Final Question on Repetitive Play Patterns, Perseveration and Self-injurious Behaviors

What are four key take home treatment strategies that SLP’s and OT’s can apply given the literature and discussion provided? What is the rationale for each of the take home strategies? 

Blog questions 1 and 2 examined and defined Repetitive Play Patterns, Perseveration, and Self-injurious Behaviors, how they manifest, and what their impacts are.

In developing treatment strategies in this area it is important to consider each child individually. Researching the topic would indicate that there is no single intervention can universally reduce or eliminate repetitive behaviors, perseveration and self-injury. However it is important to look at the behaviors, consider what might be the cause, motivator or reward, and look at how and to what degree they impact that individual’s life. OT and SLP working together can bring additional perspective and angle to treatment strategies. Co-treating can achieve the joint benefit of reinforcing each others' goals which can help consolidate new skills and assist with generalization.

Repetitive behaviors primarily impact individuals in three areas: socialization, communication and learning. (ref Blog question) Some of the reasons or causes of repetitive behaviors include:

• Stress and/or anxiety: Repetitive behaviors can assist the individual in self-calming, and sometimes provide sense of structure and comfort. Self-injury can cause endorphin release in brain. 

• Attention seeking or avoidance of demands or attention.

• Physiological Causes: self-injurious behavior may be caused by pain that isn't being addressed, illness or infections, tic disorders (Clements and Zarkowska, 2000), sub-clinical seizure activity.  

• Communication: to convey frustration or other emotions when more effective forms of communication are not possible. 

• Environmental Causes: It is possible that arousal levels and sensory issues may lead to repetitious and self-injurious behavior.
  
• Poor Executive Functioning and lack of imagination can lead to restricted repetitive play which in turn can impact learning, communication and social skills (ref Blog Q.2.)

Treatment Strategies

If it is considered that the behaviors are adversely impacting the individual’s life, the treatment strategies will directly relate to the both the probable causes and the areas of life negatively impacted.

1)Communication and social skills: Research has shown that individuals with an ASD who are actively involved in communication social programs are less likely to engage in repetitive behaviors. Studies have also shown that social isolation can cause an increase in repetitive and self-injurious behavior. (for more information refer to Ann K’s Blog on Behavioral and Social Engagement Intervention, Deepali’s blog on Communication, and Jen's on Emotion and Face Processing)  Module 2. Q.1   Mod 6 Q1 &2  Mod 7 Q1   Mod 5 Q 4  Mod. 4 Q3

2) Environmental causes: Look at the individual’s ability to deal with sensory stimulation and look at the environments. Do specific stimuli cause over arousal? Is he/she using repetitive behavior or self-injury to cope with sensory sensitivity?  Or the opposite, is he/she seeking out sensory input in response to under arousal or boredom?  Activities such as biting hands may be a way to let off steam in an environment that is too loud or complex. For those with low levels of arousal, inducing pain may be a way to provide stimulation.  Treating self-injurious behavior may be as simple as reducing or increasing the stimulation levels in the environment. For some an environment that includes toys, a lack of demands, and reinforcement for non self-injurious behaviors and redirection seems to work the best. (Iwata et al, 1994) Mod 3 Q 2

Other sensory based strategies that can be explored include deep pressure or proprioceptive input activities such as rope climbing, wheel barrow, jumping on a trampoline or pushing and pulling heavy toys. This type of play will activate receptors in the muscles and joints which can have the effect of calming the nervous system and bringing the child into a more optimum level of arousal where they are more receptive to learning new skills and communication.

Strategies for dealing with other sensory sensitivities include trying earplugs or earphones for auditory sensitivity, Irlen glasses or sun glasses to cope with changes in lighting, for tactile sensitivity look at clothing that isn’t restrictive or have rough tags. For some children simple, uncluttered environments can reduce repetitive or self-injurious behavior. (ref Blog Q.5) Mod 3 Q2

Providing safe space and limited times for stimming might allow children to release stress caused by their environment. For some it is very helpful to teach the child how to seek help when they are feeling overwhelmed or frustrated. Programs like the Alert System (how does your engine run) or Stik kids work by helping the child identify specific strategies to use when they feel over stimulated.

(ref. Blog Q.5)

3) Self-injurious behaviors:  First look at and eliminate possible health issues which may be causing pain or discomfort.  (refer to Audra’s blog on GI Issues and Diane’s on Alternative Medicines)

Strategies to prevent the child from causing themselves actual bodily harm ideally should be short term and should not draw negative attention to the child. For head banging a helmet can help reduce injury. In blog question 3 one mother used padded sports gear in an effort to protect her son from doing actual bodily harm. She also felt the sports gear might look less restrictive or medical. Sometimes providing a ‘chewy’ can reduce hand biting. (ref.Blog Q.3)

4) Executive functioning/Play skills: working on the child’s ability to play constructively and creatively. The lack of imagination and the difficulty forming a play plan can lead to repetitive restrictive play patterns. Research suggests that without the ability to regulate behaviors or to inhibit repetitive behaviors, the child with ASD may become “locked in” to certain behaviors. (Turner, 1999) (ref. Blog Q.4 &2)  Mod.5 Q.1     Mod.3 Q.3

A treatment approach that encompasses the child’s interests and then encourages and expands their play repertoire through ‘chaining’ can be helpful. A child who is simply spinning the wheels on a car can be shown how to roll it along the floor or to a peer or sibling. Creating the just-right challenge in play is important, meet the child where they are at and widen their world of play. Ensuring the approach is both fun and playful is important. Including TD peers or siblings in play both at home and in pre-school or school can model creative play and social skills for the child with an ASD. (ref. Blog Q.3)

Question 5.

Describe the role of stress upon repetition, perseveration, and self-injury. Be sure to present both physiological changes in the body during a stressful situation, as well as psychological. (can find information in animal literature, as well, for example: stress in transportation animals, etc.) ________________________________________________________

Many studies have illustrated that stress can cause an increase in repetitive, perseverative, and self-injurious behaviors. 

Individuals with ASDs have sensory processing deficits which can lead to  over stimulation, stress or in some instances extreme fear. Temple Grandin mentions that her teen years were fraught with constant fear; while the squeeze box she invented helped to calm her, it wasn’t until she started taking antidepressants that life began to feel bearable to her. 

When the body senses a stressor or a source of danger, a cascading series of events floods the body with hormones that prepare the body to meet whatever threat is perceived. When a threat is perceived, cells in the hypothalamus excrete two hormones that signal cells in the adrenal medulla and pons to put out a global alarm system. The autonomic nervous system kicks in very rapidly causing the fight or flight response, engaging the sympathetic nervous system and muting the parasympathetic nervous system. This elevates the heart rate and blood pressure, encourages the liver to release sugars into the blood stream to provide extra energy, shuts down the digestive system, preparing the body for any action necessary to avert the danger that the mind detects.Breathing becomes more rapid. Blood is shunted away from extremities causing the skin to sweat.

Children with ASDs have been found to have less activity in the amygdala, well known for its association with the emotion of fear. Social anxiety and the isolation it brings adds to stress levels.

Many children with an ASD find human touch to be uncomfortable and human interaction to be stressful because of language and perception issues. Unfortunately, this can increase stress levels further; long-term isolation is known to cause stress and repetitive behaviors in captive animals. (Mckinney, 1974) Schultz (2005) suggested that the social isolation caused by the effects of autism might cause enough stress to lead to an increase of repetitive, perseverative, and self-injurious behavior, and that this behavior might become part of a compulsory coping mechanism as the child with ASD matures.

Although people with an ASD can find human contact to be overwhelming, they still on some level crave the benefit of human contact. Deep tissue stimulation is extremely relaxing to people with ADHD, ASD, and sensory disorders. Temple Grandin, having observed the way cattle in a restraint system relaxed, created what she called a “squeeze box” that triggers a relaxed state. (Grandin, 1992)

 

Because ASDs are a complex spectrum of disorders, no single intervention can universally ease the stress causing repetitive behaviors. For children who find sensory stimulation to be too intense, earplugs, changes in lighting, clothing that isn’t restrictive or noisy, and simple, uncluttered environments may reduce repetitive or self-injurious behavior. Some studies have indicated that adaptive methods such as Irlen glasses might be beneficial.

For children with high levels of arousal, sensory stimulation/activities such as deep pressure stimulation with massage, joint pressure, weighted vests or blankets, or rolling the child up tightly in a blanket can help to bring down the arousal level.

Providing safe space and limited times for stimming might allow children to release stress caused by their environment. For some, teaching the child how to seek help when they are feeling overwhelmed by demands placed on them might limit tantrums. Exercise is extremely helpful; it provides good proprioceptive feedback as well as a healthy stress release.

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References:

Grandin, T. (1992). Calming effects of deep touch pressure in patients with autistic disorder, college students, and animals. Journal of Child and Adolescent Psychopharmacology.

Mckinney, W. T. (1974). Primate Social Isolation: psychiatric implications. Archives of General Psychiatry, 422-426.

Schultz, R. T. (2005). Developmental deficits in social perception: the role of the amygdala and fusiform face area. International Journal of Developmental Neuroscience, 125-141.

Question 4.

Summarize articles that discuss executive function and decision-making skills as they may contribute to repetitive behaviors.

As we have discussed in previous weeks, executive function disorders are a common feature shown by people with an ASD. One may assume that weak central coherence and deficits in executive function may contribute to repetitive behaviors. One study found that repetitive actions are a result of executive function as opposed to weak central coherence. (South, Ozonoff, & Mcmahon, 2007)

Executive functions control our ability to initiate and to stop actions, as well as to plan future actions. Executive function helps us to monitor what we are doing, to form abstract ideas, and to bring information together in novel ways. People with EF issues may experience poor impulse control, which may lead to verbalizing in bizarre or inappropriate ways to other people. Executive function encourages flexible thought and the ability to change topics or activities. Routine or repetitive tasks may make fewer demands upon executive functioning. (Kuhaneck & Watling, 2010)

When compared to children with ADHD, also a disorder that features problems with executive function, children with ASD exhibit more issues with planning and flexibility, while children with ADHD have more difficulty with impulse control. It has been noted that as many as half of children with an ASD seem to have ADHD symptoms as well. Is it possible, then, that the rigidity of ASD in combination with the lack of impulse control of comorbid ADHD can contribute to repetitive behavior?

(Sinzig, Morsch, Bruning, Schmidt, & Lehmkuhl, 2008)

 

Research suggests that without the ability to regulate behaviors or to inhibit repetitive behaviors, the child with ASD may become “locked in” to certain behaviors. (Turner, 1999) With a diminished system in place to enable one’s ability to self-regulate behaviors, assimilate new routines, and to remain flexible in new environments, it is easy to understand that children with an ASD engage in repetitive behaviors, especially when faced with new and stressful situations.

An EMT friend of mine relayed a story about a patient with high-functioning ASD she transported recently. He was very ill and needed surgery immediately, but he had tickets to an art exhibit the next day. He was so locked into the idea of going to the exhibit he repeatedly demanded that the doctor release him right away. She noticed that he also had a fascination with addresses, so she distracted him with the addresses of all the hospitals in the area, which kept him calm enough for transport. Fortunately, the gentleman was conserved and could not refuse the surgery that saved his life. This patient's inability to take in the information that he was critically ill and his unwillingness to cancel his trip to an art show are perfect examples of how problems with executive function and the lack of flexibility associated with ASD can impact decision making.

__________________________________________________________

References:

Kuhaneck, H. M., & Watling, R. (Eds.). (2010). Autism, A Comprehensive Occupational Therapy Approach (3rd ed.). Bethesda, MD: AOTA Press.

Sinzig, J., Morsch, D., Bruning, N., Schmidt, M. H., & Lehmkuhl, G. (2008). Inhibition, flexibility, working memory, and planning in autism spectrum disorders with and without comorbid ADHD symptoms. Child and Adolescent Psychiatry and Mental Health.

South, M., Ozonoff, S., & Mcmahon, W. M. (2007). The relationship between executive functioning, central coherence, and repetitive behaviors on the high functioning autism spectrum. Autism, 437-451.

Turner, M. (1999). Annotation: Repetitive Behaviour in Autism: A Review. Journal of Child Psychology and Psychiatry, 839-849.

Question 3.

Summarize at least 3 articles which explore play patterns, perseveration, and self-injurious behaviors. 

Play Patterns

Miller & Kuhaneck carried out a study in 2008 entitled Children’s Perceptions of Play Experiences and Play Preferences: A Qualitative Study. The study investigated the perceptions of play and rational for play preferences for ten typically developing children aged 7 to 11 years. The importance of play as being a child’s primary means to develop socially, emotionally, cognitively and physically is emphasized. How children play is often more important than what they play with. However what children select and prefer to play with is also looked at in this study.

Play choice can be influenced by many factors. In typically developing children research has shown that gender impacts play choices significantly, with girls preferring dyadic play and social interaction and boys tending to be drawn to more physical outdoor play. Another major factor impacting play is age. Typically developing children as they develop new motor and cognitive skills move towards more complex play. They use play to explore the world around them; relational play is followed by symbolic or pretend and social play.

In the study children were asked what were their favorite toys and why. They were asked how they felt when they played and how they chose what to play with. Questions also included where they played and what their favorite places to play were.

The results of the Miller & Kuhaneck study indicated that play choices for the typically developing children were primarily influenced by the ‘fun’ factor.

Fun was described by most of the children as the opposite to being bored. They talked about play being something you can do with your friends and how play made them feel happy.

The children in the study selected play activities that were perceived as ‘fun’  The primary activities chosen were  activities that incorporated a challenge,  that were seen as not too hard or too easy. They chose activities that involved  teamwork, playing with peers and bonding play with others.

The study concluded “When viewed in this manner, it becomes clear that therapists need to pay particular attention to creating the just-right challenge, being fun and playful in approach, and using peers and others in therapy.”

(Miller, E., & Kuhaneck, H. (2008). Children’s perceptions of play experiences and the development of play preferences: A qualitative study. American Journal of Occupational Therapy, 62, 407–415.)

When looking at the play patterns and choices of children with an ASD we see a very different picture.

Children with an ASD do not follow typical developmental patterns of play. Due to poor executive functioning they have difficulty initiating and carrying out play ideas. The skills inherent in executive function require that the child build a fund of knowledge about their environment and the objects in it. This fund of knowledge is built and developed through play exploration and interaction with their environment. Without these cognitive functions the child lacks the ability to generate an idea, think imaginatively, and make a plan to play.

Typically developing children appear to be intrinsically motivated to play and explore by their perception of fun. By contrast children with an ASD often appear to be motivated more by sensory needs which can result in play that is restrictive and repetitious.

The lack of constructive play patterns in children with an ASD reduces learning opportunities. The difficulties in engaging in peer or team play impacts socialization and social skills.  And restrictive repetitive play patterns means that the child misses out on exploration, as well as social and learning opportunities and the ability to have fun.

Perseveration

Perseveration refers to a set of repetitive behaviors frequently seen in individuals with an ASD. They include verbal, physical or gestural behaviors. A child who perseverates repeats a meaningless action over and over again, even though the initial stimulus is no longer present. For example, a child may perseverate by repeating a word or a question over and over again, or repeat a gesture or action repeatedly without any apparent meaning. Perseveration is one of the key diagnostic criteria in autism.  

A study was carried out by the UC Center for Research on Special Education, Disabilities and Developmental Risk to look at the various types of perseverative behaviors and document the frequency of the different types of behaviors that the children with autism displayed.

Perseveration is not specific to children with an ASD. It is also present in children with other disorders such as trisomy 21 and fragile X syndrome. 

Perseverative behaviors impact individuals in three areas: 

• socialization
• communication 
• restrictive play or interests

The study included 37 children between the ages of 29 to 73 months. All children had an autism diagnosis. The Timed Stereotypies Rating Scale, revised (Luce, 2003) was used. This rating scale was developed to ascertain the frequency of perseverative behaviors in individuals with an ASD. It looks at a diverse range of behaviors including:

• teeth grinding
• tiptoe walking
• spinning objects
• hand flapping
• biting
• covering ears or eyes
• body rocking

The results showed that the most prevalent perseverative behavior was verbal perseverative and the most infrequent behavior recorded was perseverative actions.

In summary the article stated that perseveration persists in individuals with an ASD into adulthood and these behaviors take up a large portion of the individual’s time. It suggested that further research into perseverative behaviors is imperative to improve our understanding of this phenomenon in children with autism. It is hoped this would assist in the development of appropriate interventions to address these behaviors. (Arora, 2008)



Self-Injurious Behaviors

Perhaps one of the most frightening and difficult aspects of ASD, self-injurious behaviors, result from a number of causes and may consist of the following:

• hitting or punching
• head banging or forceful shaking
• gouging the eyes 
• biting hands or fingers 
• picking at, scratching, or pinching skin
• pulling hair

Because so many people with an ASD are nonverbal it is difficult to determine exactly what triggers these behaviors. Some possible causes include:

• Physiological Causes, Self-injurious behavior may be caused by pain that isn't being addressed, illness or infections, tic disorders (Clements and Zarkowska, 2000), sub-clinical seizure activity, endorphin release,  high serotonin levels, and perhaps dopamine imbalances. 

• Social Causes Self-injurious behavior brings a great deal of attention very quickly. This behavior may be an effective way to avoid demands placed on a person with an ASD. Also, behaviors like head slapping may be a way to convey frustration or other emotions when more effective forms of communication are not possible.

• Environmental Causes It is possible that arousal levels and sensory issues may lead to self-injurious behavior. Activities such as biting hands may be a way to let off steam in an environment that is too loud or complex. For those with low levels of arousal, inducing pain may be a way to provide stimulation. 

• Perseverative Behavior Self-injurious behavior may be a part of ritualistic, repetitive behavior that is so common in ASDs.

Because such a wide array of issues may lead to these types of behaviors, it is important to rule out medical issues as well as to observe the social and environmental milieu as self-injurious behaviors are happening. Finding the cause of this behavior can be challenging and time-consuming. Caregivers have found some creative and effective ways to protect their charges from self-harm:

Treating self-injurious behavior may be as simple as reducing or increasing the stimulation levels in the environment. For some groups an environment that includes toys, a lack of demands, and reinforcement for non self-injurious behaviors and redirection seems to work the best. (Iwata et al, 1994) Future blog entries will explore the uses of drug therapies and sensory integration strategies. 

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References:

Aurora, T. (2008). Perseveration in Autism. UC Center for Research on Special Education, Disabilities, and Developmental Risk. Santa Barbara.


Clements, John, & Zarkowska, Ewa. (2000) Behavioural Concerns and Autistic Spectrum Disorders: Explanations and Strategies for Change. Philadelphia: Jessica Kingsley Publishers.


Iwata, Brian A.; Dorsey, Michael F.; Slifer, Keith J.; Bauman, Kenneth E.; Richman, Gina S. (1994) Toward a Functional Analysis of Sef-Injury. Journal of Applied Behavior and Analysis, 27, 197-209.


Miller, E., & Kuhaneck, H. (2008). Children’s perceptions of play experiences and the development of play preferences: A qualitative study. American Journal of Occupational Therapy, 62, 407–415.

Question 2.

How do skill/abilities and cognition impact perseverative play/repetitive play?

 Ducks in a row
(ed3602autism.wikispaces.com)

In a study conducted by D.K. Wong, (Wong, 2001) three major cognitive theories were proposed to account for the behavioral symptoms of autism: 

• Theory of Mind  
• Central Coherence Theory
• Executive Dysfunction

These three theories have had varying degrees of success in accounting for the repetitive behaviors, language impairments, and communicative difficulties which are symptomatic of autism. However the study concluded that deficits in Executive Functioning showed the strongest correlation with perseveration and repetitive behaviors.

Executive function is the ability to initiate an idea, make a plan, draw from memory, and carry out that plan. A child with an ASD who has poor executive function will be impacted by an inability to play constructively. The skills inherent in executive function require that the child build a fund of knowledge about his environment and the objects in it. This fund of knowledge is built and developed through play and interaction with their environment.

Without these cognitive functions the child will lack the ability to generate an idea, think imaginatively, create a mental picture or plan, or retrieve information from memory and carry out that plan.

As a result of these deficits children with an ASD will:

• Do less exploration and play with fewer toys.
• Tend not to engage in pretend or imaginative play.
• Tend not to use toys in novel ways.
• Display a lack of imagination that limits exploration and play with toys.
• Become preoccupied with certain aspects or sensory features of a particular toy like the spinning wheels of a car.
• Engage in perseverative restrictive repetitive play patterns. 

How do play patterns and self-injurious behaviors impact learning and daily function?

www.meapkids.org

The lack of constructive play patterns reduces learning opportunities. Restrictive repetitive play means that the child misses out on exploration of the uses of toys and their actions, cause/effect, and affordances. While engaging in repetitious play and self-injurious behaviors a child misses out on social and learning opportunities. It can impact their ability to attend, learn and develop imagination and pretend play.

Repetitious play and self-injurious behaviors can draw negative attention to the child causing further social isolation. A preoccupation with repetitious play and self-injurious behaviors has also been shown to impact language development and as a result communication and social skills.

_______________________________

References:

Honey, E., Leekam, S., & Turner, M. (2006, 10 27). Repetitive Behaviour and Play in Typically Developing Children. Journal of Autism and Developmental Disorders, pp. 1107-1115.

Miller Kuhaneck, H., & Watling, R. (Eds.). (2010). Autism: a Comprehensive Occupational Therapy Approach (3rd ed.). Bethesda, MD, USA: AOTA Press.

Turner, M. (1999). Annotation: Repetitive Behaviour in Autism: A Review. Journal of Child Psychology and Psychiatry, 839-849.

Wong, D. (2001). Executive functioning and repetitive behaviours in autism. Australian Society for the Study of Brain Impairment. Magnetic Island, Queensland: University of Western Australia.

Introduction    

      
     

 Repetitive Play Patterns, Perseveration and Self-injurious Behaviors

Question 1.

Autism spectrum disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted and stereotyped patterns of behavior which include repetitive play patterns, perseveration and self-injurious behaviors.

Image: Louisa Stokes, FreeDigitalPhotos.net

Repetitive play patterns, perseveration and self-injurious behaviors are core features of the ASD but what exactly are they and how do they impact a child with an ASD?

The term ‘‘repetitive behavior’’ is an umbrella term used to refer to the broad range of behaviors linked by repetition, rigidity, and invariance. 

Repetitive play patterns are frequently seen in children with ASD.  Play is an integral part of childhood development. If play value is defined as “how much play a child gets out of something” then the child with an ASD frequently does not get the same benefits from play that a typically developing child would.

In play the value of a toy is directly related to how many different options it offers for exploration and learning, for example nesting cups. Nesting cups can be nested inside each other, made into a tower, filled with other objects that can be dumped out, used in water and sand play, or sorted by color or size; and when the child finally masters assembling them together he or she has learned size discrimination. When using the same toy with a child with an ASD his play and exploration might be limited to rolling the cup across the floor. When working with Legos he would perhaps line them up rather than putting them together into any one of a myriad of things. 

So much of our early learning is encouraged by play; experimentation, learning new concepts, synthesis of new ideas, and planning and problem solving are all nurtured by a creative, diverse play experience.

When interacting with toys the child with an ASD appears to not see the toy as a whole but focuses in on details like the wheels on a car, or flipping the pages in a book back and forth without ever looking at the pictures. This form of repetitive play restricts and limits the child’s exploration and learning.

Children with ASD also often develop an attachment to a particular object or toy sometimes to the preclusion of playing with any other toy. This limits learning and social opportunities.

While repetitive play issues may be caused by an underlying issue such as OCD or an anxiety disorder, many children with ASD may use these behaviors because they find them to be soothing, increasing levels of arousal, or providing homeostasis or balance. There is also the possibility that these behaviors might be the result of an inability to understand how to interact with play objects. For instance, if a child is overly focused on the texture of the tires on a toy car, he or she may not understand that the car could possibly roll along on those tires to exciting new places.

Perseveration, a common hallmark of ASD, happens when a person repeats an utterance, a thought, or a gesture long after its usefulness has ended. This is marked by a strong resistance to change. Persevering is the ultimate goal of these actions; the problem is that these actions interfere with purposeful activity. Activities such as repeating phrases, flapping hands, ritualistic behavior, and "stimming" interfere with social activity and can isolate the child from learning activities by disrupting group interaction. 

Following is an example of perseverative behavior; a young child with ASD engaging in repetitive behavior  that may seem to be meaningless to the onlooker, but may have a specific purpose for the child.

Note that the above child repeats a ritualistic behavior at the oven door in spite of the repeated attempts at communication made by the child's caregiver. 

Perseverative behaviors may provide a sense of structure and comfort to the autistic child; it has been noted that many non-autistic people engage in ritualized, repetitive behaviors and find great comfort in them.

Self injurious behaviors are actions that a child performs that can result in direct physical harm to the child's own body.

Many children with ASD engage in self-injurious behaviors; such as biting, headbanging, or hitting oneself with hands.  These behaviors are often seen as very aberrant and disturbing and can be very socially isolating. It is not fully understood why some children with autism self injure. One theory is that children with ASD engage in hitting or hurting themselves in order to get the attention of parents or caregivers.

A similar theory is that a child may engage in self-injury in order to avoid demands that are placed on them; attention is taken away from expectations and focused on stopping the self-injurious behavior, giving the child positive reinforcement for continuing the behavior.
 

Another theory is that the release of chemicals into the brain that are pleasurable, such as endorphins, may occur when an individual self injures. Some research suggests that children may continue to injure themselves because it makes them feel good. 

Most children are thought to have highly complex reasons for self injury that are not fully understood. Most research indicates that it is a combination of these and other things that lead to self injury.
 

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References: 

Honey, Emma; Leekam, Sue; Turner, Michelle: McConachie, Helen: Repetitive Behaviour and Play in Typically Developing Children and Children with Autism Spectrum Disorders 2006

Turner, Michelle: Annotation: Repetitive Behaviour in Autism: A Review of Psychological Research, 1999 


Kuhaneck, Heather M.; Watling, Renee: Autism: A comprehensive Occupational Therapy Approach