Here, we give an overview of self-injurious behaviour and possible causes and interventions.
Self-injury can be one of the most distressing and difficult behaviours that parents, carers, family members and people with autism spectrum diroders (ASDs) themselves may be faced with. Often, the causes for these behaviours are complex and the level of risk to the individual's safety and well-being can be high. Usual behavioural intervention approaches are not always appropriate; it is generally important to get professional help to deal with these issues.
Information on how and where to get specialist support is included at the bottom of this page. Further information about self-injurious behaviour is available in the books listed in the 'Recommended reading' section on this page, or from our Autism Helpline.
For general information about behavioural issues and ASD, please refer to our Understanding behaviour information sheet (available free from the Autism Helpline).
The term 'self-injurious behaviour' refers to any activity in which an individual inflicts harm or injury to him or herself. Sometimes referred to as self-harming behaviour, self-injury can take many different forms, including:
Individuals with an ASD who have complex needs and who have concurrent learning disabilities are more likely to engage in severe self-injurious behaviours (Howlin, 1998). However, people across the spectrum and of all ages may engage in self-injurious behaviours at some point. Individuals who engaged in self-injurious behaviours as children may return to these as adults during times of stress, illness or change.
The reasons a person engages in self-injurious behaviours can be wide and varied, and will often involve a complex interaction between multiple factors. Head banging that may have started as a form of sensory stimulation may develop into a way to avoid demands. Head hitting that was initially a response to earache may develop into a way to have wants or needs met. The following are some possible causes that should be considered when thinking about self-injurious behaviour:
The first, and perhaps most important, consideration when thinking about self-injurious behaviour, is to explore and rule out possible medical or dental problems that the individual may be experiencing. Individuals with an ASD may have difficulty communicating to others that something is wrong physically and particular self-injurious behaviours (such as ear slapping or head banging) may be their way of coping with pain or communicating discomfort. Here are some examples of medical and dental problems which may be expressed through self-injurious behaviour:
Researchers have also suggested there may be a link between self-injurious behaviours and particular neuro-chemical systems as outlined below:
Research has shown that some individuals with an ASD have elevated beta-endorphin levels which increase an individuals pain threshold and may therefore contribute to the development of self-injurious behaviours.
It has also been suggested that self-injury can cause a release of opiates that produce a pleasant, even euphoric effect, which serve to reinforce the behaviour.
Researchers have suggested that elevated blood serotonin levels observed in some people with an ASD may be linked to behavioural difficulties such as self-injury (Gillberg and Cole, 1992).
Studies of individuals with Lesch-Nyhan syndrome (a hereditary condition characterized by self-injurious behaviour such as lip and finger biting) have revealed an imbalance of the dopaminergic mechanisms in the brain, which researchers have suggested may play a role in the development of self-injurious behaviours.
Linked to the opioid theories discussed above, self-injurious behaviour may be an attempt to gain sensory input (particularly if an individual has a higher tolerance to pain due to elevated beta-endorphin levels) or conversely to cope with sensory overload (ie head banging may help block out unpleasant or distressing auditory stimuli such as a dog barking or a lawnmower).
Some self-injurious behaviour may be persisting remnants of earlier motor behaviours which occur during particular developmental periods (eg hand mouthing which may continue beyond infancy).
Many self-injurious behaviours occur in individuals who have no other functional way of communicating their needs, wants and feelings. An individual who bangs their head on a hard surface will get a very quick response from other people, whether that is for attention, a preferred object or activity, or to reduce demands being placed on them.
For another individual, head slapping may be a way of communicating frustration; others may find hand biting helps them cope with anxiety or excitement. For others, skin picking or eye gouging may be a response to lack of stimulation or boredom.
The individual learns, by observing the responses of others, that self-injurious behaviour can be a very powerful way of controlling the environment. It is in this way that self-injurious behaviour (eg head slapping) which was initially a response to physical pain or discomfort eventually becomes a way of avoiding an undesired situation (eg, turning the television off).
Repetitive behaviours, obsessions and routines are inherent features of ASD, and some forms of self-injury may be expressions of this feature.
Some self-injurious behaviour may be indicative of underlying mental health issues such as depression or anxiety, particularly in individuals with high-functioning autism or Asperger syndrome.
The following are some general ideas on how to prevent and respond to self-injurious behaviours.
If the individual is engaging in serious self-injurious behaviour, it is strongly recommended that you seek professional assistance. Please refer to information provided below in the 'Where and how to get extra help' section.
What to do on a day-to-day basis to prevent self-injurious behaviour.
Arrange an appointment with the individuals GP to discuss the issue and to obtain a referral to a specialist if required. Bringing along notes about when the behaviour occurs (ie what time of day and in which situations), how often it occurs, when it first started, and how long it lasts will assist the GP in determining whether there may be a physical cause for the behaviour. Appendix 1 included at the end of this factsheet provides a basic recording sheet to keep a note of self-injurious behaviour that you could bring along to the appointment. Appendix 2 provides a list of questions to consider in terms of when the behaviour occurs.
Develop a clear understanding of the functions of the behaviour for the individual. For some people, the self-injurious behaviour may serve a sensory function (ie by increasing or reducing stimulation), for others the behaviour may be a response to some form of physical pain. As mentioned previously, the functions of self-injurious behaviour may be quite complex and it can be important to get specialist advice in these instances.
Refer to the Understanding behaviour information sheet available free from our Autism Helpline for further information regarding functions of behaviour.
Teach the individual alternative, more appropriate ways of communicating their wants, needs and physical pain or discomfort. Picture symbols can be very effective for people with an ASD, as they can be used in a broad range of situations and are particularly useful for indicating physical pain or illness.
Please refer to the Visual Supports information sheet available from the Autism Helpline for further information on how to use picture symbols.
Establish a clear daily routine for the individual to increase predictability and thereby reduce anxiety. Try to build a range of activities into the individuals routine to minimize boredom and restrict opportunities for the individual to engage in self-injurious behaviour. Make plans for difficult times of the day. Increase structure and provide additional supervision and support to the person during these periods or activities.
If the individual is engaging in self-injurious behaviour for sensory stimulation, try to find alternative activities that provide them with a similar sensory experience and build these activities into the individuals routine. Jumping on a trampoline or swinging on a swing may provide needed stimulation to the vestibular system (that head shaking or slapping may have previously provided). Providing the individual with a bum bag of edible or safe objects to chew on that provide different sensory experiences such as gum, carrots, raw pasta or sultanas may reduce the need for hand or arm biting.
Please refer to our information sheet The sensory world of autism, available free from the Autism Helpline, for further information on sensory issues.
Research suggests that regular aerobic exercise not only significantly improves emotional and physical well-being, but also can reduce the occurrence of self-injurious and aggressive behaviours (Rosenthal-Malek & Mitchell, 1997). Aerobic exercise can include activities like running, swimming, cycling, jumping on a trampoline, dancing, and aerobics and preferably needs to occur at least three times per week. Try to think about the individuals interests and choose activities that can be built into the persons weekly routine. In some instances it may be important to get specialist medical advice or support from a physical trainer before commencing a new exercise programme.
Make a point of rewarding appropriate behaviours and periods when the individual is not engaging in self-injurious behaviour throughout the day. This will help the person learn that other, more appropriate behaviours bring positive outcomes thereby increasing the frequency of these behaviours as opposed to self-injurious behaviours. Rewards can take the form of verbal praise and attention, preferred activities, toys, tokens or sometimes small amounts of favourite foods or drinks. Ensure that you clearly name the behaviour that you are rewarding, to assist the individuals learning eg Jane, thats good waiting! and ensure that rewards are provided immediately after the behaviour that you wish to encourage eg You can spend 10 minutes on the computer now. It should be noted that some individuals with an ASD do not enjoy social attention. In these circumstances verbal praise can cause distress and actually stop the individual engaging in the desired behaviour in the future.
What to do when the behaviour is occurring.
It is essential to intervene early and respond quickly to incidents of self-injury. Even if the behaviour serves the function of gaining attention from others, it is never appropriate to ignore severe self-injurious behaviour. Appropriate responses will vary according to the behaviour of concern, but the following are some general guidelines:
Please note: it is important when using any of these strategies that the individual is also provided with opportunities to develop skills to communicate their needs more appropriately and to self-regulate stress and anxiety levels.
For further information contact:
Link Design LtdSafespaces sell 'safe-room' structures, both semi-permanent and as travel versions that were specifically designed for people with autism.The Safespace is custom-made to fit an existing room, the zip out doors and windows are custom designed to align with those already present. The flexible walls and thick soft padded floor reduce the risk of the person inside being able to harm themselves on walls, floors and other hard surfaces.
Tel: 01706 816 274In extreme circumstances or emergencies, contact 999 for assistance.
Some self-injurious behaviour can place the individual at serious risk of harm. In these instances, it may be appropriate to explore the use of physical restraints such as arm splints or helmets to protect the individual against injury. Clements and Zarkowska (2001) suggest that physical restraints may be easier to fade out (ie reduce reliance on) than restraint provided by another person (ie physically holding the person to prevent self-injury), so in some respects may be the more appropriate option. However, physical restraints are still very restrictive and should always be used under the guidance of a specialist to ensure they are used safely and appropriately.
Aside from serious safety and ethical concerns if used incorrectly, in some instances restraints can actually increase the occurrence of self-injurious behaviour (Howlin, 1998). Also, physical restraints do not actually address the cause of the behaviour, so it is essential that they are never used in isolation without teaching the individual new skills which address the function of the behaviour.
There is evidence to suggest that particular medications may be effective in reducing the occurrence of self-injurious behaviour for some individuals. As with physical restraints, medication should be seen as a last resort approach to management and again, should never be used without teaching new skills. The Autism Helpline has a general factsheet regarding the use of medications for people with autistic spectrum disorders which can be provided on request, however for specific advice you will need to consult with a medical specialist.
In summary:
Arrange an appointment with your family GP and request a referral to a specialist with knowledge of ASDs and behavioural issues (eg a clinical psychologist, psychiatrist or behaviour support team if there is one operating in your area).
It can be helpful to arrange an appointment with your GP to specifically discuss behavioural concerns and to bring written information about the self-injurious behaviour. Clearly communicating your concerns to the GP regarding your child's or relative's self-injurious behaviours is important in ensuring that an appropriate referral is made. If your GP is not aware of specialists in your area, the organisations below may be able to help.
Autism HelplineThe Autism Helpline holds a database of specialists who have indicated that they have expertise or interest in the area of ASD. This database is not comprehensive (it does not include the details of all specialists across the country) and the Helpline is unable to recommend any particular specialist, however we are able to provide the details of specialists listed in different parts of the country if requested.
British Psychological Society (BPS)The Challenging Behaviour Foundation may be able to provide information regarding upcoming training and workshop opportunities and they also produce a series of fact sheets discussing a range of behavioural issues.
There are a number of very good books available which provide further information regarding self-injurious behaviours in people with an ASD. Here is a list of some of these books. Those which are available to buy from NAS Publications are marked with a star.
*Attwood, T. (1998). Asperger syndrome: a guide for parents and professionals. London: Jessica Kingsley Publishers.
*Clements, J. and Zarkowska, E. (2000). Behavioural concerns and autistic spectrum disorders: explanations and strategies for change. London: Jessica Kingsley Publishers.
Fouse, B. and Wheeler, M. (1997). A treasure chest of behavioural strategies for individuals with autism. Arlington: Future Horizons Inc.
Howlin, P. (1998). Children with autism and Asperger syndrome: a guide for practitioners and carers. Chichester: John Wiley & Sons Ltd.
Howlin, P. (1998). 'Autism', in: Howlin, P. (ed.) Behavioural approaches to problems in childhood. London: Cambridge University Press.
Gillberg, C. and Coleman, M. (1992). The biology of autistic syndromes (2nd edition). New York: Cambridge University Press.
Rosenthal-Malek A. and Mitchell S. (1997). Brief report: the effects of exercise on self-stimulatory behaviors and positive responding of adolescents with autism. Journal of Autism and Developmental Disorders, 27(2), pp. 193-202.
Schopler, E. (ed.) (1995). Parent survival manual. New York: Plenum Press.
*Whitaker, P. (2001). Challenging behaviour and autism: making sense making progress. London: The National Autistic Society.
*Wing, L. (1996). The autistic spectrum: a guide for parents and professionals. London: Constable.
If an item is marked as available from the NAS please contact:
NAS PublicationsIf you require further information about challenging behaviour, autism or related issues, please contact our Autism Helpline. Tel: 0845 070 4004 (Monday-Friday, 10am-4pm) or email: autismhelpline@nas.org.uk
Last updated: April 2009
© The National Autistic Society 2004