Self Injury

Autistic people who cannot communicate effectively or experience a lot of stress often develop what are called self-injurious behaviors (SIB). This may include hitting, biting or pinching, or banging one's head onto hard surfaces. Not every autistic person will self injure, but many do. Sometimes children only have these behaviors in the time before they learn language. Other people continue to have difficult moments throughout life.

Self injury is often done as a response to pain or overwhelming negative emotions. The autistic person does not know how to handle the terrible experience, so harming themselves is their last recourse in relieving the pain. They often find it difficult or impossible to prevent or stop until it runs its course.

Causes
Self injury can have various causes. If a self-injuring autistic person can communicate, caregivers should ask them about the episode once they are calm again. If the autistic person cannot reliably communicate, then caregivers should look for... It may be useful not to treat the SIB as a mysterious behavior, but instead looking for the underlying cause. Once the cause is treated, the SIB will no longer be needed to relieve stress.
 * Illness
 * Pain (e.g. toothache, lice, ear infection)
 * Seizures
 * Sensory needs (because self-injury may be an extreme form of sensory seeking, or an attempt to block out stimuli)
 * Emotional distress
 * Communication struggles (if the autistic person has no other way to communicate, or if caregivers do not pay attention to less drastic communication attempts)
 * Abuse by parents, caregivers, or ABA therapists

Medical Reasons
A doctor's appointment can help determine if an autistic person is having some sort of medical condition or experiencing pain. Treating this condition may make the SIB stop. For example, one autistic girl would slam her head into walls because of a severe case of lice, and quit once the lice were gone.

In some cases, SIB is caused by mental illnesses such as anxiety and depression. Like with other medical conditions, treatment of these issues may reduce or stop SIB.

Communication Issues
Communication issues can worsen SIB. There are several possibilities: The first case can be helped by focusing on developing alternative communication such as sign language, PECS, typing, and/or faciliated communication.
 * The autistic person lacks the skills to reliably communicate their needs, so frustration and unmet needs cause stress to boil over
 * The autistic person can communicate, but their communication may be ignored or silenced if others do not like what they are trying to say

The second case involves caregivers and loved ones putting forth greater effort to understand and honor requests. It may mean cutting contact with therapists who do not respect the autistic person's right to say no.

Sensory Issues
Hypersensitivity may cause SIB. Typical, everyday sensations (a dog barking or the feel of scratchy clothing, for example) may be acutely distressing. Self injury may be the only way to handle the cognitive pain. In these cases, sensory integration therapy and the removal of the distressing input may help.

Sensory hyposensitivity can also lead to SIB. If a person is bored or not getting enough input, they may begin self-injuring in order to feel something. These people may benefit from stim toys and strategies to get more physical activity in their day.

Other Reasons
It's sometimes difficult to tell what happens just before a SIB -- but often, upon careful examination, there is something happening that acts as a "trigger" for the behavior. For example, a child who does not understand that her video has ended and needs to be rewound may get suddenly upset for no apparent reason.

It is up to parents and caregivers to try to figure out what the child is trying to say through the behavior. This is sometimes referred to as the communicative intent. Sometimes even people who have language don't have the language to tell others what is so distressing.

Many autistic children have anxieties or fear of change, which can lead to self injury.

It's important to remember that autistic children struggle with communicating and understanding their feelings. Autistic children need extra help to learn social skills.

During the Episodes
"'If Emma is in the midst of an upset where she has begun to bite herself, no amount of logic will prevent her from biting mid-bite.  When Emma is biting herself this is an indication to me that I need to be quiet.  Sometimes she will come to me and allow me to put my arms around her in a firm embrace, other times she will reject all contact.  In the midst of an upset I have learned the single best thing I can do is – nothing. '"Autistic people know that self injury is harmful and bad. Your words are very unlikely to actually help.

This can be a distressing prospect. As someone who loves an autistic person, it's natural to feel horrified at the thought of them hurting and you being helpless to make it better. Most of the work you can do will be when the autistic person is not self injuring.

If you have already discussed an alternative action, a gentle verbal reminder to try the action may help set them on the right track.

Encouraging Alternatives
Autistic people do not self injure for fun. They may wish they didn't, but they might not know how to stop. Fighting the impulse to self injure can be very difficult, so it is important that they have plenty of support from therapists as well as loved ones.

In addition to treating the cause, it may be helpful to teach the autistic person other ways to handle the urge to self injure. These may help them release stress in a less destructive manner. This can be extremely difficult for the autistic person to do. Consulting a therapist can help with finding a good replacement.
 * Using a pillow as a buffer (e.g. slamming head into pillow, or placing a pillow between their head and their fists when head-banging)
 * Punching pillows or couch cushions
 * Biting a chew toy instead of themselves
 * Shaking the head rapidly instead of hitting it

Avoiding Frustration
Parents and caregivers can minimize frustrations in several ways. For children with highly specialized interests, using the language of that interest as a metaphor for behavior can also help the child understand what is being asked of him. For example, a child who loves trains can understand "Your behavior is 'off track' -- get back on track!" or "Put on the brakes!"
 * Breaking tasks up into smaller parts
 * "Please pick up the cars" instead of "Please clean your room"
 * "I'll help you clean your room. How about you put away the cars, and I'll put away the dolls?"
 * Explaining what is going to happen next
 * "After babysitting, we're going to go to the grocery store."
 * "After you fold your paper for your book, I'll staple it for you."
 * Offering choices
 * "Would you like to pick up the cars or the dolls?"
 * "Would you like a sugar cookie or a chocolate chip cookie?"
 * Explaining upsetting things or changes in routine
 * "Today is a half day of school. You'll go to school in the morning, but come home for lunchtime, because the teachers need to talk to each other this afternoon. When you come home, we can go to the park."
 * "I understand that you don't like the seatbelt, but you need it to stay safe so you don't fall and get hurt if we bump into something."
 * Listening to the autistic child
 * Sometimes autistic children exhibit challenging behaviors because less dramatic means of communication were being ignored. For example, if a child is overwhelmed and has said "let me go" to no avail, (s)he may lash out.

Medication
Sometimes therapy and support is not enough to stop self injury. In these cases, medications may be helpful in modifying a child's mood or reactivity such that educational efforts may be more productive. If self injury is related to anxiety, anti-anxiety medication may be helpful.