Efficacy of psychotropic drugs for reducing self-injurious behavior in the developmental disabilities

Multidisciplinary assessment and treatment of self-injurious behavior in autism spectrum disorder and intellectual disability: integration of psychological and biological theory and approach

The objective of this review is to consider the psychological (largely behavioral) and biological [neurochemical, medical (including genetic), and pharmacological] theories and approaches that contribute to current thinking about the etiology and treatment of self-injurious behavior (SIB) in individuals with autism spectrum disorder and/or intellectual disability. Algorithms for the assessment and treatment of SIB in this context, respectively, from a multidisciplinary, integrative perspective are proposed and challenges and opportunities that exist in clinical and research settings are discussed.

Pharmacological interventions for self-injurious behaviour in adults with intellectual disabilities: Abridged republication of a Cochrane systematic review

We aimed to determine clinical effectiveness of pharmacological interventions for self-injurious behaviour in adults with intellectual disability. We searched the following databases: CENTRAL; MEDLINE; EMBASE; PsycINFO; CINAHL; SCI; SSCI; Conference Proceedings Citation Index - Science; Conference Proceedings Citation Index - Social Science and Humanities; ZETOC; World Cat .We also searched ClinicalTrials.gov,ICTRP and the reference lists of included trials. We included randomised controlled trials that examined drug interventions versus placebo for self-injurious behaviour. We found five double-blind, placebo-controlled trials, which included a total of 50 people. Four trials compared the effects of naltrexone versus placebo and one trial clomipramine versus placebo. We did not identify any relevant placebo-controlled trials for other drugs. We presented a narrative summary, as meta-analysis was not appropriate due to differences in study designs, differences between interventions and heterogeneous outcome measures. There was weak evidence in included trials that any active drug was more effective than placebo for people with intellectual disability demonstrating self-injurious behaviour. Due to sparse data, an absence of power and statistical significance, and high risk of bias for four of the included trials, we are unable to reach any definite conclusions about the relative benefits of naltrexone or clomipramine compared to placebo.

Pharmacological interventions for self-injurious behaviour in adults with intellectual disabilities

BACKGROUND

Self-injurious behaviour among people with intellectual disability is relatively common and often persistent. Self-injurious behaviour continues to present a challenge to clinicians. It remains poorly understood and difficult to ameliorate despite advances in neurobiology and psychological therapies. There is a strong need for a better evidence base in prescribing and monitoring of drugs in this population, especially since none of the drugs are actually licensed for self-injurious behaviour.

OBJECTIVES

To determine clinical effectiveness of pharmacological interventions in management of self-injurious behaviour in adults with intellectual disability.

SEARCH METHODS

We searched the following databases on 19 February 2012: CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index - Science, Conference Proceedings Citation Index - Social Science and Humanities, ZETOC and WorldCat. We also searched ClinicalTrials.gov, ICTRP and the reference lists of included trials.

SELECTION CRITERIA

We included randomised controlled trials that examined drug interventions versus placebo for self-injurious behaviour (SIB) in adults with intellectual disability.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each trial using a data extraction form. We present a narrative summary of the results is presented. We did not consider meta-analysis was appropriate due to differences in study designs, differences between interventions and heterogeneous outcome measures.

MAIN RESULTS

We found five double-blind placebo-controlled trials that met our inclusion criteria. These trials assessed effectiveness and safety of drugs in a total of 50 people with intellectual disability demonstrating SIB. Four trials compared the effects of naltrexone versus placebo and one trial compared clomipramine versus placebo.One of the naltrexone versus placebo trials reported that naltrexone had clinically significant effects (≥ 33% reduction) on the daily rates of three of the four participants' most severe form of SIB and modest to substantial reductions in SIB for all participants; however, this study did not report on statistical significance. Another trial reported that naltrexone attenuated SIB in all four participants, with 25 mg and 50 mg doses producing a statistically significant decrease in SIB (P value < 0.05). Another trial (eight people) indicated that naltrexone administration was associated with significantly fewer days of high frequency self injury and significantly more days with low frequency self injury. Naltrexone had different effects depending on the form and location of self injury. Another trial with only 26 participants found that neither single-dose (100 mg) nor long-term (50 and 150 mg) naltrexone treatment had any therapeutic effect on SIB.Comparison of clomipramine versus placebo found no statistically significant benefit for any outcome measure, which included SIB rate and intensity, stereotypy and adverse events. However, it showed clinically significant improvement in the rate and intensity of SIB and stereotypy.There were very few noteworthy adverse events to report in any of the four trials in which these were reported.All trials were at high risk of bias, apart from one trial (Lewis 1996), which was probably at low risk of bias. The short period of follow-up was a significant drawback in the design of all five trials, as it did not allow long-term assessment of behaviour over time.We were unable to examine the efficacy of antidepressants other than clomipramine, antipsychotics, mood stabilisers or beta-blockers as we did not identify any relevant placebo-controlled trials.

AUTHORS' CONCLUSIONS

There was weak evidence in included trials that any active drug was more effective than placebo for people with intellectual disability demonstrating SIB. Due to sparse data, an absence of power and statistical significance, and high risk of bias for four of the included trials, we are unable to reach any definite conclusions about the relative benefits of naltrexone or clomipramine compared to placebo.

Self-Injurious Behavior in the Elderly

OBJECTIVE

To review the literature for self-injurious behavior (SIB) in the elderly and compare it with SIB in other populations.

DATA SOURCES

Literature searches were conducted using MEDLINE/PubMed, Merck-Medicus, clinicaltrials.gov, OVID, and an Internet search for "self-injurious behavior, SIB, and self-mutilation."

STUDY SELECTION

Sixteen studies were reviewed. Studies used provided data relative to SIB in general or treatment for the geriatric population.

DATA SYNTHESIS

The data suggest that young children, adolescents, young adults, and developmentally disabled patients most commonly exhibit self-injurious behaviors. The elderly population, in particular those with certain psychiatric and neurodegenerative illnesses, also can exhibit these behaviors. There has been little published for this cohort in comparison with other populations. The authors reviewed the literature for papers on SIB and its management in the elderly. A general overview of SIB is provided, including specific factors for the elderly. Management strategies including pharmacological and behavioral interventions are also discussed.

CONCLUSION

Although the prevalence of SIB appears to be relatively small, patients who do exhibit this behavior are of great concern to their families and caregivers. Risk factors such as dementia, depressive disorders, physical illness, and loss of a spouse, which are commonplace in the elderly, all may contribute to those who do exhibit SIB. The literature is devoid of specific drug therapies or treatments that demonstrate significant efficacy in patients with SIB, particularly the elderly. Additionally, while there is some understanding of why younger people engage in SIB, it is hypothesized that elderly SIB is different and is related to frustration, as well as to deficits in the ability to communicate effectively with others. Recognition of behavioral triggers, behavioral-care planning, and safety management are key.

Oral self-injurious behaviors in patients with developmental disabilities

Self-injurious behaviors (SIB) in patients who have developmental disabilities is a complex disorder, and its underlying etiologies are poorly understood. SIB is a significant factor in hospitalizations, decisions to use psychotropic medications, and institutional placement for people who have developmental disabilities. Because this group often manifests oral SIB, the dentist may be the first professional called upon to evaluate a patient. Dental therapy focuses on symptomatic treatment to minimize tissue damage caused by SIB, but addressing the underlying impetus for the behavior is essential for successful treatment. Determining definitive therapeutic interventions is difficult because of the mixed bio behavioral etiologies for SIB. This complication necessitates a team approach that includes medical and behavioral specialists.

[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.

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

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

Reviewing the use of antipsychotic drugs in people with intellectual disability

INTRODUCTION

Antipsychotics are the most widely prescribed drugs in people with intellectual disability even if schizophrenia and other psychotic disorders do not affect more than 3% of such population. Many authors outline the lack of studies on the efficacy of antipsychotics on schizophrenia or other psychotic disorders in people with intellectual disability.

MATERIALS AND METHODS

The aim of the present study is to review all evidences resulting from international trials selected by Medline, and compare efficacy and side effects of different antipsychotics in people with both intellectual disability and psychotic disorders and/or behavioural disorders.

RESULTS

195 studies were identified; 117 concern traditional antipychotics while 78 new generation ones. If we consider the type of studies, it results that only the 12.8% of all production is represented by meta-analyses, systematic reviews, and randomised and not controlled trials.

CONCLUSIONS

Randomised controlled trials and systematic reviews would be the golden standard for therapeutical studies; unfortunately they are really few in this field. It is anyway significative that all the studies reported focus on the use of antipsychotics in people with intellectual disability presenting behavioural problems. To increase the validity of these studies it is recommendable to proceed only with well-designed studies, possibly double-blind versus placebo or other medications. There is need to define precise inclusion criteria, precise symptomatological or behavioural targets and adaptative ability assessment, using valid and reliable diagnostic instruments.

Self-injurious behavior and the efficacy of naltrexone treatment: a quantitative synthesis

People with mental retardation, autism, and related developmental disabilities who self-injure are treated with a wide array of behavioral techniques and psychotropic medications. Despite numerous reports documenting short-term and some long-term changes in self-injury associated with the opiate antagonist naltrexone hydrochloride, no quantitative review of its efficacy has been reported. We conducted a quantitative synthesis of the peer-reviewed published literature from 1983 to 2003 documenting the use of naltrexone for the treatment of self-injurious behavior (SIB). Individual-level results were analyzed given subject and study characteristics. A sample of 27 research articles involving 86 subjects with self-injury was reviewed. Eighty percent of subjects were reported to improve relative to baseline (i.e., SIB reduced) during naltrexone administration and 47% of subjects SIB was reduced by 50% or greater. In studies reporting dose levels in milligrams, males were more likely than females to respond. No significant relations were found between treatment outcomes and autism status or form of self-injury. Results are discussed with respect to future efficacy work related to study outcomes and the pharmacological treatment of self-injury.

Pharmacologic therapies aid treatment for autism

In the absence of other guidelines, practitioners often prescribe by analogy with roles of psychotropic medicines in other psychiatric disorders (e.g., the ability of serotonergic antidepressants to reduce compulsive behavior). There is a slow but steady accumulation of data supporting the use of psychotropic medications to manage certain symptoms in children with autism. These data support the use of stimulant medications for attention/hyperactivity symptoms, with willingness to suspend such treatment if a trial is unsuccessful. Risperidone is supported for other disruptive behaviors, especially of an irritable/disruptive nature, but with attention to increases in appetite and weight. SSRIs and atypical antipsychotics may be helpful for a variety of perseverative behaviors, although one would seldom prescribe antipsychotic medication for mild perseverative behavior alone. SSRIs may be useful for anxiety. Again, there is no compelling evidence that existing pharmacologic treatments have a major role in treating the core symptoms of autism, especially the profound impairments in social interaction and communication. Further well-designed double-blind studies with significant numbers of subjects and defined target symptoms will provide the data that will guide therapeutic decisions in the future.

Differential response of operant self-injury to pharmacologic versus behavioral treatment

The purpose of this study was to investigate the hypothesis that self-injurious behavior (SIB) maintained by environmental factors will be more effectively treated by behavioral treatments than by haloperidol. Fifteen subjects were enrolled in this study. The efficacy of both haloperidol and a behavioral treatment was assessed. At the onset of treatment, subjects were randomized to receive either haloperidol or a placebo. During each day of treatment, data were collected during sessions with a behavioral treatment and sessions without a behavioral treatment. Behavioral treatment resulted in a statistically significant decrease in SIB, but haloperidol did not. Eighty-three percent of subjects were classified as responders to the behavioral treatment whereas only 25% of the subjects were responders to haloperidol (p = .019). We conclude that individuals with operant SIB are more likely to respond to behavioral treatments than to haloperidol.

Pharmacotherapy of disorders in mental retardation

This is a review of pharmacotherapy in children and adolescents with mental retardation from the perspective of DSM and ICD disorders. The existing research is reviewed in young people with mental retardation but, when data are lacking, we examined the literature from adults with mental retardation and from typically-developing children. The literature is discussed for each of the following disorders: ADHD, anxiety disorders, bipolar disorder, conduct disorder, depression, enuresis, schizophrenia, self injury, and tics and movement disorders. With the possible exception of ADHD, there is a woeful lack of empirical data on most of these disorders in young people with mental retardation. Clinicians will often be forced to extrapolate from data on adults having mental retardation and from typically-developing children. The best policy is probably to treat such patients cautiously, while gathering data on the effects of such therapy in the hopes of beginning a data base.

Mental health services for people with intellectual disability: a conceptual framework

The present paper discusses the application of the 'matrix model' to mental health services for people with intellectual disability. There is great variability between the service models in this area, which makes comparisons and conclusions difficult. The present model facilitates the breaking down of these complexities into understandable parts so that future directions for research, service planning and delivery can be logical, coherent and evidence-based.

Effect of divalproex sodium on aggression and self-injurious behaviour in adults with intellectual disability: a retrospective review

The aim of the present study was to evaluate the efficacy of divalproex sodium treatment in adults with intellectual disability, and aggressive or self-injurious behaviour. Twenty-eight adults aged between 20 and 63 years of age with severe, long-lasting behavioural problems were treated with divalproex sodium (dosage 500-4000 mg day(-1)). Clinical changes were assessed at 2-73 months into the pharmacological treatment utilizing the Clinical Global Impression Severity (CGI-S) scale, and monthly behavioural counts of aggressive and self-injurious acts. Seventy-one percent of subjects demonstrated a moderate or marked improvement on the CGI-S; another 21% demonstrated mild benefits. Among the patients for whom objective prospective behavioural counts were available, 88% showed a significant reduction in aggression and self-injurious behaviour, 46% had other psychotropic medications discontinued, and another 39% had psychotropic medications decreased. One patient had serious thrombocytopenia which required the discontinuation of divalproex sodium, and one other had vomiting and worsened aggression. The present preliminary, uncontrolled study suggests that adults with intellectual disability, and aggressive or self-injurious behaviour may respond to divalproex sodium, and that this drug is well-tolerated in the majority of subjects.

Using analog baselines to assess the effects of naltrexone on self-injurious behavior

Naltrexone (NLTX), an opiate receptor antagonist, has been prescribed as a pharmacological intervention for the treatment of self-injurious behavior (SIB). Previous research has investigated NLTX's effects in the absence of information about the role of environmental events related to SIB. This study extended previous analyses by administering NLTX on analog baselines using a double-blind, placebo-controlled reversal design. Pretreatment functional analysis results showed that the SIB of the two participants occurred in more that one assessment condition. For one participant NLTX produced slight reductions in SIB across baseline conditions. The second participant's results showed that NLTX reduced head-slapping occurring during demand sessions, but had no apparent effect on head-banging occurring during alone and demand sessions. These outcomes suggest that NLTX may have function- and/or response-specific treatment effects. The potential utility of this model as a general method for assessing pharmacological interventions, as well as other implications and limitations, are discussed.

Adult head-banging and stereotypic movement disorders

Stereotypic movement disorders (SMD) such as head-banging, which are common among children with mental retardation or pervasive developmental disorders, may also occur in intellectually normal adults. We report a 27-year history of daily head-banging with self-injury in a 49-year-old man with normal cognition. The patient had no personal or family history of Tourette's syndrome, tic disorder, obsessive-compulsive disorder (OCD), or mental retardation. The frequency of his stereotypical head-banging increased with anxiety, loud noises with startle, and boredom. He reported a sense of pleasure from his head-banging, and the frequency of this behavior decreased when he was treated with the opioid antagonist naltrexone. Although not diagnostic, the self-stimulatory or pleasurable component of head-banging, body-rocking, thumb-sucking, and other SMD may help distinguish them from tics, Tourette's syndrome, OCD, and deliberate self-harming behavior. This report reviews the disorders associated with SMD and discusses the potential mechanisms for these behaviors. The treatment of SMD includes drugs that work through opioid, serotonergic, or dopaminergic systems.

Alternative therapies in the treatment or oral self-injurious behavior: a case report

This paper presents the case of a child with severe mental retardation and a history of oral self-injurious behavior (SIB). While the behavior was refractory to a number of dental interventions, some success was achieved through a combination of behavioral therapy techniques and therapeutic touch (a relaxation technique). Etiologies of SIB are discussed, along with descriptions of alternatives to traditional dental therapy for this difficult problem.

The behavioral neurobiology of self-injurious behavior in rhesus monkeys. Current concepts and relations to impulsive behavior in humans

The objective of this report is to critically review past reports and present new data on the psychobiology of self-injurious behavior (SIB) and/or "risky" or "impulsive" behavior in primates (human and nonhuman). One aim was to reexamine how early social deprivation and neurobiological changes caused by deprivation might contribute to SIB in monkeys, and how the causes of SIB in monkeys might inform us about the psychobiology of suicide in humans. A second aim was to examine the evidence that social deprivation in monkeys produces reductions in brain 5-HT system function that are causal or coincident factors associated with self-injurious or impulsive behavior. Prior studies and new data indicate that the environmental causes of SIB and unusual aggression in rhesus monkeys do not produce reductions in brain 5-HT system activity and that experimental production of low levels of brain 5-HT system activity does not reliably promote either SIB or unusual other-directed aggression in monkeys. A third and final aim was to suggest that in severe cases of environmentally induced SIB and/or aggression in monkeys, having relatively high or low levels of 5-HT system activity may not be related to ongoing behavior because the 5-HT system may not interact with other neurotransmitter systems in the usual way. Overall, the contention is that primates exhibiting SIB and unusual aggression may have altered 5-HT system function, but this may be but one aspect of a more profound disorganization of brain function involving many neurohormonal and transmitter systems. Contemporary theorizing and experimentation tends to be restricted to the idea that altered function in one key system might be the cause of a specific form of psychopathology. In the future, research examining the probable change interactions of neurotransmitter and neuroendocrine systems as underlying causes of behavioral disorders should have a high priority.

Effects of REM sleep deprivation on the d-amphetamine-induced self-mutilating behavior

It is well known that self-mutilating behavior (SMB) is developed in rats and humans during the daily treatment with d-amphetamine. Accordingly, in this work it was found that the daily treatment with 7.5 mg/kg d-amphetamine induced in rats a progressive appearance of SMB. Lower doses (5.0 mg/kg) were uneffective and higher doses (10 mg/kg) produced a pattern of SMB in which the mutilation induced at the beginning of the d-amphetamine administration disappears completely as the treatment progresses. Interestingly, it was also found that REM sleep deprivation (48 h) potentiated significantly the SMB induced by the daily administration of 7.5 mg/kg d-amphetamine, and to lesser extent, the SMB induced by the daily treatment with 10 mg/kg d-amphetamine. R(+)-SCH-23390 a D1 dopamine (DA) receptor antagonist blocked completely or abolished the SMB induced by 7.5 mg/kg d-amphetamine in REM sleep deprived rats while (+/-)-sulpiride a D2 DA receptor antagonist had only a partial blocking effect. Haloperidol a D1/D2 DA receptor antagonist behaved as a D1 antagonist. Our results indicate that REM sleep deprivation enhances the SMB induced by the daily administration of d-amphetamine and suggest the involvement of D1 DA receptors in the mechanism underlying the SMB. A role of REM sleep deprivation is also suggested in the appearance of self-mutilating episodes in d-amphetamine addicts.

Naltrexone and self-injurious behavior: a retrospective population study

The results of studies of the opiate antagonist naltrexone (NLTX) in the treatment of self-injurious behavior (SIB) in mentally retarded people have been equivocal. They have relied on small patient samples in short-term trials with varying degrees of scientific rigor. Nor has the clinical efficacy of NLTX for SIB been tested against its wider application in nonresearch settings. The present study is a retrospective, long-term study of the clinical use of NLTX for SIB, drawn from clinical experience in the entire population of the state schools of Texas (population = 8,000). More than 50% of the 56 SIB individuals treated with NLTX were maintained on the drug by virtue of clinical benefit perceived by treating professionals; 25% of the 56 individuals could be classified as unequivocal responders based upon strict objective response criteria. Variables associated with positive response were level of disability and lack of concurrent aggression. Unexpectedly, all of the objective responders displayed a gradual and continuous decrease in SIB over-time, even after 3 years of treatment.

Treatment of autistic disorder

OBJECTIVE

To present an overview of a variety of treatment approaches in individuals with autistic disorder.

METHOD

Selected studies and articles are reviewed.

RESULTS

In the past three decades, great progress has been made in the treatment of autistic disorder, particularly in the area of education and parental involvement, with the objective to transfer to home and in other situations learning acquired in school. A role for psychoactive agents, when combined with psychosocial treatments, has been identified.

CONCLUSIONS

Although considerable advances have been made in a variety of interventions-educational, psychosocial, and biological-knowledge about the comparative and combined efficacy of the various treatment modalities is lacking. From the parents' perspective, particularly, support and continuity of services require improvement.

Psychopharmacology in child and adolescent psychiatry: a review of the past seven years. Part I

OBJECTIVE

To present a critical overview of the literature published in the past 7 years on the efficacy and safety of psychoactive agents in mental retardation with associated psychiatric disorders, autistic disorder, Tourett's disorder, and attention-deficit/hyperactivity disorder.

METHOD

Double-blind and placebo-controlled clinical trials and open studies were reviewed and selected reports presented.

RESULTS

The literature review reveals that progress has been made in the psychopharmacological treatment of the above conditions. This is partly because more studies use larger sample sizes and a narrower age range of diagnostically homogeneous patients and use a more sophisticated methodology than in previous years. Greater attention is being paid to a critical assessment of psychoactive agents and to their safety, to the efficacy as well as to the effectiveness of drugs. The 5-year National Plan for Research on Child and Adolescent Mental Disorders (1991) based on the Institute of Medicine Report (1989) already has had a significant impact on psychophamacology research.

CONCLUSIONS

Advances in methodology, initiatives of the National Institute of Mental Health, and the advent of DSM-IV should continue to enhance research and improve pharmacotherapy in clinical practice.

Diagnostic-based pharmacological treatment of behavior disorders in persons with developmental disabilities: a review and a decision-making typology

This article reviews the diagnostic rationale for treatment of behavior disorders with psychotropic medication. After reviewing the concerns over the use of psychotropic medication and the use of diagnostic criteria with persons with developmental disabilities in the past, the variety of potential diagnoses that may underlie a behavior disorder are reviewed. A model to guide clinical decision making is then developed on the basis of this review, and areas for future research are suggested. The key questions are identified as making reliable differential diagnoses of behavior disorders and demonstrating that these differential diagnoses successfully identify more effective psychotropic medications for the treatment of behavior disorders in persons with developmental disabilities.