Treating Individuals with Self-Injurious Behaviors

What is Self-Injurious Behavior?

Updated March 15, 2025

Many children and adults with and without disabilities engage in what is called self-injurious behavior (SIB). These actions result in physical injury that may be as mild as chewing a cuticle or picking a blemish until it bleeds or as severe as head banging that results in possible brain injury, blindness, broken bones and even death. Skin picking (excoriation), pulling out hair (Trichotillomania) and nail biting (onychophagia) are types of SIBs called  body focused repetitive behaviors (BFRB) that affects about 1.4% of adults in the United States.

The 1970s proved to be period of growing disability rights including lawsuits and awareness of the abusive conditions in institutions. A plethora of policies to educate, train, treat,  and desinstitutionalize people with developmental disabilities followed. Over the next several decades I learned about the relationship of SIB to neurological conditions such as sensory processing and autism spectrum disorder (SPD), behavioral challenges and the role of occupational therapy in treatment.

Diagnosing Self-Injurious behaviors (SIB)

The term self-harm is used to describe behaviors that are physically and/or mentally harmful- such as drug abuse and cutting one’s body.  According to the National Alliance of Mental Illness (NAMI), self-harm is a behavior that indicates a need for better coping skills. Several illnesses are associated with it, including borderline personality disorder, depression, eating disorders, anxiety or posttraumatic distress disorder.

The diagnostic criteria for NSSI provides details including

1. frequency
2. emotional expectations
3. problematic thoughts prior to the behavior
4. that the actions are not socially sanctioned
5. that it does not occur only in the context of psychosis, delirium or substance use/withdrawal and
6. that it is not better accounted for by another psychiatric disorder or medical condition.

Behaviors that are associated with sexual arousal and committed with conscious suicidal intent are excluded from the NSSI diagnosis (Rao, Sudarshan and Begum).

Who Assesses and Treats Individuals with Self-Injurious Behaviors?

Treating SIB may involve a psychiatrist prescribing medication, counseling or a behavior analysist’s assessment and treatment protocol. A physician should rule out medical causes such as using SIB as a way to mask another source of pain.  Therapies might include

•  speech and language therapy to develop a communication program to minimize frustrations. 
• occupational therapy to assess for specialized medical devices such as elbow or hand splints that prevent the hand from reaching one’s mouth or design a sensory diet.
• massage or other bodywork practitioner who helps to reduce tension.
• counselling by a social worker or other mental health professional to provide cognitive therapy.

Ryan, shown in the photo above typically has his hands in his mouth, causing skin breakdown and infection. He does not use his hands functionally except to grasp a cup or utensil placed in his hand. I positioned weighted and/or vibrating cushions around his shoulders and on top of his arms to discourage this behavior. This was not a restraint because Ryan could remove the objects anytime he chose. He appeared to like the sensory input from weighted materials and vibration. I wrote a treatment goal to increase the amount of time Ryan tolerated the sensory objects as demonstrated by keeping his hands under them.   

Diagnoses associated with Self-Injurious Behaviors

• • placing a cuddly cat bed on his lap
  • the socks filled with sand and vibrating toothbrush are attached to the fabric.
  • A bag of sand is also sewn to the  bottom to provide weight on his lap.

Many of my clients with IDD also presented with comorbidities such as

• Psychiatric illness such as borderline personality disorder, depression, eating disorders, anxiety or posttraumatic distress disorder.
• OCD/anxiety- which sometimes is not diagnosed  because of the person’s other challenges and poor communication skills.
• Attention Deficity Hyperactivity Disorder-(ADHD) symptoms are associated with an increased risk of NSSI in adolescents, especially in the case of girls.
• Genetic Disorders such as Lesch-Nyhan and Rett Syndromes.
• Autism Spectrum Disorders (ASD) SIB has been reported in more than 30 % of children with an autism spectrum disorder (ASD) in clinic-based studies.

Interesting Demographics

• Studies indicate that more than 30% of children on the autism spectrum in clinic-based studies have been reported to demonstrate SIB.
• The most common forms of SIB reported in the literature amongst individuals with IDD include head banging, head hitting, and self-biting;  these are reported in approximately 40% of all cases.
• Findings reveal that females with NSSI reported higher rates of cutting and scratching and more injuries to arms and legs than their male counterparts
• Males with NSSI reported more burning and hitting-type behavior, as well as injuries to the chest, face, or genitals.

Treatments for Self-Injurious Behaviors

The severity of the behavior is a factor in  determining whether protective devices are deemed necessary. Restrictive medical devices such as helmets or splints should be approved by a human rights committee and regularly monitored by a therapist to deem them safe and beneficial. Treating SIB is a team effort that should include medical, behavioral professionals as well as therapists. The following suggestions may be helpful.

Some individuals crave oral sensory stimulation- using their hands or objects. Obviously, they require close supervision and small objects that they can choke on should not be within their reach. The woman shown in the following video, puts everything in her mouth. But she is also happy manipulating objects attached to the table or tray.

• • textures
  • weighted objects
  • resistive materials such as pushing socks through a small container opening (shown in the photo aove) and
  • vibration.

Self-Care

I believe that in this day and age, especially during a pandemic, there is much more awareness of anxiety disorders, SIB and the need to provide self-care to have the best quality of life. Many of you, like myself not only have to cope with anxiety and sensory challenges but the additional stress of parenting children with disabilities. Here is how I individualize my own sensory diet.

• I sleep with a weighted blanket
• I wear a heated, aromatic, weighted collar as desired
• I lay on an accupressure mat and squeeze or rub my hands on top of a spikey cushion, hairbrush and/or sensory balls
• I play ocean white noise while sleeping
• I get a LOT of exercise
• I have a variety of fidget objects and I alternate  or change them up to meet my sensory needs.
• I limit sugar and caffeine
• Marijuana is legal in my state. I find that it reduces anxiety and is fun. Im just an old hippy!
• As I get older, I care less about what people think about me. Its very freeing and it helps that I retired when Covid hit….

There are a variety of support groups on Facebook. You can choose them according to your particular needs.  The members seem to be predominently female and often share tips about cosmetics and skin treatments that can be beneficial for people who have scars.

Lastly, you or someone you care about may benefit from occupational therapy services that specialize in skin picking or other body focused repetitive behaviors. According to occupational therapist, Tasneem Abrahams-

References

Kahng SW, Iwata BA, Lewin AB (2002) Behavioral treatment of self-injury, 1964 to 2000. Am J Ment Retard 107: 212-221.