Observing signs of pain in relation to self-injurious behaviour among individuals with intellectual and developmental disabilities

The recognition, assessment and perceptions of total pain in people with profound intellectual disabilities: A mixed methods systematic review

BACKGROUND

People with profound intellectual disabilities are a population with complex comorbidities. Total pain recognises the interconnectedness of aspects of pain; social, psychological, physical, emotional, spiritual. Pain is under-recognised due to communication challenges and carers perceptions. This review's purpose is to synthesise current literature and provide guidance for future research and care.

METHODS

Five databases were searched in this mixed methods systematic review (Cinahl, Medline, Psycinfo, Web of Science, Scopus). Articles retrieved were reported via a PRISMA flow diagram. Quality appraisal utilised the mixed methods appraisal tool (MMAT). A convergent qualitative design was the method of data synthesis.

RESULTS

Data from 16 included articles generated four themes; Absent voices, reductionist assessment, pain intensity, valuing expertise. Data included physical pain only.

CONCLUSION

Multifaceted pain needs inclusion in research. Assessment must consider the unique expressions of pain by individuals with profound intellectual disabilities. A sharing of expertise may improve pain care.

Evaluating and Handling the Pain of People With Intellectual Disability

Anecdotal reports have suggested people with intellectual disabilities experience more pain than the general population due to additional co-morbidities and secondary conditions. This multicenter comparative cross-sectional study aimed to evaluate the prevalence, factors, and treatment modalities in people with intellectual disabilities (PID) as observed by their caregivers and reported through distributed questionnaires. The study sample included 130 PID users of centers in Ciudad Real (Spain). Variables related to sociodemographic characteristics, health problems, problem behaviors, and pain were collected. Among participants, 78 (60%) of PID were males, and their mean age was 43.8 years (SD = 13.57). Pain was identified in 29 PID (22.3%; 95% confidence interval [CI] 14.99-29.81), and drugs for pain were administered to 33 PID (26.4%; 95%CI 19-34). The prevalence of pain in the sampled PID, its severity, and the analgesic administration rate were lower than those in the general population. This situation may be aggravated for PID with communication problems.

Hair Cortisol and Self-Injurious Behavior Among Children With Autism Spectrum Disorder

Elevated salivary cortisol levels have been documented in individuals who engage in self-injurious behavior (SIB), indicating acute physiological stress. Less is known about the chronicity of stress and SIB. We analyzed the relationship between parent ratings of problem behavior and hair cortisol concentrations (an index of chronic adrenocortical activity) in 23 children with autism spectrum disorder (ASD). Parent ratings of problem behavior were not significantly correlated with hair cortisol concentrations. When children were categorized into groups based on the frequency and severity of SIB, participants with the greatest frequency and severity of SIB had higher hair cortisol concentrations compared to children without SIB. Frequent and severe SIB may be associated with altered hypothalamic-pituitary-adrenal (HPA) axis activity in children with ASD.

Risk factors and topographies for self-injurious behaviour in a sample of adults with intellectual developmental disorders

BACKGROUND

Self-injurious behaviour (SIB) is a prevalent form of challenging behaviour in people with intellectual developmental disorders (IDD). Existing research has yielded conflicting findings concerning the major risk factors involved, and in addition, SIB shows multiple topographies and presentations. Although presence of autism spectrum disorders (ASD) and severity of intellectual disability (ID) are known risk factors for SIB, there are no studies comparing SIB topographies by severity degrees of ID and ASD. The purpose of the present paper has been to identify risk factors and topographies for SIB in a representative, stratified and randomised sample of adults with IDD.

METHOD

This study was conducted on the basis of data collected by the POMONA-ESP project, in a sample of 833 adults with IDD. Data concerning demographic and health information, ASD symptoms, psychopathology and ID, have been analysed to determine the presence of risk factors for SIB among participants and to explore the occurrence and topographies of SIB across different severity levels of ID and ASD symptoms.

RESULTS

Self-injurious behaviour prevalence in the sample was 16.2%. Younger age, oral pain, greater severity of ID, presence of dual diagnosis, psychiatric medication intake and higher scores on Childhood Autism Rating Scale were risk factors for SIB among participants, whereas number of areas with functioning limitations, place of residence, diagnosis of epilepsy and sex were not. SIB was more frequent in participants with ASD symptoms regardless of its severity level, and they displayed a higher number of different topographies of SIB. People with profound ID without co-morbid ASD symptoms showed similar results concerning SIB prevalence and topographies.

CONCLUSIONS

Knowledge on risk factors and topographies of SIB might play a vital role in the development of prevention strategies and management of SIB in people with IDD. The mere presence of ASD symptoms, regardless of its severity level, can be a crucial factor to be taken into account in assessing SIB. Accordingly, the presence of SIB in people with ID, especially when presented with a varied number of topographies, might provide guidance on ASD differential diagnosis.

Classification of injuries observed in functional classes of self-injurious behaviour

BACKGROUND

Limited research has examined how the functions of self-injurious behaviour (SIB) relate to the production of injuries and the location, type or severity of those injuries.

METHODS

Clinical and medical records were coded for 64 individuals hospitalised for SIB. When injuries were present, the physical properties of SIB and injuries were assessed across groups of individuals with automatically and socially maintained SIB.

RESULTS

Injuries were observed for 35 of the individuals who engaged in SIB. Individuals who engaged in a single form of SIB were more likely to have injuries (P < .05). Individuals with SIB maintained by automatic reinforcement had significantly more severe injuries to the head than those in the social group (q < .05, P = .0132, H = 12.54).

CONCLUSION

Although results are preliminary, the results provide evidence that the function of SIB may influence the severity and location of injuries produced.

Behavioral treatment of automatically reinforced SIB: 1982 - 2015

Some individuals diagnosed with intellectual and developmental disabilities engage in automatically reinforced self-injurious behavior (SIB). For these individuals, identifying effective treatments may be difficult due to the nature of the reinforcement contingency. The purpose of this study was to review the literature on the treatment of automatically reinforced SIB to determine commonalities in procedures that produced effective and ineffective treatment outcomes, as well as historical trends in the treatment of this class of SIB. Results of this review indicated that there were many high-quality studies on this topic, but also a wide range in the quality of studies. As for effective treatments, noncontingent reinforcement (the most common treatment component) was found to be more effective when informed by a competing stimulus assessment rather than a preference assessment. Suggestions to improve the quality of the published record and areas in which additional research is needed are discussed.

The Relationship Between Pain, Self-Injury, and Other Problem Behaviors in Young Children With Autism and Other Developmental Disabilities

Research has suggested that individuals who engage in self-injurious behavior may have enhanced expressions of pain, which contradicts previous assertions of blunted pain sensitivity in this population. The purpose of this study was to measure expressions of pain among young children being evaluated for autism and other neurodevelopmental disabilities. The frequency of pain-related behaviors was assessed during everyday routines using the Non-Communicating Children's Pain Checklist (NCCPC-R) for 51 children. Significant group differences between children with and without self-injury were found for the NCCPC-R total scores. The frequency and severity of self-injury, aggression, and stereotypy were also highly correlated with the total scores on the NCCPC-R. These results continue to support that individuals with self-injury may have enhanced expressions of pain.

Multidisciplinary assessment and treatment of self-injurious behavior in autism spectrum disorder and intellectual disability: integration of psychological and biological theory and approach

The objective of this review is to consider the psychological (largely behavioral) and biological [neurochemical, medical (including genetic), and pharmacological] theories and approaches that contribute to current thinking about the etiology and treatment of self-injurious behavior (SIB) in individuals with autism spectrum disorder and/or intellectual disability. Algorithms for the assessment and treatment of SIB in this context, respectively, from a multidisciplinary, integrative perspective are proposed and challenges and opportunities that exist in clinical and research settings are discussed.

Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy?

This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.

Comparative analysis of self-injury in people with psychopathology or neurodevelopmental disorders

Self-injury is a complex and poorly understood behavior observed in people with psychopathology or neurodevelopmental disorders (NDD). Despite the differences in etiology and progression of these distinct disease domains, it is possible that overlapping molecular pathways underlie the expression of self-injurious behaviors (SIBs). This review outlines the similarities and differences at the behavioural and molecular level, where SIBs in both conditions may involve opioid, nucleoside, and dopamine signalling. These points of convergence have important implications for treatment and research of SIB in both populations.

Self-injury and aggression in tuberous sclerosis complex: cross syndrome comparison and associated risk markers

BACKGROUND

Research reporting prevalence rates of self-injurious and aggressive behaviour in people with tuberous sclerosis complex (TSC) is limited. No studies have compared rates of these behaviours in TSC with those in other syndrome groups matched for degree of disability or investigated risk markers for these behaviours in TSC.

METHODS

Data from the Challenging Behaviour Questionnaire were collected for 37 children, aged 4 to 15 years, with TSC. Odds ratios were used to compare rates of self-injury and aggression in children with TSC with children with idiopathic autism spectrum disorder (ASD), fragile X, Cornelia de Lange and Down syndromes. Characteristics were measured using the Mood Interest and Pleasure Questionnaire, the Activity Questionnaire, the Social Communication Questionnaire, the Repetitive Behaviour Questionnaire, the Wessex Behaviour Schedule and the revised Non-communicating Children Pain Checklist. Mann-Whitney U analyses were used to compare characteristics between individuals with self-injury and aggression and those not showing these behaviours.

RESULTS

Rates of self-injury and aggression in TSC were 27% and 50%, respectively. These are high but not significantly different from rates in children with Down syndrome or other syndrome groups. Both self-injury and aggression were associated with stereotyped and pain-related behaviours, low mood, hyperactivity, impulsivity and repetitive use of language. Children who engaged in self-injury also had lower levels of interest and pleasure and showed a greater degree of 'insistence on sameness' than children who did not self-injure. Aggression was associated with repetitive behaviour. The majority of these associations remained significant when the association with level of adaptive functioning was controlled for.

CONCLUSIONS

Behavioural profiles can be used to identify those most at risk of developing self-injury and aggression. Further research is warranted to understand the influence of such internal factors as mood, ASD symptomatology and pain on challenging behaviour in people with intellectual disability.