Self-injury in children with learning disabilities requires an assessment that brings together health, communication, learning and individual differences (Richards et al., 2024). The evidence supports investigating the circumstances surrounding behaviour while remaining alert to pain, poor sleep and difficulties regulating behaviour. These influences can interact, making an individualised understanding essential (Oliver et al., 2020).
Understanding the child and the behaviour
The Cerebra guide focuses on children with moderate to profound intellectual disability, including those who are autistic or have a genetic syndrome. Here, learning disability refers to intellectual disability. Its focus is self-injurious behaviour that can cause physical harm; this should be distinguished from repetitive movements that do not cause injury (Richards et al., 2024). The guide also separates self-injury, seen mainly in children with moderate to profound intellectual disability, from self-harm, which is seen mainly in young people with mild or no intellectual disability and has a different evidence base (Richards et al., 2024).. Richards et al. (2012) examined self-injury in autistic people and comparison groups with genetic syndromes. Within the autistic group, self-injury was associated with characteristics including impulsivity and negative affect. Such findings encourage attention to both developmental abilities and emotional experience. They do not establish that an autism diagnosis or a particular behavioural characteristic inevitably leads to self-injury, nor that every child with the same diagnosis needs the same intervention.
Why early assessment matters
Longitudinal research shows why self-injury requires attention before it becomes established. Laverty et al. (2020) followed 67 autistic individuals over ten years using caregiver questionnaires. Self-injury persisted in 44% of those who showed it initially. Impulsivity and overactivity were associated with persistence, while a predictive model also included baseline measures of adaptive functioning, social communication, stereotyped behaviour, and interest and pleasure. This study followed participants from a mean age of approximately 13 to 24 years. It therefore offers insight into continuity across adolescence and early adulthood, rather than a prediction for every young child with an intellectual disability. Its observational design cannot show that changing impulsivity will prevent self-injury. Nevertheless, persistence over a decade supports taking early presentations into consideration and examining developmental and behavioural characteristics alongside immediate circumstances (Laverty et al., 2020).
Looking beyond the immediate trigger
The operant approach asks what happens before and after behaviour, and how its consequences affect the likelihood of recurrence. Access to something valued can reinforce behaviour; so can relief from an unpleasant situation. Understanding these relationships helps identify what the behaviour represents for a particular person. However, the significance of an event can change with the person’s physical state and circumstances. Langthorne et al. (2007) describe how biological and environmental influences can be integrated into functional assessment through the concept of motivating operations. These are conditions that alter how valuable a consequence is and how likely related behaviour becomes. For example, an uncomfortable physical state may make escape from a demand particularly valuable. The clinical question therefore extends from what followed self-injury to why that consequence mattered at that moment. This connects assessment of learning with assessment of the child’s needs.
Giving pain a place in assessment
Pain can be difficult to recognise when a child cannot describe it verbally. Assessment needs to consider physical health alongside changes in behaviour, rather than assuming that distress is explained by the developmental diagnosis. Oliver et al. (2020) identify pain and discomfort among several potentially interacting influences on behaviour in people with severe intellectual disability and complex needs. Structured observation can help make pain more visible. Breau et al. (2002) evaluated the Non-Communicating Children’s Pain Checklist–Revised using caregiver observations of 71 children aged 3–18 with severe cognitive impairments. Scores distinguished periods of pain from periods without pain and were associated with caregivers’ ratings of pain intensity. The study supports using observable behaviour to inform pain assessment when conventional verbal reporting is difficult. A checklist does not identify the medical cause of pain, its value is in organising observations and supporting communication with clinicians. The findings also underline the contribution of carers who know the child’s usual presentation. Observable changes demand interpretation in context, with clinical assessment where indicated, rather than treating a score as a diagnosis (Breau et al., 2002).
Considering behavioural control and self restraint
Self-restraint involves restricting one’s own movement and may sometimes help prevent self-injury (Richards et al., 2024). Richards et al. (2017) investigated self-injury and self-restraint in 208 autistic children and 216 autistic adults. In children, severe self-injury was associated with health conditions and overactivity or impulsivity. Self-injury and self-restraint were also associated in both age groups. These findings provided preliminary support for a model involving painful health conditions and difficulties with behavioural control. This distinction matters clinically: a child may struggle to inhibit behaviour even when its consequences are unwanted. However, questionnaire associations do not demonstrate the underlying mechanism. Self-restraint also requires careful interpretation; it cannot automatically be assumed to have one function. The study supports asking about behavioural control and self-restraint as part of assessment, while avoiding claims that executive dysfunction has been proven to cause every instance of self-injury (Richards et al., 2017).
Including sleep in the formulation
Khazaie et al. (2021) reviewed 16 studies examining sleep problems and self-injury. Short sleep duration, disrupted sleep and poor sleep quality were associated with non-suicidal self-injury, particularly in adolescents and young adults. The authors also identified possible roles for emotional dysregulation, depression and post-traumatic stress disorder in this relationshipThese findings strengthen the rationale for asking about sleep, but the review concerns non-suicidal self-injury in samples largely without intellectual disability (Richards et al., 2024). They should not be treated as direct evidence that sleep treatment reduces self-injury in children with moderate to profound intellectual disability. In this group, sleep belongs within a broader assessment that also considers health, emotional wellbeing and environmental demands (Khazaie et al., 2021; Oliver et al., 2020). The Cerebra guide organises assessment using PEACE: pain, environment, anxiety, control and exhaustion. It recommends recording sleep alongside behaviour to explore patterns (Richards et al., 2024)
Turning assessment into individualised support
Intervention should follow an understanding of the behaviour’s function and the child’s needs. NICE recommends adapting the environment and helping the person develop alternative skills that serve the same function as the behaviour. This can include communication skills, alongside intervention for coexisting physical or mental health problems (National Collaborating Centre for Mental Health, 2015). Behavioural treatment evidence also illustrates the importance of matching intervention to function. Vollmer et al. (1993) studied three people whose severe self-injury was maintained by attention. Both noncontingent reinforcement and differential reinforcement of other behaviour reduced self-injury. In the former, attention was provided on a schedule rather than being dependent on self-injury; in the latter, reinforcement depended on periods without the target behaviour. The small, functionally defined sample means these findings should not be generalised into a universal response to self-injury. The aim is to use assessment to select and evaluate support. NICE’s guideline includes ongoing review of reactive strategies and restrictive interventions, considering safety, effectiveness and continued need. Assessment and intervention should therefore remain responsive as circumstances change (National Collaborating Centre for Mental Health, 2015).
Conclusion
Research supports a broad, individualised understanding of self-injury. Longitudinal findings highlight persistence, while studies of pain, sleep and behavioural control identify important assessment questions. Functional approaches remain useful within this wider picture (Laverty et al., 2020; Oliver et al., 2020). Clinically, the task is to connect these observations with the child’s daily experience, identify needs that can be addressed, and evaluate whether support improves their situation. Risk markers guide enquiry; they do not replace an individual formulation.
Where next?
Join us on 1 December 2026 for the most important conference on self-harm this year, ‘Understanding and Responding to Self-Harm: Latest Evidence and Clinical Practice. Judy Dunn International Online Conference 2026‘, with Professor Nav Kapur, Professor Paul Plener, Professor Rose McCabe, Professor Caroline Richards, Associate Professor Johan Bjureberg and Professor Joan Asarnow.
Bringing together leading international experts, this conference will explore current evidence and key developments in the field, from emerging insights into the neurobiology of self-harm to the role of emotion regulation, assessment and engagement in care.
References
- Breau, L. M., McGrath, P. J., Camfield, C. S., & Finley, G. A. (2002). Psychometric properties of the non-communicating children’s pain checklist-revised. Pain, 99(1–2), 349–357. https://doi.org/10.1016/S0304-3959(02)00179-3
- Khazaie, H., Zakiei, A., McCall, W. V., Noori, K., Rostampour, M., Sadeghi Bahmani, D., & Brand, S. (2021). Relationship between sleep problems and self-injury: A systematic review. Behavioral Sleep Medicine, 19(5), 689–704. https://doi.org/10.1080/15402002.2020.1822360
- Langthorne, P., McGill, P., & O’Reilly, M. (2007). Incorporating “motivation” into the functional analysis of challenging behavior: On the interactive and integrative potential of the motivating operation. Behavior Modification, 31(4), 466–487. https://doi.org/10.1177/0145445506298424
- Laverty, C., Oliver, C., Moss, J., Nelson, L., & Richards, C. (2020). Persistence and predictors of self-injurious behaviour in autism: A ten-year prospective cohort study. Molecular Autism, 11, Article 8. https://doi.org/10.1186/s13229-019-0307-z
- National Collaborating Centre for Mental Health. (2015). Challenging behaviour and learning disabilities: Prevention and interventions for people with learning disabilities whose behaviour challenges (NICE Guideline No. 11). National Institute for Health and Care Excellence. https://www.ncbi.nlm.nih.gov/books/NBK305019/
- Oliver, C., Adams, D., Allen, D., Crawford, H., Heald, M., Moss, J., Richards, C., Waite, J., Welham, A., Wilde, L., & Woodcock, K. (2020). The behaviour and wellbeing of children and adults with severe intellectual disability and complex needs: The Be-Well checklist for carers and professionals. Paediatrics and Child Health, 30(12), 416–424. https://doi.org/10.1016/j.paed.2020.09.003
- Richards, C., Davies, L., & Oliver, C. (2017). Predictors of self-injurious behavior and self-restraint in autism spectrum disorder: Towards a hypothesis of impaired behavioral control. Journal of Autism and Developmental Disorders, 47(3), 701–713. https://doi.org/10.1007/s10803-016-3000-5
- Richards, C., Laverty, C., Agar, G., Marlow, K., Oliver, C., & Daniels, L. (2024). Self-injury in children with intellectual disability. Cerebra. https://cerebra.org.uk/wp-content/uploads/2025/02/Self-injury-in-children-with-an-intellectual-disability-final-1.pdf
- Richards, C., Oliver, C., Nelson, L., & Moss, J. (2012). Self-injurious behaviour in individuals with autism spectrum disorder and intellectual disability. Journal of Intellectual Disability Research, 56(5), 476–489. https://doi.org/10.1111/j.1365-2788.2012.01537.x
- Vollmer, T. R., Iwata, B. A., Zarcone, J. R., Smith, R. G., & Mazaleski, J. L. (1993). The role of attention in the treatment of attention-maintained self-injurious behavior: Noncontingent reinforcement and differential reinforcement of other behavior. Journal of Applied Behavior Analysis, 26(1), 9–21. https://doi.org/10.1901/jaba.1993.26-9
