Self Injurious Behaviour and Autism

Interventions

There are numerous interventions (treatments, services and other forms of support) designed to prevent or reduce self injurious behaviours in people on the autism spectrum. Most interventions are

• the same as those designed to help people on the autism spectrum deal with other challenging behaviours
• the same as those designed to help other people deal with self injurious behaviours

These interventions fall into three main categories: psychological techniques, medications and other approaches. In practice, these approaches may overlap. For example, a multidisciplinary team may suggest the use of medications or physical exercise alongside a behavioural support programme.

We believe that, whichever interventions are used, it is important to treat the person with respect, listen to what they say and give them choices over their lives. We also believe that any intervention should follow the principles established by Fleming, Hurley and the Goth (2015).

Functional assessment

Most researchers and practitioners believe it is essential to identify the specific factors that may be causing an individual to self injure before deciding the most appropriate intervention to use. This is normally done using a functional assessment, which is described by Minshawi et al (2014).

“Prior to the implementation of any intervention for SIB, an appro­priate evaluation of SIB should include a combination of a thorough interview with the individual and/or caregivers, indirect assessments, behavioral observation, pre-treatment objective data collection (eg, behavior logs, scatterplots, event or duration recording), a medical evaluation, and a [functional behaviour assessment]. Being able to identify and thoroughly assess the occurrence and impact of a person’s SIB on their, and others’ quality of life, as well as identifying those specific situations or events which trigger and contribute to the persistence of the individual’s problem behavior is currently the accepted method to increase more person-centered treatment plan­ning and progress monitoring in lieu of more reactive, punitive procedures.”

Psychological approaches

There are a number of psychological approaches sometimes used to prevent or reduce self injurious behaviours in people on the autism spectrum. Many of these approaches use behavioural techniques based on the principles of applied behaviour analysis and may be incorporated within a behavioural support plan. They include

• providing a more effective way for the person to tell you what they want. For example, you could teach the person to use picture cards, sign language, or a voice output communication aid
• providing more structure and routine. For example, you could build a range of activities into the person’s day to minimise boredom and reduce opportunities for self injury. You could also use a visual schedule to show them what they are expected to do and when
• for example, changing the way you ask the person to do things. For example, you could make sure you don’t ask the person to do too many difficult things all at once and give them regular breaks
• letting the person have the thing that they want, such as a snack or toy, but only if they behave in an alternative, more desirable way instead of injuring themselves
• providing more attention to the person when they are not injuring themselves, in cases where this attention will encourage the person to stop the self injurious behaviour – please see note 1
• providing less attention to the person in cases where the self injurious behaviour is encouraged by attention from other people – please see note 2
• use of response reduction procedures. For example, time-out (placing the person away from other people for a short time) and facial screens (a piece of fabric is tied over the eyes for a short time) – please see note 3 and 4
• use of aversives, such as spraying water mist into the person’s face, or putting unpleasant smells in front of them – see note 3 and 4
• use of physical restraints. For example, manual practices (such as holding the person) and protective equip­ment (such as helmets, gloves, or arm restraints) –see note 3 and 4.

Note 1: Some people on the autism spectrum do not enjoy social attention. For them, social attention may cause distress and increase challenging behaviours.

Note 2: We believe that “punishment-based” psychological techniques, such as response reduction procedures, aversives and physical restraint, should only be used in exceptional circumstances, with extreme caution and following established guidance on safeguarding. Some “punishment-based” behavioural strategies (such as the use of electric shock) are illegal in many countries including the UK.

Note 3: According to Minshawi et al (2014) “Physical restraint should be considered a last-resort form of behavioral intervention due to the restrictive nature of this intervention and the potential for injury or harm and should only be used as part of a structured behavior intervention plan”.

Medications

If the self injurious behaviour is pervasive, long standing or very severe, then medications may be considered. Many of these medications are designed to change the amount and the action of specific neurotransmitters in the brain in order to change the person’s behaviour. Those neurotransmitters include dopamine, endorphins, glutamate, and gamma-aminobutyric acid.

Specific types of medications used to treat self injurious behaviours include

• Antidepressants - such as citalopram (Celexa) and sertraline (Lustral)
• Antipsychotics - such as clonazapem (Klonopim) and lamotrigine (Lamictal).
• Opioid antagonists – such as naltrexone (Nalorex) and naloxone (Prenoxad)

Please note: Medications should only be used under the direction of a suitably qualified practitioner, such as a paediatrician or psychiatrist, and only after there has been no or limited response to other interventions. The effects should be carefully monitored and reviewed on a regular basis and the medication withdrawn if no significant benefits are seen. Some medications have significant side effects or interactions with other substances. Some may even make the self injurious behaviours worse in some people.

Other approaches

There are numerous other interventions that have been suggested as ways to prevent or reduce self injurious behaviours in people on the autism spectrum. These include

• Improvements to the social care system. For example ensuring that people on the autism spectrum have more control over their day to day lives and that they are not mistreated or abused
• Standard health care. For example providing treatments for specific medical problems, such as migraine, otitis media and reflux
• Assistive and adaptive technology/augmentative and alternative communication tools. For example, encouraging the person to use picture cards or pre-recorded voice messages in order to help them communicate more effectively
• Physical interventions. For example, encouraging the person to undertake physical exercise (swimming, swinging or trampolining) in order to resolve arousal/motor control issues
• Sensory interventions. For example, giving the person edible objects (like carrots or raw pasta) in order to provide alternative, safer sensory experiences or providing noise-dampening headphones to block out excessive noise
• Diets and dietary supplements. For example, providing DMG or vitamin B6 supplements in order to improve the body’s neurological and immunological functioning

Please note: There is currently no high quality research evidence to suggest that these interventions are effective in reducing self injurious behaviours in people on the autism spectrum, although that does not necessarily mean that they do not work.

Updated

02 Nov 2017