The Challenge of Changing Self-Injurious Behaviors in Autism

Self-injurious behaviors (SIB) and aggression are the two major destructive and devastating behaviors in individuals with developmental disabilities. The U.S. National Institutes of Health (1989) considers that self-injurious behavior (SIB) is a serious and chronic disorder that may result in significant physical, social, and educational risks. Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV: TR) does not indicate self-injurious behaviors as specific to autism, probably due to the limited research data available on SIB in autism, there is extensive literature on SIB in individuals with developmental disability (American Psychological Association, 1994; Hendren, et al., 2007).

According to Tate & Baroff (1966), self-injurious behaviors could be defined as multiple or heterogeneous responses directed toward one’s own body that result in tissue damage (Simon and Hollander, 2001; Schroeder, et al. 2002). In autism, self-injurious behaviors are one of the most concerning forms of lower-level repetitive stereotypic behaviors (RSB) (Bishop and Kleinke, 2007).

Self-injurious behaviors in autism have multiple topographies with different biochemical and social environment causes and effects. The most common topographies of these behaviors include, but are not limited to head-banging, head-hitting, face-punching/slapping, hand-biting and excessive self-rubbing and scratching (Edelson, 1999; Schroeder, et al. 2002).

Although there are not too many high-quality epidemiological studies, the prevalence rates of self-injurious behaviors in individuals with developmental disabilities (e.g. Lesch Nyhan syndrome and autism) ranges from 5-16% in several studies (Hammock, Schroeder, Levine, 1995; Rojahn & Esbensen, 2002). The prevalence of self-injurious behaviors in people with disabilities living in non-residential setting has been estimated to be 1.7% (Rojahn, 1986), while for people with disabilities living in a residential setting has been estimated to be 11.1% (Hill and Bruininks, 1984). Prevalence of self-injurious behaviors varies with intellectual ability.It has been observed that self-injurious behaviors is more often in people with severe disabilities than individuals classified with mild and moderate disabilities (Borthwick, Meyers, & Eyman, 1981; Rojahn, 1986). Self-injurious behaviors are most commonly reported as a serious behavior challenge in people diagnosed with autism, schizophrenia, mentally retardation or brain damage (Hammock et al., 1995).

Self-injurious behaviors (with restricted pattern of behaviors), movement disorders and cognitive deficits have been associated with developmental, neurological, psychiatric and genetic disorders (Bodfish & Lewis, 2002).

Disorders associated with self-injurious behaviors

Developmental disorders	Neurological disorders	Psychiatric disorders	Genetic disorders
Mental retardation	Tourette’s syndrome	personality disorders	Lesch-Nyhan syndrome
Autism	neuroacanthocytosis	eating disorders	Prader-Willi syndrome
	frontal-lobe epilepsy	schizophrenia	Rett syndrome
		trichotillomania	Cornelia de Lange syndrome
		onychophagia	Smith-magenis syndrome
			Fragile X syndrome
(Bodfish & Lewis, 2002)

Individuals with developmental disabilities injure themselves for different reasons, which require diffrerent treatments. Self-injurious behaviors may be a result of over-arousal (e.g. frustration) and self-stimulatory or stereotypic behaviors. They engage in this type of behavior to obtain attention from other people (Iwata et al., 1993), and escape or avoid a task. Furthermore, it may be due to hypersensitivity to certain sounds in the environment, communication deficits; seizure activity in the frontal and temporal lobes (Gedye, 1989; Gedye, 1992); congenital brain disorder, neurochemical dysregulation (e.g. dopaminergic mechanisms, serotonergic transmission, GABA, and imbalance in the engogenous opiod system), and health conditions (e.g. otitis media, sleep deprevation, menses, gastroensophageal reflux disease), and anxiety-provoking events, which may resemble processes in people with panic attack disorder (e.g. hyperventilation, tachycardia, perspiration) (Stein & Neihaus, 2001; Thompson & Caruso, 2002).

Unfortunately, there is not a single treatment for self-abusive behaviors. The most effective treatments for both self-abusive behaviors and aggressive behavior have been based on a multi-model approach that includes applied behavior analysis (ABA) in conjunction with pharmacological therapy (Favell et al., 1982; Johnson & Baumeister, 1978; Pelios, et al,, 1999; Sandman & Touchette, 2002; Deleon, et al, 2002). According to the National Institutes of Health (NIH, 1989), applied behavior analysis (ABA) appears to be effective in some individuals in suppressing self-injurious behaviors. Differencial reinforcement of other behavior (DRO) and differential reinforcement of incompatible behavior (DRI) interventions seem to be effective in treating some individuals with self-injurious behaviors (SIB) (Tarpley & Schroeder, 1979).

The psychopharmacologic agents used to treat self-abusive behaviors include neuroleptics, sedative-hypnotics (barbiturates), stimulants (d-amphetamine, methylphenidate), antianxiety drugs, antidepressants and mood stabilizers, anticonvulsants, antihypertensives and opiate antagonists.

There is some evidence that neuroleptic agents are beneficial in treating some individuals with developmental disabilities and aggressive behaviors, but there is no solid evidence of the efficacy of neuroleptic agents in self-injurious behaviors. However, the second-generation antipsychotics, which have effects on both the serotonin (5-HT2) and dopamine (D2) systems, have been used in controlling autistic symptoms (Rojahn & Esbensen, 2002). On October 6, 2006, the U.S. Food and Drug Administration (FDA) approved Risperdal (Risperidone) to treat maladaptive behaviors associated with autism, such as irritability, aggression, and deliberate self-injury and temper tantrums.

Other medications used to treat symptoms associated with autism including stereotypic and or impulsive self-abusive behaviors are selective serotonin reuptake inhibitors (SSRIs) such as are Fluoxetine (Prozac) and sertraline (Zoloft). Although the SSRI are relatively safe and popular, some studies have suggested that they may have undesirable effects on some people with autism (hypomania) and they have not been proven effective in autism associated with stereotypic self-injurious behaviors (Stein & Niehaus, 2001; Grossman & Siever, 2001).

In a few studies, Lithium Carbonate has been suggested to be beneficial in treating individuals who have autism with mood dysregulation disorder and display self-injurious behaviors or aggressive behaviors. Anticonvulsant such as Depakote, Trileptal, Lamictal and Tegretol have also been widely used in controlling autistic symptoms including assaultive or self-injurious behavior. Beta-adrenergic blocking agents such as Propranolol, Nadolol and Pindolol have been reported in a few studies to reduce rage-related reactions, aggression and self-abusive behaviors (Tsiouris & Brown, 2004); however, there is no clinical trials reported in individuals with autism. Other studies suggest that alpha-adrenergic agonists, such as Clonidine and Guanfacine, may be useful for symptoms such as irritability and hyperactivity, but not for restricted stereotypic behaviors (RSBs) with self-abusive behaviors. Opiate antagonists theory has shown promise in treating self-abusive behaviors; however, clinical studies of opiate antagonists such as Naloxone and Naltrexone, which block the effects of endogenous opiates, have yielded conflicting results (Thompson & Caruso, 2002; Sandman & Touchette, 2002).

Multi-drug therapy for self-injurious behaviors and autism depends on associated comorbid conditions and the neurochemical phenotypes of autistic individual. Although there are some pharmacological treatment options for individuals with autism with associated symptoms of stereotypic or impulsive self-injurious, more therapeutic alternatives are being explored. The National Institutes of Health is evaluating self-injurious behaviors in mental retardation and autism. They are testing the effectiveness of new treatments with transcutaneous electric nerve stimulation (TENS), NeuroModulation Technique (NMT), Naltrexone, Abilify (Aripiprazole) and D-Cycloserine. The purpose of these studies is to determine whether they are effective in reducing maladaptive behaviors.