Self-injurious behavior and sleep disturbance in adults with developmental disabilities

Predicting Problematic Behavior in Autism Spectrum Disorder Using Medical History and Environmental Data

Autism spectrum disorder (ASD), characterized by social, communication, and behavioral abnormalities, affects 1 in 36 children according to the CDC. Several co-occurring conditions are often associated with ASD, including sleep and immune disorders and gastrointestinal (GI) problems. ASD is also associated with sensory sensitivities. Some individuals with ASD exhibit episodes of challenging behaviors that can endanger themselves or others, including aggression and self-injurious behavior (SIB). In this work, we explored the use of artificial intelligence models to predict behavior episodes based on past data of co-occurring conditions and environmental factors for 80 individuals in a residential setting. We found that our models predict occurrences of behavior and non-behavior with accuracies as high as 90% for some individuals, and that environmental, as well as gastrointestinal, factors are notable predictors across the population examined. While more work is needed to examine the underlying connections between the factors and the behaviors, having reasonably accurate predictions for behaviors has the potential to improve the quality of life of some individuals with ASD.

Relationship between Sleep Problems and Self-Injury: A Systematic Review

Objective/Background: Previous studies suggested that sleep problems were related to non-suicidal self-injury. The current systematic review investigated more thoroughly this relationship.Methods: PubMED and Embase databases were searched. The keywords were "self-injury" OR "self-harm" OR "non-suicidal self-injury" OR "self-injurious behavior" OR "self-destructive behavior" OR "self-mutilation" AND "sleep problem" OR "sleep disturbance" OR insomnia OR nightmare OR "poor sleep quality" or "sleep disorders." A total of 16 studies were included in the present review.Results: The pattern of results indicated that sleep problems such as short sleep duration, sleep disturbances, and poor sleep quality were associated with non-suicidal self-injury. Additionally, emotional dysregulation, depression, and post-traumatic stress disorder appeared to mediate this relationship. Above all adolescents and young adults with sleep disruptions were at higher risk of non-suicidal self-injury.Conclusions:g Interventions to improve sleep quality and sleep duration might concomitantly decrease the risk of non-suicidal self-injury.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

Interventions for sleep difficulties in adults with an intellectual disability: a systematic review

BACKGROUND

Current literature highlights higher prevalence rates of sleep difficulties amongst adults with an intellectual disability. However, no synthesis has been conducted to assess the effectiveness of existing interventions in this population. Thus, the aim of this review was to assess the effectiveness of sleep interventions in adults with an intellectual disability (ID).

METHOD

Eight databases were searched to identify interventions for sleep difficulties amongst adults with an ID. The study quality was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions. Nine studies (n = 97) were eligible for inclusion in the review.

RESULTS

There was a notable study on heterogeneity in terms of the population, study design, intervention studied, sleep assessment and outcome assessments used. Eight of the nine studies reported improvement in sleep following intervention. However, these findings need additional support as only 97 participants involving a variety of interventions and measurement systems were used across all studies. Furthermore, eight of the nine studies had serious to critical risk of bias. The only study identified as having low risk of bias was a placebo-controlled randomised controlled trial for the use of melatonin.

CONCLUSIONS

This review highlights the need for objective measures such as actigraphy and studies with greater experimental control investigating sleep interventions in adults with ID.

Factors Associated with Self-Injurious Behaviors in Children with Autism Spectrum Disorder: Findings from Two Large National Samples

In this study, we explored potential associations among self-injurious behaviors (SIB) and a diverse group of protective and risk factors in children with autism spectrum disorder from two databases: Autism and Developmental Disabilities Monitoring (ADDM) Network and the Autism Speaks-Autism Treatment Network (AS-ATN). The presence of SIB was determined from children's records in ADDM and a parent questionnaire in AS-ATN. We used multiple imputation to account for missing data and a non-linear mixed model with site as a random effect to test for associations. Despite differences between the two databases, similar associations were found; SIB were associated with developmental, behavioral, and somatic factors. Implications of these findings are discussed in relation to possible etiology, future longitudinal studies, and clinical practice.

Rhesus macaques (Macaca mulatta) displaying self-injurious behavior show more sleep disruption than controls

Self-injurious behavior (SIB) is a pathology observed in both humans and animals. In humans, SIB has been linked to various mental health conditions that are also associated with significant sleep disruption. In rhesus macaques, SIB consists of self-directed biting which can range from mild skin abrasions to wounds requiring veterinary care. However, only one study suggests possible sleep disruption in macaques with SIB. We evaluated sleep disruption using a noninvasive system (infra-red camera and a video surveillance program) which created videos for every movement over the nighttime hours. Nighttime activity was examined in 13 macaques (three females) of which six were classified as having SIB (one female). Each monkey was studied for a total of 6 nights spanning a period of 4 months. Measures included total movement time (TMT), time moving in the first hour (HR1), time moving in the last hour (HR11), and number of videos <10 secs, ≥10 secs, and ≥30 secs in length. Overall, SIB monkeys had higher TMT (p < 0.01), higher HR1 (p<0.001), and generated more videos ≥10 secs (p < 0.01) and ≥30 secs (p < 0.01). Thus, SIB monkeys showed significant sleep disruption. A four-fold difference between SIB and control monkeys in the ≥30 secs videos revealed many more significant awakenings in the SIB group. Overall higher nighttime activity, in the first hour but not in the last hour, is consistent with sleep-onset insomnia in humans. Whether increased nighttime activity contributes to the SIB condition during the day or, conversely, SIB causes higher nighttime activity remains undetermined.

The mediating role of sleep disturbances in the relationship between posttraumatic stress disorder and self-injurious behavior

Although posttraumatic stress disorder (PTSD) is associated with self-injurious behavior, it is currently unclear what mechanisms may account for this relationship. Sleep disturbances may be relevant as they are common among those with PTSD and are associated with emotion regulation difficulties, which may increase vulnerability to self-injurious behavior. As such, we investigated the relationship between PTSD and self-injurious behaviors, and the mediating roles of nightmares and insomnia. Hypotheses were tested cross-sectionally in a sample of psychology clinic outpatients (N=255). Participants completed a structured clinical interview assessing PTSD and self-report questionnaires measuring insomnia, nightmares, and self-injurious behaviors (i.e., Have you ever cut, burned, or scratched yourself on purpose?). PTSD was associated with self-injurious behavior after covarying for depression, and nightmare severity mediated the relationship between PTSD and self-injurious behavior. Findings are consistent with research indicating that sleep disturbances, specifically nightmares, are important predictors of poor outcomes among those with PTSD, and extend this research to suggest their role in self-injurious behaviors as well.

Treating aggression in persons with autism spectrum disorders: a review

Aggression is one of the most frequent and debilitating problems observed among persons with autism spectrum disorders (ASD). It is common and can be more problematic than many core symptoms of ASD. Thus, treating the behavior is a high priority. A surprisingly limited number of studies have addressed treatment when taken in the context of the vast ASD literature. This paper reviews many of these papers and describes the types of interventions that have been used and the characteristics of the people who have been studied.

The association between self-injurious behaviors and autism spectrum disorders

A key area of concern in children with autism spectrum disorders (ASDs) are self-injurious behaviors (SIBs). These are behaviors that an individual engages in that may cause physical harm, such as head banging, or self-biting. SIBs are more common in children with ASD than those who are typically developing or have other neurodevelopmental disabilities. Therefore, it is important that clinicians who work with children with ASD have a solid understanding of SIB. The purpose of this paper is to review the research on the epidemiology of SIB in children with ASD, factors that predict the presence of SIB in this population, and the empirically supported behavioral treatments available.

Prevalence, associated factors and treatment of sleep problems in adults with intellectual disability: a systematic review

In people with intellectual disability (ID), impaired sleep is common. Life expectancy has increased in this group, and it is known that in general population sleep deteriorates with aging. Therefore the aims of this systematic review were to examine how sleep problems are defined in research among adults and older people with ID, and to collect information on the prevalence, associated factors and treatment of sleep problems in this population. PubMed, EMBase, PsycINFO and Web of Science were searched for studies published between January 1990 and August 2011. All empirical studies covering sleep problems in adults with ID were included, and assessed on quality (level of evidence), using a slightly modified version of the SIGN-50 methodology checklist for cohort studies. Of 50 studies that were included for systematic review, one was of high quality, 14 were well conducted, 14 were well conducted but with a high risk of bias, and 21 were non-analytical. The reported estimated prevalence rates of sleep problems in adults with ID ranged from 8.5% to 34.1%. A prevalence of 9.2% was reported for significant sleep problems. Sleep problems were associated with the following factors: challenging behavior; respiratory disease; visual impairment; psychiatric conditions; and using psychotropic, antiepileptic and/or antidepressant medication. Little information was found on older people specifically. Two studies reported treatment effects on sleep problems in larger populations; their findings suggest that non-pharmaceutical interventions are beneficial. Research on the prevalence, associated factors and treatment of sleep problems in adults and older people with ID has mainly focused on subjectively derived data. The definitions used to describe a sleep problem are not uniform, and associations are mainly described as correlations. In order to give recommendations for clinical practice further research is needed, involving objective measurements and multivariate analysis.

Recent research on aetiology, development and phenomenology of self-injurious behaviour in people with intellectual disabilities: a systematic review and implications for treatment

BACKGROUND

Behavioural interventions conceptualise self-injurious behaviour (SIB) as developing from early repetitive behaviours through acquisition of homeostatic functions in regulating stimulation and subsequent shaping into SIB through socially mediated or automatic operant reinforcement. Despite high success rates, such interventions rarely completely eliminate SIB, and overall effectiveness has not increased since the 1960s.

METHODS

Research (excluding studies of single genetic syndromes) on the early development, functional properties and phenomenology of SIB in persons with intellectual disabilities (IDs) published from 1999 to 2010 inclusive is reviewed.

RESULTS

Despite evidence to support the operant shaping hypothesis, in some cases tissue-damaging SIB, especially head-banging, emerges at a similar or younger age than stereotyped behaviours or 'proto-SIB', often associated with tantrums following frustrative non-reward and/or abrupt situational transitions. Many young children show undifferentiated patterns of responding in functional analyses of SIB, and SIB is associated with aggression and impulsivity as well as with repetitive behaviour.

CONCLUSIONS

One dynamic in the development of SIB may be Pavlovian conditioning of aggression, originally elicited by aversive events or frustrative non-reward, to stimuli associated with such situations. Integration into operant technology of interventions based on Pavlovian principles such as graduated exposure (with or without counterconditioning) to aversive stimuli may enhance the effectiveness of behavioural interventions.

Exploring the use of actigraphy to investigate sleep problems in older people with intellectual disability

BACKGROUND

The aim of this study was to explore the use of actigraphy to investigate sleep problems in a convenience sample of clients of Dutch intellectual disability (ID) care providers. Based on data obtained in a large multi-centre study on healthy ageing in people with ID, research questions were: 'To what degree are actigraphic measurements successful in this population?' and 'What is the influence of different sensitivity settings of the Actiwatch Sleep Analysis software on the distribution of sleep variables in this group?'

METHODS

Data were collected in a cross-sectional descriptive study design. We included 563 participants, aged 50 years or older, with borderline to profound ID. Sleep-wake data were measured continuously during 14 days and nights using the Actiwatch AW7. A complete measurement of at least 7 days and nights, including at least one weekend day, was considered successful. Objective variables of sleep were analysed using different sensitivity settings of the Actiwatch AW7 Sleep Analysis software.

RESULTS

In 200 participants (35.5%), a successful measurement was obtained. Unsuccessful measurements were caused primarily by problems with wearing the device and incomplete information on bed time and get up time. Of 382 participants who started wearing the Actiwatch, 354 (92.3%) wore it for at least 7 days. Application of different sensitivity settings of the Sleep Analysis software resulted in clear differences of all sleep parameters.

CONCLUSIONS

Further research is needed into the validity of objective sleep parameters, as measured with the Actiwatch, for screening and epidemiological research in older people with ID. It needs to be investigated which sensitivity setting of the Actiwatch gives most valid results in this specific group, whereas reference data on sleep parameters and cut-off values are to be obtained.

Physical conditions and challenging behaviour in people with intellectual disability: a systematic review

BACKGROUND

Challenging behaviour is a major problem among people with intellectual disabilities. Physical factors may be an important cause. The aim of the present systematic review was to determine the physical conditions associated with challenging behaviour.

METHODS

A literature search was conducted in PubMed and the Cochrane systematic review database for empirical studies published between 1990 and 2008. The quality of all the studies that met the inclusion criteria was assessed using the SIGN-50 methodology checklists.

RESULTS

The search identified 45 studies, which looked at general medical conditions, motor impairment, epilepsy, sensory impairment, gastrointestinal disease, sleep disorders, dementia and others. There were four high-quality observational studies, seven well-conducted observational studies, 21 observational studies of low methodological quality and 13 non-analytical studies. There were significant and independent associations between challenging behaviours and urinary incontinence, pain related to cerebral palsy and chronic sleep problems, and between self-injurious behaviour and visual impairment. No association was found with hearing impairment, bowel incontinence, mobility impairment or epilepsy. Many other physical conditions were not addressed at all.

CONCLUSION

Medical conditions can play a role in challenging behaviour, and this should be evaluated in the clinical setting. So far, the level of evidence is generally low, and longitudinal studies are completely lacking. We recommend a systematic approach to research examining the role of physical conditions in challenging behaviour, the ultimate aim being to establish a basis for the development of clinical guidelines.

Maladaptive behaviors are linked with inefficient sleep in individuals with developmental disabilities

The purpose of the current study was to assess the relations between nightly sleep patterns and the frequency of daily maladaptive behavior. Antecedent and consequential relations between sleep patterns and behavior were evaluated with time series analysis. Sleep efficiency and maladaptive behavior were determined for 20 female residents of an institutional care facility for adults with developmental disabilities. Daily maladaptive behavioral data and nightly sleep/awake logs were collected for 4 months for each participant. Efficient sleep patterns were significantly associated with lower frequencies of maladaptive behaviors. All lagged cross-correlations 8 days before and 8 days after an evening of sleep were significant. These findings suggested that inefficient sleep was associated with increased maladaptive behaviors and that the lagged associations reflected a chronic but not an acute linkage between sleep and behavior.

The use of melatonin to treat sleep disorder in adults with intellectual disabilities in community settings - the evaluation of three cases using actigraphy

BACKGROUND

Sleep disorders are known to be very prevalent in adults with intellectual disabilities (ID) but to date there has been limited objective assessment of either sleep disorders or of interventions such as the use of melatonin.

METHODOLOGY

A protocol-driven assessment and intervention procedure was followed with three people with moderate to severe ID identified as having a possible sleep disorder. Actigraphic assessment was used to determine the nature of the sleep disorder, after which sleep hygiene advice and then individual treatment with melatonin were provided, following which further actigraphic assessment was carried out. Behavioural disturbance was formally assessed before and after the intervention phase.

RESULTS

Following treatment with melatonin, changes in circadian rhythm were noted, together with improvements in challenging behaviour, but no significant effects were noted with regard to either quantity or quality of sleep.

CONCLUSIONS

A standardised procedure for assessment and treatment of sleep disorders in people with ID was established. Although no apparent effects on sleep quantity or quality were noted, this may reflect factors inherent in the sample, rather than the relative efficacy of melatonin treatment per se.

[Self-injurious-behavior in children and adolescents with intellectual disabilities]

10% of the children and teenagers with intellectual disability develop self-injurious behavior during lifespan. The causes for this are investigated, often various and reach from learn-theoretical up to neurobiological conditions. The available work gives overview of the current state of research to the etiology, further factors of influence as well as the process of self-injurious behavior by intellectual disability. Beyond that current diagnostics procedures, standard of treatment of the last thirty years and their effectiveness are presented and discussed finally.

A rhesus monkey model of self-injury: effects of relocation stress on behavior and neuroendocrine function

BACKGROUND

Self-injurious behavior (SIB), a disorder that afflicts many individuals within both clinical and nonclinical populations, has been linked to states of heightened stress and arousal. However, there are no published longitudinal data on the relationship between increases in stress and changes in the incidence of SIB. This study investigated the short- and long-term behavioral and neuroendocrine responses of SIB and control monkeys to the stress of relocation.

METHODS

Twenty adult male rhesus macaques were exposed to the stress of relocation to a new housing arrangement in a newly constructed facility. Daytime behavior, sleep, and multiple measures of hypothalamic-pituitary-adrenocortical (HPA) axis function were investigated before and after the move.

RESULTS

Relocation induced a complex pattern of short- and long-term effects in the animals. The SIB animals showed a long-lasting increase in self-biting behavior, as well as evidence of sleep disturbance. Both groups exhibited elevated cortisol levels in saliva, serum, and hair, and also an unexpected delayed increase in circulating concentrations of corticosteroid binding globulin (CBG).

CONCLUSIONS

Our results indicate that relocation is a significant stressor for rhesus macaques and that this stressor triggers an increase in self-biting behavior as well as sleep disturbance in monkeys previously identified as suffering from SIB. These findings suggest that life stresses may similarly exacerbate SIB in humans with this disorder. The HPA axis results underscore the potential role of CBG in regulating long-term neuroendocrine responses to major stressors.

Health and sleep problems in Cornelia de Lange Syndrome: a case control study

BACKGROUND

Self-injury, sleep problems and health problems are commonly reported in Cornelia de Lange Syndrome (CdLS) but there are no comparisons with appropriately matched participants. The relationship between these areas and comparison to a control group is warranted.

METHOD

54 individuals with CdLS were compared with 46 participants with intellectual disability (ID) of mixed aetiology who were similar in terms of degree of ID, mobility, age and gender using informant-based measures of health problems, sleep and self-injury.

RESULTS

Participants with CdLS experienced significantly more current and lifetime health problems with eye problems and gastrointestinal disorders prominent. Although 55% of those with CdLS experienced sleep problems this prevalence was not different from the comparison group. Sleep disorder was not associated with self-injury in the CdLS group, skin problems were associated with severity of self-injury but not presence.

DISCUSSION

People with CdLS experience a range of significant health problems and have more health concerns than others with the same degree of ID. Although this has been well documented in the past, the current high prevalence of health concerns indicates the need for regular health assessment and appropriate intervention.

Sleep and Developmental Disabilities: Assessment, Treatment, and Outcome Measures

People with developmental disabilities sleep less and experience higher incidence of clinical sleep disorders than the general population. Exploring the neurophysiology linking sleep with daytime performance in patients with developmental disabilities is now possible using minimally sufficient sleep and sleep-sensitive behavioral assays. Although frequent sampling represents the primary difficulty, it is required to untangle coincident effects of sleep quality amidst circadian variation. Recent evidence finds high quality sleep promotes brain plasticity, improves health measures, and enriches quality of life. Sleep treatments for apnea, insomnia, restless limbs, and conditioned sleep-aversion are available, although not readily provided, for people with developmental disabilities. This population would gain both clinical and behavioral benefits as improved sleep-monitoring, behavioral testing, and sleep-treatment technology is adapted to their needs.