The Association Between Repetitive, Self-Injurious and Aggressive Behavior in Children With Severe Intellectual Disability

  • Chris Oliver
  • Jane Petty
  • Loraine Ruddick
  • Monique Bacarese-Hamilton
Original Paper


We evaluated the independent association between adaptive behavior, communication and repetitive or ritualistic behaviors and self-injury, aggression and destructive behavior to identify potential early risk markers for challenging behaviors. Data were collected for 943 children (4–18 years, M = 10.88) with severe intellectual disabilities. Odds ratio analyses revealed that these characteristics generated risk indices ranging from 2 to 31 for the presence and severity of challenging behaviors. Logistic regressions revealed that high frequency repetitive or ritualistic behavior was associated with a 16 times greater risk of severe self-injury and a 12 times greater risk of showing two or more severe challenging behaviors. High frequency repetitive or ritualistic behaviors independently predict challenging behavior and have the potential to be early risk markers for self-injury and aggression of clinical significance.


Stereotyped behavior Repetitive behavior Self-injury Aggression Intellectual disability Autism spectrum disorder Prevalence 



We are grateful to South Birmingham Primary Care NHS Trust and Cerebra for part funding this project.


  1. Arron, K., Oliver, C., Berg, K., Moss, J., & Burbidge, C. (2011). Delineation of behavioural phenotypes in genetic syndromes. Prevalence, phenomenology and correlates of self-injurious and aggressive behaviour. Journal of Intellectual Disability Research, 55, 109–120.PubMedCrossRefGoogle Scholar
  2. Baghdadli, A., Pascal, C., Grisi, S., & Aussilloux, C. (2003). Risk factors for self-injurious behaviours among 222 young children with autistic disorders. Journal of Intellectual Disability Research, 47, 622–627.PubMedCrossRefGoogle Scholar
  3. Borthwick-Duffy, S. A. (1994). Prevalence of destructive behaviors: A study of aggression, self-injury and property destruction. In T. Thompson & D. B. Gray (Eds.), Destructive behavior in developmental disabilities: Diagnosis and treatment (pp. 3–23). London: Sage Publications Ltd.Google Scholar
  4. Bott, C., Farmer, R., & Rohde, J. (1997). Behavior problems associated with lack of speech in people with learning disabilities. Journal of Intellectual Disability Research, 41, 3–7.PubMedCrossRefGoogle Scholar
  5. Bradley, E. A., Summers, J. A., Wood, H. L., & Bryson, S. E. (2004). Comparing rates of psychiatric and behavior disorders in adolescents and young adults with severe intellectual disability with and without autism. Journal of Autism and Developmental Disorders, 34, 151–161.PubMedCrossRefGoogle Scholar
  6. Cooper, S. A., Smiley, E., Allan, L. M., Jackson, A., Finlayson, J., Mantry, D., et al. (2009a). Adults with intellectual disabilities: Prevalence, incidence and remission of self-injurious behaviour, and related factors. Journal of Intellectual Disability Research, 53, 200–216.PubMedCrossRefGoogle Scholar
  7. Cooper, S. A., Smiley, E., Jackson, A., Finlayson, J., Allan, L., Mantry, D., et al. (2009b). Adults with intellectual disabilities: Prevalence, incidence and remission of aggressive behaviour and related factors. Journal of Intellectual Disability Research, 53, 217–232.PubMedCrossRefGoogle Scholar
  8. Davidson, P. W., Houser, K. D., Cain, N. N., Sloane-Reeves, J., Quijano, L., Matons, L., et al. (1999). Characteristics of older adults with intellectual disabilities referred for crisis intervention. Journal of Intellectual Disability Research, 43, 38–46.PubMedCrossRefGoogle Scholar
  9. Emerson, E., Kiernan, C., Alborz, A., Reeves, D., Mason, H., Swabrick, R., et al. (2001). The prevalence of challenging behaviors: A total population study. Research in Developmental Disabilities, 22, 77–93.PubMedCrossRefGoogle Scholar
  10. Field, A. (2000). Discovering statistics: Using SPSS for windows. London: Sage Publications.Google Scholar
  11. Guess, D., & Carr, E. (1991). Emergence and maintenance of stereotypy and self-injury. American Journal on Mental Retardation, 96, 299–319.PubMedGoogle Scholar
  12. Hall, S., Oliver, C., & Murphy, G. H. (2001). Early development of self-injurious behaviour: An empirical study. American Journal on Mental Retardation, 106, 189–199.PubMedCrossRefGoogle Scholar
  13. Hall, S., Thorns, T., & Oliver, C. (2003). Structural and environmental characteristics of stereotyped behaviors. American Journal on Mental Retardation, 108, 391–402.PubMedCrossRefGoogle Scholar
  14. Hallam, A., & Trieman, N. (2001). The cost effectiveness of specialised facilities for service users with persistent challenging behaviors. Health and Social Care in the Community, 9, 429–435.PubMedCrossRefGoogle Scholar
  15. Harris, P. (1993). The nature and extent of aggressive behavior amongst people with learning difficulties (mental handicap) in a single health district. Journal of Intellectual Disability Research, 37, 221–242.PubMedCrossRefGoogle Scholar
  16. Harvey, S. T., Boer, D., Meyer, L. H., & Evans, I. M. (2009). Updating a meta-analysis of intervention research with challenging behaviour: Treatment validity and standards of practice. Journal of Intellectual & Developmental Disability, 34, 67–80.CrossRefGoogle Scholar
  17. Hyman, P., Oliver, C., & Hall, S. (2002). Self-injurious behavior, self-restraint, and compulsive behaviors in Cornelia de Lange syndrome. American Journal on Mental Retardation, 107, 146–154.PubMedCrossRefGoogle Scholar
  18. Kahng, S. W., et al. (2002). Behavioral treatment of self-injury, 1964–2000. American Journal of Mental Retardation, 107, 212–221.PubMedCrossRefGoogle Scholar
  19. Kebbon, L., & Windahl, S.-I. (1986). Self-injurious behaviour—Results of a nation-wide survey among mentally retarded persons in Sweden. In J. M. Berg & J. M. DeLong (Eds.), Science & service in mental retardation (pp. 142–148). London: Methuen.Google Scholar
  20. Knapp, M., Comas-Herrera, A., Astin, J., Beecham, J., & Pendaries, C. (2005). Intellectual disability, challenging behaviour and cost in care accommodation: What are the links? Health and Social Care in the Community, 13, 297–306.PubMedCrossRefGoogle Scholar
  21. Kushlick, A., Blunden, R., & Cox, G. (1973). A method of rating behaviour characteristics for use in large scale surveys of mental handicap. Psychological Medicine, 3, 466–478.PubMedCrossRefGoogle Scholar
  22. McClintock, K., Hall, S., & Oliver, C. (2003). Risk markers associated with challenging behaviours in people with intellectual disabilities: A meta-analytic study. Journal of Intellectual Disability Research, 47, 405–416.PubMedCrossRefGoogle Scholar
  23. Meyer, L. H., & Evans, I. M. (2006). Literature review on interventions with challenging behaviour in children and youth with developmental disabilities. Wellington, NZ: Ministry of Education. Retrieved 22 October 2010, from
  24. Molyneux, P., Emerson, E., & Caine, A. (1999). Prescription of psychotropic medication to people with intellectual disabilities in primary health-care settings. Journal of Applied Research in Intellectual Disabilities, 12, 46–57.CrossRefGoogle Scholar
  25. Murphy, G. H., Beadle-Brown, J., Wing, L., Gould, J., Shah, A., & Holmes, N. (2005). Chronicity of challenging behaviors in people with severe intellectual disabilities and/or autism: A total population sample. Journal of Autism and Developmental Disorders, 35, 405–418.PubMedCrossRefGoogle Scholar
  26. Murphy, G. H., Hall, S., Oliver, C., & Kissi-Debra, R. (1999). Identification of early self-injurious behaviour in young children with intellectual disability. Journal of Intellectual Disability Research, 43, 149–163.PubMedCrossRefGoogle Scholar
  27. Murphy, O., Healy, O., & Leader, G. (2009). Risk factors for challenging behaviors among 157 children with autism spectrum disorder in Ireland. Research in Autism Spectrum Disorders, 3, 474–482.CrossRefGoogle Scholar
  28. Oliver, C. (1993). Self-injurious behaviour: From response to strategy. In C. Kiernan (Ed.), Research to Practise?: Implications of Research on the Challenging Behaviours of People with Learning Disabilities (pp. 135–188). Clevedon: British Institute of Learning Disabilities.Google Scholar
  29. Oliver, C. (1995). Annotation: Self-injurious behaviour in children with learning disabilities: Recent advances in assessment and intervention. Journal of Child Psychology and Psychiatry, 30, 909–927.CrossRefGoogle Scholar
  30. Oliver, C., Hall, S., & Murphy, G. (2005). The early development of self-injurious behaviour: Evaluating the role of social reinforcement. Journal of Intellectual Disability Research, 49, 591–599.PubMedCrossRefGoogle Scholar
  31. Oliver, C., Murphy, G. H., & Corbett, J. A. (1987). Self-injurious behaviour in people with mental handicap: A total population study. Journal of Mental Deficiency Research, 31, 147–162.PubMedGoogle Scholar
  32. Palmer, J., & Jenkins, J. (1982). The “Wessex” behaviour rating system for mentally handicapped people: Reliability study. British Journal of Mental Subnormality, 28, 88–96. Google Scholar
  33. Petty, J., Allen, D., & Oliver, C. (2009). Relationship among challenging, repetitive and communicative behaviors in children with severe intellectual disabilities. American Journal on Intellectual and Developmental Disabilities, 114, 356–368.PubMedCrossRefGoogle Scholar
  34. Petty, J., & Oliver, C. (2005). Self-injurious behaviour in individuals with intellectual disabilities. Current Opinion in Psychiatry, 18, 484–489.PubMedCrossRefGoogle Scholar
  35. Powell, S. B., Bodfish, J. W., Parker, D., Crawford, T. W., & Lewis, M. H. (1996). Self-restraint and self-injury: Occurrence and motivational significance. American Journal on Mental Retardation, 101, 41–48.PubMedGoogle Scholar
  36. Pritchard, A., & Roy, A. (2006). Reversing the export of people with learning disabilities and complex health needs. British Journal of Learning Disailities, 34, 88–93.CrossRefGoogle Scholar
  37. Richman, D. M. (2008). Early intervention and prevention of self-injurious behaviour exhibited by young children with developmental disabilities. Journal of Intellectual Disability Research, 52, 3–17.PubMedCrossRefGoogle Scholar
  38. Robertson, J., Emerson, E., Gregory, N., Hatton, C., Kessissoglou, S., & Hallam, A. (2000). Receipt of psychotropic medication by people with intellectual disability in residential settings. Journal of Intellectual Disability Research, 44, 666–676.PubMedCrossRefGoogle Scholar
  39. Robertson, J., Emerson, E., Pinkney, L., Caesar, E., Felce, D., Meek, A. et al. (2005). Treatment and management of challenging behaviours in congregate and noncongregate community-based supported accommodation. Journal of Intellectual Disability Research, 49, 63–72.Google Scholar
  40. Rojahn, J., Borthwick-Duffy, S. A., & Jacobson, J. W. (1993). The association between psychiatric diagnoses and severe behavior problems in mental retardation. Annals of Clinical Psychiatry, 5, 163–170.PubMedCrossRefGoogle Scholar
  41. Rojahn, J., Matson, J. L., Naglieri, J. A., & Mayville, E. (2004). Relationships between psychiatric conditions and behavior problems among adults with mental retardation. American Journal on Mental Retardation, 109, 21–33.PubMedCrossRefGoogle Scholar
  42. Saloviita, T. (2000). The structure and correlates of self-injurious behavior in an institutional setting. Research in Developmental Disabilities, 21, 501–511.PubMedCrossRefGoogle Scholar
  43. Singh, A. N., Matson, J. L., Cooper, C. L., Dixon, D., & Sturmey, P. (2005). The use of risperidone among individuals with mental retardation: Clinically supported or not? Research in Developmental Disabilities, 26, 203–218.PubMedCrossRefGoogle Scholar
  44. Sloneem, J., Arron, K., Hall, S. S., & Oliver, C. (2009). Self-injurious behaviour in Cornelia de Lange syndrome: 2. Association with environmental events. Journal of Intellectual Disability Research, 53, 590–603.Google Scholar
  45. Smith, S., Branford, D., Collacott, R. A., Cooper, S. A., & McGrother, C. (1996). Prevalence and cluster typology of maladaptive behaviours in a geographically defined population of adults with learning disabilities. British Journal of Psychiatry, 169, 219–227.PubMedCrossRefGoogle Scholar
  46. Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vineland adaptive behavior scales: Survey form manual. Circle Pines, MN: American Guidance Service.Google Scholar
  47. Symons, F. J., Sperry, L. A., Dropik, P. L., & Bodfish, J. W. (2005). The early development of stereotypy and self-injury: A review of research methods. Journal of Intellectual Disability Research, 49, 144–158.PubMedCrossRefGoogle Scholar
  48. Taylor, L., Oliver, C., & Murphy, G. (2011). The chronicity of self-injurious behaviour: A long-term follow-up of a total population study. Journal of Applied Research in Intellectual Disability, 25, 107–117.Google Scholar
  49. Totsika, V., Toogood, S., Hastings, R. P., & Lewis, S. (2008). Persistence of challenging behaviours in adults with intellectual disability over a period of 11 years. Journal of Intellectual Disability Research, 52, 446–457.PubMedCrossRefGoogle Scholar
  50. Turner, M. (1997). Towards an executive dysfunction account of repetitive behaviour in autism. In J. Russell (Ed.), Autism as an Executive Disorder (pp. 57–100). Oxford: Oxford University Press.Google Scholar
  51. Turner, M. (1999). Annotation: Repetitve behaviour in autism: A review of psychological research. Journal of Child Psychology and Psychiatry, 40, 839–849.PubMedCrossRefGoogle Scholar
  52. Tyrer, P., Oliver-Africano, P., Romeo, R., Knapp, M., Dickens, S., Bouras, N., et al. (2009). Neuroleptics in the treatment of aggressive challenging behaviour for people with intellectual disabilities: A randomised controlled trial (NACHBID). Health Technology Assessment, 13, 1–54.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Chris Oliver
    • 1
  • Jane Petty
    • 1
  • Loraine Ruddick
    • 1
    • 2
  • Monique Bacarese-Hamilton
    • 1
  1. 1.Cerebra Centre for Neurodevelopmental Disorders, School of PsychologyUniversity of BirminghamEdgbaston, BirminghamUK
  2. 2.Department of Clinical PsychologyBirmingham Children’s HospitalBirminghamUK

Personalised recommendations