Autism spectrum disorders (ASD) are considered to be among the most serious of the mental health conditions. Concomitant with many cases of ASD is intellectual disability. Further compounding the disability is the fact that both conditions are known risk factors for self-injurious behavior (SIB). To date, the most effective intervention methods, based on the available data, appear to be variants of behavior modification. This article provides an overview of the current status of learning-based interventions for SIB in ASD and provides a review of specific studies. Although most studies describe some combination of reinforcement and punishment procedures, efforts are under way to develop more positively oriented strategies, such as functional assessment, to decrease the use of punishment. However, almost all the treatment studies employ single case designs, thus preventing a comparison of treatment efficacy. These issues are discussed along with other strengths, weaknesses, and future directions for clinical practice and treatment.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author .
2.
Bachman, J.A. (1972). Self-injurious behavior: A behavior analysis. Journal of Abnormal Psychology, 80, 211-224.
3.
Baghdadli, A., Pascal, C., Grisi, S., & Aussilloux, C. (2003). Risk factors for self-injurious behaviors among 222 young children with autistic disorders. Journal of Intellectual Disability Research, 47, 622-627.
4.
Bailey, S.L., Pokrzywinski, J., & Bryant, L.E. (1983). Using water mist to reduce self-injurious and stereotypic behavior. Applied Research in Mental Retardation , 4, 229-241.
5.
Blankenship, M.D., & Lamberts, F. (1989). Helmet restraint and visual screening as treatment for self-injurious behavior in persons who have profound mental retardation . Behavioral Residential Treatment, 4, 253-265.
6.
Cannella, H.I., O'Reilly, M.F., & Lancioni, G.E. (2006). Treatment of hand mouthing in individuals with severe to profound developmental disabilities: A review of the literature. Research in Developmental Disabilities , 27, 529-544.
7.
Chavez, B., Chavez-Brown, M., & Rey, J.A. (2006). Role of risperidone in children with autism spectrum disorder. Annals ofPharmacotherapy, 40, 909-916.
8.
Conroy, M., Dunlap, G., Clarke, S., & Alter, P. (2005). A descriptive analysis of positive behavioral intervention research with young children with challenging behavior. Topics in Early Childhood Special Education, 25, 157-166.
9.
Davies, M., Howlin, P., Bernal, J., & Warren, S. (1998). Treating severe self-injury in a community setting: Constraints on assessment and intervention. Child Psychology and Psychiatry Review, 3, 26-32.
10.
Day, R.M., Rea, J.A., Schussler, N.G., Larsen, S.E., & Johnson, W.L. (1988). A functionally based approach to the treatment of self-injurious behavior. Behavior Modification, 12, 565-589.
11.
DeLeon, I.G., Fisher, W.W., & Marhefka, J.M. (2004). Decreasing self-injurious behavior associated with awaking in a child with autism and developmental delays. Behavioral Interventions, 19, 111-119.
12.
Dominick, K.C., Davis, N.O., Lainhart, J., Tager-Flusberg, H., & Folstein, S. (1997). Atypical behaviors in children with autism and children with a history of language impairment. Research in Developmental Disabilities, 28, 145-162.
13.
Emerson, E., Kiernan, C., Alborz, A., Reeves, D., Mason, H., Swarbrick, R., et al. (2001). Predicting the persistence of severe self-injurious behavior. Research in Developmental Disabilities, 22, 67-75.
14.
Falcomata, T.S., Roane, H.S., & Pabico, R.R. (2007). Unintentional stimulus control during the treatment of pica displayed by a young man with autism. Research in Autism Spectrum Disorders, doi:10.1016/j.rasd.2006.12.004.
15.
Favell, J.E., McGimsey, J.F., & Jones, M.L. (1978). The use of physical restraint in the treatment of self-injury and positive reinforcement. Journal of Applied Behavioral Analysis, 11, 225-241.
16.
Ferreri, S.J., Tamm, L., & Kristin, G. (2006). Using food aversion to decrease severe pica by a child with autism. Behavior Modification, 30, 456-471.
17.
Fisher, W.W., Bowman, L.G., Thompson, R.H., Contrucci, S.A., Burd, L., & Alon, G. (1998). Reductions in self-injury produced by transcutaneous electrical nerve stimulation. Journal of Applied Behavior Analysis, 31, 493-496.
18.
Fombonne, E. (1999). The epidemiology of autism: A review. Psychological Medicine, 29, 769-786.
19.
Forehand, R., & Baumeister, A.A. (1976). Deceleration of aberrant behavior among retarded individuals. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 2, pp. 223-278). New York: Academic Press.
20.
Gibbs, J.W., & Luyben, P.D. (1985). Treatment of self-injurious behavior: Contingent versus noncontingent positive practice overcorrection. Behavior Modification, 9, 3-21.
21.
Hanley, G.P., Piazza, C.C., Keeney, K.M., Blakeley-Smith, A.B., & Worsdell, A.S. (1998). Effects of wrist weights on self-injurious and adaptive behaviors. Journal of Applied Behavior Analysis, 31, 307-310.
22.
Harding, J.W., Wacker, D.P., Berg, W.K., Barretto, A., & Rawkin, B. (2002). Assessment and treatment of severe behavior problems using choice-making procedures. Education & Treatment of Children, 25, 26-46.
23.
Harding, J., Wacker, D.P., Berg, W.K., Barretto, A., & Ringdahl, J. (2005). Evaluation of relations between specific antecedent stimuli and self-injury during functional analysis conditions. American Journal on Mental Retardation, 110, 205-215.
Hill, J., & Furniss, F. (2006). Patterns of emotional and behavioural disturbance associated with autistic traits in young people with severe intellectual disabilities and challenging behaviours. Research in Developmental Disabilities , 27, 517-528.
26.
Holburn, C.S. (1986). Aerophagia: An uncommon form of self-injury. American Journal of Mental Deficiency, 91, 201-203.
27.
Holden, B., & Gitlesen, J.P. (2006). A total population study of challenging behaviour in the county of Hedmark, Norway: Prevalence, and risk markers. Research in Developmental Disabilities, 27, 456-465.
28.
Horner, R.H., Carr, E.G., Strain, P.S., Todd, A.W., & Reed, H.K. (2002). Problem behavior interventions for young children with autism: A research synthesis. Journal of Autism and Developmental Disorders, 32, 423-446.
29.
Iwata, B.A., Dorsey, M., Slifer, K., Bauman, K., & Richman, G. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 131-144.
30.
Iwata, B.A., Pace, G.M., Willis, K.D., Gamache, T.B., & Hyman, S.L. (1986). Operant studies of self-injurious hand biting in the Rett syndrome. American Journal of Medical Genetics , 24, 157-166.
31.
Jacobson, J.W., & Ackerman, L.J. (1993). Who is treated using restrictive behavioral procedures? A population perspective. Research in Developmental Disabilities, 14, 51-65.
32.
Kahng, S.W., Iwata, B.A., & Lewin, A.B. (2002). Behavioral treatment of self-injury, 1964 to 2000 . American Journal on Mental Retardation, 107, 212-221.
33.
Kern, L., Carberry, N., & Haidara, C. (1997). Analysis and intervention with two topographies of challenging behavior exhibited by a young woman with autism. Research in Developmental Disabilities, 18, 275-287.
34.
Kiley, M., & Lubin, R. (1983). Epidemiology methods. In J. L. Matson & J. A. Mulick (Eds.), Handbook of Mental Retardation (pp. 541-556). New York: Pergamon.
35.
Kurtz, P.F., Chin, M.D., Huete, J.M., Tarbox, R.S.F., O'Connor, J.T., Paclawskyj, T.R., et al. (2003). Functional analysis and treatment of self-injurious behavior in young children: A summary of 30 cases. Journal of Applied Behavior Analysis, 36, 205-219.
36.
Lalli, J.S., Mace, F.C., Livezey, K., & Kates, K. (1998). Assessment of stimulus generalization gradients in the treatment of self-injurious behavior. Journal of Applied Behavior Analysis, 31, 479-483.
37.
Lam, K.S.L., Aman, M.G., & Arnold, L.E. (2006). Neurochemical correlates of autistic disorder: A review of the literature. Research in Developmental Disabilities , 27, 254-289.
38.
La Malfa, G., Lassi, S., Bertelli, M., Salvini, R., & Placidi, G.F. (2004). Autism and intellectual disability: A study of the prevalence on a sample of the Italian population. Journal of Intellectual Disability Research, 48, 262-267.
39.
La Malfa, G., Lassi, S., Salvini, R., Giganti, C., Bertelli, M., & Albertini, G. (2007). The relationship between autism and psychiatric disorders in intellectually disabled adults. Research in Developmental Disabilities, doi:10.1016/j.rasd.2006.10.004.
40.
Larson, S.A., Lakin, K.C., Anderson, L., Kwak, N., Lee, J.H., & Anderson, D. (2001). Prevalence of mental retardation and developmental disabilities: Estimates from the 1994/1995 National Health Interview Survey Disability Supplements. American Journal on Mental Retardation , 106, 231-252.
41.
Lerman, P.C., Iwata, B.A., Shore, B.A., & DeLeon, I.G. (1997). Effects of intermittent punishment on self-injurious behaviour: An evaluation of schedule thinning . Journal of Applied Behavior Analysis, 30, 187-201.
42.
Lewis, F.M., Murdoch, B.E., & Woodyatt, G.C. (2007). Linguistic abilities in children with autism spectrum disorder. Research in Autism Spectrum Disorders, 1, 85-100.
43.
Lindberg, J.S., Iwata, B.A., Roscoe, E.M., Worsdell, A.S., & Hanley, G.P. (2003). Treatment efficacy of noncontingent reinforcement during brief and extended applications. Journal of Applied Behavior Analysis, 36, 1-19.
Luiselli, J.K., Suskin, L., & McPhee, D.F. (1981). Continuous and intermittent application of overcorrection in a self-injurious autistic child: Alternating treatments design analysis. Journal of Behavior Therapy and Experimental Psychiatry, 12, 355-358.
46.
Machalicek, W., O'Reilly, M.F., Beretvas, N., Sigafoos, J., & Lancioni, G.E. (2007). A review of interventions to reduce challenging behavior in school settings for students with autism spectrum disorders. Research in Autism Spectrum Disorders , doi:10.1016lj.rasd.2006.10.005.
47.
Magnusson, A.F., & Gould, D.D. (2007). Reduction of automatically-maintained self-injury using contingent equipment removal. Behavioral Interventions , 22, 57-68.
48.
Mancil, R.G. (2006). Functional communication training: A review of the literature related to children with autism. Education and Training in Developmental Disabilities, 41, 213-224.
49.
Mansell, W., & Morris, K. (2004). A survey of parents' reactions to the diagnosis of an autistic spectrum disorder by a local service. Autism , 8, 387-407.
50.
Matson, J.L. (2007a). Current status of differential diagnosis for children with autism spectrum disorders. Research in Developmental Disorders, 28, 109-118.
51.
Matson, J.L. (2007b). Determining treatment outcome in early intervention programs for autism spectrum disorders: A critical analysis of measurement issues in learning based interventions. Research in Developmental Disabilities, 28, 207-218.
52.
Matson, J.L., Benavidez, D.A., Stabinsky-Compton, L., Paclawskyj, T., & Baglio, C. (1996). Behavioral treatment of autistic persons: A review of research from 1980 to the present. Research in Developmental Disabilities, 17, 433-465.
53.
Matson, J.L., Cooper, C., Malone, C.J., & Moskow, S.L. (2007). The relationship of self-injurious behavior and other maladaptive behaviors among individuals with severe and profound intellectual disability. Research in Developmental Disabilities, doi:10.1016/ j.ridd.2007.02.001.
54.
Matson, J.L., & Keyes, J.B. (1990). A comparison of DRO to movement suppression timeout and DRO with two self-injurious and aggressive mentally retarded adults. Research in Developmental Disabilities, 11, 111-120.
55.
Matson, J.L., & Minshawi, N.F. (2006). Early intervention for autism spectrum disorders: A critical analysis. New York : Elsevier.
56.
Matson, J.L., & Nebel-Schwalm, M. (2006). Assessing of challenging behaviors in persons with autism spectrum disorders. Research in Developmental Disabilities, doi:10.1016/ j.ridd.2006.08.001.
57.
Matson, J.L., Nebel-Schwalm, M.S., & Matson, M.L. (2007). A review of methodological issues in the differential diagnosis of autism spectrum disorders in children: Diagnostic systems and scaling methods. Research in Autism Spectrum Disorders, 1, 38-54.
58.
Matson, J.L., & Smith, K.R.M. (2007). Current status of intensive behavioral interventions for young children with autism and PDD-NOS. Research in Autism Spectrum Disorders, doi:10.1016/j.rasd.2007.03.003.
59.
Matson, J.L., & Taras, M.E. (1989). A 20 year review of punishment and alternative methods to treat problem behaviors in developmentally delayed persons. Research in Developmental Disabilities, 10, 85-104.
60.
Matson, J.L., Wilkins, J., & Gonzalez, M.L. (2007). Early identification and diagnosis of autism spectrum disorders in young children and infants: How early is too early. Research in Autism Spectrum Disorders , doi:10.1016/j.rasd.2007.03.002.
McGlynn, A.P., & Locke, B.J. (1997). A 25-year follow-up of a punishment program for self-injury. Behavioral Interventions, 12, 203-207.
63.
Mohr, C., & Sharpley, C.F. (1985). Elimination of self-injurious behavior in an autistic child by use of overcorrection. Behavior Change, 2, 143-147.
64.
Naoi, N., Yokoyama, K., & Yamamoto, J. (2007). Intervention for tact as reporting in children with autism. Research in Autism Spectrum Disorders, 1, 174-184.
65.
Odom, S., Brown, W., Frey, T., Karasu, N., Smith-Canter, L., & Strain, P. (2003). Evidence based practice for young children with autism: Contributions for single-subject design research. Focus on Autism and Other Developmental Disabilities, 10, 166-175.
66.
O'Reilly, M., Sigafoos, J., Lancioni, G., Edrisinha, C., & Andrews, A. (2005). An examination of the effects of a classroom schedule on levels of self-injury and engagement for a child with severe autism. Journal of Autism and Developmental Disorders, 35, 305-311.
67.
Paisey, T.J.H., Whitney, R.B., & Wainczak, S.M. (1993). Case study: Noninvasive behavioral treatment of self-injurious hand stereotypy in a child with Rett syndrome. Behavioral Residential Treatment, 8, 133-145.
68.
Repp, A.C., & Deitz, S.M. (1974). Reducing aggressive and self-injurious behavior of institutionalized retarded children through reinforcement of other behaviors . Journal of Applied Behavior Analysis, 7, 313-325.
69.
Roberts, M.L., Mace, F.C., & Daggett, J.A. (1995). Preliminary comparisons of two negative reinforcement schedules to reduce self-injury. Journal of Applied Behavior Analysis, 28, 579-580.
70.
Rojahn, J., Schroeder, S.R., & Hoch, T.A. (in press). Self-injurious behavior in intellectual disabilities. New York: Elsevier.
71.
Rush, K.S., Crockett, J.L., & Hagopian, L.P. (2001). An analysis of the selective effects of NCR with punishment targeting problem behavior associated with positive affect. Behavioral Interventions, 16, 127-135.
72.
Salvy, S.J., Mulick, J.A., Butter, E., Bartlett, T.G., & Linscheid, T.R. (2004). Contingent electric shock (SIBIS) and a conditioned punisher eliminate severe head banging in a preschool child. Behavior Interventions, 19, 59-72.
73.
Saunders, R.R., Saunders, M.D., Brewer, A., & Roach, T. (1996). The reduction of self-injury in two adolescents with profound retardation by the establishment of a supported routine. Behavioral Interventions, 11, 59-86.
74.
Shore, B.A., Iwata, B.A., DeLeon, I.G., Kahng, S., & Smith, R.G. (1997). An analysis of reinforcer substitutability using object manipulation and self-injury as competing responses. Journal of Applied Behavior Analysis, 30, 21-41.
75.
Sigafoos, J., & Meikle, B. (1996). Functional communication training for the treatment of multiply determined challenging behavior in two boys with autism. Behavior Modification, 20, 60-84.
76.
Siklos, S., & Kerns, K.A. (2007). Assessing the diagnostic experiences of a small sample of parents of children with autism spectrum disorders. Research in Developmental Disabilities, 28, 9-22.
77.
Smith, R.G., Lerman, D.C., & Iwata, B.A. (1996). Self-restraint as positive reinforcement for self-injurious behavior. Journal of Applied Behavior Analysis, 29, 99-102.
78.
Smolev, S.R. (1971). Use of operant techniques for the modification of self-injurious behavior. American Journal of Mental Deficiency , 76, 295-305.
79.
Swinkels, S.H.N., Dietz, C., Van Daalen, E., Kerkhof, I.H.G.M., Van Engeland, H., & Buitelaar, J.K. (2006). Screening for autism spectrum disorders in children aged 14 to 15 months. I: The development of the Early Screening of Autistic Traits Questionnaire (ESAT). Journal of Autism and Developmental Disorders, 36, 723-732.
80.
Turner, M.A. (1999). Annotation: Repetitive behaviour in autism: A review of psychological research. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 839-849.
81.
Underwood, L.A., Figueroa, R.G., Thyer, B.A., & Nzeocha, A. (1989). Interruption and DRI in the treatment of self-injurious behavior among mentally retarded and autistic self-restrainers. Behavior Modification, 13, 471-481.
82.
Vollmer, T.R. (2002). Punishment happens: Some comments on Lerman and Vorndran's review. Journal of Applied Behavior Analysis, 35, 469-473.
83.
Vollmer, T.R., Marcus, B.A., & LeBlanc, L. (1994). Treatment of self-injury and hand mouthing following inconclusive functional analysis. Journal of Applied Behavior Analysis, 27, 331-344.
84.
Vollmer, T.R., Sloman, K.W., & Borrero, C.S.W. (in press). Behavioral assessment of self-injury . In J. L. Matson, F. Andrasik, & M. L. Matson (Eds.), Assessing childhood psychopathology and developmental disabilities. New York: Springer.
85.
Wallace, M.D., Iwata, B.A., Zhou, L., & Goff, G.A. (1999). Rapid assessment of the effects of restraint on self-injury and adaptive behavior. Journal of Applied Behavior Analysis, 32, 525-528.
86.
Wong, S.E., Floyd, J., Innocent, A.J., & Woolsey, J.E. (1991). Applying a DRO schedule and compliance training to reduce aggressive and self-injurious behavior in an autistic man: A case report. Journal ofBehavior Therapy & Experimental Psychiatry , 22, 299-304.
87.
Wordsdell, A.S., Iwata, B.A., Hanley, G.P., Thompson, R.H., & Kahng, S.W. (2000). Effects of continuous and intermittent reinforcement for problem behavior during functional communication training. Journal of Applied Behavior Analysis, 33, 167-179.
88.
Zarcone, J.R., Iwata, B.A., Vollmer, T.R., Jagtiani, S., Smith, R.G., & Mazaleski, J.L. (1993). Extinction of self-injurious escape behavior with and without instructional fading. Journal of Applied Behavior Analysis, 26, 353-360.
