What is the management approach for self-injurious behavior (SIB) and tantrums for attention?

Management of Self-Injurious Behavior for Attention and Tantrums

The most effective approach for managing self-injurious behavior (SIB) used for attention-seeking and during tantrums is a comprehensive behavioral assessment followed by targeted interventions that address the specific function of the behavior, combined with appropriate psychological and pharmacological treatments when necessary.

Assessment of Self-Injurious Behavior

Functional Assessment

• A thorough behavioral assessment to determine the function of self-injurious behaviors is the essential first step in developing an effective treatment plan 1
• Self-injurious behaviors often serve specific functions, with social-negative reinforcement (escape from demands) accounting for 38.1% of cases, social-positive reinforcement (attention or access to desired items) accounting for 26.3%, and automatic (sensory) reinforcement accounting for 25.7% 2
• Attention-seeking SIB requires different interventions than SIB that serves other functions 2

Clinical Evaluation

• Assessment should include a review of conduct problems, triggers, response to previous interventions, and potential posttraumatic rage triggers 3
• Standardized aggression evaluation instruments like the Overt Aggression Scale can help track aggressive behavior and alert staff to potential dangers 3
• Collateral information from caregivers or others who have knowledge about the patient's state of mind is crucial, as patients frequently minimize the severity of their symptoms 3

Behavioral Interventions

First-Line Approaches

• Cognitive behavioral therapy (CBT) is recommended as a primary treatment for irritability and anger, targeting deficits in emotion regulation and social problem-solving associated with aggressive behavior 4
• Parent management training helps parents develop strategies to prevent aggressive behavior and de-escalate situations before they escalate, particularly effective for children with irritability and anger issues 4
• Treatment plans should include strategies to prevent aggressive behavior, de-escalate behavior before restrictive interventions become necessary, and address underlying psychopathology 4

Specific Techniques

• For attention-seeking SIB, implement differential reinforcement strategies where appropriate behaviors receive attention while SIB is not reinforced 2
• Behavioral interventions should be individualized to reflect particular triggers, coping mechanisms, and outcome requirements 3
• For children with psychosis, distraction techniques may be helpful, while anxious children may benefit from processing upsetting events to gain perspective 3

Pharmacological Interventions

For Severe Cases

• Risperidone or aripiprazole are recommended as first-line treatments for severe irritability and aggression, particularly in patients with autism spectrum disorder 5, 4
• Aripiprazole (5-15 mg/day) is FDA-approved for irritability associated with ASD in children and adolescents aged 6-17 years 5
• Risperidone (0.5-3.5 mg/day) has shown significant improvement on the Aberrant Behavior Checklist Irritability subscale compared to placebo 5

For Specific Symptoms

• For hyperactivity and inattention that may contribute to SIB, methylphenidate has shown efficacy in 49% of children with ASD versus 15.5% on placebo 5
• SSRIs may show some benefit for repetitive behaviors that include self-injury, though evidence is limited 5
• For sleep disturbances that may exacerbate SIB, melatonin is often used as first-line treatment 5

Integrated Approach

Combined Interventions

• Combining medication with behavioral interventions is more efficacious than medication alone for decreasing serious behavioral disturbance 5, 4
• Regular assessment of treatment response using standardized rating scales is recommended to track progress 5, 4
• Medication should facilitate the child's adjustment and engagement with educational and behavioral interventions 5

Special Considerations

• Higher IQ is associated with better outcomes for irritability treatment, likely because more cognitively able individuals have more resources to regulate their mood 4
• Children with intellectual disability may require additional assessment and specialized interventions 3
• For patients with specific genetic conditions associated with SIB (like Smith-Magenis syndrome or Lesch-Nyhan syndrome), targeted approaches based on the specific condition may be necessary 3, 6

Prevention Strategies

Environmental Modifications

• Assessing for potential environmental triggers of aggression is crucial in managing SIB 5
• Physical characteristics of the environment should be considered, including safe spaces and appropriate staffing levels 3
• Cultural and peer influences in the child's home environment should be considered when developing approaches to aggression management 3

Warning Signs

• Identifying early warning signs of escalation can help implement de-escalation techniques before SIB occurs 3
• Hypnotherapy, relaxation techniques, and biofeedback procedures aimed at managing stress have been reported to improve some symptoms of irritability 4

Monitoring and Follow-Up

• Regular reassessment of treatment efficacy is essential, with federal law requiring re-evaluation at least every 3 years in school-aged children with intellectual disabilities 3
• Monitor for side effects of medications, particularly with atypical antipsychotics 4
• Avoid long-term use of benzodiazepines and oral corticosteroids due to unfavorable risk-benefit profiles 5