[Reduction of dysfunctional self-injurious and self-stimulatory behaviors in autism disorders spectrum through occupational therapy]. / Reducción de las conductas autolesivas y autoestimulatorias disfuncionales en los trastornos del espectro del autismo a través de la terapia ocupacional.

Self-stimulatory and self-injurious behaviors are very frequent in neurodevelopmental disorders, being a source of anxiety and suffering for persons who have that behavior and their families. Sometimes these behaviors are so intense and frequent that it becomes a selfintegrity risk. A bibliographic review was conducted on the different approaches that have been developed until today; in addition, this article explains the methodology applied in our clinic, with a data collection on the effect of therapy on self-injurious and self-stimulatory behaviors in 20 cases, as a starting point for future research. The sensory integration model that complements pharmacological and behavioral cognitive treatment is highlighted, since it considers sensory needs relevant and trains the capacity for functional self-regulation.

Las conductas auto estimulatorias y auto lesivas son muy frecuentes en los trastornos del neurodesarrollo, siendo una fuente de ansiedad y sufrimiento importante tanto para las personas que las presentan como para sus familias. En ocasiones estas conductas son tan intensas y frecuentes que llegan a ser un peligro para la salud del sujeto. Se realiza una revisión bibliográfica sobre las diferentes vías de atención de estas conductas desarrolladas hasta el momento, y se expone la metodología aplicada en nuestra clínica, presentando datos recopilados sobre el efecto de la terapia sobre las conductas auto lesivas y auto estimulatorias en 20 casos, como punto de partida para próximas investigaciones. Se destaca el modelo de integración sensorial que complementa el tratamiento farmacológico y el cognitivo conductual, ya que considera relevante las necesidades sensoriales y entrena la capacidad de auto regulación funcional.

Borderline personality disorder and chronic pain: a practical approach to evaluation and treatment.

Patients with chronic pain present a spectrum of complexity that can be overwhelming for the individual practitioner. These patients require thoughtful care and a comprehensive treatment plan. This complexity should be acknowledged, not avoided, and the patient should be engaged, not shunned. A practical approach will assist in developing expertise and proceeding empathically. The presence of a superimposed personality disorder significantly increases the difficulty of caring for these patients. Studies investigating the prevalence of borderline personality disorder in patients with chronic pain averaged 30 %, highlighting the importance of being able to effectively treat this patient population. Appropriate management of these patients should focus on a collaboration to practice productive behaviors despite intense emotional distress. Longitudinal research provides a foundation for an optimistic prognosis that can be enhanced with this rehabilitative approach.

What is missed in self-immolated patients' care? A grounded theory study.

AIMS AND OBJECTIVES: To explore rehabilitation care process in patients who commit self-immolation. BACKGROUND: Self-immolation is not only a type of burn injury, but it is also a suicidal method. It is placed in burn injury category that requires long-term rehabilitation and treatment measures. As a suicidal method, among all forms of suicidal attempts, it is the most dramatic, violent and often difficult one to understand. Unfortunately, there are few reported studies investigating experiences and perceptions of nurses about burn care and with qualitative study about the patients' experiences and perceptions. DESIGN: On the basis of the research question, the grounded theory method was used. METHODS: Considering ethical codes of Belmont and Helsinki statements, purposive sampling was used to select the participants. The patients were deliberately selected, based on the research needs. They were self-immolated patients being referred to Talaghani hospital of Ilam (western Iran) or discharged previously (time of interview and observation ranged from immediately later the burn till 5 years after), in Ilam, where self-immolation rate is very high. The main methods for data collection were deep, open ended, semi-structured interviews, dairies and observations. The interviews were audio taped in Persian, and verbatim transcriptions were made. By doing so, semantic meaning is preserved, and misinterpretation of data due to translation into English is minimised. Data analysis was conducted using the Strauss and Corbin method. RESULTS: Five main categories were emerged: situation of crisis unprofessional care, prolongation and formidability of the journey, self-immolation as paralyse, and attempt for self-management. Finally, by constant, comparison of collected data and emerged categories, central variable entitled unintegrated care emerged as the main problem of self-immolated patients' care. CONCLUSION: The study comes to the conclusion that we need to focus on specific considerations to provide integrated care for the burned patients as it is a decisive component of care that is missed. RELEVANCE TO CLINICAL PRACTICE: Although self-immolation requires long-term treatment and social, emotional rehabilitation, such a rehabilitation care process is not clear.

Self-harm and the positive risk taking approach. Can being able to think about the possibility of harm reduce the frequency of actual harm?

BACKGROUND: This article presents the results of an audit of self-harming across three women's units over a period of 6 years. All three units use a positive risk-taking approach to self-harm whereby the risk that this behaviour presents is considered in an effort to reduce actual harm. AIMS: To explore patterns and frequency of self-harm across three units within a women's service. METHOD: Incidents of deliberate self-harm were collected from incident forms completed across the units from 2004 to 2009. RESULTS: Frequency graphs show a reduction of self-harm over the course of admission, and parametric analyses show that there was a significant difference in the frequency of self-harm during the first and last 3 months of admission. CONCLUSIONS: These results are discussed within a psychoanalytical framework, with particular reference to relational security and the value of positive risk-taking.

Characteristics and co-occurrence of adolescent non-suicidal self-injury and suicidal behaviours in pediatric emergency crisis services.

During the potentially tumultuous adolescent period, non-suicidal self-injury (NSSI) and suicide attempts are relatively common, particularly amongst youth who present to mental health services. These phenomena frequently co-occur but their relationship is unclear. This study evaluated clinical data from 468 youth between the ages of 12 and 17 years (63.5% female) to determine the incidence of NSSI 24 h prior to presentation at emergency crisis services, evaluated the overlap between NSSI and suicide attempt, and examined the characteristics of different types of self-harm. Half of the adolescents presenting to emergency crisis services had self-harmed within the previous 24 h, with most of these (91%) classified as NSSI only. The percentage of youth with a suicide attempt was 5% and the co-occurrence of these two behaviours was 4%. Group differences in depressive symptoms, suicidal ideation and impulsivity were identified, with the co-occurring NSSI and suicide attempt group presenting with the highest level of psychopathology. This study underscores the necessity of assessing suicidal ideation and NSSI in all youth presenting to mental health services.

Brief report: Aggressive challenging behaviour in adults with intellectual disability following community resettlement.

BACKGROUND: Aggressive challenging behaviour is common in adults with intellectual disability (ID) in long-term care facilities. The government's commitment to the closure of all facilities in England has led to concerns over how to manage this behaviour in the community. The aim of this study was to assess changes in aggressive challenging behaviour and psychotropic drug use in adults with ID following resettlement using a person-centred approach. METHOD: The Modified Overt Aggression Scale was administered to carers of 49 adults with ID prior to discharge from a long-stay hospital and 6 months and 1 year after community resettlement. RESULTS: All areas of aggressive challenging behaviour reduced significantly between baseline and 6 months following resettlement (P < 0.001). This reduction remained (but did not decrease further) at 1-year follow-up. CONCLUSIONS: Further work is needed to evaluate the role of environmental setting on aggressive challenging behaviour in adults with ID.

[Reducing self-injurious behaviour through functional communication training--a single case study]. / Reduzierung selbstverletzenden und aggressiven Verhaltens durch Funktionelles Kommunikationstraining. Eine Einzelfallstudie.

Carr and Durand (1977) postulated for the first time that self-injurious and aggressive behaviour can be reduced in individuals with intellectual impairment by teaching them communication responses. Meanwhile, primarily in the Anglo-American linguistic area, a number of publications exist that address the topic of Functional Communication Training. Conducted in this single case study were a preference assessment to identify edible and material reinforcers, and an experimental functional analysis to document the functions of the self-injurious behaviour. In addition, the efficacy of Functional Communication Training was assessed within an ABAB design. The results underscore the importance of functional assessment, which, within the intervention discussed, led to a significant reduction of self-injurious behaviour.

Developing a therapeutic relationship with a blind client with a severe intellectual disability and persistent challenging behaviour.

PURPOSE: A blind, severely intellectually impaired boy aged 17 with Down syndrome and persistent serious challenging behavior received attachment-based behavior modification treatment. The aim was to study the effect of the treatment and the development of the therapeutic attachment relationship. METHOD: In a single-case study, attachment therapy sessions alternated with control sessions. Treatment started with attachment therapy (phase 1), followed by behavior modification (phase 2). The instruments used were: Residential observation lists for challenging behavior, video analyses of attachment behavior in therapy sessions and physiological indicators of affect regulation measuring the pre-ejection period (PEP) and respiratory sinus arrhythmia (RSA) as indices of cardiac sympatho-vagal activity. RESULTS: The client exhibited less frequent and less intensely challenging behavior. The data indicated more appropriate replacement behavior and less PEP arousal during the behavior modification treatment given by the attachment therapist compared to the control therapist who used the same protocol. The client showed more active and longer-lasting attachment behavior, especially proximity seeking, towards the attachment therapist than towards the control therapist. CONCLUSIONS: Attachment-based psychotherapy proved successful in eliciting attachment behavior in a severely intellectually disabled, socially deprived, behaviorally and affectively dysregulated adolescent. The resulting relationship proved to be a therapeutic platform conducive to behavior change.

Motivations for self-injury in an adolescent inpatient population: development of a self-report measure.

OBJECTIVE: The aim of this study was to develop and pilot an instrument for the assessment of self-injury in adolescent inpatients. METHODS: The Self-Injury Motivation Scale was modified for use in adolescents. Thirty-eight consenting adolescent inpatients with a history of self-injury completed the Self-Injury Motivation Scale-Adolescent version (SIMS-A) and the Self-Injury Interview (SII) to collect information about a range of factors associated with self-injury, other clinical variables and demographic details. RESULTS: The SIMS-A was acceptable to this adolescent sample and motivations for self-injury were similar to those of adults using the original SIMS scale. Adolescents were, however, more likely to use self-injury for communicating to/influencing others compared to adults. The participants most frequently reported self-injury by hitting, cutting and burning. The clinical diagnosis most frequently associated with self-injury was major depression. Females reported earlier onset, higher frequency and multiple methods of self-injury compared to males. Distraction from emotional pain was the most common motivation for self-injury in both males and females. CONCLUSIONS: This pilot study suggests the SIMS-A is a useful self-report measure to assist clinicians and adolescent patients to understand a behaviour that may be associated with shame, guilt or other difficult emotions for the adolescent. Results also support the contention that there are often multiple and conflicting motivations for self-injury. Self-injury in this population was more common and severe in female adolescents compared to males, while clinical depression was a risk factor for self-injury in both males and females. The small sample size of adolescent inpatients is an important limitation of this pilot study, and research using the SIMS-A in larger samples is warranted.

Birth during autumn is a risk for adolescent self-mutilative behavior.

BACKGROUND: A season of birth tendency has been shown for several psychiatric disorders and suicidal behavior. Our aim was to examine the association between season of birth and self-mutilative behavior (SMB) among adolescent psychiatric inpatients. METHODS: The study sample consisted of 508 (40.9% males) 12- to 17-year-old adolescents consecutively admitted to the Department of Psychiatry of Oulu University Hospital, Finland, between April 2001 and May 2006. The birth month of each adolescent was categorized into one of the four seasons: spring (March-May), summer (June-August), autumn (September-November) or winter (December-February). The information on SMB was based on the K-SADS-PL interview, which included an item on nonsuicidal physical self-damaging acts without intent to die. A total of 144 adolescents (27 males, 117 females) met the criteria for SMB. The association between season of birth and SMB was assessed with a logistic regression analysis after controlling for each adolescent's age, previous suicide attempts and DSM-IV-diagnosed psychiatric disorders. RESULTS: The monthly distribution of births of adolescents with SMB differed statistically significantly from that observed in the general population of the same age. An association between season of birth and SMB was seen in girls, but not in boys. The likelihood for SMB was significantly increased (adjusted OR 2.9; 95% CI 1.4-6.2) among girls born in autumn compared to those born in winter. CONCLUSIONS: Birth during autumn may predispose girls to SMB via dysfunctional serotonergic or other neurotransmitter systems. These findings may also be related to seasonal rhythms in parental mood and poor early care of the offspring.

Further analysis of subtypes of automatically reinforced SIB: A replication and quantitative analysis of published datasets.

Hagopian, Rooker, and Zarcone (2015) evaluated a model for subtyping automatically reinforced self-injurious behavior (SIB) based on its sensitivity to changes in functional analysis conditions and the presence of self-restraint. The current study tested the generality of the model by applying it to all datasets of automatically reinforced SIB published from 1982 to 2015. We identified 49 datasets that included sufficient data to permit subtyping. Similar to the original study, Subtype-1 SIB was generally amenable to treatment using reinforcement alone, whereas Subtype-2 SIB was not. Conclusions could not be drawn about Subtype-3 SIB due to the small number of datasets. Nevertheless, the findings support the generality of the model and suggest that sensitivity of SIB to disruption by alternative reinforcement is an important dimension of automatically reinforced SIB. Findings also suggest that automatically reinforced SIB should no longer be considered a single category and that additional research is needed to better understand and treat Subtype-2 SIB.

Monitoring deliberate self-harm presentations to general hospitals.

Monitoring of deliberate self-harm (DSH) presentations to hospitals (and in other settings) is receiving increased attention in many countries. This is due to greater recognition of the size of the problem and awareness of its relevance to suicide prevention policy initiatives, because of the strong association between DSH and suicide. A system for monitoring all DSH presentations has been in place in the general hospital in Oxford for 30 years. Based on our experience, in this paper we describe procedures for monitoring, including case definition and identification, linkage of persons and episodes in order to investigate repetition of DSH and other outcomes (including deaths), and data protection and ethical issues. We also provide details of how to carry out monitoring, including different models of data collection, and what data to collect. Finally we consider the potential uses of the data for both clinical and research purposes, including evaluation of national suicide prevention initiatives.

The influence of pre-existing psychiatric illness on recovery in burn injury patients: the impact of psychosis and depression.

We hypothesised that patients with a co-morbid psychiatric illness would show poorer outcomes in recovery from their burn injury compared to patients with equivalent burn injury but without a pre-existing psychiatric illness. A secondary aim was to investigate the effect of self-inflicted burn injury. Consecutive admissions (n = 190) to a burns inpatient unit were screened for the existence of a formal pre-burn psychiatric disorder. Nine patients suffering from psychosis and eight suffering from depression were matched with 18 and 15 patients, respectively not suffering a pre-burn psychiatric disorder on gender, age, burn severity, type, depth and location. Patients with a pre-burn psychiatric diagnosis spent significantly longer in hospital, spent more time in care until discharged from outreach and their burn injuries took longer to heal than matched burn injury patients without a pre-existing psychiatric illness. Time in hospital and to wound healing were significantly greater in psychotic patients compared to their controls but not between depressed patients and their matched controls. Both psychotic and depressed patients had significantly more surgery than their matched controls. Patients whose burn was self-inflicted spent significantly longer in hospital and their wounds took longer to heal. Patients with pre-existing psychiatric conditions, especially psychosis, and those with self-inflicted injuries are associated with difficulties in clinical management and higher economic cost yet staff receive very little specialist training in their management.

Effects of sensory integration intervention on self-stimulating and self-injurious behaviors.

This study compared the effects of occupational therapy, using a sensory integration (SI) approach and a control intervention of tabletop activities, on the frequency of self-stimulating behaviors in seven children 8-19 years of age with pervasive developmental delay and mental retardation. Daily 15-min videotape segments of the subjects were recorded before, immediately after, and 1 hour after either SI or control interventions performed during alternating weeks for 4 weeks. Each 15-min video segment was evaluated by investigators to determine the frequency of self-stimulating behaviors. The results indicate that self-stimulating behaviors were significantly reduced by 11% one hour after SI intervention in comparison with the tabletop activity intervention (p = 0.02). There was no change immediately following SI or tabletop interventions. Daily ratings of self-stimulating behavior frequency by classroom teachers using a 5-point scale correlated significantly with the frequency counts taken by the investigators (r = 0.32, p < 0.001). These results suggest that the sensory integration approach is effective in reducing self-stimulating behaviors, which interfere with the ability to participate in more functional activities.

Reducing pawing in horses using positive reinforcement.

Aversive control is a common method to reduce undesirable behavior in horses. However, it often results in unintended negative side effects, including potential abuse of the animal. Procedures based on positive reinforcement, such as differential reinforcement of other behavior (DRO), may reduce undesirable behaviors with fewer negative consequences. The current study used DRO schedules to reduce pawing using a multiple baseline design across 3 horses. Results indicated that DRO schedules were effective at reducing pawing. However, individual differences in sensitivity to DRO and reinforcer efficacy may be important considerations.

Effects of arm-splint rigidity on self-injury and adaptive behavior.

The current study replicated and extended previous research on the use of a rapid assessment to identify effective arm-splint rigidity with 2 participants who had been diagnosed with autism and who engaged in self-injurious behavior (SIB). We varied rigidity levels within a multielement design across several adaptive tasks and identified the most effective rigidity level in terms of reductions in SIB and levels of compliance.

Further investigation of a rapid restraint analysis.

Research related to the use of mechanical restraint devices (e.g., arm splints) has been limited despite the frequency with which they are used in the clinical treatment of severe and dangerous self-injurious behavior (SIB). Wallace, Iwata, Zhou, and Goff () used a rapid restraint analysis (RRA) to evaluate the effects of different levels of arm-splint flexion on rates of hand-to-head SIB and adaptive behavior. The goal of the current study was 3-fold: (a) to extend previous research on RRA by reporting RRA results for 10 participants and investigating post-RRA outcomes, (b) to investigate whether the RRA might have the potential to eliminate the need for restraint fading altogether for some individuals, and (c) to investigate whether the RRA might help to identify a starting point for restraint fading for individuals for whom fading is necessary. Results suggested that the RRA helped to eliminate the need for restraint fading for 6 participants. With respect to the identification of a starting point for restraint fading, results were mixed. Overall, 8 of the 10 participants were discharged from the inpatient unit at a less restrictive level of flexion or at the same level of flexion identified by the RRA. Implications for adoption of the RRA are discussed.

Functional analysis and treatment of problem behavior exhibited by children with fragile X syndrome.

The efficacy of function-based interventions for the treatment of severe problem behavior exhibited by individuals with intellectual and developmental disabilities (IDD) is well established. However, few studies have reported on behavioral interventions in fragile X syndrome (FXS) specifically. The present study is a consecutive case-series analysis that reports on functional analysis and treatment of problem behavior of nine children with FXS. Assessment findings were consistent with previous research indicating that among individuals with FXS, problem behavior is more commonly maintained by escape from demands and access to tangible items, relative to the broader population of individuals with IDD. Functional analysis-based behavioral interventions resulted in a mean reduction in problem behavior of 95.2% across the nine participants. Additionally, generalization of treatment effects from controlled clinical settings to home, school, and community was demonstrated. The current findings suggest that function-based behavioral interventions shown to be effective with the broader population of individuals with IDD are also effective for individuals with FXS. Our results in combination with those of previous studies describing functional analysis outcomes provide additional evidence for a unique functional behavioral phenotype for severe problem behavior in individuals with FXS. Implications of study findings for early intervention and prevention of problem behavior in children with FXS are discussed.

Self-injurious, aggressive and destructive behaviour in children with severe intellectual disability: Prevalence, service need and service receipt in the UK.

Children with severe intellectual disabilities are at increased risk of presenting with self-injurious, aggressive and destructive behaviour. Severity of these behaviours is an important predictor of psychological and behavioural service use by people with intellectual disabilities. However, studies suggest that the needs of children with intellectual disabilities and their families are not being met. The aims of the present study were to: (1) describe the self-injurious, aggressive and destructive behaviours and subsequent support needs of children with severe intellectual disabilities attending special schools in one major city within the UK, (2) compare teacher and primary carer ratings of behaviour and service need and (3) explore the extent to which the needs of children with intellectual disabilities are being met in terms of contact with relevant specialist services. Questionnaires were completed by teachers and primary family carers of children with a severe intellectual disability. Results indicated that at least 5.3% and 4.1% of children showed at least one behaviour at a clinically significant frequency and management difficulty respectively. Primary carers identified more children with significant behaviour difficulties and support needs than teachers. The odds for children presenting with high levels of the behaviours of interest for having a service need for behavioural intervention were at least 13 times those for children not showing the behaviours, yet only doubled for contact with a specialist relevant health-care professional. These results quantify the magnitude of the substantial gap between level of need and relevant support received.