Multidisciplinary Assessment and Treatment of Self-Injurious Behavior in Autism Spectrum Disorder and Intellectual Disability: Integration of Psychological and Biological Theory and Approach

Minshawi, Noha F.; Hurwitz, Sarah; Morriss, Danielle; McDougle, Christopher J.

doi:10.1007/s10803-014-2307-3

Cited by 72 publications

(41 citation statements)

References 249 publications

(258 reference statements)

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“…The pathway draws on different aspects of treatment models proposed for people with developmental or intellectual disabilities such as the neurobehavioral model, [67][68][69][70] which describes the tandem usage of psychiatric assessment and applied behavioral analysis for the treatment of severe problem behavior. A recent article by Minshawi et al 71 provides a similar approach to the treatment of selfinjurious behavior, specifically in ASD. In contrast with such detailed reviews, however, the practice pathway presented here is designed to assist PCPs with initiating and coordinating interventions in the primary care setting.…”

Section: Discussionmentioning

confidence: 99%

Irritability and Problem Behavior in Autism Spectrum Disorder: A Practice Pathway for Pediatric Primary Care

McGuire

Fung

Hagopian³

et al. 2016

Pediatrics

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OBJECTIVE: Pediatric primary care providers (PCPs) caring for patients with autism spectrum disorder (ASD) often encounter irritability (vocal or motoric outbursts expressive of anger, frustration, or distress) and problem behavior (directed acts of aggression toward other people, self, or property). The Autism Intervention Research Network on Physical Health and Autism Speaks Autism Treatment Network charged a multidisciplinary workgroup with developing a practice pathway to assist PCPs in the evaluation and treatment of irritability and problem behavior (I/PB). METHODS:The workgroup reviewed the literature on the evaluation and treatment of contributory factors for I/PB in ASD. The workgroup then achieved consensus on the content and sequence of each step in the pathway. RESULTS:The practice pathway is designed to help the PCP generate individualized treatment plans based on contributing factors identified in each patient. These factors may include medical conditions, which the PCP is in a key position to address; functional communication challenges that can be addressed at school or at home; psychosocial stressors that may be ameliorated; inadvertent reinforcement of I/PB; and co-occurring psychiatric conditions that can be treated. The pathway provides guidance on psychotropic medication use, when indicated, within an individualized treatment plan. In addition to guidance on assessment, referral, and initial treatment, the pathway includes monitoring of treatment response and periodic reassessment. CONCLUSIONS:The pediatric PCP caring for the patient with ASD is in a unique position to help generate an individualized treatment plan that targets factors contributing to I/PB and to implement this plan in collaboration with parents, schools, and other providers. Dr McGuire contributed to the design of the practice pathway, played a leading role in drafting the initial manuscript, and revised the manuscript; Drs Fung, Hagopian, Vasa, Mahajan, Bernal, and Coury and Ms Silberman and Ms Wolfe contributed to the design of the practice pathway and reviewed and revised the manuscript; Drs Hardan and Veenstra-VanderWeele contributed to the conceptualization and design of the practice pathway and reviewed and revised the manuscript; Dr Whitaker played a leading role in conceptualizing and designing the practice pathway, drafted portions of the initial manuscript, and reviewed and revised the manuscript; and all authors approved the fi nal manuscript as submitted.

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Section: Discussionmentioning

confidence: 99%

Irritability and Problem Behavior in Autism Spectrum Disorder: A Practice Pathway for Pediatric Primary Care

McGuire

Fung

Hagopian³

et al. 2016

Pediatrics

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“…Behavioral, pharmacological, surgical, and even electroconvulsive therapies have been used. 10 Case 3 experienced a dramatic reduction in SIB after being admitted to an inpatient rehabilitation program that was targeted at controlling head trauma. While delaying surgery to control SIB is a reasonable decision, it prolongs the period of visual disability experienced by a patient with SIB.…”

Section: Discussionmentioning

confidence: 99%

“…While delaying surgery to control SIB is a reasonable decision, it prolongs the period of visual disability experienced by a patient with SIB. This could potentially exacerbate SIB, because decreased vision may aggravate patient anxiety 10 and worsen resultant amblyopia in a younger child.…”

Section: Discussionmentioning

confidence: 99%

Cataract secondary to self-inflicted blunt trauma in children with autism spectrum disorder

Lee

Lenhart

Lambert

2016

Journal of American Association for Pediatric Ophthalmology and

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We report 3 cases of bilateral cataract secondary to self-inflicted blunt eye trauma in children with autism spectrum disorder (ASD). All 3 children hit their foreheads, orbits, or globes repeatedly for long periods of time and developed cataracts. Clinicians must be aware of this phenomenon to diagnose ocular pathology early and to provide adequate education, counseling, and services to affected patients and their families and to put appropriate postoperative care mechanisms in place to prevent permanent ocular damage.

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“…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).…”

Section: Discussionmentioning

confidence: 99%

“…For example, one theory speculates that endogenous opioids stimulated by pain result in down-regulation of receptors culminating in the phenomenon of "pain addiction" (2,5). SIB may be related to hypothalamuspituitary-adrenal dysfunction that involves dysfunction of the stress-related substance proopiomelanocortin, which is an endogenous opioid precursor.…”

Section: Discussionmentioning

confidence: 99%

Naltrexone for Severe Eye-Gouging in Down Syndrome

Hauptman

2016

AJP Residents' Journal

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We present the case of a profoundly intellectually disabled, nonverbal woman in her 40s with Down syndrome who experienced life-long severe self-injurious behavior (SIB), including chronic eye-gouging that resulted in blindness. She had been unsuccessfully treated for SIB with decades of polypharmacy, including neuroleptics, antidepressants, and anxiolytics, but ultimately showed complete resolution of SIB with naltrexone therapy. CASE"Ms. B" carried a diagnosis of Down syndrome. She was nonverbal, and while formal neuropsychological testing was not available, the evidence from history and clinical interview suggested profound intellectual disability. In addition to intellectual disability, the patient suffered from severe violent outbursts and SIB that had begun in early childhood. Of particular importance, her SIB took the form of chronic eye-rubbing and gauging. This symptom persisted for decades, was recalcitrant to treatment, and resulted in the patient blinding herself from chronic abrasion and infection. Aggressive and violent outbursts were common in her younger years but improved with age and neuroleptic management. She was first reported to have been seen by a psychiatric practitioner at 30 years old; however, numerous caregiver transfers and a complex psychosocial history resulted in considerable uncertainty about many historical details.At the time of presentation, Ms. B was in the care of her foster mother. Details of why she was in foster care were vague; however, it was reported to be related to her intense special care needs rather than specific issues in the household of her biological family. Her foster mother was experienced with caring for intellectually disabled individuals and was an excellent support. Ms. B received nursing assistance for medication management and activities of daily living. She lived at home with her foster mother.No specific family history of mental illness was known to providers. There was no known history of early-life trauma or neglect, though this cannot be known definitively, since the patient had undergone numerous housing and care transfers. To our knowledge, she had not been psychiatrically hospitalized, and despite chronic eyegauging SIB, there was no known history of suicidality. She carried no other primary psychiatric diagnoses. Down syndrome had been confirmed early in life by genetic testing. There was no suspicion of any history of substance use, legal history, or homelessness.At presentation, Ms. B was being treated with escitalopram (10 mg), paliperidone (3 mg daily), and buspirone (15 mg b.i.d.). The rational for this medication regimen was reported by her foster mother to be unclear. A primary concern had been aggression and self-injury. Despite long-term polypharmacy, she persisted in having constant, daily self-injurious eye rubbing and gouging that resulted in frequent infection. Aggressive behaviors, however, were well controlled on this regimen at the time, though no change in medication had occurred in recent history, and thus it is unknown wheth...

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Multidisciplinary Assessment and Treatment of Self-Injurious Behavior in Autism Spectrum Disorder and Intellectual Disability: Integration of Psychological and Biological Theory and Approach

Cited by 72 publications

References 249 publications

Irritability and Problem Behavior in Autism Spectrum Disorder: A Practice Pathway for Pediatric Primary Care

Irritability and Problem Behavior in Autism Spectrum Disorder: A Practice Pathway for Pediatric Primary Care

Cataract secondary to self-inflicted blunt trauma in children with autism spectrum disorder

Naltrexone for Severe Eye-Gouging in Down Syndrome

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