Bio-behavioral diagnosis and treatment of self-injury

Characterizing Automatically Maintained Self-Injury With the Aberrant Behavior Checklist

Multidimensional variables linked to repetitive behavior, hyperactivity, and mood dysregulation are correlated with the prevalence and severity of self-injurious behavior (SIB) in individuals with intellectual and developmental disabilities (IDD). The purpose of this exploratory study was to examine differences in Aberrant Behavior Checklist (ABC) subscales between individuals with socially maintained SIB and automatically maintained SIB (ASIB). Overall, there were not significant differences in ABC subscale elevations between the SIB and ASIB groups. However, when ASIB was stratified into distinct subtypes, notable differences in subscale elevations were observed. Our results indicate the ABC may have utility for further characterizing the neurobehavioral divergence among individuals with IDD who engage in self-injury.

The multiple faces of catatonia in autism spectrum disorders: descriptive clinical experience of 22 patients over 12 years

A retrospective review was conducted from the inpatient and outpatient records of twenty-two autistic youth presenting to a neurobehavioral service over a twelve-year period for combined psychiatric and behavioral pathology who also met DSM5 criteria for catatonia. Six autistic girls and 16 autistic boys ranging from ages eight to 26 years old were identified, and their variegated symptoms evaluated. Stereotypy, posturing, negativism, mutism and stupor were the most common catatonic symptoms, each present in more than half of the study patients. One patient had abnormal vital signs indicative of malignant catatonia. Twenty patients had concomitant repetitive self-injurious behaviors that had led to significant tissue injury and were refractory to psychotropic and behavioral interventions. The sample was weighted towards patients with severe self-injurious behavior, which often was the reason for admission. The many "faces" of catatonia in autism spectrum disorders are seen in this sample, and the novel recognition of repetitive self-injury as an under-recognized motor symptom of catatonia is highlighted. The preliminary findings in this study open many important future vistas for ongoing research regarding catatonia in ASDs.

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

PURPOSE OF REVIEW

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.

RECENT FINDINGS

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.

SUMMARY

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.

Treatment of severe problem behaviour in children with autism spectrum disorder and intellectual disabilities

Children with autism spectrum disorder (ASD) and intellectual disabilities (ID) present with problem behaviour at rates disproportionately higher than their typically-developing peers. Problem behaviour, such as self-injury, aggression, pica, disruption, and elopement result in a diminished quality-of-life for the individual and family. Applied behaviour analysis has a well-established research base, detailing a number of assessment and treatment methods designed to address behaviour problems in children with ASD and ID. Although the variables that lead to the emergence of problem behaviour are not precisely known, those that are currently responsible for the maintenance of these problems can be identified via functional behaviour assessment, which is designed to identify events that occasion problem behaviour, consequences that maintain it, as well as other environmental factors that exert influence on the behaviour. Corresponding function-based treatment is implemented when environmental determinants are identified, with the aim of decreasing or eliminating problem behaviour, as well as teaching the individual to engage in more appropriate, alternative behaviour. In some cases, when problem behaviour is under the control of both environmental and biological variables, including psychiatric conditions, combining behavioural and pharmacological interventions is viewed as optimal, although there is limited empirical support for integrating these approaches.

Tony nevin: The embrace of translational work by a basic scientist

Here I summarize John A. "Tony" Nevin's evolution as a translational author. All of his publications were classified by title and content as being primarily experimental analysis of behavior or translational. Translational works were subtyped as interpretative, descriptive research, or experimental research. During the first 20 years of his publication career, Tony published exclusively experimental analysis of behavior work. In 1982, he began a series of interpretative translational analyses on topics of significant social importance. These interpretative papers translated behavioral science into logical accounts of issues of war and peace, for example, and performed quantitative analyses of available data to show that social behavior, even at the level of the group or society, conforms to predictions based on established behavioral principles. Tony began experimental translational research in 1990, first to establish whether his analysis of behavioral momentum generalized to humans. Several experimental studies later addressed the persistence of clinically relevant behavior and treatment relapse. The objective descriptions of Tony's publication patterns are punctuated with anecdotes from our 32-year collaboration and friendship.

Delineating subtypes of self-injurious behavior maintained by automatic reinforcement

Self-injurious behavior (SIB) is maintained by automatic reinforcement in roughly 25% of cases. Automatically reinforced SIB typically has been considered a single functional category, and is less understood than socially reinforced SIB. Subtyping automatically reinforced SIB into functional categories has the potential to guide the development of more targeted interventions and increase our understanding of its biological underpinnings. The current study involved an analysis of 39 individuals with automatically reinforced SIB and a comparison group of 13 individuals with socially reinforced SIB. Automatically reinforced SIB was categorized into 3 subtypes based on patterns of responding in the functional analysis and the presence of self-restraint. These response features were selected as the basis for subtyping on the premise that they could reflect functional properties of SIB unique to each subtype. Analysis of treatment data revealed important differences across subtypes and provides preliminary support to warrant additional research on this proposed subtyping model.

Combining psychiatric and psychological approaches in the inpatient assessment of aggression in a client with moderate intellectual disability

The literature on challenging behaviour is large, with heavy emphasis on behavioural approaches. In recent years more attention has been given to the effect of psychiatric illness on the behaviour of people with intellectual disability. However, theoretical differences between disciplines can lead to one or other approach dominating the assessment process. Increasingly, functional assessment is receiving attention as an assessment approach by both psychiatrists and psychologists. When used properly it can give a holistic overview of the individual and their behaviour, allowing a team approach to assessment and treatment that ensures the consideration of all possible psychiatric/medical/behavioural/environmental possibilities (a bio-behavioural model) in the aetiology and maintenance of challenging behaviour. This case study illustrates the effectiveness of teamwork in this area using functional assessment as a tool. The case also illustrates the possible futility of such comprehensive assessments of challenging behaviour in the absence of appropriate resources to implement the recommendations of such an assessment.

Challenging behavior in Smith-Lemli-Opitz syndrome: initial test of biobehavioral influences

OBJECTIVE

To study challenging behavior (destruction, aggression, self-injury, stereotypy) in children with Smith-Lemli-Opitz syndrome (SLOS) using a biobehavioral model that helps distinguish biological from socially mediated variables influencing the behavior.

BACKGROUND

SLOS is an autosomal-recessive syndrome of multiple malformations and intellectual disability resulting from a genetic error in cholesterol synthesis in all cells and tissues, including brain. The exact cause of the challenging behavior in SLOS is unclear, but defective brain cholesterol synthesis may contribute. Because the precise genetic and biochemical etiology of SLOS is known, this disorder is a good model for studying biological causes of challenging behavior.

METHOD

In a preliminary application of a biobehavioral model, we studied the association between cholesterol levels (as a biochemical indicator of disease severity) and behavior subtype ("biological" vs "learned") in 13 children with SLOS. Parents completed a questionnaire that categorized challenging behavior as influenced primarily by social or nonsocial (thus, presumably biological) factors.

RESULTS

The severity of the cholesterol synthesis defect correlated significantly with behavior subtype classification for 1 of 2 challenging behaviors. Greater severity of the cholesterol synthesis defect was associated with behavior being classified as primarily influenced by biological factors.

CONCLUSION

The interplay between challenging behavior and defective cholesterol synthesis in SLOS may help explain biological influences on the behavior. Our findings have implications for research on the effectiveness of behavioral and medical treatments for behavioral difficulties in SLOS and other neurodevelopmental disorders.

Assessment and Treatment of Self-Injurious Behavior Associated with Donnai-Barrow Syndrome

Donnai and Barrow (American Journal of Medical Genetics, 68, 441-444, 1993) reported multiple participants who shared a variety of specific physical and neurological anomalies. Relatively few cases have been reported since then and few of those have progressed to an age such that the developmental progression of the disorder can be ascertained. We describe one participant with Donnai-Barrow syndrome who engaged in repetitive self-injurious behavior (SIB), which heretofore has not be described in this population. Direct observations of the participant's SIB were conducted across a range of contexts, and the behavior was successfully decreased using a combination of procedures. This case is discussed within the context of the behavioral phenotype of Donnai-Barrow syndrome.

Limitations of Functional Analysis: The Case for Including Valued Outcomes Analysis in the Investigation of Difficult Behaviour

Effective behaviour change is based on understanding the reasons for difficult behaviour. However, current functional analytic technology is often limited in its effectiveness in the clinical setting because the focus is on labelling and classifying behavioural outcomes rather than conducting a detailed analysis of the manner in which these outcomes assist the client to operate in the environment. The effectiveness of existing functional analytic techniques might be enhanced by moving the focus of the investigation from identifying the consequent variables that impact on behaviour to systematically exploring client–environment interactions as well as the manner in which the client experiences the consequences of his/her actions. One potential method (Valued Outcomes Analysis) that provides a framework for the systematic investigation of the effects of ‘inner skin’ factors on the incidence of behavioural difficulties is described here.

Reviewing risk for individuals with developmental disabilities

There are many categories of risky behaviors that are of interest to individuals, agencies, and institutions interested in care for developmentally disabled persons. These include challenging behaviors such as aggression and self-injury, psychiatric diagnoses, medical problems, criminal behaviors, and victimization. The literature in this area is difficult to digest due to a number of methodological problems. This paper reviews the research on one of these behaviors, self-injury, and provides a framework that can be applied to other research on predicting risk. Additionally, it attempts to organize the findings in such a way as to maximize the utility to providers and suggest useful directions for future research.

Pharmacotherapy for aggressive behaviours in persons with intellectual disabilities: treatment or mistreatment?

BACKGROUND

Antipsychotic medications have been used extensively to treat aggressive behaviours in persons with intellectual disabilities (ID) when the main psychiatric diagnoses given to them in the past were schizophrenia, childhood psychoses and ID with behaviour problems. Today, antipsychotics are still estimated to comprise 30-50% of all the psychotropics prescribed for persons with ID, although the prevalence of psychotic disorders is only 3% in this population. The overuse of antipsychotics in persons with ID could be justified if their aggressive behaviours were associated with mostly psychotic disorders and not other psychiatric disorders or factors and if the anti-aggressive properties of the antipsychotics have been supported by basic research or reviews of clinical studies. Is that so? This article explores these questions.

METHODS

The literature on aggressive behaviours, their associations with psychiatric disorders and other contributing factors and the past and current treatment options for aggressive behaviours in persons with and without ID was reviewed. Also, the literature on basic research regarding the brain receptors implicated in aggressive behaviours and the basic research and clinical studies on the anti-aggressive properties of antipsychotics was reviewed.

RESULTS

Aggressive behaviours in persons with ID serve different functions and many factors contribute to their initiation, maintenance and exacerbations or attenuation including most of the psychiatric and personality disorders. Genetic disorders, early victimisation, non-enriched and restrictive environments during childhood or later on and traumatic brain injury, which are common in persons with ID, have been associated with aggressive behaviours and with mostly non-psychotic disorders in persons with and without ID. If the factors above and the knowledge derived from studies of domestic violence and premeditated aggression in persons without ID are considered and applied during the evaluation of the most severe aggressive behaviours in persons with ID, more appropriate and effective treatment than antipsychotics can be implemented. Basic research implicates mostly the GABA and the serotonin pre-post synaptic brain receptors influence the initiation, modulation or inhibition of aggression in animals. The anti-aggressive properties of the antipsychotics have not been supported by reviews of clinical studies and basic research is absent. Antipsychotics are the indicated treatment only for psychiatric disorders and for aggressive behaviours associated with psychotic disorders and psychotic features as activation of dopamine receptor leads to defensive aggression.

CONCLUSIONS

Most of the persons with ID and aggressive behaviours do not have a diagnosis of psychotic disorder and there is lack of strong evidence supporting the anti-aggressive properties of the antipsychotics. The overuse of antipsychotics in this population may be explained by the old, faulty notion that aggressive behaviour in persons with ID is mostly associated with psychotic disorders. Given the discrediting of this notion, the use of antipsychotics in persons with ID may, in some cases, be considered mistreatment rather than proper treatment. In order to reverse the practice of over-prescribing antipsychotics for aggressive behaviours in persons with ID, basic research information on aggression must be disseminated, the search for the 'quick fix' must be abandoned and the promotion of antipsychotics as anti-aggressive drugs must be discouraged. Matching the treatment with the variables contributing to the aggressive behaviours, seeking a long-term rather than a short-term solution and avoiding the promotion of only one type of treatment for all types of aggression might change the current practice and improve the quality of life for many persons with ID.

Treatment of life-threatening self-injurious behavior secondary to hereditary sensory and autonomic neuropathy type II: a controlled case study

Although self-injurious behavior is present in all subtypes of hereditary sensory and autonomic neuropathy, the literature has not sufficiently addressed the issue of treatment of self-injury in this population. Therefore, the purpose of the current case study was to describe a method for assessing and treating self-injurious behavior associated with hereditary sensory and autonomic neuropathies. This study was conducted with an 11-year-old boy diagnosed with hereditary sensory and autonomic neuropathy type II admitted to an inpatient behavioral unit over a 4-month period. A simplified version of a habit reversal treatment was used, consisting of awareness training, self-monitoring, competing responses, and social support. Treatment resulted in a 98% reduction in the rate of self-injurious behavior relative to pretreatment baseline rates. This case study illustrates that behavioral interventions may be a viable option for treating self-injury secondary to hereditary sensory and autonomic neuropathies.

A computerized test of self-control predicts classroom behavior

We assessed choices on a computerized test of self-control (CTSC) for a group of children with features of attention deficit hyperactivity disorder (ADHD) and a group of controls. Thirty boys participated in the study. Fifteen of the children had been rated by their parents as hyperactive and inattentive, and 15 were age- and gender-matched controls in the same classroom. The children were observed in the classroom for three consecutive mornings, and data were collected on their activity levels and attention. The CTSC consisted of two tasks. In the delay condition, children chose to receive three rewards after a delay of 60 s or one reward immediately. In the task-difficulty condition, the children chose to complete a difficult math problem and receive three rewards or complete an easier problem for one reward. The children with ADHD features made more impulsive choices than their peers during both conditions, and these choices correlated with measures of their activity and attention in the classroom.

Self-injurious behavior to the lower extremities among children with atypical development: a diagnostic and treatment algorithm

Self-injurious behavior is a devastating and persistent condition that results in severe tissue damage, permanent impairment, or, occasionally, death. This aberrant behavior seen in specific childhood syndromes is compounded when the lower limbs are injured. Secondary complications are more frequent, depending on the site of the injury, resulting in significant morbidity and depletion of hospital resources. A substantial body of empirical evidence indicates that this deviant behavior is partly learned and partly of biologic origin. Therefore, this article presents a case study and reviews the components of a biopsychosocial paradigm of treatment for self-inflicted wounds to the lower extremity and formulates a prototypical algorithm for its diagnosis and management.

Daniel's story: self-injury and the case study as method

This article explores the value of case study methodology as a means of investigating the relationship between people with learning disabilities and self-injury. One life story might appear to be of limited value in this regard; however, it is argued that it might not only be of use in demonstrating the development of an isolated self-injuring career, but there may also be insights into its entrenchment in the lives of others. The telling of one story might serve as a filter, through which the interventions of medication, mechanical restraint and behaviourism can be observed over time. Furthermore, studying one life in some detail might be used to illustrate broader concerns about the context of the transition from institutional to community care. The restrictions of such an approach are acknowledged, particularly in the telling of a story where the main character's words cannot be heard, but maybe that is also the point of undertaking research about those at the margins of society.

People with learning difficulties who engage in self-injury

This article represents some of the findings of the author's research into the relationship between self-injury and learning disability. It identifies the key theoretical discourses associated with the phenomenon, before elaborating on the main principles of each and identifying resultant intervention strategies. These interventions, psychotropic medication, mechanical restraint, and the behavioural approach are subsequently described. Case-study methodology was employed since this enabled the examination over time of these intervention strategies in the lives of individuals fulfilling the necessary criteria of persistent self-injury and significant communication difficulties. The findings of the research suggest a frequently piecemeal approach to self-injury, with arbitrary selection of behavioural intervention approaches, a continued reliance on powerful medication, and ambivalence concerning the use of mechanical restraint. Nurses were often skilled in working from a behavioural perspective, but were hindered by complex family circumstances and a failure to gain the confidence of direct care staff. There was also a lack of appreciation about the relationship between the individual and his/her self-injury, and recognition of the nature of the intransigence.

Olanzapine for chronic, stereotypic self-injurious behaviour: a pilot study in seven adults with intellectual disability

Dopamine one (D1) receptor supersensitvity in the corpus striatum is said to be the primary mechanism within the dopamine model proposed for chronic, refractory self-injurious behaviour (SIB), which may explain why conventional neuroleptics have proven largely ineffective. In common with other atypical antipsychotic agents, olanzapine has more affinity for the D1 receptor. The present study explored whether olanzapine could reduce rates of the stereotypic form of chronic SIB, a subtype where dopamine dysfunction is the most likely underlying mechanism. A clinical sample of seven patients with various levels of learning disability who displayed features of stereotypic SIB were assessed over a 6-week period of baseline measurement and a 15-week treatment phase during which olanzapine was added to existing medication. Both SIB and other aberrant behaviours were measured by daily nurse rating and the Self-Injury Trauma Scale (SITS). All measurements were unblind. Doses ranged from 5 to 15 mg. Out of the seven subjects, three showed a clear improvement, one showed a marginal improvement, one deteriorated, and the data was equivocal for the remaining two individuals. The means of the SITS Number and Severity Indices (NI and SI, respectively) reduced significantly from baseline during both the 5- and 10-mg treatment phases, and taking treatment as a whole, by 53% and 48%, respectively (NI: mean = 0.7 units reduction, P = 0.02; SI: mean = 0.9 units reduction, P = 0.04). The risk index also reduced, but did not reach significance. A modest reduction in mean nurse-rated SIB was not significant for either phase or for treatment as a whole. At doses above 5mg, mean scores deteriorated on balance, although two responders showed a marginal additional improvement. Olanzapine was well tolerated with one adverse event reported (somnolence) which was mild and transient. The present pilot study suggests that olanzapine can reduce stereotypic SIB. A larger trial is indicated.

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.