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Self-injurious behavior (SIB) in individuals with mental retardation is a severe behavioral disorder that has significant social and medical consequences. Although considerable research evidence indicates that SIB can be maintained by either environmental contingencies or biologic conditions, integrative diagnostic and treatment models have yet t o be developed. We have piloted a bio-behavioral diagnostic and treatment model t o classify and subtype cases of SIB, leading t o the selection of specific behavioral or pharmacologic treatments. A functional analysis defines SIB as operant, possibly biologic, or mixed operant and possibly biologic.Subtyping within these classes is based on the delineation of specific operant functions and the clinical characteristics of the individual patient. Our preliminary research suggests that this empirical decisionmaking model can lead t o specific treatments that are effective and that reduce the incidence of nonresponders t o behavioral intervention and medication.

Brachmann-de Lange syndrome (BDLS) is a rare multiple congenital anomaly/mental retardation (MCA/MR) syndrome with variable expression, making diagnosis of mild cases difficult. The most consistent manifestations appear to be the characteristic face, which can be subtle in children who are mildly affected [Ireland and Burn, 1991: Twelfth Annual David W. Smith Workshop on Malformations and Morphogenesis]. Other aspects of the syndrome include variable degrees of mental retardation, growth retardation, structural abnormalities of the limbs, and behavior abnormalities, noted to be "autistic" [Jones, 1988: "Smith's recognizable patterns of human malformation"]. Johnson et al. [1976: Pediatr Res 10:843-850] described a behavior phenotype felt to be common in patients with BDLS. They predicted that patients with BDLS may respond to "behavioral intervention". Other behavior abnormalities in BDLS have been reported [Barr et al., 1971: Neuropadiatrie 3:46-66; Hawley et al., 1985: Am J Med Genet 20:453-459]. We report on a 6-year-old boy with the facial characteristics of BDLS, normal birth weight, prenatal onset of a small head relative to length, postnatal onset growth deficiency, nearly normal psychomotor development with onset of clear developmental delays by 2 years. He developed behavior problems similar to those seen in other patients with BDLS. These behaviors are most consistent with Pervasive Development Disorder-NOS (PDD), and Autistic Disorder [DSM-III-R, 1987] which encompasses a spectrum of mild to severe autistic behaviors. We report successful in-patient care utilizing medical and behavioral techniques to reduce the frequency of the behaviors. We feel that the presence of the characteristic behaviors may be helpful in confirming the diagnosis of BDLS.