Unlocking Behaviors: Head-Banging
By Risley “Ley” Linder, MA, MED, BCBA & Craig Escudé, MD, FAAFP, FAADM
This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion.
Sarah is a 45-year-old woman with a severe intellectual disability. She has lived in the same group home for 12 years, longer than any of her current support staff has worked there.
She is described as mostly cooperative but not very interactive with others. She does not use words to communicate but can usually indicate her preferences and needs with gestures. She is a picky eater, and her support staff has reported that occasionally, Sarah will hit herself in the head or hit her head on a nearby firm surface, such as a wall or table. She has exhibited this behavior intermittently for as long as they have known her. It appears to be “just want Sarah does, sometimes,” and hasn’t been looked into much further.
A couple of times a year, Sarah has been noted to have an upper respiratory tract infection, but overall is healthy. She sees her doctor annually for a physical exam, which is often limited because she will become agitated and hit her head. She sees the dentist twice a year, but, again, she receives minimal intervention because of her agitation.
“Sarah will hit herself in the head or hit her head on a nearby firm surface, such as a wall or table.”
Medical Discussion
Head-banging behavior can have several etiologies but should never be seen as “just something that people with IDD do.” Even when someone has done this for many years, there still may be a treatable underlying cause.
Some people have what I call a “limited repertoire” of actions or responses to distress or pain. Just because someone is banging her head in response to pain does not always mean that the pain is in a part of their head. For instance, a person may exhibit head-banging behavior as their primary means of expressing discomfort in any part of their body, including if they have an ingrown toenail. They may also exhibit that same behavior in response to social or environmental distress as well. That said, let’s talk about common medical causes of head pain that might trigger agitation or self-injurious behavior.
When looking for a cephalic cause of discomfort, I try to think of the possibility of it coming from “any hole in a person’s head.” Let’s look at them. Eyes—glaucoma, a foreign body, conjunctivitis. Ears— foreign body, cerumen impaction, otitis externa, otitis media, middle ear effusion. Nose—foreign body, sinusitis, allergic rhinitis. Mouth—dental abscess, dental caries, pharyngitis, ulcers, tongue or lip trauma from an accidental, self-inflicted bite. Other types of head-related discomfort include various types of headaches, scalp lesions, vision disturbances, or hearing disturbances.
“Head-banging behavior… should never be seen as ‘just something that people with IDD do.’”
I’m probably leaving out a few, but the idea is to think about all possible causes of pain or discomfort that could be causing a behavior change. Once all medical causes have been ruled out, it’s time to look for other potential reasons, including those from social, environmental, and behavioral perspectives.
Behavioral discussion
Behaviorally, the presentation of head-banging and other forms of self-abuse can be confounding for caregivers and practitioners alike. Sarah’s head-banging presentation brings to light three primary areas of focus: the function(s) of the behavior, temporal dimensions, and potential medical concerns, as already noted.
In behavior analysis, we work to identify the function of (or reason for) behavior, which we categorize into four primary areas: access to attention, access to items/activities, escape/avoidance, and sensory (e.g., pain attenuation). In the context of potential medical concerns, Sarah’s periodic head-banging could be related to pain attenuation/discomfort for recurrent respiratory infections. Further expounded, head-banging behaviors could also be impacted by the inability to have more comprehensive medical exams and preventative care, such as going to the dentist, which can lead to poor oral health and painful dental issues.
Sarah has been noted to engage in head-banging behaviors in two scenarios: intermittently at home and at medical appointments. As with most behaviors, they do not have a singular function, and although the behavior may look the same across time, settings, and people, the behavior can serve different functions. In Sarah’s case, we need to rule out possible medical causes (sensory function) but also address head-banging behavior when attending medical appointments (escape/avoidance function). In other words, we have identified one behavior but two functions, which means we will need multiple (at least two!) strategies/interventions to address Sarah’s head-banging behavior.
Of note when reviewing Sarah’s head-banging behaviors is the mention that the behavior is intermittent and she is a picky eater. Intermittent self-abusive behavior, only occurring two to three times a year, supports the notion of an acute medical condition, as opposed to self-abusive behavior that occurs at high rates or frequencies, which could lean towards a possible self-stimulatory function. Of particular interest, behaviorally, the staff mentioned she is a picky eater. Colloquially, being a picky eater is based on likes and dislikes. However, what if being a picky eater is rooted in aversion (because of pain)? For example, “Sarah always eats pudding at snack time, but sometimes she refuses to eat cookies, which we know she likes.” Is Sarah periodically refusing cookies because they are crunchy and avoiding them due to pain and discomfort while eating? These temporal dynamics of when the behavior is occurring over time, the time of day (e.g., “Is head-banging more likely to occur at mealtime?”), and other changes in behavior (e.g., food preferences) are all components a behavior analyst would examine.
From a future programming perspective, addressing the barriers impeding successful routine medical appointments (e.g., physician and dentist) would be beneficial. Sarah was noted to not be interactive with others, and communication deficits may be impacting her globally in that she is unable to effectively communicate pain and discomfort, but also stress and anxiety related to medical appointments. Increasing her ability to communicate effectively, instead of head-banging behaviors, and eliminating barriers to preventative medical care, are fundamental for Sarah’s long-term health and quality of life.
Outcome
As it turns out, Sarah was seen by the dentist and was noted to have yet another dental abscess. Her teeth were in exceedingly poor overall condition. After careful consideration and discussion with her support team and family, the decision was made for her to undergo a full mouth extraction. Indeed, the better option would have been for her to have been able to receive proper preventive and restorative care throughout her life, and I’ll leave that to my dental colleagues to discuss in more detail. However, for Sarah, this was felt to be the best option.
After Sarah healed from her surgery… the incidence of her head-banging behavior dropped by 90 percent.
After Sarah healed from her surgery, she began eating much better and was smiling more, and the incidence of her head-banging behavior dropped by 90 percent. This points to the likelihood that she had been experiencing significant dental pain for years.
While this was a heart-breaking case, it’s all too common. Remember that just because someone has always had a particular behavior, it does not mean it’s not due to an underlying, treatable cause.
The Authors
Ley Linder is a Board-Certified Behavior Analyst with an academic and professional background in gerontology and applied behavior analysis. Ley’s specialties include behavioral gerontology and the behavioral presentations of neurocognitive disorders, in addition to working with high-management behavioral needs for dually diagnosed persons with intellectual disabilities and mental illness. He is an officer on the Board of Directors for the National Task Group on Intellectual Disabilities and Dementia Practices, works closely with national organizations such as the National Down Syndrome Society, and is the owner/operator of Crescent Behavioral Health Services based in Columbia, SC.
Dr. Craig Escudé is a board-certified Fellow of the American Academy of Family Physicians and the American Academy of Developmental Medicine and is the President of IntellectAbility. He has more than 20 years of clinical experience providing medical care for people with IDD and complex medical and mental health conditions. He is the author of “Clinical Pearls in IDD Healthcare” and developer of the “Curriculum in IDD Healthcare”, an eLearning course used to train clinicians on the fundamentals of healthcare for people with IDD.