I have shared previous posts by Bill Nason, consultant and author of the Facebook page,
Autism Discussion page. Today, I'd like to share his post on severe self injurious behavior (SIB). Bill does a great job of discussing not only why SIB may occur, but more importantly, what we can do to support a person during these episodes.
Severe Self-Injurious Behavior
A small percentage of people with
developmental disabilities engage in frequent self injurious behavior.
My first 12 years in the field were spent in an institutional setting
providing services to severely impaired individuals with multiple
behavior challenges. During this time I had the opportunity to work
with some very fragile individuals, with severe physical
and
emotional vulnerabilities. Self injury took a variety of forms
including biting, digging, hitting, slapping, kicking, head banging, and
ingesting inedible items. During that time I learned that self
abusive behavior occurs for several reasons:
1. Self abusive
behavior is more common with individuals who are nonverbal and have no
consistent way of expressing themselves. Consequently, self abusive
behavior often is communicating pain, discomfort, frustration, task
demands, need for attention, etc. Self abuse can be used to communicate
any intense emotional reactions.
2. Most self abusive
behavior involves strong proprioception (tension to joints, tendons, and
muscles), which reduces stress chemicals (cortisol) in the nervous
system. Hitting, kicking, biting, and head banging provides strong
proprioception that reduces stress chemicals during times of emotional
outbursts. When the stress chemicals accumulate to boiling point, the
“fight or flight” stress response is activated, seeking strong
proprioception to reduce the stress chemicals.
3. Abusing
yourself produces strong reactions from others and these reactions can
increase the frequency of self abuse. The person learns that self
injury gains a lot of attention, and also allows them to escape
situations that they want to avoid. People around them will do
anything to stop the self abuse. The individuals learn that the
behavior can create a lot of control over their social environment
(people let them escape unwanted situations, give them what they want,
let them have their way in order to pacify them).
4. Self
abusive behavior can be used to mask, or dull pain. Individuals may
bang their head to mask pain from headaches and ear infections. They
may hit themselves in the jaw to distract from toothaches. When self
abuse begins, or increases significantly, medical evaluation is
important.
5. Self abusive behavior can be for self
stimulation, to help regulate the nervous system. It can alert the
nervous system when under-aroused, and release stress chemicals when
over-aroused. This behavior often occurs frequently during times of no
activity or when overwhelmed by too much activity.
Severe and
persistent self injury can start for any of the above reasons, but can
become addicting over time. The pain from self injury stimulates the
body to release endorphins which is the body’s natural pain killer.
Endorphins act like opiates, which feel good, and the person can get
addicted to the “feel good” endorphins. Not only do endorphins help
dull the sense of pain, but it also feels good. The individual self
injures to stimulate the release of endorphins to maintain the
“feeling.” Since the endorphins act to dull the pain, the behavior Is
not felt as painful. Now, self abuse that occurs for this reason can
get worse over time. Like all addiction, the body begins to “habituate”
(gain a tolerance for) the stimulation, requiring the individual to do
it more intensively, to stimulate the pain to release the endorphins.
The brain has a defense mechanism to dull the sense of pain over time,
making it necessary to increase the intensity to stimulate the
endorphins. In addition, scaring that can occur from the injury dulls
the pain, requiring the individual to dig or bite deeper to stimulate
pain. These individuals will gradually go from minor injuries to
creating severe injury as the skin becomes more and more scared. The
individual then has to gouge or tear out tissue to get deeper for pain.
In such case the medication naltrexone can be used to block the body’s
release of endorphins. By doing so, the self abuse hurts more, plus
it no longer releases the “feel good” endorphins. If this works, the
self abuse begins to hurt more, and doesn’t release the “feel good”
chemicals that is addicting.
In many cases chronic, persistent
self injurious behavior ends up being maintained by several of the above
functions. It can start because of only one of the functions, but once
started, can gain many secondary values by the addition of several of
the other functions. In most cases, professional help is needed to
isolate the functions, and develop effective strategies to treat each
function.
Treating Self Injurious Behavior
1.
Treating self injurious behavior usually starts with doing a “functional
behavior assessment” to identify the “functions” that the behavior
serves (communication, stress release, escaping unwanted events, self
stimulation, etc.) Functional behavior assessments involve tracking and
identifying the situations under which the behavior occurs (when,
where, with whom) and observing the immediate effects that the behavior
produces. By identifying what triggers the behavior, and what occurs
immediately after the behavior, we begin to get an idea of which
function it provides.
2. Treatment the usually proceeds with
changing the conditions (lowering demands, reducing stimulation,
increasing support, etc.) that trigger the behavior, and teaching
another, more appropriate, “replacement” behavior that meets the same
need (function).
3. First we look at what environment demands
are overwhelming, or lacking, for the person. This may require
modifying the environmental demands, building in accommodations to
lessen their impact, or providing greater assistant to support the
person when faced with these conditions. If the person has too many
demands placed on them, we look at providing less demands, lowering how
hard the demands are, or providing added support in face of the demands.
We want to better match the demands of the situation to the skill
level of the person.
4. If the function of self abuse is to
communicate needs and wants, then we focus on teaching the child
communication skills. If person is nonverbal then we teach an
alternative means of communication, such as pictures, gestures, signing,
etc. We identify what the person is trying to communicate and then try
and teach another, more appropriate way of communicating.
5.
If the behavior is occurring to escape or avoid unwanted situations, we
often need to look at “why” the person is trying to escape or avoid the
situation in the first place. Then we build in added supports, or
lessen the demands. In addition, we need to teach another way to
communicate “stop” or “help”. Teach them another behavior to
appropriately escape the situation. Then we prompt the child to use the
replacement way of escape, and immediately allow them to escape. It is
important that the new, more appropriate way of “escaping” is
immediately reinforced with successful avoidance.
6. If the
self abuse occurs for proprioception to release stress chemicals, than
we look at (a) developing a sensory diet that gives frequent physical
activity and other forms of proprioceptive stimulation (chewing gum,
squish balls, weighted vest, etc.) that provides proprioception to
release stress chemicals throughout the day, and (2) alternative
replacement behavior to substitute for the self abuse. For example, if
the child bites their wrist, we might provide a chewy tube to bite on.
This would provide an appropriate form of biting/chewing. Substituting
one form of proprioceptive tool for another.
7. If the person
is engaging in self abuse to mask pain, than we identify the source of
pain and treat it. We also try and teach the person a method of
communicating to others that they feel pain.
8. If the person
is self abusing to get strong reactions from others, we (a) lower the
intensity of our reactions, and (2) provide stronger attention for other
more appropriate behavior.
9. If the person is engaging in
self abuse for self stimulation then we try and increase the stimulation
the person Is receiving (keep them busier, provide an environment rich
in stimulation) and teach other forms of self stimulation that either
calms or alerts the nervous system. We also build in a sensory diet to
provide the person frequent stimulation.
10. . If the
behavior is the result of high anxiety, and the above doesn’t help, then
medications are often used to calm the nervous system.
11. In
rare occasions when the self injurious behavior may be maintained by
endorphins (as discussed above) then we give naltrexone to block the
release of endorphins.
