Understanding and Addressing Self-Injurious Behaviors in Autistic Individuals

It is estimated that about 42% of autistic people engage in self-injurious behaviors. Self-injurious behavior (SIB) is when a person physically harms themselves by head banging on floors, walls or other surfaces, hand or arm biting, hair pulling, eye gouging, face or head slapping, skin picking, scratching, rubbing or pinching, or forceful head shaking.

Another term you may hear is self-harm. The National Health Service in the UK describes self-harm as “when somebody intentionally damages or injures their body. Self-harm is most often described as a way to express or cope with emotional distress.”

The difference between self-harm and self-injurious behavior is self-harm is intentionally causing physical pain or harm to oneself, often as an attempt to manage difficult emotions or distress. It doesn’t necessarily mean that someone wants to end their life. It can also be called non-suicidal self-harm (NSSI). Self-injurious behavior is the result of an attempt to regulate or express immediate physical pain or discomfort, or communicate a particular need.

Autistica UK lists the following reasons for self-harm which differ from SIB:

• to regulate depression or numbness
• to express or cope with emotional distress
• to feel a sense of control
• to punish themselves
• to relieve unbearable tension
• to cry for help (this is not the same as attention seeking)
• to distract from intrusive thoughts

What are some of the causes of self-injurious behaviors (SIBs)?

Some causes of SIBs may be:

1. Medical – For some autistic individuals, SIB may be a way to mediate pain. By creating pain in a controlled way through an SIB, a person may mask another source of pain such as an ear infection, toothache, headache or constipation. When my daughter was 2 years old, she pulled all of her hair out around her ear. I discovered later that she had an ear infection. Working on interoceptive awareness may help an individual to understand where their pain is and be able to point to where their pain either on themselves or on a body check chart.
2. Sensory Differences–  Individuals may engage in SIB to increase their arousal level or to counteract sensory overwhelm/overload. Relaxation techniques, calming activities or exercise may help regulate a person.
3. Communication Difficulties – When under stress, it may be difficult to communicate wants and needs. If the individual struggles with functional communication, frustration and an increase in anxiety can occur which may trigger SIBs. SIB may be the way a person is trying to communicate. For example, hand biting might help cope with anxiety or excitement. Skin picking may relieve boredom. Head banging on a hard surface may be a way of telling you they are frustrated.
4. Repetitive Behavior – Some forms of self-injury might be part of a repetitive behavior, an obsession, or a routine.
5. Avoidance or Escape from Non-Preferred Activities or Undesirable Stimuli – Some individuals may learn that they can avoid or escape from undesired activities or stimuli if they engage in SIB.
6. Needing Attention – SIB may be a way to get help or attention from other people; however, this doesn’t usually explain why SIBs occur in the first place. There is usually another reason (such as compensating for communication difficulties).
7. Developmental Stages – An individual might still do some things that most people stop doing as young children, such as hand mouthing – putting their fingers or hand into their mouth – causing injury. My son used to do this when he was at the computer to the point of making himself vomit.

What can we do when self-injurious behaviors occur?

The National Autistic Society suggests the following things you can do when SIBs happen:

1. Respond Quickly– Respond quickly and consistently when a person self-injures, no matter what the reason is. It’s never appropriate to ignore severe self-injurious behavior.
2. Use Low Key Responses – Limit verbal comments, facial expressions and other displays of emotion. Try to speak calmly and clearly, in a neutral and steady tone of voice. We talk about this in Low Arousal Approach training. It is part of de-escalation.
3. Reduce Demands – Stop talking and reduce demands on the individual. You can come back to things later when the person feels calm.
4. Remove Physical and Sensory Discomforts – Figure out what is causing the individual’s discomfort. It may be noise, smells, bright lights, or other people’s proximity.
5. Redirect – Try to redirect the person on what they need to do rather than engaging in the SIB. Try another activity that can’t be done at the same time as the self-injurious behavior. For my son, that might be coloring in a coloring book.

How can we prevent self-injurious behaviors?

Consult a health professional for help with any self-injurious behavior which is difficult to manage or places the person at risk of harm.

1. Rule out medical or dental problems. Visit a GP or a dentist. Bring your observational notes on when the SIB occurs, when it started, how long it lasts, and the situation when it occurs.
2. Figure our the function of the SIB – There is always a reason for an SIB. Keep a journal and record what is occurring before, during and after the behavior. Make notes about the environment, including who was there, any change in the environment and how you think the person was feeling.
3. Have a structured environment and routine. Structure and routine support predictability which lessens anxiety. Creating predictability and lowering anxiety can go a long way towards creating an environment that supports the most communication possible.
4. Create a sensory diet and use sensory tools. A sensory diet is an individualized plan of physical activities and accommodations to help a person meet their sensory needs. This plan provides the sensory input needed to stay focused and organized throughout the day. It prevents sensory and emotional overload by meeting the nervous system’s sensory needs. Sensory tools such as noise cancelling headphones reduce auditory input. For a child who chews, a chewy pendant may be just the thing.
5. Use communication tools. A body check chart, pictures or symbols for symptoms may help a person communicate their discomfort.

Addressing self-injurious behaviors in autistic individuals requires a multi-faceted approach. When we understand the root causes of SIBs, support communication, and foster healthy ways of coping, we create an environment that supports health and well-being, enhancing the quality of life autistic individuals.

References

Autistica. Self-harm and autism

CAR Autism Roadmap (June 16, 2020). Self-Injurious Behavior. Children’s Hospital of Philadelphia

Ferguson, E. (December 3, 2024). Self-Regulation Strategies for Self-Injury. Autism Research Institute

National Autistic Society. Self-harm

National Autistic Society (August 14, 2020). Self-injurious behaviour – a guide for all audiences