched controls at the same institution. This observation is consistent with reports that in the general population, adolescents with CBD are smaller and have different growth patterns than healthy control subjects, in light of the above links between SBD and CBD in the mentally retarded, we designed a placebo-controlled doubleblind, cross-over trial of clomipramine (CMI) for the treatment of SBD. In the I I subjects studied to date, CMI is associated with a significant decrease in stereotyped movements, as well as a reduction in self-injurious behavior.

What makes extinction work: an analysis of procedural form and function.

We examined methods for determining how extinction should be applied to different functions of self-injurious behavior (SIB). Assessment data indicated that the head banging of 3 children with developmental disabilities was maintained by different reinforcement contingencies: One subject's SIB was positively reinforced by attention from adults, the 2nd subjects SIB was negatively reinforced by escape from educational tasks, and the 3rd subject's SIB appeared to be automatically reinforced or "self-stimulatory" in nature. Three functional variations of extinction--EXT (attention), EXT (escape), and EXT (sensory)--were evaluated, and each subject was exposed to at least two of these variations in reversal or multiple baseline designs. Reductions in SIB were observed only when implementation of "extinction" involved the discontinuation of reinforcement previously shown to be responsible for maintaining the behavior. These results highlight important differences among treatment techniques based on the same behavioral principle (extinction) when applied to topographically similar but functionally dissimilar responses, and further illustrate the practical implications of a functional analysis of behavior disorders for designing, selecting, and classifying therapeutic interventions.

Naltrexone reduces self-injury and improves learning.

Author(s): Sandman, CA; Hetrick, WP; Taylor, DV; Barron, JL; Touchette, P; Lott, I; Crinella, F; Martinazzi, V | Abstract: A cross-over study of 24 Ss with self-injurious behavior (SIB) was conducted over a continuous 10-week period. Treatment with naltrexone (NTX) was provided for 3 weeks in a randomized, reversal design with different doses or placebo each week. Videotaped observations (20 hr/subject), neurological examinations, and ratings of adaptive and maladaptive behavior were collected. Treatment with 2 mg/kg NTX produced at least a 50% reduction in SIB in a significant (p l.01) number of Ss. The 1.0 mg/kg was less effective (p l.02), and no significant change was observed at 0.5 mg/kg. Eighteen of 21 Ss achieved at least a 25% reduction in SIB after treatment of at least 1 dose of NTX (p l.0001). More than half of the Ss (52%) had a l 50% reduction (p l.001), and a significant number of Ss (33%) decreased SIB by more than 75% after at least 1 dose of NTX. Significant improvement was measured after NTX on measures of learning and attention.

Therapeutic Effect of Fluoxetine on Naltrexone-Resistant Self-Injurious Behavior in an Adolescent with Mental Retardation

ABSTRACT A significant and sustained reduction in self-injurious behavior (SIB) was observed in a 17-year-old male with severe to profound mental retardation who was treated in an open clinical trial with fluoxetine. The 45-55% reduction in SIB was accompanied by improvement in affective stability, motor capacities, and social activity. No adverse effects or diminishing therapeutic effects were observed during 2 years of treatment at 40 mg daily. Twelve weeks before the start of the fluoxetine trial, this adolescent had been found to be unresponsive to the opiate receptor blocker naltrexone in a double-blind placebo-controlled trial following identical methodology. This case raises the possibility that different patients with SIB may respond preferentially to pharmacological treatments that modify either serotonin or endorphin mechanisms. The findings also suggest that some cases of SIB may represent a type of obsessive-compulsive disorder or body grooming disorder. Additional clinical studies are needed before fluoxetine can be considered for routine use in treating SIB.

B‐endorphin disregulation in autistic and self‐injurious behavior: A neurodevelopmental hypothesis

Peptides derived from pro-opiomelanocortin (POMC) influence neurodevelopmental processes. Earlier studies indicated that MSH/ACTH compounds improved behavioral efficiency in retarded individuals. Recent studies have shown that opiate blockers reduce treatment-resistant self-injurious behavior (SIB), an autistic-like, developmental disorder. Although the exact mechanisms are unknown, prenatal POMC disregulation, addiction to endogenous opiates and elevated pain threshold have been proposed to account for this behavior. In study one, four SIB patients were given 0, 25, 50 or 100 mg of naltrexone on separate weeks in a double blind, Latin square design. A specific dose dependent reduction in SIB was observed in three patients. In study two, plasma b-endorphin was measured in 40 patients with SIB, a related behavior, stereotypy (ST) or controls. SIB and ST patients had higher levels of endorphin than controls. These data added new support for the role of b-endorphin in a treatment-resistant patient group.