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AGGRESSION AND SELF-INJURIOUS BEHAVIOR (SIB)

Background
Medical Management Considerations
References
Resources for Families
Publication Information

Learning Points

  • Restate the estimated prevalence of aggression/self-injurious behavior in people with mental retardation (8% to 23%).
  • List the four environmental factors that may cause aggression/self-injurious behavior; i.e.,
    • Fear and frustration
    • Hunger
    • Sleep deprivation
    • Excessive demands made by others in the environment
  • Delineate the four behavioral factors underlying aggression/self-injurious behavior: i.e.,
    • Attempt to get attention
    • Attempt to avoid undesired activities/situations
    • Method of self-stimulation
    • Attempt to communicate
  • Restate four comorbid psychiatric conditions associated with aggression/self-injurious behavior: e.g.,
    • Depression
    • Mania
    • Schizophrenia
    • Obsessive-compulsive disorder
  • List three disabilities associated with aggression/self-injurious behavior: e.g.,
    • Autistic spectrum disorders (ASD)
    • Cornelia de Lange syndrome
    • Fragile X syndrome
  • Describe two characteristic features of aggression/self-injurious behavior: e.g.,
    • Higher rates in boys and men than in girls and women
    • Higher rates as IQ decreases
  • Recognize that a large percentage of cases of aggression/self-injurious behavior will be secondary to acute onset of psychiatric illness, medical problems, neurological problems, psychosocial stressors, ineffective communication means, and inadequate behavioral management.
  • Confirm that the clinician first must evaluate aggression/self-injurious behavior from a broad and general perspective and rule out other possible causes, rather than automatically associating it with the developmental disability.
  • Acknowledge that prognosis, in general, is quite variable, but the best outcomes occur with a multimodal approach.
  • Identify two scales used to rate aggression and agitation (the Overt Aggression Scale and the Overt Agitation Severity Scale).
  • Describe when pharmacotherapy should be considered (when behavioral approaches and cognitive therapies have proved insufficient).
  • Refer families to appropriate resources.

BACKGROUND
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Description and Occurrence

Estimates of the prevalence of aggression/self-injurious behavior in people with mental retardation has ranged from 8% to 23%. The highest prevalence is among individuals with severe or profound mental retardation. Base rates of aggression in people with mental retardation in public residential facilities is estimated at 36%. The rates are even higher with new admissions at 42% and readmissions 45%. The potential consequences of aggressive/self-injurious behaviors include bodily injury, death, isolation from family/peers/community, harm to others, development of related psychopathology, and placement in restrictive settings. The assessment and management requires a multimodel treatment and team approach, as self-injury is often under behavioral control or a combination of behavior and biological control.

Manifestations

  • Self-striking (face slapping, head banging)
  • Scratching, pinching, gouging, or pulling body parts
  • Self-biting
  • Repeated vomiting or rumination
  • Severe pica (eating nonedible substances) and coprophagia

Causes include:

Environmental factors

  • Fear and frustration
  • Hunger
  • Sleep deprivation
  • Excessive demands made by others in the environment

Behavioral factors

  • Attempt to get attention
  • Attempt to avoid undesired activities/situations
  • Method of self-stimulation
  • Attempt to communicate

Comorbid psychiatric conditions

  • Depression
  • Mania
  • Schizophrenia
  • Obsessive-compulsive disorder
  • Panic/anxiety

Medical conditions

  • Physical pain, often ongoing

Disabilities Associated with Aggression/SIB

  • Autistic spectrum disorders (ASD)
  • Cornelia de Lange syndrome
  • Fragile X syndrome
  • Hereditary sensory neuropathy
  • Lesch-Nyhan syndrome
  • Rett syndrome
  • Severe and profound mental retardation
  • Tourette syndrome
  • Visual impairment

Characteristic Features

  • Higher rates in boys and men than in girls and women
  • Higher rates as IQ decreases
  • Association with certain genetic disorders (e.g., Lesch Nyan Syndrome; Cri du Chat)
  • Associated to underlying acute medical/neurological problems, especially those associated with pain
  • Higher rates in response to psychosocial stressors
  • Higher rates with onset of psychopathology
  • Higher rates with inadvertent behavioral reinforcement
  • Higher rates with poor communication abilities

Diagnostic Considerations

When evaluating aggression/self-injurious behavior, one must be careful not to automatically associate mental retardation as the causal element. In fact, a large percentage of cases of aggression/self-injurious behavior will be secondary to acute onset of psychiatric illness, medical problems, neurological problems, psychosocial stressors, ineffective communication means, and inadequate behavioral management. Some aggression or self-injurious behaviors can be related to persistent, intense, stereotypic movements. The above listed factors can impact the frequency, intensity, and duration. In these individuals when evaluating aggression/self-injurious behavior, the clinician first must evaluate it from a broad and general perspective and rule out other possible causes, rather than automatically associating it with the developmental disability. When a specific condition other than (or associated with) the developmental disability can be identified as the cause of the aggressive-like behaviors, the behavioral and pharmacological treatments should address the diagnosis/cause itself, rather than the developmental disability.

MEDICAL MANAGEMENT CONSIDERATIONS
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In general, aggression/self-injurious behavior is considered a medical emergency requiring specialized attention. Stabilization of these behaviors may require constant observation, psychiatric evaluation, medical and neurologic evaluation, psychosocial assessment, behavioral assessment, and pharmacotherapy evaluation. Prognosis, in general, is quite variable, but the best outcomes occur with a multimodel approach.

Initial Evaluation

A careful evaluation is necessary to identify and appropriately treat the underlying behavioral, medical, and/or psychiatric conditions resulting in the self-injurious behavior. A practitioner should identify and quantify behaviors in terms of frequency, intensity, duration, and temporal patterns, preferably with a rating scale that can give a numeric score to follow while treatments are administered. Examples of scales used to rate aggression and agitation are the Overt Aggression Scale and the Overt Agitation Severity Scale, respectively.

Specific situations in which the person tends to exhibit aggression/self-injurious behaviors should be identified. The time of day, specific environment, level of activity, and presence or absence of other people should be noted. The environmental factors that precipitate or exacerbate the problem can then be modified.

Behavior-based treatment approaches include:

  • Modeling (the demonstration of appropriate behaviors, especially helpful with nonverbal individuals)
  • Positively reinforcing desired behaviors (Hyman)
  • Encouraging a behavior (e.g., keeping hands in pockets) that is incompatible with the SIB (Hyman)
  • Supporting a more appropriate form of communication (when SIB is thought to be an attempt to communicate) (Hyman)
  • Emotional retraining/ skills to cope (teaching the use of relaxation techniques in anxious or fearful situations)
  • Cognitive retraining/self-control (teaching the individual to identify the cause of frustration, consider alternative ways to respond, and think about the consequences of the action) or taking “time-outs”

Medication Management

Pharmacotherapy should only be considered once behavioral approaches and cognitive therapies have proved insufficient. Consider continuing the nonpharmacological treatments throughout pharmacotherapy with the goal of discontinuing medications as soon as the behavior problems are under control.

In most cases, medication management can be carried out by the primary care physician in consultation with a psychiatrist. If the diagnosis suggests a psychiatric condition underlying the behavior, medication management should be sought from a psychiatrist and choice of medication should be based on a psychiatric evaluation and assessment. Medication strategies are based on comorbid psychopathology, psychosocial stressors, behavioral analysis, and comorbid medical problems or neurological problems. A wide range of psychotropic medications has been successfully used to help manage psychiatric conditions that lead to aggression/self-injurious behavior. Medications may be selected based on comorbid symptoms or diagnoses (e.g., concurrent psychotic disorders leading to atypical antipsychotic). A practitioner should monitor for tardive diskinesia.

[Return to the index for a full document on Tardive Dyskinesia]

Some examples are listed below:

Atypical Antipsychotics

Often prescribed for SIB/aggression resulting from schizophrenia or mania

  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)

Potential side effects:

tardive dyskinesia, weight gain, and sedation; when used on a long-term basis: supersensitivity psychosis, tardive dyskinesia, akathisia, and neuroleptic malignant syndrome

Selective Serotonin Reuptake Inhibitors

Prescribed for repetitive stereotypical SIB associated with obsessive-compulsive behaviors

  • Fluoxetine (generic, Prozac, or Prozac weekly)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil or Paxil CR)
  • Fluvoxamine (Luvox)
  • Citalopram (Celexa or Lexipro)

Potential side effects:

  • headaches
  • activation
  • increased anxiety
  • gastrointestinal effects
  • sleep difficulties
  • mild weight gain

Mood Stabilizers

Prescribed for aggression and SIB especially with a cyclical pattern of escalation and/or labile/irritable mood

  • Lithium – requires EKG, routine periodic blood tests (check level [0.7 – 1.0], kidney function tests, electrolytes, TSH)
  • Valproic acid – requires periodic blood tests (check level [25 – 100], liver function tests, CBC with platelets)
  • Carbamazepine – requires EKG, periodic blood tests (check level [4 – 12], CBC with platelets, liver function tests)
  • Oxcarbazepine (Trileptal) is rapidly gaining use as it is similar to carbamazepine and less toxic
  • Other newer anticonvulsants are under investigation include topiramate, lamotrigine, and gabapentin

Opioid Antagonist (Naltrexone) may also be considered for repetitive SIB and requires monitoring of liver function tests.

Other drugs

  • Buspirone – no monitoring
  • Propanolol – check blood pressure; avoid with diabetics

REFERENCES
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Aman, M.G., Collier-Crespin, A., Lindsay, R.L. (2000). Pharmacotherapy of Disorders in Mental Retardation. European Child and Adolescent Psychiatry, 9(1), 98-107

Bihm, E.M., Poindexter, A.R., Warren, E.R. (1998), Aggression and Psychopathology in Persons with Severe or Profound Mental Retardation. Research in Developmental Disabilities, 19(5), 423-438.

Ferleger, D. (2008) Human Services Restraint: Its Past and Future. Intellectual and Developmental Disabilities, 46(2), 154-165.

Hyman, S.L. (1996). A Transdisciplinary Approach to Self-Injurious Behavior. In A.J. Capute & P.J. Accardo (Eds.), Developmental Disabilities in Infancy and Childhood (vol. II, 2nd ed., pp. 317-333). Baltimore: Paul H. Brookes.

Kaplan, H.I., Sadock, B.J. (1995). (Eds.) Comprehensive Textbook of Psychiatry/VI, (Vol.II, 2, 6th ed.) Baltimore: Williams & Wilkins

Mauk, J.E., Reber, M., Batshaw, M.L. (1997). Autism: And Other Pervasive Developmental Disorders. In M.L. Batshaw (Ed.), Children with Disabilities (4th ed., pp. 425-447). Baltimore: Paul H. Brookes.

McDonough, M., Hillery, J., Kennedy, N. (2000). Olanzapine for Chronic, Stereotypic Self-Injurious Behaviour: a Pilot Study in Seven Adults with Intellectual Disability. Journal of Intellectual Disability Research, (44)6, 677-684.

Reber, M., Borcherding, B.G. (1997). Dual Diagnosis: Mental retardation and Psychiatric Disorders. In ML Batshaw (Ed.), Children with disabilities (4th ed., pp. 405-424). Baltimore: Paul H. Brookes.

Ross-Collins, M.S., Cornish, K. (2002). A survey of the Prevalence of Stereotypy, Self-Injury and Aggression in Children and Young Adults with Cri du Chat Syndrome. Journal of Intellectual Disability Research, 46(2), 133-140.

Rush, A.J., Frances, A. (2000). Treatment of Psychiatric and Behavioral Problems in Mental Retardation. American Journal of Mental Retardation, 105(3) 1-71.

Schroeder, R., et al. (2001). Self-Injurious Behavior: Gene-Brain-Behavior Relationships. In Mental Retardation and Developmental Disabilities Research Reviews, 7, 3-12.

Schuckit, M.A. (1998). A Clinical Review of the Treatment of Aggressive-Like Behaviors in Persons with Developmental Disabilities. In Developmental Disabilities Clinical Insights: The Use of Medications in Persons with Developmental Disabilities. San Diego, CA: San Diego Regional Center for the Developmentally Disabled.

Smith. S.A., Koenig, K.P. (2005). Effects of Sensory Integration Intervention on Self-Stimulating and Self-Injurious Behaviors. The American Journal of Occupational Therapy, 59(4), 418-425.

Sovner, R., Fogelman, S. (1996). Irritability and Mental Retardation. Seminar of Clinical Neuropsychiatry, 1(2),105-114.

Szymanski, L., King, B.H. (1999). Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38(12), 5-31.

RESOURCES FOR FAMILIES
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American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue, N.W.
Washington, D.C. 20016-3007
202-966-7300

American Psychiatric Association
1400 K Street N.W.
Washington, DC 20005
888-337-7924

The Arc (formally Association for Retarded Citizens)
500 East Border Street, Suite 300
Arlington, Texas 76010
617-261-6003
800-433-5225

Association of University Centers on Disabilities
8630 Fenton Street, Suite 410
Silver Spring, MD 20910-3803
301-588-8252

California Alliance for the Mentally Ill
1111 Howe Avenue, Suite 475
Sacramento, CA 95825-8541
916-567-0163
800-950-NAMI
Fax: 916-567-1757
califami@aol.com
http://www.nami.org

California Department of Developmental Services
P.O. Box 944202
Sacramento, CA 94244-2020
916-654-1690

California Regional Centers
915-654-1958

The National Association for the Dually Diagnosed
132 Fair Street
Kingston, NY 12401
800-331-5362

National Mental Health Association Information Center
2001 North Beauregard Street, 12th floor
Alexandria, VA 22311
703-684-7722
800-969-6642
Fax: 703-684-5968
infoctr@nmha.org

Project MED (Medical Education for Consumers)

The Tarjan Center for Developmental Disabilities at UCLA

PUBLICATION INFORMATION
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This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services.

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