Self-Injury Behavior (SIB)

7/31/2019 Self-Injury Behavior (SIB)

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Self-injurious Behavior

A teenage boy with severe mental retardation,

non verbal, who was demonstrating increasing

self-injury. To the point where both his mother

and the care team at the facility where he lives

were at their wits end. He was already on

multiple medications, including antipsychotics

and clonidine.(Was his SIB a clue?)


2/18

Journal of Developmental & Behavioral

Pediatrics (2010) discussed a similar

case A 7 yo male with severe mental retardation

and self-injurious behavior(hitting his facewith his fist, banging his head against the

wall/floor/table. Increasing infrequency/intensity for the last 6 monthscausing bruising and swelling of his forehead.

Parents reported that these behaviors wouldoccasionally occur due to frustration, butmore frequently occur for no reason at all.


3/18

Parents had tried verbal reprimands, andphysically restraining.

PMH: AOM, constipation, GERD as an infant.

Currently on no medications. Sleeps 9 hrs each night, no change in his appetite

or sleep.

Parents estimate he has ~ 20 words

Lives at home with parents, 2 sibs. For the past 2years attended the same life skills class with 8other students


4/18

Physical exam shows no changes in his growth

percentiles. No AOM. R side of his face is

erythematous


5/18

The safety concerns for the patient and the

disruptive effects of SIB on the family or

caretakers creates a situation that requires

immediate attention.

h d l d d


6/18

Why do general pediatricians need to

be comfortable taking care of these

patients? Because you will be seeing more of them!!!

(There will be more patients with self-injuriousbehaviors, and more of them will be managed inthe community)

Recurrent SIB will be seen by primary carepediatricians, primarily in young children with

autism and in adolescents with depression andcutting.

Hopefully you will have a B&D pediatrician, childpsychologist, child psychiatrist for consultations.


7/18

Autism, for example. A recent 2010 AAP journal

article, discusses how to evaluate GI disorders in

patients with ASD. Often these patients are

nonverbal and cannot describe their symptoms.

These patients will present with vocal and motor

behaviors, such as self-injury and aggression, as

well as sleep disturbance and irritability. 5-17% of people with mental retardation and

autism do serious harm to themselves by biting,

pulling out hair, banging their head or gougingtheir eyes on a regular basis.


8/18

Medical intervention

Chronic or acute health problems increase SIB. So it isvery important to diagnose and treat health conditionsthat are constantly aggravating the patient.

Ear problems, sleep disturbance, and digestive/GI

complaints(constipation, GERD) are the most commonculprits. Also want to rule out sinusitis, dentalproblems, migraine headaches, allergies,dysmenorrhea, seizures

(This is the Pediatricians major role, but not necessarilyhis only role.)

If no underlying medical condition is apparent, eval andtreatment just became more complicated.


9/18

Behaviorist Approach

For some patients with intellectual deficits, SIB is their way ofcommunicating that something is wrong or they want to be left alone. (In~70% of SIB cases, individuals are using the behavior as a form ofcommunication)

Can try to track antecedents and consequences of the behavior todetermine what the patient is trying to communicate. (Diary)

Has anything changed in the patients world (home, school)

SIB is very effective in eliciting attention.

Teaching new strategies for expressing needs and relating to other peoplewould be the preferred intervention in this case

(There are some studies that show 25% are refractory to behavioral

intervention, in terms of long-term effects) Stimulation theory?

Beta-endorphin release following SIB generates euphoric/anesthetic-likeeffect theory?


10/18

Medications

When there is a chemical imbalance in the brain, treatmentmust include medication.

There is no current drug that has been created specificallyfor SIB.

There has been some success with Risperidone, anantipsychotic serotonin/dopamine modulator. In a 2002clinical study there was a 25-50% reduction in SIB episodesin all but one patient.

UC Irvine has reported success with opiate-blockers such as

Naltrexone. (There is a theory that these patient have aninability to feel normal pain.)

Treament success depends on the patients unique brainchemistry.


11/18

Medications

Atypical antipsychotics*,

anticonvulsants/mood stabilizers*, SSRIs*,

opiate antagonists, and beta blockers have all

been used

BUT there are No evidence based guidelines


12/18

Genetic causes of SIB

Many forms of mental retardation are genetic,

and in some disorders SIB is so predictable it is

considered part of the disorder

Examples are Lesch-Nyhan(metabolic

syndrome), Prader-Willi, Smith-Magenis, de

Lange, and Fragile X


13/18

Will not only encounter SIB in autistm

or mental retardation

Some adolescents may self-mutilate to take

risks, rebel, reject their parents' values, state

their individuality or merely be accepted.

Patients may injure themselves out of

desperation or anger to seek attention.


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SIB can be a clue to psychological

issues or serious psychiatric disease

Hopelessness and worthlessness, or because they

have suicidal thoughts. These children may suffer

from serious psychiatric problems such as

depression, psychosis, Posttraumatic StressDisorder (PTSD) and Bipolar Disorder.

Children who have been abused or abandoned

Some adolescents who engage in self-injury maydevelop Borderline Personality Disorder as adults.


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Key to Treatment

Pick up on the clues - what is driving the SIB?

Combination of education, behavioral

intervention/counseling, and medication

For a PCP, the treatment approach is often

rule out any medical causes or sources of pain,

then referral to a psychologist(for behavioral

therapy) or neurologist/psychiatrist(for med

assessment)


16/18

What would you have done with the

patient???


17/18

What happened with our patient

Sent him for a complete medical workup (CBC,

esr, crp, CMP, thyroid, UA, stool sample)

Prescribed Valium as an emergent measure,

until the medical workup was complete and

we could consult with psychiatry about

modifying his medication regimen.


18/18

References

http://merrill.ku.edu/PDFfiles/selfinjurious%20behavior.pdf

http://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Families

Journal of Developmental & BehavioralPediatrics, Challenging Cases in Developmentaland Behavioral Pediatrics. April 2010

Jounal of American Academy of Pediatrics,Gastrointestinal Disorders in Individuals withAutism Spectrum Disorders. Jan 2010
http://merrill.ku.edu/PDFfiles/selfinjurious%20behavior.pdfhttp://merrill.ku.edu/PDFfiles/selfinjurious%20behavior.pdfhttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Familieshttp://merrill.ku.edu/PDFfiles/selfinjurious%20behavior.pdfhttp://merrill.ku.edu/PDFfiles/selfinjurious%20behavior.pdfhttp://merrill.ku.edu/PDFfiles/selfinjurious%20behavior.pdf

Self-Injury Behavior (SIB)

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