Skip to main content

Risk Factors for Self-injurious Behavior in an Inpatient Psychiatric Sample of Children with Autism Spectrum Disorder: A Naturalistic Observation Study


Limited information about self-injurious behavior (SIB) is known for children and adolescents with Autism Spectrum Disorder (ASD) who require intensive behavioral health interventions. We examined risk-factors for SIB in 302 individuals with ASD (ages 4–20) admitted to six specialized psychiatric inpatient units. Seventy-four percent were reported by a caregiver to display SIB, however, only 25% were observed to engage in daily SIB during hospitalization. Those exhibiting SIB across environments had significantly higher ratings on caregiver questionnaires of SIB severity. Tree-structured classification was used to develop and validate two predictive models, one indicating which inpatient youth with ASD are likely to have SIB and a second indicating which individuals with SIB at home are likely to continue in an inpatient setting.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  • Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. (1985a). The Aberrant Behavior Checklist: A behavior rating scale for the assessment of treatment effects. American Journal of Mental Deficiency, 89, 485–491.

    PubMed  Google Scholar 

  • Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. (1985b). Psychometric characteristics of the Aberrant Behavior Checklist. American Journal of Mental Deficiency, 89, 492–502.

    PubMed  Google Scholar 

  • Baghdadli, A., Pascal, C., Grisi, S., & Aussiloux, C. (2003). Risk factors for self-injurious behaviours among 222 young children with autistic disorders. Journal of Intellectual Disability Research, 47(8), 622–627.

    Article  PubMed  Google Scholar 

  • Benjamini, Y., & Hochberg, Y. (1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal Statistical Society Series B, 57, 289–300.

    Google Scholar 

  • Bodfish, J. W., Symons, F., & Lewis, M. (1999). The Repetitive Behavior Scales: A test manual. Morganton, NC: Western Carolina Center Research Reports.

    Google Scholar 

  • Cohen, I. L., Tsiouris, J. A., Flory, M. J., Kim, S. Y., Freedland, R., Heaney, G., et al. (2010). A large scale study of the psychometric characteristics of the IBR modified overt aggression scale: Findings and evidence for increased self-destructive behaviors in adult females with autism spectrum disorder. Journal of Autism and Developmental Disorders, 40, 599–609.

    Article  PubMed  Google Scholar 

  • Esbensen, A. J., Seltzer, M. M., Lam, K. S., & Bodfish, J. W. (2009). Age-related differences in restricted repetitive behaviors in autism spectrum disorders. Journal of Autism and Developmental Disorders, 39, 57–66.

    Article  PubMed  Google Scholar 

  • Furniss, F., & Biswas, A. B. (2012). Recent research on aetiology, development and phenomenology of self-injurious behaviour in people with intellectual disabilities: A systematic review and implications for treatment. Journal of Intellectual Disability Research, 56, 453–475.

  • Gleser, L. J., & Olkin, I. (2009). Stochastically dependent effect sizes. In H. Cooper, L. V. Hedges & J. C. Valentine (Eds.), The handbook of research synthesis and meta analysis (pp. 357–376). New York: Russell Sage Foundation.

    Google Scholar 

  • Hastie, T., Tibshirani, R., & Friedman, J. (2009). The elements of statistical learning: data mining, inference, and prediction (2nd ed.). New York: Springer Science + Business Media LLC.

    Book  Google Scholar 

  • Lam, K. S., & Aman, M. G. (2007). The Repetitive Behavior Scale-Revised: Independent validation in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37, 855–866.

    Article  PubMed  Google Scholar 

  • Lecavalier, L. (2006). Behavioral and emotional problems in young people with pervasive developmental disorders: Relative prevalence, efforts and subject characteristics, and empirical classification. Journal of Autism and Developmental Disorders, 36, 1101–1114.

    Article  PubMed  Google Scholar 

  • Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. L. (2012). Autism diagnostic observation schedule: A standardized observation of communicative and social behavior. Torrance, CA: Western Psychological Services.

    Google Scholar 

  • Matson, J. L., & Rivet, T. T. (2008a). The effects of severity and autism and PDD-NOS symptoms on challenging behaviors in adults with intellectual disabilities. Journal of Developmental and Physical Disabilities, 20, 41–51.

    Article  Google Scholar 

  • Matson, J. L., & Rivet, T. T. (2008b). Characteristics of challenging behaviours in adults with autistic disorder, PDD-NOS, and intellectual disability. Journal of Intellectual and Developmental Disability, 33, 323–329.

    Article  PubMed  Google Scholar 

  • McClintock, K., & 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.

    Article  PubMed  Google Scholar 

  • R Core Team. (2016). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna.

  • Richards, C., Oliver, C., Nelson, L., & Moss, J. (2012). Self-injurious behavior in individuals with autism spectrum disorder and intellectual disability. Journal of Intellectual Disability Research, 56(5), 476–489.

    Article  PubMed  Google Scholar 

  • Richman, D. M., Barndard-Brak, L., Bosch, A., Thompson, S., Grubb, L., & Abby, L. (2013). Predictors of self-injurious behavior exhibited by individuals with autism spectrum disorder. 223(5), 429–439.

  • Roid, G. H., Miller, L. J., Pomplun, M., & Koch, C. (2013). Leiter International Performance Scale (3rd ed.). Torrance, CA: Western Psychological Services.

    Google Scholar 

  • Rojahan, J., Aman, M. G., Matson, J. L., & Mayville, E. (2003). The Aberrant Behavior Checklist and the Behavior Problems Inventory: Convergent and divergent validity. Research in Developmental Disabilities, 24, 391–404.

    Article  Google Scholar 

  • Rojahn, J., Wilkins, J., Matson, J. L., & Boisjoli, J. (2010). A comparison of adults with intellectual disabilities with and without ASD on parallel measures of challenging behavior: The Behavior Problems Inventory-01 (BPI-01) and Autism Spectrum Disorders-Behavior Problems for intellectually disabled adults (ASD-BPA). Journal of Applied Research in Intellectual Disabilities, 23, 179–185.

    Article  Google Scholar 

  • Rutter, M., Bailey, A., & Lord, C. (2003). The social communication questionnaire manual. Los Angeles, CA: Western Psychological Services.

    Google Scholar 

  • Schroeder, S. T., Marquis, J. G., Reese, R. M., Richman, D. M., Mayo-Ortega, L., Oyama-Ganiko, R., et al. (2014). Risk factors for self-injury, aggression, and stereotyped behavior among young children at risk for intellectual and developmental disabilities. American Journal on Intellectual and Developmental Disabilities, 119(4), 351–370.

    Article  PubMed  PubMed Central  Google Scholar 

  • Siegel, M., Doyle, K., Chemelski, B., Payne, D., Ellsworth, B., Harmon, J., Robbings, D., Milligan, B., & Lubetsky, M. (2012). Specialized inpatient psychiatry units for children with autism and developmental disorders: A United States survey. Journal of Autism and Developmental Disorders, 42, 1863–1869.

    Article  PubMed  Google Scholar 

  • Siegel, M., Smith, K. A., Mazefsky, C., Gabriels, R. L., Erickson, C., Kaplan D., et al. (2015). The autism inpatient collection: Methods and preliminary sample description. Molecular Autism.

    Article  PubMed Central  PubMed  Google Scholar 

  • Smith, K. R. M., & Matson, J. L. (2010). Behavior problems: Differences among intellectually disabled adults with co-morbid autism spectrum disorders and epilepsy. Research in Developmental Disabilities, 31, 1062–1069.

    Article  PubMed  Google Scholar 

  • Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland Adaptive Behavior Scales (2nd ed.). San Antonio, TX: Pearson.

    Google Scholar 

  • Therneau, T., Atkinson, B., & Ripley, B. (2015). Rpart: Recursive Partitioning and Regression Trees. R package version 4.1-10.

  • Yates, T. M. (2004). The developmental psychopathology of self-injurious behavior: Compensatory regulation in posttraumatic adaptation. Clinical Psychology Review, 24, 35–74.

    Article  PubMed  Google Scholar 

Download references


The ADDIRC is made up of the co-investigators: Matthew Siegel, MD (PI) (Maine Medical Center Research Institute; Tufts University), Craig Erickson, MD (Cincinnati Children’s Hospital; University of Cincinnati), Robin L. Gabriels, PsyD (Children’s Hospital Colorado; University of Colorado), Desmond Kaplan, MD (Sheppard Pratt Health System), Carla A. Mazefsky, PhD (Western Psychiatric Institute and Clinic; University of Pittsburgh), Eric M. Morrow, MD, PhD (Bradley Hospital; Brown University), Giulia Righi, PhD (Bradley Hospital; Brown University), Susan L. Santangelo, ScD (Maine Medical Center Research Institute; Tufts University), and Logan Wink, MD (Cincinnati Children’s Hospital; University of Cincinnati). Collaborating investigators and staff: Jill Benevides, BS, Carol Beresford, MD, Carrie Best, MPH, Katie Bowen, LCSW, Briar Dechant, BS, Joanne Dixon, PhD, Tom Flis, BCBA, LCPC, Holly Gastgeb, PhD, Angela Geer, BS, Louis Hagopian, PhD, Benjamin Handen, PhD, BCBA-D, Adam Klever, BS, Martin Lubetsky, MD, Kristen MacKenzie, BS, Zenoa Meservy, MD, John McGonigle, PhD, Kelly McGuire, MD, Faith McNeill, BA, Ernest Pedapati, MD, Christine Peura, BA, Joseph Pierri, MD, Christie Rogers, MS, CCC-SLP, Brad Rossman, MA, Jennifer Ruberg, LISW, Cathleen Small, PhD, Kahsi A. Pedersen, PhD, Nicole Stuckey, MSN, RN, Barbara Tylenda, PhD, Mary Verdi, MA, Jessica Vezzoli, BS, Deanna Williams, BA, and Diane Williams, PhD, CCC-SLP. We gratefully acknowledge the contributions of the coordinating site advisory group: Donald L. St. Germain, MD and Girard Robinson, MD, and our scientific advisory group: Connie Kasari, PhD., Bryan King, MD, James McCracken, MD, Christopher McDougle, MD, Lawrence Scahill, MSN, PhD, Robert Schultz, PhD and Helen Tager-Flusberg, PhD, the input of the funding organizations and the families and children who participated.


This study was funded by the Simons Foundation Autism Research Initiative (SFARI #296318 to M.S.) and the Nancy Lurie Marks Family Foundation.

Author information

Authors and Affiliations




MT, CM, KP and RG conceived of the parent study on which this manuscript is based, collaborated in the coordination of the study and supervised the data collection. BH conceived of the study, participated in its design and drafted the manuscript. MW performed the statistical analysis. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Benjamin L. Handen.

Ethics declarations

Conflict of interest

Dr. Handen received support from the National Institute for Aging (R01AG031110-03A1; 1 R01 AG051406-01), Autism Speaks, Roche and Eli Lilly. Dr. Mazefsky receives support from the National Institute of Child Health and Human Development (R01HD079512; K23HD060601). Drs. Gabriels, Pedersen, Wallace have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Handen, B.L., Mazefsky, C.A., Gabriels, R.L. et al. Risk Factors for Self-injurious Behavior in an Inpatient Psychiatric Sample of Children with Autism Spectrum Disorder: A Naturalistic Observation Study. J Autism Dev Disord 48, 3678–3688 (2018).

Download citation

  • Published:

  • Issue Date:

  • DOI:


  • Autism Spectrum Disorder (ASD)
  • Autism Inpatient Collection (AIC)
  • Self-injurious behavior (SIB)
  • Psychiatric hospitalization