The troubling issue of self-injurious behaviour
SEN Magazine: Self-harm can take many forms, and definitions can change over time and according to cultural factors. How is self-injurious behavior (SIB) currently defined in the UK?
Dr Holland: SIB has been defined as “Any behaviour, initiated by the individual, which directly results in physical harm to that individual. Physical harm … [may] include bruising, laceration, bleeding, bone fractures and breakages and other tissue damage” (Murphy and Wilson, 1985, p.15).
Considering this definition, it becomes evident that many different behaviours may be considered as being self-injurious. Some of the more common SIBs exhibited by individuals with SEN include:
- skin picking
- head hitting/banging
- pica (eating inedible substances)
- gouging of body parts
- chewing/biting fingers
SEN Magazine: How common is SIB amongst children with SEN, and is it more prevalent for children with certain conditions?
Dr Holland: It has been widely reported that between 10 and 50 per cent of people with learning difficulties may, at some point in their lives, self-injure. Prevalence rates tend to differ depending upon the environments in which individuals with special needs reside. Those in hospital settings have been known to exhibit higher rates of SIB, followed by those in special schools and day centres, with the lowest rates displayed by those individuals living at home. The difference in rates of self-injury between these different environments is likely to be a result of the ratio of care providers to individuals who self-injure. Related to this is the potential for specific and consistent intervention. Within the home there is often only one individual with special needs and sometimes multiple carers to provide input. Also, due to the increased likelihood of extended one to one input, the individual within the home setting is more likely to receive a programme that is individualised and regular.
Prevalence is also dependent upon individual characteristics and diagnosis. Individuals with severe or profound disabilities, sensory deficits, limited (or no) communication skills and those diagnosed with Prader-Willi syndrome, Fragile-X syndrome, Tourette’s syndrome or autism have been known to display more SIB. Despite this, not all children with these diagnoses or particular characteristics will necessarily self-injure. This is particularly true if such children receive appropriate early intervention.
SEN Magazine: How easy is it for carers, parents and teachers to identify instances of self-harm, and what are the warning signs?
Dr Holland: On the whole, SIB is relatively visible and, as such, is readily identifiable. However, it must be remembered that the severity of such instances will differ greatly. Because of this, minor instances of SIB may be easily overlooked. The warning signs obviously include the physical signs of SIB. However, considering that SIB is often a way of expressing needs, desires or feelings, poor communication skills coupled with evidence of frustration tend to be things to watch out for. In addition, self-stimulatory behaviour that is not considered to be self-injurious, but has a link with sensory deprivation (or overload), is sometimes considered to be a warning sign for potential self-injury. Again, this is not always the case but, as with any behaviour, SIB has a function; it serves a purpose. Potential functions of SIB include, to gain attention, to escape situations, to avoid something, to receive desired items (e.g. sweets), and general self-stimulation (as in the case of those experiencing sensory deprivation/dysfunction). If we can identify the purpose, we can aim to reduce, if not eliminate, the SIB.
SEN Magazine: What can we do to help prevent or minimise instances of SIB?
Dr Holland: Considering that SIB is often the result of poor communication skills, early training in this area is vital. All children (and adults) should have some means of communication. If this is achieved, individuals who do self-injure, or who may in the future, will have an alternative means of expressing themselves. In addition, we should not react to the self-injurious behaviour. Obviously we need to ensure the safety of our children, but it is important not to reinforce such behaviours with attention, escape, avoidance or “treats”. If we do, we will only strengthen the SIB.
SEN Magazine: What kinds of treatments and interventions are most effective at helping self-harming children with SEN?
Dr Holland: To date, the most effective treatment for SIB is a combination of behavioural intervention and communication training. As mentioned before, SIB serves a purpose. What behavioural intervention will initially focus on is the determination of the function/s of the behaviour. The function of SIB may be one or more of the following: attention, escape, avoidance, self-stimulation, to receive desired items. When it is more clearly understood why an individual is self-harming, it is much easier to develop an individualized behaviour modification plan. The important word here is “individual”. There is no such thing as a “one intervention fits all” approach to behavioural difficulties, including SIB.
Communication training has also been known to be an effective intervention for SIB. Providing individuals with a means of expression allows them to make known their desires, frustrations, and general feelings. Most importantly, communication skills give individuals with SEN more control over their environment and, therefore, the need to self-injure as a means of expression is reduced.
In terms of medical intervention, only one drug has been known to reduce SIB: Naltrexone. However, such intervention is reported as not being effective for all individuals. As always, medical advice should be sought from a qualified professional.
In conclusion, for the special needs population, it is important that we focus on early intervention. If children with SEN are taught communication skills and provided with appropriate interventions from an early age, the likelihood of challenging and/or self-injurious behaviours emerging and consequently becoming an established part of their lives is lessened.
Dr Paul Holland is a behavioural psychologist renowned for his personal, child-friendly approach.
Article first published in SEN Magazine issue 41: July/August 2009.