Research roundup: Self-injurious behavior, part II

The final part in the series focuses on self-injurious behaviors among individuals with intellectual or developmental disabilities

By Practice Research and Policy staff

November 17, 2011Self-injurious behaviors occur at a higher frequency among individuals with various neurodevelopmental disorders such as autism. The patterns of self-injurious behavior, including possible predictors and contingency factors, are different among this population than among more traditional psychiatric populations that self-injure. Distinguishing the different patterns of occurrence and continued behavior is essential for quality assessment and intervention.

MacLean, W.E., Tervo, R. ., Hoch, J., Tervo, M., & Symons, F.J. (2010). Self-injury among a community cohort of young children at risk for intellectual and developmental disabilities. The Journal of Pediatrics, 157(6), 979-983.    

Summary

Case records from a neurodevelopmental pediatric clinic at a children’s specialty hospital were used to study 196 children between the ages of 18 and 72 months. Most of these children were white males coming from a two-parent household in which parents were semiprofessionals or higher, with a minimum of a high school degree. Data from a demographic questionnaire and the Child Development Inventory, Inventory for Client and Agency Planning and the Child Behavior Checklist (CBCL) were analyzed. Lower intelligence and expressive language, sensory and motor impairment, and co-occurring diagnoses of cerebral palsy, autism or epilepsy did not serve as distinguishing factors in identifying those participants who self-injure despite reports from other studies listing these traits as risk factors for self-injury. Children displaying self-injurious behavior had higher rates of hurting others, destruction and unusual or compulsive habits than their non self-injurious peers. Adult attention to negative behavior may be a powerful reinforcer for the continuation of such behavior.

Practical considerations

Given that one third of this community cohort was found to self-injure relatively often at a low rate of severity, the provision of a comprehensive evaluation of young children referred to a neurodevelopmental pediatric clinic is strongly recommended. The use of broad spectrum behavioral measures such as the CBCL and the Motivation Assessment Scale to measure functioning is a useful component of these comprehensive assessments. Parents of children with similar age and level of functioning could benefit from group functional communication training, to monitor and prevent minor child self-injury. Much research is still needed to better understand the pathways and processes that evolve into self-injury in early development, especially for children with intellectual and/or developmental delay. 

Jasper, A.D. & Morris, C.W. (2011). Special educators and nonsuicidal self-injurious behavior: Self-injury training, exposure, and self-efficacy. Teacher Education and Special Education, 34(4). doi: 0888406411413144

Summary

A survey of 390 special educators throughout the rural and urban Midwest collected information regarding special educator training, experiences and knowledge of nonsuicidal self-injury behavior (NSSIB). Most participants held either a bachelor’s or master’s degree, worked in an elementary or secondary school and worked in a teaching capacity in addition to separate work with students who have mild disabilities. With 78 percent of participants reporting interactions with self-injuring students, it is of significant concern that only 37 percent received training in that area. Those with training reported higher self-efficacy and competence in identifying symptoms and risks of self-injury as well as effectively intervening in these cases. Untrained special educators were less likely to report encounters with self-injuring students. This raises the concern of whether untrained special educators are recognizing the signs of and risks for self-injury among their students.

Practical considerations

Psychologists who work in school settings, consult to schools or work with students with mild disabilities are often asked to intervene with students who self-injure. Knowing that the majority of teachers, who report interacting with self-injurious students have never received training in this area will help psychologists better determine how best to provide services to these students. Psychologists may be called upon to educate other staff or to develop intervention plans in order to reduce the incidence of self-injury. Recognizing the limits of training may ensure that appropriate education and guidance is provided to those who will implement psychologist-designed interventions. Since most professionals, regardless of training, still did not feel very confident in their ability to intervene with self-injury, improved quality and accessibility of appropriate training is needed.

Darrow, S.M., Follette, W.C., Maragakis, A., & Dykstra, T. (2011). Reviewing risk for individuals with developmental disabilities. Clinical Psychology Review, 31(3), 472-477. doi: 10.1016/j.cpr.2010.11.008

Summary

This article provides an overview of the the current literature on developmentally delayed individuals in an effort to develop a framework for future research. One common finding was that those with lower social skill levels were more likely to self-injure. Several methodological challenges were identified, including substantial inconsistency in defining and assessing self-injury. Partly due to this inconsistency, results from studies of self-injurious behavior (SIB) report prevalence rates ranging from two to 50 percent. Two primary models for predicting SIB were identified in the literature — a biomedical model and a behavior analytic model. While the models provide some plausible explanations for the occurrence of SIB, they have not yet translated to clinical practice possibilities.

Practical considerations

Due to poorly operationalized definitions and other methodological inconsistences, the existing literature on self-injurious behavior should be read with a critical eye. Careful assessment of the predictors and contextual factors identified in the literature may facilitate case formulation. The literature provides some guidance for clinicians, yet awareness of the many possible explanations for such behavior may prompt further analysis regarding cause and effect for each individual client.

Symons, F.J. (2011). Self-injurious behavior in neurodevelopmental disorders: Relevance of nociceptive and immune mechanisms. Neuroscience and Biobehavioral Reviews, 35(5), 1266-1274. doi: 10.1016/j.neubiorev.2011.01.002

Summary

The author describes a biomedical model of self-injurious behavior (SIB) among those with intellectual and neurodevelopmental delay. The relationship between SIB and pain, as well as possible links to development of chronic neuropathic pain — such as symptoms due to repeated tissue damage–is explored. Such a biomedical model of SIB suggests that self-inflicted stimulation could become highly resistant to change, which finding is consistent with the existing literature indicating that the process of eliminating SIB is a slow, difficult one. This provides a framework to test predictions focused on behavioral and biological aspects of SIB and pain that may differ in a population with intellectual and developmental disabilities (IDD). It is suggested that IDD individuals who self-injure have dysregulated pain or their nociceptive capacities develop altered, disrupted or impaired pain thresholds, expression and signaling. For those who have severe communication delay, this circumstance is made more difficult as they may have difficulty describing or understanding an explanation of experiences of pain. The author suggests that treatment of SIB in IDD individuals cannot be effective without addressing issues of biomedical variables that relate to health and wellbeing, such as immune and inflammatory systems associated with pain.

Practical Considerations

SIB that occurs without early intervention may be related to the development of a chronic pain system that causes sensory and sickness-like behavior. This results in a cyclical process with SIB being supported not only socially but biologically as well. Once this cyclical process is established in an individual, interventions may need to be tuned to the possibility that potential pain receptor have changed. Therefore, a multi-pronged assessment and treatment strategy may be needed in order to reduce or eliminate SIB once it has become established in individuals with many neurological, psychiatric and developmental disorders.