Use of Skin-Shock at the Judge Rotenberg Educational Center (JRC)

 

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Using Standard Celeration Charts to Support Discontinuation of Anti-Psychotic Medications with Individuals with Severe Behavior Disorders in a Residential Facility 

Patricia Rivera, PhD, Robert vonHeyn, PhD, Anthony Joseph, MD, Lisa Northman, PhD, and Matthew Israel, PhD

Judge Rotenberg Educational Center
Canton, MA

 

The Judge Rotenberg Educational Center (JRC) operates day and residential programs for children and adults with behavior problems, including conduct disorders, emotional problems, brain injury, psychosis, autism and developmental disabilities. The basic approach taken in all of JRC's programs is the use of behavioral psychology and its various technological applications, such as behavioral education, programmed instruction, precision teaching, behavior modification, behavior therapy and behavioral counseling.  From JRC's inception, its basic philosophy has always included the following principles: a willingness to accept students with the most difficult behavioral problems and a refusal to reject or expel any student because of the difficulty of his or her presenting behaviors; the use of a highly structured, consistent application of behavioral psychology to both the education and treatment of its students; a minimization of the use of psychotropic medication; and the use of the most effective behavioral education and treatment procedures available.

Abstract

Historically, individuals referred to residential facilities are often prescribed some form of psychotropic medication to address their behavior difficulties.  These “behavior difficulties” include severe aggressive, disruptive, and health dangerous behavior that can sometimes be categorized as psychotic.  Increasingly, antipsychotic medications are used when other medications fail to show significant results or as a supplement to mood stabilizers or anti-depressants.  Over 50% of the individuals admitted to the Judge Rotenberg Center were admitted on at least one anti-psychotic medication.  Using a comprehensive behavioral support program we have been able to reduce, or in most cases completely eliminate, the use of anti-psychotic medication with concurrent behavioral improvement in all of the individuals.  Data will be presented in the form of standard celeration charts showing anti-psychotic medication reduction/elimination and behavioral improvement.  Specific behavioral programming will also be discussed. 

Introduction

Individuals who require residential placement for severe behavior disorders often have significant histories of experiencing failure with other modalities of treatment These individuals have various diagnoses such as autism, mental retardation, conduct disorder, intermittent explosive disorder, etc and have failed out of special education classrooms/schools, individual/group outpatient therapy, and/or psychiatric hospitalizations.  Often, individuals with severe behavioral disorders that are referred for residential treatment are also prescribed psychotropic medications. Although these individuals may present with some symptoms of psychiatric disorders, medication is often used to target maladaptive and aggressive behavior without a specific psychiatric disorder being present or without scientific evidence that the particular medication actually influences the behaviors (Schaal & Hackenberg, 1994).  In most cases, psychiatrists meet with the individuals for a specific period of time and base their decisions for medication additions/discontinuations on verbal reports from the individual themselves or from various residential staff.  Decisions may also be based on sound clinical practice guidelines. From a behavior analytic perspective, rates of the aberrant behaviors being treated should drive treatment decisions.  Given that this perspective is not always of primary concern to psychiatric professionals, it would make sense to present data in a manner that is difficult to dispute. Standard celeration charts, which have been shown to have numerous advantages over add-model charts, are an easily read visual presentation of behavior occurrence data.

Participants

Eight current students from the Judge Rotenberg Center (JRC) participated in this study.  The students were involved in all aspects of JRC’s educational and residential programming.  All students were referred to JRC because they exhibited a high frequency of inappropriate behaviors and were not able to be maintained within a regular school setting or less restrictive residential setting.  They exhibited maladaptive behaviors such as aggression, destruction, and self-abuse that interfered with their educational growth and put themselves and others at high risk for potential harm.  All of the students have also received multiple psychiatric diagnoses and prescribed various psychotropic medications.  They were involved in special education at early ages and due to their behaviors were placed in various psychiatric hospitals and residential facilities.  These students had been rejected from numerous facilities due to the severity of their behavior.  Alternative treatments for these students’ behavior problems prior to JRC included positive only behavior modification, medication management as well as individual and group therapy.  All of these interventions proved to be ineffective in reducing the frequency of their maladaptive behaviors.

Participant 1:  K.M.

-          14 y. o. at admission

-          Diagnosis history:  Mild MR, Intermittent Explosive Disorder, ADHD, Bipolar disorder NOS

-          Maladaptive behaviors: physical aggression, property destruction, suicidal/homicidal ideation

-          Medication on admission:  Lithium, Depakote, Risperdal, Thorazine

Participant 2:  J.P.

-          18 y.o. at admission

-          Diagnosis history:  Psychotic Disorder, ADHD, Mild MR

-          Maladaptive behaviors:  elopement, auditory hallucinations, stealing

-          Medication on admission: Dexadrine, Risperdal, Cogentin

Participant 3:  E.M.

-          16 y.o. at admission

-          Diagnosis history:  Psychotic Disorder NOS

-          Maladaptive behaviors:  gang involved, threatening others, property destruction, marijuana use, inappropriate defecation

-          Medication on admission:  Ablify, Zyprexa

Participant 4:  D.B.

-          9 y.o. at admission

-          Diagnosis history:  Bipolar Disorder NOS, Pervasive Developmental Disorder

-          Maladaptive behaviors:  physical aggression, property destruction, elopement, non-compliance

-          Medication on admission:  Seroquel, Tenex, Zoloft

Participant 5:  H.H.

-          14 y.o. at admission

-          Diagnosis history:  Psychotic Disorder, Intermittent Explosive Disorder, Pervasive Developmental Disorder, Oppositional Defiant Disorder, Borderline Intellectual Functioning, Fetal Alcohol Syndrome

-          Maladaptive behaviors:  physical aggression, threatening others, fire-

-          setting, property destruction, elopement, non-compliance

-          Medication on admission:  Seroquel, Buspar, Celexa, Lithium, Lamictal

Participant 6:  K.S.

-          14 y. o.

-          Diagnosis history:  Mood Disorder NOS, PTSD

-          Maladaptive behaviors:  sexualized behavior, physical aggression, suicide attempts, elopement, property destruction

-          Medication on admission:  Seroquel, Dpakote, Topamax, Trazadone

Participant 7:  W.S.

-          10 y. o. on admission

-          Diagnosis history:  ADHD, Conduct Disorder

-          Physical aggression, running off a bus, non-compliance

-          Medication on admission:  Seroquel, Depakote, Methylin

Participant 8:  M.P.

-          16 y. o. on admission

-          Diagnosis history:  Mood Disorder, Conduct Disorder

-          Maladaptive behaviors:  physical aggression, property destruction, elopement, sexualized behavior, threatening

-          Medication on admission:  Seroquel, Celexa

Method

All of the students in this study were being prescribed at least 1 anti-psychotic medication when they were admitted to JRC.  During a baseline period of 4-6 weeks positive only programming was implemented.  Their treatment was comprised primarily of positive reinforcement and token economy systems.  Social reprimands as consequences for inappropriate behavior, and ignoring of certain problematic behaviors were also incorporated into the students’ behavior modification programs.  DRO contracts of varied lengths (range1 minute to 1 month) were also implemented.  Due to the intensity and frequency of four of the students’ inappropriate behaviors, a court approved aversive program was implemented for those 4 students that included the use of a contingent skin shock device used to decelerate inappropriate behaviors.  Frequency data were recorded 24 hours a day and tally charts were converted to standard celeration charts in order to track behavior changes and adjust the length and time of contracts.  Following the baseline period, one of JRC’s consulting psychiatrists evaluated each student and reviewed their behavior charts.  The psychiatrist would meet with each individual student, consult with a staff clinician and study the student’s behavioral data whenever medication changes were considered.  The standard celeration charts were used as a guide for medication reduction and eventual elimination.  Approximately 1-2 months from the last medication taper the psychiatrist would again meet with the student and review their celeration charts before discharging the student from his caseload.

Results

Standard Celeration charts (Figures 1-8) show weekly or monthly frequency data of each student for their “dangerous behaviors” (aggression, destruction, health dangerous behavior, major disruptive behavior, and non-compliance).  Phaselines indicate medication discontinuation (medication reduction occurred in between dates noted).  Figures 5-8 also include phaselines for the beginning of contingent skin shock as a supplement to the positive behavioral programming.  All of the behavioral charts show a steady and sustained deceleration in students’ maladaptive behaviors with medication reduction and elimination. 

Discussion

By using the standard celeration charts to examine the student’s behavior the psychiatrist was able to visually see continued behavioral improvement with medication reduction.  Eventually, complete elimination of psychotropic medications resulted in continued sustained behavioral improvement allowing these students better access to education as well as increasing their social development.  This study supports the utility of the standard celeration chart to guide treatment decisions for psychiatrist when considering medication reduction.