SELF-INJURY IN AUTISM

AN EXCRUCIATING CHALLENGE: Self-injury is the most excruciating behavioral challenge parents of children with autism, their teachers and doctors encounter. Self-Injurious Behavior (SIB) is repetitive intentional acts by the individual that may inflict tissue damage on themselves. SIB in autism is different from self-inflicted harm by individuals who have major mental disorders, such as schizophrenia, bipolar disorder or borderline personality disorder. In the latter cases, the self-inflicted harm is usually infrequent (e.g. weekly, monthly or less often) and it occurs during a psychotic episode (in schizophrenia or bipolar disorder) or a conscious ritual (e.g. self cutting in borderline personality disorder). SIB TYPES: The most common SIBs in autism are head-hitting and self-biting. The child may strike his own face, arms or legs with his/her hands or fists, or strike body parts against hard surfaces (e.g. the floor, walls, tables, door frames or bathroom fixtures). SIB may also involve self-biting, at times causing serious damage to fingers, wrists or hands. A third type of SIB involves self- scratching or pinching causing abrasions, sores or bruises, which can become infected if not treated and bandaged. It is not uncommon for individuals to poke or strike at their eyes, nose or ears, which is particularly dangerous. BOUTS OF SIB: SIB occurs in bouts. An environmental event usually triggers the beginning of a bout of SIB, but once started, it may continue independently of what triggered the SIB. A bout may last several minutes with repeated face slaps, head hits or attempts at self-biting, but at times may occur over several hours, sometimes nearly all day. Factors that are associated with more severe SIB are low IQ and lack of a communication skills (spoken or augmentative). Children with frequent illnesses are also more prone to bouts of SIB (e.g. ear aches, toothaches, gastrointestinal problems). The combination of inability to communicate, lack of basic skills and irritability caused by physical illness are predisposing factors. SOCIAL FUNCTIONS OF SIB: From half to two-thirds of episodes of SIB are attempts to escape or avoid a situation the child finds intolerable. The most common trigger events are thwarting a highly preferred activity (e.g. watching a preferred video), a change in expected routine (e.g. giving the child pieces of fresh apple instead of applesauce), or asking the child to do something they are unable to do (e.g. put on their shoes), or something they don't understand or find alarming (e.g.enter a crowded shopping mall). Adult caregivers stop making the request in order to terminate the SIB episode, which teaches the child SIB is an effective way of stopping adult demands. About 1/3 of the time children with ASDs who engage in SIB do so to produce adult caregiver attention. Naturally, parents, teachers and therapists quickly intervene by restraining the child so s/he won't further harm him or herself. That teaches the child that if they want adult attention, an effective way to obtain it is by hurting him or herself. PREVENTING SIB: The most effective treatment for SIB is to prevent it from happening in the first place. There are two reasons. First, once SIB has begun caregivers must attend to the behavior, which reinforces it and makes it more likely to recur. Second, once a serious bout of SIB has been initiated it feeds on itself and continues largely independently of what is going on around the child. This appears to be an internal chemical response to the self-inflicted pain. Preventing SIB requires figuring out what triggers the problem and teaching the child alternative skills that will achieve the same purpose. For example, a child needs to be able to make a request for what it is they want, rather than biting their hand until a caregiver figures out what they want. If a caregiver asks the child to do something they don't know how to do, they need to be taught to ask for help. If giving attention to the target child's sibling or another student in the classroom triggers SIB, the child should be taught a legitimate method for requesting attention other than self-injuring. HEALTH PROBLEMS: If the child has other health problems, such as earache or toothache, it is important the source of the illness be identified and treated. A child who is in pain will be irritable and more easily set-off. Preschool and kindergarten age children who engage in SIB can usually be helped by using the foregoing techniques alone, or in some cases, with minimal medication treatment. If the child is easily upset and has poor ability to self-calm once they lose control, sometimes the blood pressure medications Catapres or Tenormin can help reduce this over arousal. MEDICATIONS: Antidepressant medications are not FDA approved for younger children, though some doctors prescribe them in low doses Off Label. School age children are more frequently treated with Prozac, Paxil, Celexa or one of the other SSRI antidepressants in dosages adjusted for their lower body weights. Older children with severe self injury may be treated with an atypical antipsychotic medication such as Risperdal or Abilify. Some physicians treat older children with antiepileptic medications that are also used for treating Bipolar Disorder, such as Tegretol or Depakote. Some pediatricians treat children with ASDs who also meet the diagnostic criteria for Attention Deficit Hyperactivity Disorder with stimulants, such as Ritalin, Adderal, Concerta or Focalin. These medications seldom stop self-injury alone. Medication combined with behavioral treatment as outlined above is most often effective. Between 1/3 and half of individuals with severe self-injury are responsive to the opiate antagonist medication, naltrexone which is sold under the trade name, Revia. Individuals who have benefited from naltrexone have tended to engage in numerous episodes of SIB per day, and most often involved hand or finger biting and/or head hitting. Again, a combination of behavioral intervention and naltrexone tend to be most beneficial. REFERENCES Carr, E.G., Levin, L., McConnachie, G., Carlson, J.I., Kemp, D.C., Smith, C. E., & Magito McLaughlin, D. (1999). Comprehensive multisituational intervention for problem behavior in the community: Long-term Maintenance and social validation. Journal of Positive Behavior Interventions, 1, 5-25. Hollander, E, Soorya, L, Wasserman, S, Esposkito, K, Chaplin, W and Anagnostou, E. Divolproex sodium vs. placebo in treatment of repetitive behavior in autistic disorder. Int J. Neuropsychopharmacol 9: 209-13 Kolevzon, A, Mathewson, KA and Hollander, E. (2006) Selective Serotonin Reuptake Inhibitors in Autism: A review of Efficacy. J. Clin Pyschiatry, 67: 407-14 Santosh, PJ, Baird, G, Pityaratstian, N, Tavare, E and Gringas, P (2006) Impact of comorbid autism spectrum disorders on stimulant response in children with attention deficit hyperactivity disorder: a retrospective and prospective effectiveness study. Child Care Health Dev 32: 575-83. Symons, F. J., Fox, N. D., Thompson, T. (1998). Functional communication training and naltrexone treatment of self-injurious behavior: an experimental case report. Journal of Applied Research and Intellectual Disabilities, (11) 3, 273-292. Thompson, T., Hackenberg, T., Cerutti, D., Baker, D., & Axtell, S. (1994). Opioid antagonist effects on self-injury: Response form and location as determinants of medication effects. American Journal on Mental Retardation, 99, 85-102. Zarcone, J. R., Lindauer, S. E., Morse, P. S., Crosland, K. A., Valdovinos, M. G., McKerchar, T. L., Reese, R. M., Hellings, J. A., & Schroeder, S. R. (2004). Effects of risperidone on destructive behavior of persons with developmental disabilities: III. functional analysis. American Journal of Mental Retardation, 109 (4), 310-321.

Dr. Thompson has devoted much of his career to developing new treatments for individuals with self-injury. In most cases a behavior intervention alone or in combination with medication can reduce or eliminate self-injury