The association between self-injurious behaviors and autism spectrum disorders

Forecasting High-Risk Behavioral and Medical Events in Children with Autism through Analysis of Digital Behavioral Records

Individuals with Autism Spectrum Disorder may display interfering behaviors that limit their inclusion in educational and community settings, negatively impacting their quality of life. These behaviors may also signal potential medical conditions or indicate upcoming high-risk behaviors. This study explores behavior patterns that precede high-risk, challenging behaviors or seizures the following day. We analyzed an existing dataset of behavior and seizure data from 331 children with profound ASD over nine years. We developed a deep learning-based algorithm designed to predict the likelihood of aggression, elopement, and self-injurious behavior (SIB) as three high-risk behavioral events, as well as seizure episodes as a high-risk medical event occurring the next day. The proposed model attained accuracies of 78.4%, 80.68%, 85.43%, and 69.95% for predicting the next-day occurrence of aggression, SIB, elopement, and seizure episodes, respectively. The results were proven significant for more than 95% of the population for all high-risk event predictions using permutation-based statistical tests. Our findings emphasize the potential of leveraging historical behavior data for the early detection of high-risk behavioral and medical events, paving the way for behavioral interventions and improved support in both social and educational environments.

Measurement properties of tools used to assess self-harm in autistic and general population adults

Autistic people are at increased risk of experiencing self-harm compared to the general population. However, it is unclear which tools are being used to assess self-harm in autistic people, or whether existing tools need to be adapted for this group. This two-stage systematic review aimed to identify tools used to assess self-harm in autistic and general population adults, evaluate these tools on their measurement properties, and make recommendations for their appropriate use in research and clinical practice. Four databases were systematically searched (PsycINFO, Embase, MEDLINE and Web of Science). Eight frequently used self-harm assessment tools were identified and assessed for risk of bias, criteria for good measurement properties, and quality of evidence using the COSMIN checklist. Of these, two tools had sufficient evidence of internal consistency (ISAS, QNSSI), and one had been frequently used with autistic adults (NSSI-AT). These three tools may have potential for use with autistic adults but require further investigation for content validity and measurement properties in the autistic population. More research and potential adaptations to current self-harm assessment tools are recommended in order to better conceptualise and understand self-harm and its measurement in autism.

Service Acquisition for Children with Autism Spectrum Disorder in Rural Southwest Virginia: The Role of Caregiver Psychoeducation

PURPOSE

Evidence-based intervention can significantly improve the trajectory of symptoms and overall outcomes for children with autism spectrum disorder (ASD), especially when implemented at an early age. However, families residing in rural communities experience barriers to accessing ASD-related services. The purpose of this pilot study was to assess how the provision of accessible caregiver psychoeducation related to new service acquisition for children recently diagnosed with ASD in rural Southwest Virginia.

METHODS

Psychoeducation was delivered either live by a clinician (Live PE, n = 13 caregivers) or via paper materials (Paper PE, n = 10 caregivers) and included content on ASD epidemiology and symptoms, risk factors, evidence-based interventions, and navigating service systems. Survey data were collected from caregivers of 20 children to measure new service acquisition within six months following psychoeducation.

RESULTS

Results indicated that 81.8% of children whose caregivers received Live PE obtained at least one new service within six months, compared to 55.6% of those whose caregivers received Paper PE. An independent samples t-test showed a significant difference in the number of new services obtained between groups, such that the Live PE group received over 2.5 times as many services as the Paper PE group.

CONCLUSION

Results suggest that psychoeducation, particularly delivered by a clinician, positively impacted service acquisition, and emphasize the clinical importance of personalized, accessible ASD psychoeducation for rural families. Future implications are discussed, including recommendations to evaluate the role of psychoeducation on service acquisition in larger samples.

Assessing suicidal thoughts and behaviors and nonsuicidal self-injury in autistic and non-autistic early adolescents using the Columbia Suicide Severity Rating Scale

LAY ABSTRACT

Autistic adolescents are more likely to experience suicidal thoughts and behaviors and nonsuicidal self-injury than non-autistic adolescents, per caregiver- and self-report on single-item questionnaires. Comprehensive, clinician-rated measures of suicide risk have not been used to measure suicidal thoughts and behaviors and nonsuicidal self-injury in autistic youth despite greater parent-child rating discrepancies among autistic youth than their non-autistic peers. The Columbia Suicide Severity Rating Scale is a widely used, clinician-rated measure of suicide risk that has not been tested with autistic youth. In this study, the Columbia Suicide Severity Rating Scale was employed to assess suicidal thoughts and behaviors and nonsuicidal self-injury in a community sample of 239 early adolescents (10:0-13:9 years old), of whom 138 youth were autistic and 101 were not autistic. Multiple analyses examined diagnostic (autistic vs non-autistic) and sex-based (male vs female) differences in suicidal thoughts and behaviors and nonsuicidal self-injury, as well as youth consistency in reporting across self- and clinician-rated measures. Findings show that a greater proportion of autistic youth reported lifetime suicidal thoughts and nonsuicidal self-injury than non-autistic youth; however, there were no sex-based differences. The majority of non-autistic youth were consistent in reporting suicidal thoughts on self- and clinician-rated measures; however, nearly one in five autistic youth disclosed suicidal thoughts on a self-report measure but not to a psychiatrist on the Columbia Suicide Severity Rating Scale. Findings suggest that autism diagnostic status, but not sex, confers significant risk for suicidal thoughts and behaviors and nonsuicidal self-injury in early adolescents and that the Columbia Suicide Severity Rating Scale may be a useful measure of suicide risk for some autistic youth, but it may not detect all autistic youth experiencing suicidal thoughts.

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.

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

Role of gastrointestinal health in managing children with autism spectrum disorder

Children with autism spectrum disorders (ASD) or autism are more prone to gastrointestinal (GI) disorders than the general population. These disorders can significantly affect their health, learning, and development due to various factors such as genetics, environment, and behavior. The causes of GI disorders in children with ASD can include gut dysbiosis, immune dysfunction, food sensitivities, digestive enzyme deficiencies, and sensory processing differences. Many studies suggest that numerous children with ASD experience GI problems, and effective management is crucial. Diagnosing autism is typically done through genetic, neurological, functional, and behavioral assessments and observations, while GI tests are not consistently reliable. Some GI tests may increase the risk of developing ASD or exacerbating symptoms. Addressing GI issues in individuals with ASD can improve their overall well-being, leading to better behavior, cognitive function, and educational abilities. Proper management can improve digestion, nutrient absorption, and appetite by relieving physical discomfort and pain. Alleviating GI symptoms can improve sleep patterns, increase energy levels, and contribute to a general sense of well-being, ultimately leading to a better quality of life for the individual and improved family dynamics. The primary goal of GI interventions is to improve nutritional status, reduce symptom severity, promote a balanced mood, and increase patient independence.

A systematic review and meta-analysis of suicidality in autistic and possibly autistic people without co-occurring intellectual disability

BACKGROUND

Suicidality is highly prevalent in autistic people without co-occurring intellectual disabilities, and high autistic traits are found in adults who have attempted suicide. However, prevalence rates for both autistic and possibly autistic people have not been synthesised meta-analytically.

AIMS

To (1) calculate pooled prevalence estimates of suicidality in autistic people and possibly autistic people without co-occurring intellectual disability; (2) evaluate the influence of participant and study level characteristics on heterogeneity; and (3) determine the quality of evidence.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PsycINFO, Embase, MEDLINE and Web of Science were systematically searched from 1992 to January 25, 2022. Empirical quantitative studies reporting prevalence of suicidal ideation, suicide plans, or suicide attempts and behaviours were considered for inclusion. Random effects models were used to estimate pooled prevalence of each suicidality outcome with 95% confidence intervals. Heterogeneity was explored using sensitivity and moderator analyses.

RESULTS

Data from 48,186 autistic and possibly autistic participants in 36 primary studies were meta-analysed. Pooled prevalence of suicidal ideation was 34.2% (95% CI 27.9-40.5), suicide plans 21.9% (13.4-30.4), and suicidal attempts and behaviours 24.3% (18.9-29.6). High levels of heterogeneity (I² > 75) were observed in all three analyses. Estimates did not differ between autistic or possibly autistic samples. Geographical location (p = 0.005), transgender or gender non-conforming samples (p < 0.001) and type of report (p < 0.001) significantly moderated suicidal ideation, whereas age group (p = 0.001) and measure of suicidality (p = 0.001) significantly moderated suicide plans. There was a significant association between the proportion of male participants and prevalence of suicide plans, with a decrease in the proportion of males for every unit change of suicide plan prevalence (p = 0.013). No variables were found to moderate estimates of suicide attempts and behaviours.

CONCLUSIONS

The results confirm suicidality is highly prevalent in both autistic and possibly autistic people without co-occurring intellectual disability and highlights potential moderators. Possibly autistic individuals require more attention in clinical and research considerations going forward to further understand and prevent suicide in both groups.

The Autism Spectrum: Behavioral, Psychiatric and Genetic Associations

Autism spectrum disorder (ASD) consists of a group of heterogeneous genetic neurobehavioral disorders associated with developmental impairments in social communication skills and stereotypic, rigid or repetitive behaviors. We review common behavioral, psychiatric and genetic associations related to ASD. Autism affects about 2% of children with 4:1 male-to-female ratio and a heritability estimate between 70 and 90%. The etiology of ASD involves a complex interplay between inheritance and environmental factors influenced by epigenetics. Over 800 genes and dozens of genetic syndromes are associated with ASD. Novel gene–protein interactions with pathway and molecular function analyses have identified at least three functional pathways including chromatin modeling, Wnt, Notch and other signaling pathways and metabolic disturbances involving neuronal growth and dendritic spine profiles. An estimated 50% of individuals with ASD are diagnosed with chromosome deletions or duplications (e.g., 15q11.2, BP1-BP2, 16p11.2 and 15q13.3), identified syndromes (e.g., Williams, Phelan-McDermid and Shprintzen velocardiofacial) or single gene disorders. Behavioral and psychiatric conditions in autism impacted by genetics influence clinical evaluations, counseling, diagnoses, therapeutic interventions and treatment approaches. Pharmacogenetics testing is now possible to help guide the selection of psychotropic medications to treat challenging behaviors or co-occurring psychiatric conditions commonly seen in ASD. In this review of the autism spectrum disorder, behavioral, psychiatric and genetic observations and associations relevant to the evaluation and treatment of individuals with ASD are discussed.

Adapted suicide safety plans to address self-harm, suicidal ideation, and suicide behaviours in autistic adults: protocol for a pilot randomised controlled trial

BACKGROUND

Suicide prevention is a national priority for the UK government. Autistic people are at greater risk of experiencing self-harm and suicidal thoughts and behaviours than the general population. Safety plans are widely used in suicide prevention but have not yet been designed with and for autistic people. We developed the first safety plan specifically targeting suicidality in autistic adults: the Autism Adapted Safety Plan (AASP). It consists of a prioritised list of hierarchical steps that can be used prior to or during a crisis to mitigate risk of self-harm and suicidal behaviour. This is a pilot study that aims to assess the feasibility and acceptability of the AASPs and the research processes, including the response rates, potential barriers and reach of AASPs, methods of recruitment, what comprises usual care, and economic evaluation methods/tools.

METHODS

This is an external pilot randomised controlled trial of a suicide prevention tool aimed at mitigating the risk of self-harm and suicidal behaviour in autistic adults: AASPs. Participants will be assessed at baseline and followed up 1 month and 6 months later. Assessments include questions about self-harm, suicidality, service use, and their experience of the AASP/taking part in the study. Autistic adults who have a clinical autism diagnosis and self-reported history of self-harm, suicidal thoughts, or suicidal behaviours within the last 6 months will be invited to take part in the study. Informed consent will be obtained. Participants will be recruited via community and third sector services (including community settings, autism charities, and mental health charities). They may also "self-refer" into the study through social media recruitment and word of mouth. Ninety participants will be randomised to either develop an AASP or receive their usual care in a 1:1 ratio.

DISCUSSION

The present study will provide an evaluation of the suitability of the processes that would be undertaken in a larger definitive study, including recruitment, randomisation, methods, questionnaires, outcome measures, treatment, and follow-up assessments.

TRIAL REGISTRATION

ISRCTN70594445, Protocol v4: 8/2/22.

Addressing Self-Injurious Behavior in the Medically Complex Child: Identifying the Root Cause vs Blocking Resulting Behavior

Gillian is a 7-year-old nonverbal, internationally adopted girl with significant visual impairment (sees shadows and objects with high contrast), moderate-severe hearing loss, autism spectrum disorder, profound intellectual disability, and a seizure disorder. She resided in an orphanage until age 4 years when she was adopted by her mother. She is referred to the multidisciplinary team in developmental-behavioral pediatrics by her gastroenterologist, who is managing her constipation, for evaluation and management of self-injurious behavior that occurs before bowel movements.Gillian's adoptive mother reported that Gillian has a history of repetitive and self-injurious behavior including hitting her head with the palm of her hand and poking her eyes. The head-hitting behavior has resulted in consistent bruising to her forehead and nasal bridge. The eye poking is of significant concern because of the possibility of resultant injury including corneal abrasion or retinal detachment. Eye poking occurs exclusively during the hour before stooling, at home and school, and is accompanied by screaming, pacing, and increased aggression toward her mother/teachers. Mother typically responds by blocking the eye poking, redirecting Gillian to the toilet, providing prompts to use calming strategies (e.g., deep breathing), or providing sensory input by rubbing her arms/back. Teachers respond in a similar way at school. Gillian's mother has tried to place goggles over Gillian's eyes during eye poking, but this resulted in increased aggressive behaviors.Gillian is not fully bowel trained but will sit on the toilet to urinate when prompted. She completes toilet-sits at home/school 5 to 7 times daily. Gillian passes small, soft bowel movements 2 to 4 times daily on a bowel management regimen consisting of polyethylene glycol 3350 17 grams twice daily and liquid senna 8.8 mg daily. Seizures are reportedly well controlled with an antiepileptic medication managed by her neurologist. Previous medical evaluation by otolaryngology, ophthalmology, neurology, and gastroenterology did not identify a source of pain or other cause for the eye poking. Physical examination reveals normal bowel sounds and a mildly distended abdomen but is otherwise unremarkable. What are your next steps for evaluation and treatment?

Is language ability associated with behaviors of concern in autism? A systematic review

This review systematically synthesized evidence on the association between structural language ability and behaviors of concern (BoC) in autism. Four databases were searched for studies that included >10 autistic participants, measures of structural language (content and/or form of language) and BoC, and an analysis of their association. BoCs included self-injurious behavior (SIB), aggression, tantrums, and externalizing behavior. Methodological quality of studies were assessed using the Newcastle Ottawa Scale. Forty-five publications (n = 11,961) were included. Forty studies were cross-sectional and five were prospective cohort studies. Over 70% of the studies investigating expressive language and SIB (n = 10), aggression (n = 5), tantrums (n = 3), and externalizing behavior (n = 17) reported an inverse association, where lower expressive language ability was associated with increased BoC. Eleven out of sixteen studies of combined expressive and receptive language reported an inverse relationship with SIB or aggression. All outcomes were rated as moderate to very low certainty of evidence. This review highlights evidence showing an inverse association between expressive or combined language ability and SIB, and externalizing behavior in autism. However, further high-quality studies that use standardized, consistent measures of language and behavior and investigate longitudinal associations are needed. Early detection and support for reduced structural language difficulties have substantial potential to assist in reducing BoC.

The combination of autism and exceptional cognitive ability is associated with suicidal ideation

Autism with co-occurring exceptional cognitive ability is often accompanied by severe internalizing symptoms and feelings of inadequacy. Whether cognitive ability also translates into greater risk for suicidal ideation is unclear. To investigate this urgent question, we examined two samples of high-ability autistic individuals for factors that were predictive of suicidal ideation. In the first sample (N = 1,074 individuals seen at a clinic specializing in gifted/talented youth), we observed a striking excess of parent-reported suicidal ideation in autistic individuals with IQ ≥ 120 (Odds Ratio = 5.9, p=0.0007). In a separate sample of SPARK participants, we confirmed higher rates of suicidal thoughts compared to non-autistic children from the ABCD cohort (combined N = 16,049, Odds Ratio = 6.8, p<2.2e-16), and further that autistic children with suicidal thoughts had significantly higher cognitive ability (p<2.2e-16) than those without. Elevated polygenic scores (PGS) for cognitive performance were associated with increased suicidal thoughts (N = 1,983, Z=2.16,p=0.03), with PGS for educational attainment trending in the same direction (Z=1.4,p=0.17). Notably, similar results were found in parents of these autistic youth, where higher PGS for educational attainment was associated with increasing thoughts of suicide (N = 736, Z=2.28,p=0.02). Taken together, these results suggest that on a phenotypic and genetic level, increasing cognitive ability is an unexpected risk factor for suicidal ideation in individuals diagnosed with, or at risk for autism.

“It’s possible”: reducing the coercion in care for adults living with neurodevelopmental disorders: a mixed-methods study

Introduction

Adults living with a neurodevelopmental disorder may present episodes of aggression, which may lead to the use of seclusion or restraint. The aim of the study was to assess the effect of an intervention aimed at reducing the use of coercive measures in a long-term care unit for adults suffering from a neurodevelopmental disorder with or without psychiatric co-morbidities.

Method

The single-center study used a sequential mixed-methods explanatory design. Retrospective data on periods of seclusion, with and without physical restraint, were collected for the ten-month pre-intervention and post-intervention periods. A qualitative survey was conducted at the end of the intervention period among the health professionals working in the unit to review the implementation and the efficiency of the approach.

Results

A significant decrease was observed between the pre- and post-intervention period in the number of seclusion and restraint sequences, the number of patients experiencing seclusion and restraint, and the duration of seclusion and restraint sequences. The efficiency of the approach was confirmed by the health care professionals and was attributed to leadership focused on limiting coercive measures, better adherence to legal obligations, team cohesion, and the implementation of alternative tools and methods.

Discussion

Reducing the use of coercive measures with adults with neurodevelopmental disorders is possible. Further studies are needed to confirm the effectiveness of alternative strategies to seclusion and restraint.

Teachers' Familiarity, Confidence, Training, and Use of Problem Behavior Interventions for Learners with Autism Spectrum Disorder in School Settings

Our main purpose in this study was to investigate the levels of and the relationship between familiarity, confidence, training, and use of problem behavior interventions by special education teachers working with learners with autism spectrum disorder (ASD) in school settings. A total of 80 special education teachers in South Carolina and Virginia completed an online survey. Results indicate a positive correlation between teachers' familiarity, confidence, training, and use of problem behavior interventions. Across all intervention categories, providing choices, prompting, modeling, and direct instruction received the highest rankings for familiarity, confidence, and use. In addition, our results reveal that familiarity and confidence in implementing these interventions differs across groups of special education teachers based on years of experience. The most frequently reported factors that limit the use of problem behavior interventions in school settings were competing responsibilities, the need to involve multiple people, the amount of time required, and the difficulty using interventions during typical routines. Implications for research and practice are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10882-022-09885-2.

Characteristics of children with autism and unspecified intellectual developmental disorder (intellectual disability) presenting with severe self-injurious behaviours

Objective: This study aims to delineate the characteristics of severe self-injurious behaviors (SIB) in a cohort of children with autism and unspecified intellectual developmental disorder (UIDD) (intellectual disability) and examine potential risk factors for developing SIB. Methods: A retrospective chart review studied characteristics of severe SIB in 30 children with autism spectrum disorder (ASD) and UIDD referred to a tertiary care center. Characteristics examined include genetic syndromes, brain MRI abnormalities, verbal ability, adaptive functioning, SIB frequency and severity, age of onset, number of psychopharmacological agents, irritability, hyperactivity, stereotypy, psychiatric and physical comorbidities, among others. Descriptive and bivariate analysis were applied to explore potential relationships between factors. Results: Children with severe SIB exhibit this behaviour with high frequency, inflicting moderate to severe injury. Most children in the study sample are non-verbal and have ASD (93.3%; n = 28) with psychiatric (96.7%; n = 29) and physical (90%; n = 27) comorbidities. Overall SIB improvement using the Clinical Global Impression, Improvement Score (CGI-I) was 3.0 (minimally improved). A minority were much or very much improved following appropriate intervention. Conclusions: The severity of SIB is much higher in this sample than previously noted in the literature. Severe SIB is associated with ADHD, early onset mood disorders, tics, avoidant restrictive food intake disorder and Obsessive-Compulsive Disorder.

Connectivity in deep brain stimulation for self-injurious behavior: multiple targets for a common network?

Self-injurious behavior (SIB) is associated with diverse psychiatric conditions. Sometimes (e.g., in patients with autism spectrum disorder or acquired brain injuries), SIB is the most dominant symptom, severely restricting the psychosocial functioning and quality of life of the patients and inhibiting appropriate patient care. In severe cases, it can lead to permanent physical injuries or even death. Primary therapy consists of medical treatment and if implementable, behavioral therapy. For patients with severe SIB refractory to conventional therapy, neuromodulation can be considered as a last recourse. In scientific literature, several successful lesioning and deep brain stimulation targets have been described that can indicate a common underlying neuronal pathway. The objectives of this study were to evaluate the short- and long-term clinical outcome of patients with severe, therapy refractory SIB who underwent DBS with diverse underlying psychiatric disorders and to correlate these outcomes with the activated connectivity networks. We retrospectively analyzed 10 patients with SIB who underwent DBS surgery with diverse psychiatric conditions including autism spectrum disorder, organic personality disorder after hypoxic or traumatic brain injury or Tourette syndrome. DBS targets were chosen according to the underlying disorder, patients were either stimulated in the nucleus accumbens, amygdala, posterior hypothalamus, medial thalamus or ventrolateral thalamus. Clinical outcome was measured 6 months after surgery and at long-term follow-up after 10 or more years using the Early Rehabilitation Barthel index (ERBI) and time of restraint. Connectivity patterns were analyzed using normative connectome. Based on previous literature the orbitofrontal cortex, superior frontal gyrus, the anterior cingulate cortex, the amygdala and the hippocampus were chosen as regions of interest. This analysis showed a significant improvement in the functionality of the patients with DBS in the short- and long-term follow-up. Good clinical outcome correlated with higher connectivity to the amygdala and hippocampus. These findings may suggest a common pathway, which can be relevant when planning a surgical procedure in patients with SIB.

Hospital staff at most psychiatric clinics in Stockholm experience that patients who self-harm have too long hospital stays, with ensuing detrimental effects

BACKGROUND

Previous research on patients who self-harm has indicated potential negative effects from long hospital stays. Yet, such care has been reported to occur regularly. We conducted this questionnaire study to investigate how hospital staff, who treat self-harming patients, experience the relation between lengths of stay and self-harm behaviour, and the motives for non-beneficial hospital stays.

METHODS

The respondents of the questionnaire were nurses and mental health workers employed at public inpatient wards in Stockholm, treating patients who self-harm. The questionnaire contained questions with fixed answers and room for comments. A total of 304 questionnaires were distributed to 13 wards at five clinics, and the response rate was 63%. The data were analysed with descriptive statistics and qualitative descriptive content analysis.

RESULTS

The results show that most staff experienced that more than a week's stay either increased (57%) or had no effect (33%) on self-harm behaviour. Most respondents at most clinics considered the stays to be too long at their wards, and that the stays could be reduced. The respondents recognized several reasons for non-beneficial hospital stays, like fear of suicidal behaviour and doctors' fear of complaints. Patients appearing as demanding or fragile were thought to be given more care than others. The respondents' comments confirmed the majority's experience of detrimental effects from longer hospital stays.

CONCLUSIONS

A majority of the health care staff experienced that patients who self-harm often receive too long hospital stays, with detrimental effects, and they had experienced several non-medical reasons for such care.

Patterns of Restricted and Repetitive Behaviors in Toddlers and Young Children with Autism Spectrum Disorder

Objectives

Restricted and repetitive behaviors (RRBs) are a core symptom in the diagnosis of autism spectrum disorder (ASD). The complexity of behavioral patterns has called for the creation of phenotypically homogeneous subgroups among individuals with ASD. The purpose of this study was 1) to investigate the different types of RRBs and 2) to explore whether subgroups created by RRBs would show unique levels of functioning in toddlers and young children with ASD.

Methods

A total of 313 children with ASD, aged 12–42 months were included in the analysis. The Autism Diagnostic Interview-Revised was used to obtain information on the different types of RRBs by grouping 15 items into six categories. The Vineland Adaptive Behaviors Scale, a parent-reported questionnaire, was used to measure adaptive functioning. A portion of the children were analyzed separately for verbal-related RRBs based on their expressive language level. Two-step cluster analysis using RRB groups as features was used to create subgroups. Analysis of covariance while covarying for age and language was performed to explore the clinical characteristics of each cluster group.

Results

Sensory-related RRBs were the most prevalent, followed by circumscribed interests, interest in objects, resistance to change, and repetitive body movements. A subset of the children was analyzed separately to explore verbal-related RRBs. Four cluster groups were created based on reported RRBs, with multiple RRBs demonstrating significant delays in adaptive functioning.

Conclusion

Heterogeneity of RRBs emerges at a young age. The different patterns of RRBs can be used as valuable information to determine developmental trajectories with better implications for treatment approaches.

Parent-reported measure of repetitive behavior in Phelan-McDermid syndrome

Background

Phelan McDermid syndrome (PMS) is a neurogenetic condition associated with a high prevalence of intellectual disability (ID) and autism spectrum disorder (ASD). This study provides a more comprehensive and quantitative profile of repetitive behaviors within the context of ID seen with the condition.

Methods

Individuals age 3–21 years with a confirmed PMS diagnosis participated in a multicenter observational study evaluating the phenotype and natural history of the disorder. We evaluated data collected from this study pertaining to repetitive behaviors from the Repetitive Behavior Scales-Revised (RBS-R).

Results

There were n = 90 participants who were part of this analysis. Forty-seven percent (n = 42/90) were female, and the average age at baseline evaluation was 8.88 ± 4.72 years. The mean best estimate IQ of the cohort was 26.08 ± 17.67 (range = 3.4–88), with n = 8 with mild ID (or no ID), n = 20 with moderate ID, and n = 62 with severe-profound ID. The RBS-R total overall score was 16.46 ± 13.9 (compared to 33.14 ± 20.60 reported in previous studies of ASD) (Lam and Aman, 2007), and the total number of items endorsed was 10.40 ± 6.81 (range = 0–29). After statistical correction for multiple comparisons, IQ correlated with the RBS-R stereotypic behavior subscale score (r_s = − 0.33, unadjusted p = 0.0014, adjusted p = 0.01) and RBS-R stereotypic behavior total number of endorsed items (r_s = − 0.32, unadjusted p = 0.0019, adjusted p = 0.01). IQ did not correlate with any other RBS-R subscale scores.

Conclusions

The RBS-R total overall score in a PMS cohort appears milder compared to individuals with ASD characterized in previous studies. Stereotypic behavior in PMS may reflect cognitive functioning.

Examining the Relation between Self-reported ASD Symptoms and Sensory Sensitivities from a Community-based Sample of Adults

Atypical responses to sensory stimuli, termed sensory sensitivities, are a commonly reported symptom for individuals diagnosed with Autism Spectrum Disorder (ASD). In this community-based study of 604 adults, the correlation between sensory sensitivities and ASD symptoms was r = 0.23, p < .001, representing a smaller relation than estimates previously reported in the peer-reviewed research. Additionally, when examining only participants who met or exceeded the ASD screening cutoff score, the relation between sensory sensitivities and ASD symptoms was only slightly larger at r = 0.25, p < .001. Forty-four percentage who met the screening cutoff score for ASD also reported the lowest degree of sensory sensitivities. Finally, just over one-third who met the screening cutoff score for ASD had the highest sensory sensitivities. Sensory sensitivities did not appear to be a consistent feature across adults meeting the ASD screening cutoff score, but a proportion meeting the ASD screening cutoff score also exhibited the most extreme sensory sensitivities.

The Impact of COVID-19 Restrictions on Psychological Distress in Family Caregivers of Children with Neurodevelopmental Disability in the UK

Caregivers of a child with a neurodevelopmental disability are more vulnerable to mental health difficulties. These difficulties are influenced by the child’s challenging behaviours, and the caregiver’s coping strategies; factors impacted by the COVID-19 pandemic. An online mixed methods survey was conducted on caregivers of children with neurodevelopmental disabilities (n = 43) and children who are typically developing (n = 67). The results showed that presence of challenging behaviours related to neurodevelopmental disability, and caregiver coping strategies predicted caregiver psychological distress during lockdown. Themes that emerged included ‘confusing messages and guidance’, ‘loss of freedom’ and ‘unsupported and forgotten’. The results demonstrate the pressing need for the implementation of appropriate support to protect the mental health of caregivers across the UK.

Autistic adults' subjective experiences of hoarding and self-injurious behaviors

LAY ABSTRACT

Hoarding and self-injurious behaviors are relatively common in autism, but knowledge about their expressions in adulthood is scarce. Through interviews collecting subjective experiences of autistic adults, these behaviors were explored, and categorized to their underlying purposes. Findings portray the occurrence of these behaviors in the lives of autistic adults, their self-regulatory purposes, and their relationship to other behaviors in the domain of Restrictive and Repetitive Behaviors and Interests.

Autism in Turkey: demographics, behavior problems, and accompanying medical conditions in a sample of Turkish youth with autism spectrum disorder

Autism spectrum disorder (ASD) is an etiologically heterogeneous neurodevelopmental condition that eludes a single explanation or cure. Epidemiological studies reveal risk factors, relevant comorbidities, and behavioral correlates to reach a better understanding of ASD. To contribute such data from an understudied ASD population, this paper presents epidemiological data from a Turkish sample of individuals with ASD (n = 911, 748 boys (82.1%) and 163 girls (17.9%) between 1 and 18 years of age). Average age at diagnosis was 31.06 ± 11.88 months, and the male-to-female ratio was 4.6:1. Three in 4 individuals with ASD had obsessive behaviors, and 1 in 4 had allergic conditions, inappropriate sexual behaviors, self-harming behaviors, and harmful behaviors towards others. One in 3 received a dietary treatment for at least 3 months; almost half received vitamin supplements; the majority (70%) did not experience constipation; and 2 in 3 were picky eaters. This paper presents data on the age of diagnosis, gender ratios, accompanying behaviors, and dietary interventions in Turkish individuals with ASD, which are topics of current research interest about ASD. Such data from non-Western populations may supplement epidemiological knowledge gained from Western populations to help reach a more comprehensive understanding of this condition with many unknowns.

Response patterns for individuals receiving contingent skin shock aversion intervention to treat violent self-injurious and assaultive behaviours

A small proportion of patients with intellectual disabilities (IDs) and/or autism spectrum disorder (ASD) exhibit extraordinarily dangerous self-injurious and assaultive behaviours that persist despite long-term multidisciplinary interventions. These uncontrolled behaviours result in physical and emotional trauma to the patients, care providers and family members. A graduated electronic decelerator (GED) is an aversive therapy device that has been shown to reduce the frequency of severe problem behaviours by 97%. Within a cohort of 173 patients, we have identified the four most common patterns of response: (1) on removal of GED, behaviours immediately return, and GED is reinstated; (2) GED is removed for periods of time (faded) and reinstated if and when behaviours return; (3) a low frequency of GED applications maintains very low rates of problem behaviours; and (4) GED is removed permanently after cessation of problem behaviours. GED is intended as a therapeutic option only for violent, treatment-resistant patients with ID and ASD.

Maltreatment of Children With Disabilities

Over the past decade, there have been widespread efforts to raise awareness about maltreatment of children. Pediatric providers have received education about factors that make a child more vulnerable to being abused and neglected. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population at increased risk for maltreatment. This report updates the 2007 American Academy of Pediatrics clinical report "Maltreatment of Children With Disabilities." Since 2007, new information has expanded our understanding of the incidence of abuse in this vulnerable population. There is now information about which children with disabilities are at greatest risk for maltreatment because not all disabling conditions confer the same risks of abuse or neglect. This updated report will serve as a resource for pediatricians and others who care for children with disabilities and offers guidance on risks for subpopulations of children with disabilities who are at particularly high risk of abuse and neglect. The report will also discuss ways in which the medical home can aid in early identification and intervene when abuse and neglect are suspected. It will also describe community resources and preventive strategies that may reduce the risk of abuse and neglect.

Indoor Acoustic Requirements for Autism-Friendly Spaces

The architecture of spaces for people on the autistic spectrum is evolving toward inclusive design, which should fit the requirements for independent, autonomous living, and proper support for relatives and caregivers. The use of smart sensor systems represents a valuable support to internal design in order to achieve independent living for impaired people. Accordingly, these devices can monitor or prevent hazardous situations, ensuring security and privacy. Acoustic sensor systems, for instance, could be used in order to realize a passive monitoring system. The correct functioning of such devices needs optimal indoor acoustic criteria. Nevertheless, these criteria should also comply with dedicated acoustic requests that autistic individuals with hearing impairment or hypersensitivity to sound could need. Thus, this research represents the first attempt to balance, integrate, and develop these issues, presenting (i) a wide literature overview related to both topics, (ii) a focused analysis on real facility, and (iii) a final optimization, which takes into account, merges, and elucidates all the presented unsolved issues.

Understanding the experiences of self-injurious behavior in autism spectrum disorder: Implications for monitoring technology design

OBJECTIVE

Monitoring technology may assist in managing self-injurious behavior (SIB), a pervasive concern in autism spectrum disorder (ASD). Affiliated stakeholder perspectives should be considered to design effective and accepted SIB monitoring methods. We examined caregiver experiences to generate design guidance for SIB monitoring technology.

MATERIALS AND METHODS

Twenty-three educators and 16 parents of individuals with ASD and SIB completed interviews or focus groups to discuss needs related to monitoring SIB and associated technology use.

RESULTS

Qualitative content analysis of participant responses revealed 7 main themes associated with SIB and technology: triggers, emotional responses, SIB characteristics, management approaches, caregiver impact, child/student impact, and sensory/technology preferences.

DISCUSSION

The derived themes indicated areas of emphasis for design at the intersection of monitoring and SIB. Systems design at this intersection should consider the range of manifestations of and management approaches for SIB. It should also attend to interactions among children with SIB, their caregivers, and the technology. Design should prioritize the transferability of physical technology and behavioral data as well as the safety, durability, and sensory implications of technology.

CONCLUSIONS

The collected stakeholder perspectives provide preliminary groundwork for an SIB monitoring system responsive to needs as articulated by caregivers. Technology design based on this groundwork should follow an iterative process that meaningfully engages caregivers and individuals with SIB in naturalistic settings.

Intentional Self Harm in Children with Autism

The study examined the demographic, socioeconomic, and clinical correlates of self injurious behaviors (SIBs) in a large clinical sample of children with autism spectrum disorder (ASD). A case record review of 1252 ASD children for whom complete information on socioeconomic background variables and presence/absence of SIBs was available were included. The overall prevalence of SIBs was 22.1% and the most prevalent SIBs were head banging (47%), followed by self hitting (27.8%). Several factors including age at diagnosis (t = 2.09, P = 0.037), education of mother (χ² = 14.48, P = 0.0001), presence of co-morbid medical condition (χ² = 4.22, P = 0.040), intellectual disability (χ² = 23.17, P = 0.0001), sensory processing abnormalities (χ² = 13.01, P = 0.0001), and severity of autism (χ² = 51.13, P = 0.0001) were found to be significantly associated with presence of SIBs. Logistic regression analysis revealed that severity of autism was the only significant predictor of SIBs. Intentional self harm is related with significant morbidity and needs early intervention.

Measurement Properties of the Suicidal Behaviour Questionnaire-Revised in Autistic Adults

We explored the appropriateness and measurement properties of a suicidality assessment tool (SBQ-R) developed for the general population, in autistic adults—a high risk group for suicide. 188 autistic adults and 183 general population adults completed the tool online, and a sub-sample (n = 15) were interviewed while completing the tool. Multi-group factorial invariance analysis of the online survey data found evidence for metric non-invariance of the SBQ-R, particularly for items three (communication of suicidal intent) and four (likelihood of suicide attempt in the future). Cognitive interviews revealed that autistic adults did not interpret these items as intended by the tool designers. Results suggest autistic adults interpret key questions regarding suicide risk differently to the general population. Future research must adapt tools to better capture suicidality in autistic adults.

Parent-Reported Rates and Clinical Correlates of Suicidality in Children with Autism Spectrum Disorder: A Longitudinal Study

This study investigated rates of suicidal ideation (SI) and suicidal and/or self-injurious behaviour (SSIB) reported by parents on the Child Behavior Checklist for 178 children with ASD over four annual assessments (ages 7-11 years). Analyses examined the frequency and persistence of SI and SSIB, and the association of SI and SSIB at any time point with child characteristics and internalizing and externalizing problems at age 7. SI occurred in 9.6% of children and was associated with fewer ASD symptoms and better adaptive functioning at age 7. SSIB occurred in 14.6% and was associated with poorer adaptive functioning and more externalizing behaviour at age 7. Internalizing problems were not associated with SI or SSIB at any time point. SI and SSIB rarely co-occurred (4%).

The Prevalence of Self-injurious Behaviour in Autism: A Meta-analytic Study

Self-injurious behaviour is purportedly common in autism, but prevalence rates have not yet been synthesised meta-analytically. In the present study, data from 14,379 participants in thirty-seven papers were analysed to generate a pooled prevalence estimate of self-injury in autism of 42% (confidence intervals 0.38-0.47). Hand-hitting topography was the most common form of self-injury (23%), self-cutting topography the least common (3%). Sub-group analyses revealed no association between study quality, participant intellectual disability or age and overall prevalence rate of self-injury. However, females obtained higher prevalence rates than males (p = .013) and hair pulling and self-scratching were associated with intellectual disability (p = .008 and p = .002, respectively). The results confirm very high rates of self-injury in autism and highlight within group risk-markers.

Multi-level modeling with nonlinear movement metrics to classify self-injurious behaviors in autism spectrum disorder

Self-injurious behavior (SIB) is among the most dangerous concerns in autism spectrum disorder (ASD), often requiring detailed and tedious management methods. Sensor-based behavioral monitoring could address the limitations of these methods, though the complex problem of classifying variable behavior should be addressed first. We aimed to address this need by developing a group-level model accounting for individual variability and potential nonlinear trends in SIB, as a secondary analysis of existing data. Ten participants with ASD and SIB engaged in free play while wearing accelerometers. Movement data were collected from > 200 episodes and 18 different types of SIB. Frequency domain and linear movement variability measures of acceleration signals were extracted to capture differences in behaviors, and metrics of nonlinear movement variability were used to quantify the complexity of SIB. The multi-level logistic regression model, comprising of 12 principal components, explained > 65% of the variance, and classified SIB with > 75% accuracy. Our findings imply that frequency-domain and movement variability metrics can effectively predict SIB. Our modeling approach yielded superior accuracy than commonly used classifiers (~ 75 vs. ~ 64% accuracy) and had superior performance compared to prior reports (~ 75 vs. ~ 69% accuracy) This work provides an approach to generating an accurate and interpretable group-level model for SIB identification, and further supports the feasibility of developing a real-time SIB monitoring system.

Long-term outcomes of pediatric traumatic cataracts and retinal detachments due to self-inflicted injuries

PURPOSE

To report the characteristics and longitudinal visual outcomes of traumatic cataracts and retinal detachments in children with self-inflicted injury.

METHODS

A retrospective case series of pediatric patients at a tertiary care center who sustained ocular trauma due to self-inflicted injury between 2000 and 2014.

RESULTS

A total of 11 children, all with an intellectual disability and a mean age of 10 ± 4.8 years (range, 2.8-16.2), were identified with traumatic cataract secondary to ocular self-inflicted injury over the study period. Five eyes had a concurrent unilateral retinal detachment. Over the course of follow-up, one additional eye developed a cataract and five eyes developed a retinal detachment. Patients underwent an average of 2.5 ± 2.3 procedures and 17.1 ± 10.7 eye examinations over 11.7 ± 4.2 years of follow-up; 36% required general anesthesia for examination. Visual acuity was improved or preserved in 77% of the eyes that underwent surgical interventions, but was worse in the remaining cases due to development of traumatic retinal detachment. The use of protective helmets, eye shields, and immobilizing orthoses were essential in management of active self-inflicted injury.

CONCLUSION

Traumatic cataracts and retinal detachments due to self-inflicted injury may cause severe visual loss. Visual prognosis although poor in children with severe intellectual disabilities may be optimized with risk awareness for early detection and customized interventions.

Caring for Adult Patients With Autism in the Critical Care Setting

Many adults with autism spectrum disorders (ASDs) are admitted as an inpatient, and much has been reported on their ASD-related characteristics and aggressive behaviors that complicate their care during hospitalizations. A variety of surgical and medical clinical conditions have required their admissions in the critical care unit. A limited number of case studies are present for hospitalized adults with ASD; most literature about young children was on how to provide care for them. An interdisciplinary approach with a focus on determining information specific to adult patients with ASD, medical problems or common causes of challenging behaviors, and medication history, as well as nutritional needs, is essential in meeting the care needs of autistic adults. Suggestions informed by multiple sources of evidence are presented to assist critical care nurses on how to provide support to care needs of adult patients with ASD during their hospital stay and transition to home.

Detecting and Classifying Self-injurious Behavior in Autism Spectrum Disorder Using Machine Learning Techniques

Traditional self-injurious behavior (SIB) management can place compliance demands on the caregiver and have low ecological validity and accuracy. To support an SIB monitoring system for autism spectrum disorder (ASD), we evaluated machine learning methods for detecting and distinguishing diverse SIB types. SIB episodes were captured with body-worn accelerometers from children with ASD and SIB. The highest detection accuracy was found with k-nearest neighbors and support vector machines (up to 99.1% for individuals and 94.6% for grouped participants), and classification efficiency was quite high (offline processing at ~ 0.1 ms/observation). Our results provide an initial step toward creating a continuous and objective smart SIB monitoring system, which could in turn facilitate the future care of a pervasive concern in ASD.

Observed emotional reactivity in response to frustration tasks in psychiatrically hospitalized youth with autism spectrum disorder

LAY ABSTRACT

Large emotional reactions (e.g. outbursts, tantrums) can be common and distressing in the lives of individuals with autism spectrum disorder and their families. Most previous research that has examined these types of emotional responses have used questionnaire data or focused only on young children. In addition, very little research has included individuals across a large range of intellectual and functional abilities or individuals with more severe emotional and/or behavioral difficulties. This study examined emotional reactions to frustrating tasks in 6-21-year-olds with autism spectrum disorder who were psychiatrically hospitalized due to emotional and/or behavioral difficulties. We describe change in the amount, intensity, duration, and range of emotional reactions that the participants displayed from a neutral activity to the frustrating tasks and then to a neutral recovery period. We also examined associations between characteristics of the participants and these emotional reactions. We found that younger children displayed more negative emotions across the neutral and frustrating tasks; however, age did not relate to how big their reactions to frustration were. Furthermore, we found that individuals with fewer adaptive skills (i.e. age-appropriate life skills) and minimally verbal individuals had bigger reactions and recovered less following the frustration tasks. The results highlight the importance of examining emotional reactions in individuals with lower verbal and adaptive abilities and for interventions to consider the connection between verbal and adaptive skills and emotional reactions.

Associated Factors of Self-injury Among Adolescents with Autism Spectrum Disorder in a Community and Residential Treatment Setting

Self-injurious behavior (SIB) occurs in up to 50% of individuals with autism. As one of the most serious conditions in individuals with developmental disabilities, SIB affects the individual and his or her family in multiple contexts. A systematic analysis of factors most commonly associated with SIB could inform the development of individualized intervention strategies. The current study examined factors related to SIB in an analysis of client records of 145 children with autism in a comprehensive care center. Predictor variables included age, gender, the Adaptive Behavior Composite, sensory processing, aggression, stereotypies, irritability, adaptive skills, and medical conditions. Age, irritability, and the Adaptive Behavior Composite were found to significantly predict SIB.

Links between self-injury and suicidality in autism

BACKGROUND

Autistic individuals without intellectual disability are at heightened risk of self-injury, and appear to engage in it for similar reasons as non-autistic people. A wide divergence of autistic perspectives on self-injury, including those who frame it as a helpful coping mechanism, motivate investigating the link between self-injury, suicide ideation, and attempts which has been reported in typically developing individuals.

METHOD

One hundred three autistic participants completed the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT), the Suicide Behaviors Questionnaire (SBQ-R), and the Interpersonal Social Evaluation List (ISEL-12) across two online studies. Logistic regression was conducted to predict self-harming status via responses to questions on suicidality, and to predict whether certain self-injurious behaviors, including cutting, were especially associated with suicide ideation and attempts. Non-parametric correlation analysis examined relationships between suicide ideation/attempts and other variables that might characterize self-harmers especially at risk of suicidality. These included perceived access to social support, purposes or reasons for self-injury, the number of different self-injurious behaviors engaged in, the duration and lifetime incidence of self-injury, and the individual's feelings about their self-injury.

RESULTS

While self-injuring status was significantly predicted by responses to a question on suicide ideation and attempts, there was no relationship between suicide ideation/attempts and a participant's personal feelings about their self-injury. The method of cutting was also predicted by suicide ideation and attempts, though other methods common in autistic people were at borderline significance. Use of self-injury for the regulation of low-energy emotional states like depression, for self-punishment or deterrence from suicide, and for sensory stimulation, was associated with suicide ideation and attempts, as was the number of self-injurious behaviors engaged in. There was no significant relationship between suicide ideation/attempts and the duration and lifetime incidence of self-injury or social support.

CONCLUSIONS

These preliminary data suggest that while individuals might frame their self-injury as a positive or neutral thing, there remains a concerning relationship between self-injury and suicidality which exists regardless of individual feelings on self-injury. This is consistent with the theoretical perspective that self-injury can be a "gateway" through which individuals acquire capability for lethal suicidal behaviors. The data highlight that particular methods (cutting) and reasons for self-injury may be of significant concern, but this information, which might be of extreme value for clinicians, requires further investigation and validation.

Behavioral Treatment of Self-Injury: 2001 to 2016

Individuals diagnosed with intellectual and developmental disabilities (IDD) frequently exhibit self-injurious behavior (SIB). Previous research has examined the published literature on behavioral treatments of SIB from 1964-2000. Results suggested that these treatments were highly efficacious at decreasing SIB, particularly when based on the results of a functional assessment. The purpose of this review is to update, replicate, and extend the previous research. The current findings indicate an increase in studies reporting automatically maintained SIB as well as less efficacious treatments overall. Discussion of our conclusions and methods of SIB assessment and treatment are discussed, both as they relate to the previous review and for future directions.

Self-Injurious Behavior Among Adults With ASD: Hospitalizations, Length of Stay, and Costs of Resources to Deliver Care

OBJECTIVE

Research on hospitalizations related to self-injurious behavior and ideation among adults with autism spectrum disorder (ASD) is limited. This study compared admissions, average length of stay, and costs of resources to deliver care for such hospitalizations between adults with and without ASD.

METHODS

The 2014 Healthcare Cost and Utilization Project National Inpatient Sample was used to compare 5,341 discharge records for adults with ASD and 16,023 records for adults without ASD, matched on age and gender in a 1:3 ratio. Hierarchical logistic and linear regressions accounted for clustering by hospital. Covariates included gender, race-ethnicity, age, region, comorbidities, number of procedures, and insurance.

RESULTS

Among hospitalized adults, those with ASD were twice as likely as those without ASD to have a hospitalization related to self-injurious behavior and ideation. Among hospital stays for self-injurious behavior and ideation, adults with ASD had average lengths of stay that were 2.14 days longer (95% confidence interval [CI]=1.20-3.08) compared with adults without ASD. Among adults with a hospitalization related to self-injurious behavior and ideation, unadjusted average costs for those with ASD were 36.8% higher than for adults without ASD. After the analysis accounted for covariates and length of stay, adults with ASD still had 7.48% (95% CI=1.05%-14.32%) higher costs.

CONCLUSIONS

Adults with ASD were twice as likely as adults without ASD to have a hospitalization related to self-injurious behavior and ideation. Among adults with such a hospitalization, those with ASD had longer stays and, even after the analysis accounted for length of stay, higher costs.

Self-harm prevalence and ideation in a community sample of cis, trans and other youth

Background: Trans youth have been reported to have high rates of self-harm, depression and bullying, and find it difficult to seek support. However, much of this research comes from gender identity clinics; non-clinical samples and those who reject gender binaries remain under-researched. Aims: This study investigated the experiences of a community school-based sample of Trans, identifying youth, Other, and cis-gendered adolescents in relation to their experiences of low mood, bullying, associated support, self-harm ideation and peer-related self-harm. Methods: An online survey was completed by 8440 13-17 year olds (3625 male, 4361 female, 227 Other, and 55 Trans). Results: Trans and Other students had significantly higher rates of self-harm ideation and peer self-harm, in comparison to cis-gendered students. These Trans and Other students reported significantly higher rates of bullying and self-reported depression and significantly less support from teachers and staff at school, in fact these students did not know where to go to access help. Discussion: This community sample confirms findings of high rates of self-harm ideation, self-reported depression and bullying for Trans youth as previously reported in clinic-based samples. However, by accessing a community sample, the salience of the category "Other" was established for young people today. While Other and Trans identified students both struggled to find support, those who identified as Trans were more likely to have been bullied, and have experienced self-reported depression and thoughts of self-harm. Thus, those who identify as transgender represent a high-risk group that needs targeted support within schools and by statutory and nonstatutory community services. Unpacking the category of Other would be beneficial for future research, as well as exploring resilience within this group and intersecting identities such as sexuality, Autism, or experiences such as earlier abuse.

A 'choice', an 'addiction', a way 'out of the lost': exploring self-injury in autistic people without intellectual disability

Background

Non-suicidal self-injury (NSSI) describes a phenomenon where individuals inflict deliberate pain and tissue damage to their bodies. Self-injurious behaviour is especially prevalent across the autism spectrum, but little is understood about the features and functions of self-injury for autistic individuals without intellectual disability, or about the risk factors that might be valuable for clinical usage in this group.

Methods

One hundred and three autistic adults who responded to an online advertisement were classified as current, historic or non-self-harmers in accordance with responses to the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT). Multinomial regression aimed to predict categorisation of participants in accordance with scores on tests of autistic traits, alexithymia, depression, anxiety, mentalising and sensory sensitivity. Linear regression examined relationships between these predictors and the range, frequency, lifetime occurrence and functional purposes of NSSI. Qualitative analysis explored the therapeutic interventions that participants had found helpful, and what they wished people understood about self-injury.

Results

Current, historic and non-self-harming participants did not differ in age, age at diagnosis, male-to-female ratio, level of employment or education (the majority qualified to at least degree level). The most common function of NSSI was the regulation of low-energy affective states (depression, dissociation), followed by the regulation of high-energy states such as anger and anxiety. Alexithymia significantly predicted the categorisation of participants as current, historic or non-self-harmers, and predicted use of NSSI for regulating high-energy states and communicating distress to others. Depression, anxiety and sensory-sensitivity also differentiated participant groups, and sensory differences also predicted the range of bodily areas targeted, lifetime incidence and frequency of NSSI. Sensory differences, difficulty expressing and identifying emotions also emerged as problematic in the qualitative analysis, where participants expressed the need for compassion, patience, non-judgement and the need to recognise diversity between self-harmers, with some participants perceiving NSSI as a practical, non-problematic coping strategy.

Conclusions

Alexithymia, depression, anxiety and sensory differences may place some autistic individuals at especial risk of self-injury. Investigating the involvement of these variables and their utility for identification and treatment is of high importance, and the voices of participants offer guidance to practitioners confronted with NSSI in their autistic clients.

Parenting preschoolers with autism: Socioeconomic influences on wellbeing and sense of competence

BACKGROUND

Previous research suggests that parents raising a child with autism experience higher levels of psychological distress than parents of typically developing children and parents of children with other developmental disorders. Little is known, however, about the intersection between the effects of socioeconomic status (SES) on the wellbeing and sense of parental competency of parents of pre-schoolers with autism and how it relates to child symptom severity.

AIM

To examine the relationship between their child’s symptom severity, SES, as measured by neighbourhood advantage and occupational status, on the psychological wellbeing and perceived parenting competence among parents of preschoolers with autism.

METHODS

Parents of 117 preschool-aged children with a diagnosis of autism spectrum disorder (ASD), 107 mothers and 54 fathers, completed questionnaires about their child’s symptoms of ASD and functioning, their own perceptions of their wellbeing and parental competence on entry to an early intervention program in Sydney, Australia. Parents also provided demographic information pertaining to their occupation, level of education attained and address (postcode). All children were also assessed for their severity of symptoms using the Autism Diagnostic Observation Schedule. The Australian Socioeconomic Index of occupational status as a measure of familial SES and the Index of Relative Socio-economic Advantage and Disadvantage as a measure of neighbourhood advantage were used to examine the impact of SES on parental sense of competence and wellbeing.

RESULTS

Compared to normative populations, both mothers and fathers in our sample reported significantly higher levels of parenting sense of efficacy but lower levels of interest in the parenting role. Mothers also displayed higher levels of satisfaction. Both mothers and fathers displayed higher levels of depression than normative populations with mothers also reporting greater levels of stress and anxiety. Child symptom severity was associated with maternal parenting competency with these relationships amplified among mothers with higher familial SES and who lived in areas of greater neighbourhood advantage. Increased adaptive functioning was associated with better maternal wellbeing, particularly among mothers who lived in areas of greater neighbourhood advantage. Contrastingly, paternal parenting competence was generally not influenced by child adaptive functioning or symptom severity, although for those in higher familial SES brackets, children’s symptom severity and maladaptive symptoms were negatively related to paternal sense of parenting efficacy. There was a trend towards moderate relationships between lower familial SES and greater depression, stress and anxiety among fathers, but no relationship with their child’s ASD symptom severity or functioning.

CONCLUSION

SES differentially impacts wellbeing and sense of parenting competence and its relationship to the impact of child symptoms for mothers and fathers of preschoolers with autism.