UNDERSTANDING AND TREATING
SELF-INJURIOUS BEHAVIOR
Written by Stephen M. Edelson, Ph.D.
Center for the Study of Autism, Salem, Oregon
Self-injurious behavior is one of the most devastating
behaviors exhibited by people with developmental disabilities. The
most common forms of these behaviors include: head-banging, hand-biting,
and excessive self-rubbing and scratching. There are many possible
reasons why a person may engage in self-injurious behavior, ranging
from biochemical to the social environment. This paper will discuss
many of the causes of self-injury and will describe interventions
based on the underlying cause.
Functional analysis
Initially, a functional analysis should be conducted
in order to obtain a detailed description of the person’s self-injurious
behavior and to determine possible relationships between the behavior
and his/her physical and social environment (see Wacker, Northup
& Lambert, 1997). The information obtained from a functional
analysis should include: Who was present? What happened before,
during and after the behavior? When did it happen? Where did it
happen? Hopefully, the answers to these questions may help reveal
the reason(s) for the behavior.
Prior to data collection, it is important to define
the behavior of interest. The focus of the functional analysis should
be on a specific behavior (e.g., wrist-biting) rather than a behavior
category (e.g., self-injury). Combining several types of self-injury
into one general behavior may make it difficult to determine different
reasons for each behavior. For example, if a child engages in wrist-biting
and excessive self-scratching, there may be different a reason for
each behavior (see Edelson, Taubman & Lovaas, 1983). Wrist-biting
may be a reaction to frustration, whereas excessive scratching may
be a means of self-stimulation.
During data collection, salient characteristics
of the self-injurious behavior should be recorded, such as the frequency,
duration, and severity. Data collection should also include information
about the person's physical and social environment. The physical
environment should include: the setting (e.g., classroom, cafeteria,
playground), lighting (natural light, florescent, incandescent),
and sounds (e.g., lawn mower, another child screaming). The names
(or codes) of everyone in the person's environment should also be
recorded, such as teachers, parents, staff, visitors and students/clients.
Other factors to be recorded are: time of day and day of the week.
Physiological Reasons for Self-Injurious Behavior
Biochemical
Some researchers have suggested that the levels
of certain neurotransmitters are associated with self-injurious
behavior. Beta-endorphins are endogenous opiate-like substances
in the brain, and self-injury may increase the production and/or
the release of endorphins. As a result, the individual experiences
an anesthesia-like effect and, ostensibly, he/she does not feel
any pain while engaging in the behavior (Sandman et al., 1983).
Furthermore, the release of endorphins may provide the individual
with a euphoric-like feeling. Support for this explanation comes
from studies in which drugs that block the binding at opiate receptor
sites (e.g., naltrexone and naloxone) can successfully reduce self-injury
(Herman et al., 1989).
Research on laboratory animals as well as research
on administering drugs to human subjects have indicated that low
levels of serotonin or high levels of dopamine are associated with
self-injury (DiChiara et al., 1971; Mueller & Nyhan, 1982).
In a study on a heterogeneous population of mentally retarded individuals,
Greenberg and Coleman (1976) administered drugs,
such as reserpine and chlorpromazine, to reduce serotonin levels.
These researchers observed a dramatic increase in both aggressive
and self-aggressive behavior. Drugs that elevate dopamine levels,
such as amphetamines and apomorphine, have been shown to initiate
self-injurious behavior (Mueller & Nyhan, 1982; Mueller et al.,
1982).
Interestingly, Coleman (1994) studied a group
of autistic children who had low levels of calcium (i.e., hypocalcinuria).
These individuals often exhibited eye-poking behavior. When given
calcium supplements, the eye-poking decreased substantially. In
addition, language functioning improved.
What to look for. When self-injury is
associated with a biochemical abnormality, there may be little or
no relationship between the person's physical/social environment
and self-injury. Thus, the behavior may occur in various settings
and around different people. However, self-injury may occur less
frequently in situations in which the person's behavior is incompatible
with self-injury, such as eating, playing, and working on a task.
Intervention. Nutritional and medical
interventions can be implemented to normalize the person's biochemistry;
this, in turn, may reduce the severe behavior. Although drugs are
often used to increase serotonin levels or to decrease dopamine
levels, the Autism Research Institute in San Diego has received
reports from thousands of parents who have given their son/daughter
vitamin
B6, calcium and/or DMG. These parents often observed rather
dramatic reductions in, and, in some cases, elimination of self-injurious
behavior. Parents have also reported reductions in severe behavior
problems soon after placing their child on a restricted diet, such
as a gluten/casein-free
diet, or removing specific foods to which their child showed
signs of an allergic
reaction.
Seizures
Self-injurious behavior has also been associated
with seizure
activity in the frontal and temporal lobes (Gedye, 1989; Gedye,
1992). Behaviors often associated with seizure activity include:
headbanging, slapping ears and/or head, hand-biting, chin hitting,
scratching face or arms, and, in some cases, knee-to-face contact.
Since this behavior is involuntary, some of these individuals seek
some form of self-restraint (e.g., having their arms tied down).
Seizures may begin, or are more noticeable, when the child reaches
puberty, possibly due to hormonal changes in the body.
What to look for. Since seizure-induced,
self-injurious behaviors are involuntary, one may not observe a
relationship between the person's behavior and his/her environment.
However, since stress can trigger a seizure, there may be a relationship
between stressors in the environment and self-injury. This may include
too much physical stimulation (e.g., lighting, noise) and/or social
stimulation (e.g., reprimands, demands). Foods may also induce seizures
(Rapp, 1991). If the behavior began or got worse during puberty,
one may also consider the possibility of seizure activity. If seizures
are suspected, it is recommended that the person have an EEG.
Intervention. Although drugs are used
to control seizure activity, they are often associated with adverse
side effects. There is evidence that DMG will reduce seizure activity
without negative side effects (Gascon et al., 1989; Roach &
Carlin, 1982).
Genetic
Self-injurious behavior is also common among several
genetic disorders, including Lesch-Nyhan Syndrome, Fragile
X Syndrome, and Cornelia de Lange Syndrome. Since these genetic
disorders are associated with some form of structural damage and/or
biochemical dysfunction, these abnormalities may cause the person
to self-injure.
What to look for. Those individuals with
Lesch-Nyhan Syndrome often bite around the mouth area and their
fingers; those with Fragile X Syndrome often engage in self-biting
(including lips and fingers); and those with Cornelia de Lange Syndrome
often engage in self-biting and face hitting.
Interventions. Biochemical interventions,
such as nutritional supplements and drugs, appear to be the treatment
of choice for these individuals. It is also possible that other
interventions discussed in this paper may help these individuals.
For example, behavior modification may teach the person to inhibit
these behaviors.
Arousal
It has often been suggested that a person's level
of arousal is associated with self-injurious behavior. Researchers
have suggested that self-injury may increase or decrease one's arousal
level. The under-arousal theory states that some individuals function
at a low level of arousal and engage in self-injury to increase
their arousal level (Edelson, 1984; Baumeister & Rollings, 1976).
In this case, self-injury would be considered an extreme form of
self-stimulation.
In contrast, the over-arousal theory states that
some individuals function at a very high level of arousal (e.g.,
tension, anxiety) and engage in self-injury to reduce their arousal
level. That is, the behavior may act as a release of tension and/or
anxiety. High arousal levels may be a result of an internal, physiological
dysfunction and/or may be triggered by a very stimulating environment.
A reduction in arousal may be positively reinforcing, and thus,
the client may engage in self-injury more often when encountering
arousal-producing stimuli (Romanczyk, 1986).
What to look for. With respect to under-arousal,
self-injury would be observed when the person is bored and/or is
not involved in stimulating activities. With respect to over-arousal,
self-injury would be observed in arousal-inducing situations, such
as an especially noisy or brightly lighted room. Social interaction
may also be perceived as very stimulating.
Intervention. If the person is under-aroused,
an increase in activity level may be helpful. For example, an exercise
program can be implemented (e.g., stationary bicycle). If the person
is over-aroused, it is recommended that steps be taken, usually
before the behavior begins, to reduce his/her arousal level. This
may include: relaxation techniques (Cautela & Groden, 1978),
deep pressure (Edelson et al. 1998), vestibular stimulation (King,
1991), and/or removing the person from a stimulating situation.
Exercise may also be used to reduce arousal level.
Pain
Another reason why an individual may engage in
headbanging is to reduce pain such as pain from a middle ear infection
or a migraine headache (de Lissovoy, 1963; Gualtieri, 1989). There
is growing evidence that pain associated with gastrointestinal
problems, such as acid reflux and gas, may be associated with
self-injury. In addition, some autistic individuals report that
certain sounds, such as a baby crying or a vacuum cleaner, can cause
pain. In all of these instances, self-injury may release beta-endorphins
which would dampen the pain. Conversely, these individuals may be
'gating' the pain. In this case, stimulating one area of the body
(in this case by injuring oneself) may reduce or dampen the pain
located in another area of the body.
What to look for. Self-injury behavior
may occur sporadically. The person may show signs of illness or
appear to be in pain on those days he/she exhibits self-injury.
The person's family history should be checked to see if migraines
run in the family. If possible, the person should have his/her ears
examined and body temperature measured to check for a middle ear
infection.
Intervention. Consumption of dairy products
are often associated with middle ear infections in many children.
Certain foods in the person's diet may be responsible for migraines.
Additionally, magnesium deficiency is associated with an increase
in sound sensitivity. Magnesium
supplements are safe and can reduce sound sensitivity in some
individuals. The recommended dosage is 3 to 4 milligrams per 10
pounds a day. Auditory
integration training has also been shown to reduce sound sensitivity
(Rimland & Edelson, 1994).
Sensory
Excessive self-rubbing or scratching may be an
extreme form of self-stimulation.
The person may not feel normal levels of physical stimulation; and
as a result, he/she damages the skin in order to receive stimulation
or increase arousal (Edelson, 1984).
What to look for. The person appears
to be insensitive to pain and possibly touch. The behavior may decrease
when the person is busy (e.g., playing, working on a task) because
his/her attention is directed away from his/her body.
Intervention. The person may be encouraged
to apply safe forms of physical stimulation to those parts of the
body which he/she rubs and/or scratches excessively. This could
include applying a massaging vibrator, rubbing textured objects
against the skin (such as uncooked beans or macaroni), and rubbing
a brush against the skin. There is also evidence that placing a
topical anesthetic on the self-injured area may reduce the behavior.
Frustration
Caretakers and parents often report that the child's
self-injury is a result of frustration. This is consistent with
the traditional Frustration è Aggression model proposed by Dollard
and his colleagues (1939). Commonly reported scenarios include:
a person with poor communication
skills becomes frustrated because of his/her lack of understanding
of what was said to him/her (poor receptive communication) or because
the caretaker does not understand what is said/requested; or an
individual who has good communication skills but does not get what
he/she wants. These reasons are discussed more in the next section.
Social Causes
Communication
Communication problems have often been associated
with self-injurious behavior. If a person has poor receptive and/or
has poor expressive language skills, then this may lead to frustration
and escalate into self-injury.
What to look for. If the person has poor
receptive skills, communication may be the problem if the behavior
occurs after someone says something to him/her. Additionally, if
a person has poor expressive skills, self-injurious behavior may
occur after he/she tries to communicate, perhaps by gesture; and
the caretaker does not understand or does not respond appropriately.
Intervention. With respect to expressive
language, these individuals should be taught functional communication
skills (Dyer & Larsson, 1997). With respect to receptive communication
skills, the person may be chronically ill (e.g., constant headache,
nausea) and may not be able to clearly focus his/her attention to
what was said. This may be due to sensitivity to certain food items.
In addition, there is evidence that auditory
integration training (AIT) may improve receptive language skills
as a result of better retrieval of information from long-term memory
(Edelson et al., 1999).
Social Attention
A great deal of research has investigated social
contingencies of self-injury. Lovaas
and his colleagues were able to control the frequency of self-injury
by manipulating social consequences (Lovaas et al., 1965; Lovaas
& Simmons, 1969). Basically, positive attention can increase
the frequency of self-injury (i.e., positive
reinforcement), whereas ignoring
the behavior can decrease the frequency (i.e., extinction).
What to look for. Following an episode
of self-injury, observe if/how the caretaker attends to the individual.
This attention may be positive (e.g., "What do you want?")
or negative ("Don't do that"). Note that the individual
may interpret a negative comment in a positive manner; and consequently,
the behavior may still be positively reinforced.
Interventions. If the person tends to
receive attention following the behavior, especially if the attention
is positive, then the caretaker should do his/her best to ignore
the behavior. If this is not possible because the person may injure
him-/herself, then the caretaker should minimize contact with the
individual while displaying little facial expression (neither approving
nor disapproving).
Consistency is very important because the behavior
will continue if the individual receives intermittent reinforcement
(i.e., attention) for the behavior. In fact, the behavior will be
stronger and more resistant to extinction if intermittently reinforced.
Since these individuals seek attention, which is quite normal for
most people, they should receive attention, but it should not be
contingent on self-injury. For example, the caretaker should give
the person attention when he/she does not engage in self-injury
(e.g., positive attention following ten minutes without an episode
of self-injury). There are numerous contingency strategies and schedules
that can be implemented to provide attention to the individual (e.g.,
DRO--differential reinforcement of other behaviors).
Obtain Tangibles
Another reason why an individual may engage in
self-injurious behavior is to obtain an object or event (Durand
1986; Durand & Cremmins, 1988). For instance, an individual
may request something, not receive it, and then engage in self-injurious
behavior. Additionally, the behavior may be reinforced positively
if the individual should, on occasion, receive the desired object
or event. A survey by Maisto et al. (1978) reported that 33% of
the clients engaged in self-injury because "they wanted something."
What to look for. Self-injury will typically
occur after he/she requests something and does not get it. The person
occasionally does get what he/she wants during or soon after engaging
in self-injury.
Interventions. In this situation, the
person's caretakers should not give anything to the person during
or following an episode of self-injury. Consistency is also important
because the behavior will continue even if the individual 'gets
what he wants' on only some occasions. (See previous discussion
on intermittent reinforcement.) A behavioral program can also be
set up to allow the person to make requests to obtain what he/she
wants, but this should occur in a controlled, systematic and non-violent
manner (e.g., giving the person options at specific times of the
day).
Avoidance/Escape
Some individuals engage in self-injury to avoid
or escape an 'aversive' social encounter (Carr et al., 1976; Edelson
et al., 1983). The individual may engage in self-injury just prior
to the social interaction; and thus, he/she may avoid the social
interaction before it begins. Alternatively, the individual may
engage in self-injury to escape (or terminate) a social encounter
that has already begun. For example, a caretaker may ask a client
to do something (e.g., to leave the play area); and if the person
does not want to comply, he or she may then engage in self-injury.
As a consequence, the caretaker's initial request is dropped or
forgotten, and the caretaker's attention is then directed at stopping
the behavior.
What to look for. In an 'avoidance' situation,
the person may begin to self-injure soon after someone enters the
room or approaches the person. In an 'escape' situation, the person
may begin to self-injure during a social encounter. The caretaker's
requests (or demands) are often abandoned soon after the person
engages in self-injury.
Interventions. In this situation, it
is important that the caretaker 'follows-through' with his/her requests
or demands placed on the individual. If the person should engage
in self-injury, the caretaker can continue to make the requests
during the behavior; or the caretaker may direct his/her attention
to stop the behavior but then present the request again until the
individual complies.
Concluding Remarks
It is important to understand that there are different
reasons why individuals engage in self-injurious behavior. Edelson
et al. (1983) observed three different forms of self-injury by the
same individual. This client was observed for a total of five hours,
and all antecedents and consequences of self-injury were recorded.
The client banged his head against his knee and then received attention;
pinched his stomach after the staff asked him to do something; and
bit his wrist after he asked for something but did not receive it.
It is also possible that one form of self-injury
may serve more than one function. For example, a person may engage
in wrist-biting when he is unable to communicate his needs and when
he does not get what he wants.
When conducting a functional analysis, the underlying
reason for the self-injurious behavior may not be obvious in some
cases. Based on observational data, the possible reasons for the
behavior should be ranked ordered, from most likely to least likely.
This rank ordering can then determine the order in which different
interventions are implemented.
Research has also shown that aversives (i.e.,
punishment) may effectively reduce or eliminate self-injurious behavior
by training the person to inhibit his/her behavior. If the behavior
is severe and if numerous attempts have failed to reduce the behavior,
then one may consider using an aversive to stop the behavior. Visual
screening (i.e., placing a cloth or piece of white paper in front
of the person's face) has been shown to be rather effective in reducing
severe behaviors, such as self-injury and aggression (Jones et al.
1991).
Other forms of aversives include: squirting lemon
juice in the mouth, spraying the person's face with a water mist,
tilting the person backwards, and in some cases, using a mild electric
shock. Great care should be taken when using an aversive strategy.
For example, inconsistency should be avoided, generalization across
different settings and caretakers should take place, and built-in
safe-guards to protect against possible abuse should be incorporated.
By carefully examining a person's behavior, one
can make a reasonable deduction regarding the appropriate intervention.
This strategy is much better than relying on 'trial and error.'
Finally, it is important to have a positive outlook when trying
to understand and treat this behavior. Behavior, even self-injurious
behavior, can usually be controlled in most situations.
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