Management of Self-Injurious Behavior in Adolescents with Autism Spectrum Disorder

Initial Assessment and Functional Analysis

The American Academy of Pediatrics recommends conducting a functional behavioral assessment before any intervention to identify what triggers the self-injurious behavior and what consequences maintain it, examining environmental antecedents, patterns of reinforcement, communication deficits, and comorbid conditions 2, 1
A functional behavioral assessment should specifically examine environmental antecedents, such as sensory triggers, transitions, and communication breakdowns, as well as patterns of reinforcement, including attention-seeking, escape from demands, and sensory stimulation 3, 1
The assessment should also examine communication deficits that may manifest as self-injury when the adolescent cannot express needs, with a prevalence of depression, anxiety, and sleep difficulties in ASD 2, 4, 5

Applied Behavioral Analysis techniques with functional communication training are the primary treatment approach, teaching alternative behaviors that serve the same function as self-injury, using forward or backward chaining with reinforcement for completion of adaptive behaviors 5, 1, 2
The intervention should implement visual schedules, planners, and timers to address working memory and processing speed deficits common in ASD, and introduce augmentative communication systems immediately to reduce frustration-based self-injury 2, 4, 5
Active family involvement as co-therapists is essential, with appropriate supervision, training, and monitoring, helping set treatment goals, teach alternative behaviors, and facilitate generalization of skills across home and school settings 6, 7, 8, 5

The American Academy of Child and Adolescent Psychiatry recommends that pharmacotherapy should only be added when self-injurious behavior is severe enough to cause physical harm, prevents participation in behavioral interventions, or when behavioral interventions have been inadequately effective after an appropriate trial 5, 1
Risperidone is the FDA-approved first-line medication for irritability associated with autistic disorder, including self-injury, with a starting dose of 0.25 mg/day if weight <20 kg, and 0.5 mg/day if weight ≥20 kg, titrated to 0.5-3.5 mg/day based on clinical response 5, 1

The evaluation team should include a psychologist, physician, and speech/language pathologist, measuring global cognitive ability, sustained attention, working memory, and processing speed, as well as receptive and expressive language, and pragmatic language skills 2, 4
Speech/language therapy is essential for adolescents with significant communication challenges that may underlie self-injury, with occupational and physical therapy sustained even when difficulties appear improved 2, 5

Environmental modifications should be implemented to reduce triggers, controlling light and noise levels, using visual communication systems to prepare for transitions, providing regular brief breaks, and considering occupational therapy techniques such as weighted items or fidget toys to provide sensory input 9, 3
The adolescent should be prepared for any new experiences or settings by describing what will happen, the sequence of events, and how stressful situations will be handled, with anticipatory guidance beginning before the experience and continuing as an ongoing process 3

Standardized rating scales, such as the Aberrant Behavior Checklist-Irritability subscale and Clinical Global Impression-Change scale, should be used to monitor treatment response, allowing for timely adjustment of interventions 5
Initial cognitive and functional evaluations should be completed to optimize therapy targets, using tools such as the Verbal Behavior Milestones Assessment and Placement Program or Assessment of Basic Language and Learning Skills-Revised to enhance target selection 4