Self-injurious Behavior

A teenage boy with severe mental retardation, non verbal, who was demonstrating increasing self-injury. To the point where both his mother and the care team at the facility where he lives were at their wits end. He was already on multiple medications, including antipsychotics and clonidine. (Was his SIB a clue?)

Journal of Developmental & Behavioral Pediatrics (2010) discussed a similar case

A 7 yo male with severe mental retardation and self-injurious behavior(hitting his face with his fist, banging his head against the wall/floor/table. Increasing in frequency/intensity for the last 6 months causing bruising and swelling of his forehead. Parents reported that these behaviors would occasionally occur due to frustration, but more frequently occur for no reason at all.

 Parents had tried verbal reprimands, and physically restraining. PMH: AOM, constipation, GERD as an infant. Currently on no medications. Sleeps 9 hrs each night, no change in his appetite or sleep. Parents estimate he has ~ 20 words Lives at home with parents, 2 sibs. For the past 2 years attended the same life skills class with 8 other students

 Physical exam shows no changes in his growth percentiles. No AOM. R side of his face is erythematous

 The safety concerns for the patient and the disruptive effects of SIB on the family or caretakers creates a situation that requires immediate attention.

Why do general pediatricians need to be comfortable taking care of these patients?

Because you will be seeing more of them!!! (There will be more patients with self-injurious behaviors, and more of them will be managed in the community) Recurrent SIB will be seen by primary care pediatricians, primarily in young children with autism and in adolescents with depression and cutting. Hopefully you will have a B&D pediatrician, child psychologist, child psychiatrist for consultations.

 Autism, for example. A recent 2010 AAP journal article, discusses how to evaluate GI disorders in patients with ASD. Often these patients are nonverbal and cannot describe their symptoms. These patients will present with vocal and motor behaviors, such as self-injury and aggression, as well as sleep disturbance and irritability. 5-17% of people with mental retardation and autism do serious harm to themselves by biting, pulling out hair, banging their head or gouging their eyes on a regular basis.

Medical intervention
Chronic or acute health problems increase SIB. So it is very important to diagnose and treat health conditions that are constantly aggravating the patient. Ear problems, sleep disturbance, and digestive/GI complaints(constipation, GERD) are the most common culprits. Also want to rule out sinusitis, dental problems, migraine headaches, allergies, dysmenorrhea, seizures (This is the Pediatricians major role, but not necessarily his only role.) If no underlying medical condition is apparent, eval and treatment just became more complicated.

Behaviorist Approach
For some patients with intellectual deficits, SIB is their way of communicating that something is wrong or they want to be left alone. (In ~70% of SIB cases, individuals are using the behavior as a form of communication) Can try to track antecedents and consequences of the behavior to determine what the patient is trying to communicate. (Diary) Has anything changed in the patients world (home, school) SIB is very effective in eliciting attention. Teaching new strategies for expressing needs and relating to other people would be the preferred intervention in this case (There are some studies that show 25% are refractory to behavioral intervention, in terms of long-term effects) Stimulation theory? Beta-endorphin release following SIB generates euphoric/anesthetic-like effect theory?

Medications
When there is a chemical imbalance in the brain, treatment must include medication. There is no current drug that has been created specifically for SIB. There has been some success with Risperidone, an antipsychotic serotonin/dopamine modulator. In a 2002 clinical study there was a 25-50% reduction in SIB episodes in all but one patient. UC Irvine has reported success with opiate-blockers such as Naltrexone. (There is a theory that these patient have an inability to feel normal pain.) Treament success depends on the patients unique brain chemistry.

Medications
Atypical antipsychotics*, anticonvulsants/mood stabilizers*, SSRIs*, opiate antagonists, and beta blockers have all been used BUT there are No evidence based guidelines

Genetic causes of SIB

Many forms of mental retardation are genetic, and in some disorders SIB is so predictable it is considered part of the disorder Examples are Lesch-Nyhan(metabolic syndrome), Prader-Willi, Smith-Magenis, de Lange, and Fragile X

Will not only encounter SIB in autistm or mental retardation

Some adolescents may self-mutilate to take risks, rebel, reject their parents' values, state their individuality or merely be accepted. Patients may injure themselves out of desperation or anger to seek attention.

SIB can be a clue to psychological issues or serious psychiatric disease

Hopelessness and worthlessness, or because they have suicidal thoughts. These children may suffer from serious psychiatric problems such as depression, psychosis, Posttraumatic Stress Disorder (PTSD) and Bipolar Disorder. Children who have been abused or abandoned Some adolescents who engage in self-injury may develop Borderline Personality Disorder as adults.

Key to Treatment
Pick up on the clues - what is driving the SIB? Combination of education, behavioral intervention/counseling, and medication For a PCP, the treatment approach is often rule out any medical causes or sources of pain, then referral to a psychologist(for behavioral therapy) or neurologist/psychiatrist(for med assessment)

What would you have done with the patient???

What happened with our patient

Sent him for a complete medical workup (CBC, esr, crp, CMP, thyroid, UA, stool sample) Prescribed Valium as an emergent measure, until the medical workup was complete and we could consult with psychiatry about modifying his medication regimen.

References
http://merrill.ku.edu/PDFfiles/selfinjurious%20be havior.pdf http://aacap.org/page.ww?name=SelfInjury+in+Adolescents&section=Facts+for+Famili es Journal of Developmental & Behavioral Pediatrics, Challenging Cases in Developmental and Behavioral Pediatrics. April 2010 Jounal of American Academy of Pediatrics, Gastrointestinal Disorders in Individuals with Autism Spectrum Disorders. Jan 2010