Given the lack of SIB improvement despite numerous neuroleptics, anxiolytics, antidepressants, and other medication families, naltrexone was initiated at 25 mg and quickly titrated to 50 mg. Within 1 month of medication initiation, SIB had ceased entirely. The patient had no further eye gouging and no subsequent infections of the eye.
No other SIBs were present. Escitalopram was decreased and discontinued with no adverse effects on mood, anxiety, SIB, aggression, or behavioral symptoms; then, buspirone was tapered and discontinued over 2 months without any adverse effects. The patient remained on paliperidone 3mg and naltrexone with persistent resolution in her baseline severe SIB and continued resolution of aggression.
The association between self-injurious behaviors and autism spectrum disorders
This case evidences the potential severity of SIBs in adults with intellectual disability. Naltrexone was chosen in this case due to failure of approved medications commonly used for SIB in intellectual disability. The risks and benefits were carefully weighed and, in particular, given the seriousness of this form of self-injury, as well as the long-term risks of unnecessary polypharmacy, naltrexone was considered a safe and low-risk option. Naltrexone was considered with full awareness of the fact that it is not a Food and Drug Administration FDA -approved medication and with attention to the large number of anecdotal reports in the literature suggesting safety and potential efficacy in a range of forms of self-injurious populations.
Evidence of naltrexone efficacy in SIB in the heterogeneous population of intellectually disabled adults is limited with few double-blind placebo-controlled studies.
As a result of limited data, for example, a recent Cochrane Review concluded that recommendations could not be made for use of naltrexone for SIB in intellectual disability 1. Notably, three of the albeit small studies suggested clinical benefits. Safety, efficacy, dosing, and population variability in the use of naltrexone for SIB in intellectual disability requires further empirical study 1. Despite limited data, naltrexone is frequently used off-label in self-injuring intellectual disabled patients due to the high side-effect burden of many of the other medications often utilized.
Aripiprazole and risperidone are approved for behavioral treatment in autism, but there is little formal guidance for SIB management in these populations. SIB pathophysiology is not well understood. Dysregulation of a number of neurotransmitters has been linked with SIB, including dopamine, endogenous opioid, serotonin, glutamate, and GABA systems 2. For example, the caudate nucleus, which is heavily innervated by dopaminergic neurons, has been shown to be abnormal in cases of SIB associated with a wide range of neurodevelopmental conditions 3.
Glutamate works in a regulatory relationship with dopamine between the basal ganglia and prefrontal cortex and has been implicated in animal studies of SIB 4. Endogenous opioid theories of SIB are particularly relevant in the case of naltrexone. SIB may be related to hypothalamus-pituitary-adrenal dysfunction that involves dysfunction of the stress-related substance proopiomelanocortin, which is an endogenous opioid precursor.
Naltrexone, a centrally acting opioid blocker that is FDA-approved for alcohol and opioid dependence, may act on this system to provide relief of self-injurious urges 6. Further exploration of SIB in intellectual disability is clearly warranted. This report adds to the evidence of potential benefit for naltrexone in severe SIB in intellectual disabled adults. Self-injury in a range of neurodevelopmental disabilities is not uncommon.
Aripiprazole and risperidone are Food and Drug Administration FDA -approved for treatment of behavioral issues in autism, but many other medications are often used off-label for behavioral management due to side-effect burden and variable efficacy. Naltrexone, while not FDA-approved for self-injury in intellectual disability and neurodevelopmental disabilities, has shown some effectiveness in a range of reports. Further research is warranted. The lower side-effect profile compared with neuroleptics may warrant its consideration in treatment-refractory and severe self-injurious behaviors in intellectually disabled individuals.
Moreover, whilst catatonia is classically associated with mood and psychotic disorders, it is increasingly recognized as comorbid with autism spectrum disorder, and many of these patients also demonstrate more classical akinetic motor signs, characteristic of catatonic states associated with mood disorders or schizophrenia.
Consistent with the sensitivity of catatonia to electroconvulsive therapy ECT , we and others have found ECT can produce life-changing results in IDD patients with extreme SIB that is unresponsive to conventional pharmacological and behavioral therapies. Accordingly, there is a need to develop alternate non-convulsive forms of chronic stimulation for these patients.
We found that high frequency stimulation administered via implanted electrodes at the subthalamic nucleus STN-HFS significantly suppressed excessive self-grooming. Suppression starts acutely when stimulation is switched on and persists for several days after HFS is stopped. As it would be important to distinguish between these two mechanisms before considering invasive or non-invasive neuromodulation for patients, we propose employing an optogenetics-based approach to help determine which pathways mediate the response.
Self-injurious behavior associated with intellectual and developmental disabilities is prevalent and can be devastating. External risk markers are those in which the person is not central. They involve what is going on around the person but the person generally has little or no control over them. Self injurious behaviours can cause all sorts of problems for people on the autism spectrum, their families and carers, and society as a whole. It is also important to understand that self injurious behaviours in people on the autism spectrum can be very distressing for family carers and service providers.
There are numerous interventions treatments, services and other forms of support designed to prevent or reduce self injurious behaviours in people on the autism spectrum. Most interventions are. These interventions fall into three main categories: psychological techniques, medications and other approaches.
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In practice, these approaches may overlap. For example, a multidisciplinary team may suggest the use of medications or physical exercise alongside a behavioural support programme. We believe that, whichever interventions are used, it is important to treat the person with respect, listen to what they say and give them choices over their lives. We also believe that any intervention should follow the principles established by Fleming, Hurley and the Goth Most researchers and practitioners believe it is essential to identify the specific factors that may be causing an individual to self injure before deciding the most appropriate intervention to use.
This is normally done using a functional assessment, which is described by Minshawi et al There are a number of psychological approaches sometimes used to prevent or reduce self injurious behaviours in people on the autism spectrum. Many of these approaches use behavioural techniques based on the principles of applied behaviour analysis and may be incorporated within a behavioural support plan. Note 1: Some people on the autism spectrum do not enjoy social attention. For them, social attention may cause distress and increase challenging behaviours. If the self injurious behaviour is pervasive, long standing or very severe, then medications may be considered.
Those neurotransmitters include dopamine, endorphins, glutamate, and gamma-aminobutyric acid. Please note: Medications should only be used under the direction of a suitably qualified practitioner, such as a paediatrician or psychiatrist, and only after there has been no or limited response to other interventions.
The effects should be carefully monitored and reviewed on a regular basis and the medication withdrawn if no significant benefits are seen. Some medications have significant side effects or interactions with other substances. Some may even make the self injurious behaviours worse in some people. There are numerous other interventions that have been suggested as ways to prevent or reduce self injurious behaviours in people on the autism spectrum. These include.
Please note: There is currently no high quality research evidence to suggest that these interventions are effective in reducing self injurious behaviours in people on the autism spectrum, although that does not necessarily mean that they do not work. We have identified 30 research papers reviews and other significant studies of self injury in people on the autism spectrum published in peer-reviewed journals. Some of the papers looked at studies which included only people on the autism spectrum, for example, Weiss J.
Others looked at studies which included people with a range of conditions including autism, for example, Oliver and Richards Some of the papers looked only at individuals from a specific age range -such as children, for example Richman ; adolescents, for example Rattaz et al. Other papers looked at individuals from across the age range, for example Richards et al. Many of the papers looked at interventions designed to prevent or reduce self injury, for example, Minshawi N. Other reviews looked at related issues, such as the assessment and prevalence of self injury, for example Duerden et al.
Many of the papers for example, Minshawi et al, recommended undertaking a functional assessment of the self injurious behaviours before undertaking any intervention. Some of the papers reported some benefits from specific types or groups of intervention. Some of the papers reported that there was currently mixed or insufficient evidence to support the use of some interventions. For example, Mahatyma et al reported that the medication naltrexone may reduce self injurious behaviours in some individuals on the autism spectrum but make them worse in others.
There are limitations in most of the research reviews and studies we have identified to date and in most of the studies included in those reviews. Some of the papers looked only at individuals from a specific age range such as children, for example Richman ; adolescents, for example Rattaz et al. Some of the papers were limited to people on the autism spectrum with additional conditions. For example, Richards et al. One paper, Lang et al.
For example, Rana et al. Only one of these studies included any participants 17 who were on the autism spectrum and injuring themselves.see url
Challenging Behavior in Autism: Self-Injury | Interactive Autism Network
There is a need for further research into self injurious behaviours and people on the autism spectrum and the most effective interventions to overcome those self injurious behaviours. We have identified a number of organisations that have published best practice guidance on challenging behaviours. The following is a summary of some of the key points from its guidance on challenging behaviours in adults The National Institute for Health and Care Excellence NICE is a UK government body which supports healthcare professionals and others to make sure that the care they provide is of the best possible quality and offers the best value for money.
NICE has not published any specific recommendations on treating self injurious behaviours in people on the autism spectrum. However it has published recommendations on treating challenging behaviours — which includes self injurious behaviours — in people on the autism spectrum. The following is a summary of the NICE guidance on challenging behaviours in people on the autism spectrum , Before initiating other interventions for challenging behaviour, you should address any identified factors that may trigger the behaviour by offering:.
Once you have tried these, you may need to consider a psychosocial intervention.
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When deciding on the nature and content of a psychosocial intervention, use a functional analysis. The functional analysis should facilitate the targeting of interventions that address the function s of problem behaviour s. Psychosocial interventions for challenging behaviour should be based on behavioural principles and informed by a functional analysis of behaviour.
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Consider antipsychotic medication in conjunction with a psychosocial intervention for challenging behaviour when there has been no or limited response to other interventions. Antipsychotic medication should be prescribed by a specialist and quality of life outcomes monitored carefully. Review the effects of the medication after 3—4 weeks and discontinue it if there is no indication of a clinically important response at 6 weeks. You can find more reviews and studies of self injurious behaviour in our publications database. If you know of any other studies we should include please email info researchautism.
This page provides details of other publications on self injurious behaviour, autism and related issues. You can find other publications on self injurious behaviour in our publications database.
Related Self-Injurious Behavior in Intellectual Disabilities
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