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Self-injury in patients with intellectual disability

Shannon, Teresa RN, BS

doi: 10.1097/01.NURSE.0000475497.85020.db
Department: CLINICAL QUERIES
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Teresa Shannon is currently enrolled in a BSN program at SUNY Brockport, in Brockport, N.Y.

The author has disclosed that she has no financial relationships related to this article.

What nursing interventions can I use for self-injurious behavior in patients with intellectual disability (ID)?–T.S., N.Y.

Teresa Shannon, RN, BS, replies: ID affects approximately 1% of the population1 and people with ID are at increased risk for self-injurious behaviors (SIB). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, patients with intellectual and adaptive behavior deficits are diagnosed with ID.2

The most common SIB include head-banging, hand-biting, excessive self-rubbing, and scratching.3 All of these behaviors can cause significant long-term physical damage in addition to short-term injury and pain and can have a negative impact on interpersonal relationships and quality of life.4

A number of theories about the cause of SIB have been proposed, such as the inability to communicate needs.4 SIB is profoundly difficult to manage, but psychotropic medication shouldn't be the first line of defense. Initially, a complete physical assessment should be performed to identify any underlying physical cause for the behavioral disorder, such as infection or constipation.3 If physical assessment yields no underlying cause, perform a functional behavior assessment (FBA).

FBA is a systematic method of establishing the cause of behavior by exploring the antecedents and consequences.4 Patterns of behavior, such as when and how the SIB manifests, are documented by staff or family on data sheets or in log books, providing clues to possible underlying causes.

If an underlying cause has been identified, nurses can devise strategies for changing the patient's environment in order to address the identified need.5 For example, Ms. V is a patient with ID who lives in a group home, has no language skills, and often repeatedly slaps her face. Conducting a FBA helped caregivers determine that this behavior occurred when she was hungry and that she wanted more or different food than what she'd been offered. Her clinical team determined her food preferences and regularly offered her favorite foods. Her treatment plan also included higher quantities of low-calorie foods to address her desire for more food.

Prescribing antipsychotics for patients with SIB should be a last resort, and reserved for patients who exhibit behaviors resulting in significant self-injury or potential harm to others.6 Adverse reactions to psychotropic medications can be significant, such as neuroleptic malignant syndrome and weight gain. The patient should be monitored closely by staff and family.

Preventing SIB is difficult, but with patience, excellent assessment, and problem-solving skills, nurses can find ways to modify a patient's behavior and reduce medication use. Get to know your patients; observe them and spend time with them. That simple strategy may give you the information you need to reduce the incidence of SIB.

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REFERENCES

1. Pivalizza P, Lalani SR. Intellectual disability (mental retardation) in children: definition; diagnosis; and assessment of needs. 2015. www.uptodate.com/contents/intellectual-disability-mental-retardation-in-children-definition-diagnosis-and-assessment-of-needs?source=search_result&search=intellectual+disability&selectedTitle=2~150.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: APA; 2013.
4. Minshawi NF, Hurwitz S, Fodstad JC, Biebl S, Morriss DH, McDougle CJ. The association between self-injurious behaviors and autism spectrum disorders. Psychol Res Behav Manag. 2014;7:125–136.
5. Schmidt JD, Drasgow E, Halle JW, Martin CA, Bliss SA. Discrete-trial functional analysis and functional communication training with three individuals with autism and severe problem behavior. J Posit Behav Interv. 2014;16(1):44–55.
6. Baldor R, O'Brien JM. Primary care of the adult with intellectual disability (mental retardation). 2009. http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?35/0/35840?source=see_link.
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