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Self Injurious Behaviour in Autism

Prevalence of Self Injurious Behaviours in Autism: Underlying Clinical and Pain Issues

Implications for Behaviour Management Strategies  

Illustrative Video

Behavioural issuesSample of 270 children

Unspecified

Throwing self on the floor

Hair (pulling)

Body (hitting, biting, scratching)

Hands (biting)

Head (banging, punching, hitting, poking and stabbing)

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Types of Self-Injurious Behaviours

SIB

Avoidance

Attention Seeking

Confusion

Denied Request

Requesting

Sensory overload

Transition

Dietary

Pain

HealthFatigue

Function?

Setting?

Coping

Behavioural Functional Analysis Peter Sturmey, 2001. 

Description of behaviourWhat is the behaviour?How often does the behaviour occur in a day?/ week?How long does it last for?Is the behaviour more prevalent at certain time, on certain days/period?Does the behaviour seem to occur “out of the blue”?List the situations preceding 3 instances of behaviour?Describe how you respond to the behaviour?What does the child do after the behaviour occur?

Environment Related FactorsDoes the behaviour occur more often in certain environment?Does the behaviour occur more often when the environment is noisy?Does the behaviour occur more often when the room is warm?Does the behaviour occur more often in a crowed place?Does the behaviour occur more often when the child is asked to participate to an activity or respond to a demand?Does the behaviour occur after the child has been told no or is prevented to do something of his own choosing.Is the behaviour related to changes of activity or environment?Does the behaviour occur when the child is on his own in room without anybody present?

Behavioural Functional Analysis (Cont.)Biological factorsDoes the behaviour occur more often when the individual is in the same environment/position for an extended period of time?Does the behaviour occur more often when the individual has a cold?Does the behaviour occur more often when the individual has gut problems?Could the behaviour be related to pain or discomfort (abdominal-, ear-, tooth-, head-ache)

Fatigue-related factorsDoes the behaviour occur more towards the end of the day?Does the behaviour occur more towards the end of a long, busy day, or following a prolonged activity?Does the individual show signs of being tired immediately before the occurrence of the behaviour?

Sleep-related factorsIs the occurrence of the behaviour related, in any way, to a change of sleep habits?Does the behaviour occur more often immediately after waking up?

Dietary-related factorsCould the behaviour be related to a specific food allergy or intolerance?Could the behaviour be related to sugar intake?Is the behaviour more likely to occur after meals or before meals?Is the behaviour related to a dietary change?Is the behaviour related to change in appetite change?

Alertness-related factorDoes the individual appear vague, puzzled, confused or baffled just prior, during or after a change (increase/decrease) of behaviour?

Communication-related factorsDoes the behaviour occur following the individual’s inability to communicate a need?Is the behaviour related to misunderstanding requests or instructions by the caregivers?Is the behaviour related to the caregiver’s misunderstanding of the individual request? Modified Functional Analysis Check List adapted from Peter Sturmey, 2001. 

Challenging behaviour rated as either not at all= 0, just a little = 1, fairly often = 2, very often = 3. VocalMoaning, whining, whimpering (fairly soft)Crying (moderately loud)Screaming or yelling (very loud)A specific sound or vocalization for pain

SocialNot cooperating, cranky, irritable, unhappy Less interaction, withdrawnSeeks comfort or physical closenessDifficult to distract, not able to satisfy or pacify

FacialFurrow browChange in eyes, including: squinting, eyes opened wide, eyes frownTurn down of mouth, not smilingLips pucker up, tight, pout, or quiverClenches or grinds teeth, chews, thrusts tongue out

ActivityNot moving, less active, quietJumping around, agitated, fidgety

Body and limbsFloppyStiff, spastic, tense, rigidGesture to or touches part of body that hurtsProtects, favours, or guards part of body that hurtsFlinches or moves away part of body that hurtsMoves or position self in specific way to show pain

Physiological signsShiveringChange of colour, pallorSweating, perspiringTears Sharp intake of breath, gaspingBreath holding Adapted from Breau et al 2002. 

Non-Communicative Children’s Pain Checklist

Behaviour Rating Scales

Rarely SIB and Challenging Behaviours (CB) receive a great deal of attention in Autism

Aberrant Behavior Checklist (Amoan et al 1985)

Nisonger Child Behavior Rating Form (Aman et al 1996)

Behavior Problem Inventory (Rojahn et al 1995)

PDD-BI (PDD Behavior Inventory) (Cohen 2003)

Overt Aggression Scale (Hellings et al 2005)

Case Studies

Child BS Age: 12 years old.

Diagnosis: Autism.

Communication: Non verbal/ no assisted communication.

SIB: Daily– episodes lasting for up to 6 hours. Hit forehead, jaws, side of face with wrists.

Development: Onset of difficulties at 18 months. Chronic constipation. Regression at temporally association with vaccination.

Clinical presentation: Thin (<2nd percentile), pale complexion and dark circle under eyes. Enlarged lymph nodes. Chronic constipation. Inflammation (upper and lower GI). Gut dysbiosis. Pain.

Child JW Age: 9 years old.

Diagnosis: Autism.

Communication: Non verbal/ no assisted communication.

SIB: Daily– episodes lasting for up to one hour. Hit forehead, jaws, side of face with wrists.

Development: Onset of difficulties at 4 months. Kidney and liver infection at 8 months, requiring hospitalisation. Chronic constipation. Regression at 18-24 months (temporally association with vaccination).

Clinical presentation: Thin (2nd percentile), pale complexion and dark circle under eyes. Enlarged lymph nodes. Chronic constipation

Child TG

Age: 9 years old.

Diagnosis: Autism.

Communication: Single words for requests.

SIB: Daily– episodes lasting for up to 30 min. Head banging wall and floor.

Development: Onset of difficulties 2 years and 6 months. Loss of language and became socially withdrawn (cause unknown).

Clinical presentation: Thin (< 2nd percentile), pale complexion and dark circle under eyes. Chronic constipation. Enterocolitis. Gut pathogens. Calprotectin <20 (normal). Gut Dysbiosis.

Child CL

Age: 9 years old.

Diagnosis: Autism.

Communication: Non verbal, some Makaton signs and PECS.

SIB: Daily. Head banging against wall, bites hands on knuckles and finger nails causing them to split half way.

Development: Onset of difficulties 2 years and 6 months. Lost language and became socially withdrawn (cause unknown).

Clinical presentation: Thin (5th percentile), pale complexion and dark circle under eyes. Chronic constipation. Abdominal bloating. Rectal prolapse not healing because of constipation. Calprotectin: 700. Daily anal bleeding. No inflammation of colon and gastric system. Gut Dysbiosis, H. pilori infection.

Pain Measurement Child

Domains BS JW TG CLVocal (0-12) 9 11 10 7Social (0-12) 10 11 7 8Facial (0-15) 14 6 6 4

Activity (0-6) 3 3 3 4Body and limbs (0-18) 12 8 10 4

Physiology (0-15) 11 2 10 2Total count 61 41 46 29

Pain measurement using the Non-Communicative Children’s Pain Checklist-Postoperative Version (NCCPC-PV) for children BS, JW,TG and CL. Total scores were recorded in each behaviour areas. The behaviours were rated as either not at all= 0, just a little = 1, fairly often = 2, very often = 3.

Source of Pain?

Nutritional deficits

Intestinal dysbiosis

GI inflammation

Motility issues

Food sensitivities

GASTROINTESTINAL

TOXICOLOGICAL

Methylation issues

Oxidative stress

Glutathione depletion

Heavy metal toxicity

NEUROLOGICAL

False neurotransmitters

Neuronal inflammation

Dysregulated neurotransmitters

Autonomic dysfunction

IMMUNOLOGICAL

Environmental allergies

Chronic inflammation

Autoimmune reactions

Chronic infections

Health presentation Sample of 270 children

EatingIssuesn=272

FrequentInfectionn=267

Allergyn=270

Eczeman=271

Asthman=269

MotorIssuesn=232

Epilepsyn=257

Behaviour partly relates to healthSelf-injury

Statistical association with hyperactivity and immune problems

Gut problemsClinically defined as:Abnormal bloatingPosturingConstipation and/or diarrhoeaAbnormal stools:

ColourConsistencyUndigested foodMucusBloodSmellAmountsShape

In terms of stool markers:Inflammation:

CalprotectinLyzosymeWhite blood cellsLactoferrin

Immune imbalancesIgA

DysbiosisParasiteBeneficial gut floraCommensalPathogenicYeastShort Chain Fatty acidspH

Absorption-digestion

Gut problems

0%

10%

20%

30%

40%

50%

60%

70%

80%

58.82%

40.82%

28.00%

36.96%

26.53%

52.08%

68.69%62.62%

35.55%

61.73%

33.17%

66.51%

Percentage (no gut problems)

Percentage (gut prob-lems)

Statistical association with regressive autism, hyperactivity and parental immune problems

Gut problemsAssociations with current gut problems: Pearson’s chi-square Current gut problems and regressive autismThere was a significant association between those with current gut problems and those with regressive autism χ2 (1) = 5.619, p = .018. This is reflected by the odds ratio whereby those with current gut problems were 1.93 times more likely to have regression than those without. Current gut problems and hyperactivityThere was a significant association between those with current gut problems and those with hyperactivity χ2 (1) = 9.665, p = .002. This is reflected by the odds ratio whereby those with current gut problems were 2.33 times more likely to have hyperactivity than those without. Current gut problems and crying There was a significant association between those with current gut problems and those with crying problems χ2 (1) = 5.075, p = .024. This is reflected by the odds ratio whereby those with current gut problems were 1.80 times more likely to have crying problems than those without. Current gut problems and sleep problemsThere was a significant association between those with current gut problems and those with sleep problems χ2 (1) = 6.649, p = .010. This is reflected by the odds ratio whereby those with crying problems were 1.96 timesmore likely to have sleep problems than those without.

Immune problems

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

76.14%

47.78%

31.87%

55.29%

22.73%

64.77%

83.05%

62.94%

35.88%

57.14%

35.19%

62.50%

Percentage (no immune problems)

Percentage (immune problems)

Is SIB associated with any biochemical marker?

e.g. Oxydative stress marker (Isoprostane) and Cell-mediated immune marker (neopterine)?

Self Injurious Behaviour Self Injurious Behaviour

No Yes No Yes

Immune markers 1

Self Injurious Behaviour

No YesSelf Injurious Behaviour

No Yes

Immune markers 2

Self Injurious Behaviour

No Yes

Self Injurious Behaviour

No Yes

Intervention

Individualised intervention based on individuals needs

Key elementsRemove Stressors

GF/CF –SCD- Sugar etc.Allergens

ToxinsInfection

Optimal metabolism & physiologyNutritionDigestion

Immune systemLiver & kidney functions

Hormonal

InflammationLDN

Nicotine PatchPrednisolone and other steroidal anti-inflammatory

agents

• The case studies presented suggest that SIB, characterised by a sudden occurrence of behaviour and absence of identifiable triggers likely correlates with pain. • Clinical investigations of these children combined with a functional behavioural analysis indicate that inflammatory gastro-intestinal dysregulations could be related to their pain and self injurious behaviour.

Conclusion I

• Larger group analysis suggest that no particular biomedical marker is specifically associated with SIB, however, immune dysfunction appears to be more prevalent in this sub-group of ASD children.

• Successful interventions require to go beyond the basic nutritional and dietary interventions and should include an anti-inflammatory element.

• The source of inflammation should ultimately be identified for a sustained recovery from SIB and pain.

Conclusion II

• Any health deterioration can potentially precipitate the reoccurrence of SIB, even if there is no direct impact on the GI system in children with known GI inflammation and SIB.

• Teaching alternative modes of communication is essential to replace SIB in children who have learned to use such behaviour to communicate their needs.

Conclusion III