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

 

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Medication and Behavior Modification Treatment in Cases of Schizophrenia, Bipolar Disorder, and Head Injury

Worsham, Robert W., von Heyn, Robert E., and Israel, Matthew L.

 Judge Rotenberg Educational Center

240 Turnpike St.
Canton, MA 02021
(781) 828-2202

 

Based on a poster presented at Association for Behavior Analysis Conference, May 2002, Toronto, CA

 

1) Conclusions

• Risperdal and Ativan drastically reduced the aggressive behavior of a 19-year-old man diagnosed with Psychotic Disorder NOS, and brain injury secondary to anoxia.

Risperdal drastically reduced the aggressive behavior of a 24-year-old man diagnosed with Atypical Psychosis, Pervasive Developmental Disorder, and Mild Mental Retardation.

Depakote broke up and eliminated the rapid-cycling verbal symptoms of a 19-year-old man diagnosed as having Bipolar Disorder I With Rapid Cycling.

2) Introduction

The Judge Rotenberg Educational Center (JRC) is a residential special education school that emphasizes the use of behavior modification and minimizes the use of psychoactive medication. Historically, the school has mostly treated those with mental retardation and/or autism. This population has typically been over-medicated for behavior problems when effective behavior modification has not been available to them.

In recent years JRC has admitted students from more diverse populations, such as those with psychosis, major mood disorders, and brain injury. A small number of students with major psychiatric diagnoses have not responded maximally to highly structured behavior modification treatment. In cases such as these we may add the use of medication as a supplement to behavior modification treatment. We present data for three students for whom medication was added as a supplement to their treatment.

3) Method

ER was 19 years old when admitted to JRC. He had the diagnosis of Psychotic Disorder NOS and also had suffered brain damage at age 17 from anoxia, which resulted from an attempt to hang himself. On admission he was receiving Ativan (1 mg per day) and Risperdal (6 mg per day), which were discontinued shortly after admission.

BS was 24 years old at the time of his second admission to JRC. He was demonstrating overtly psychotic behaviors, and had been diagnosed as having Atypical Psychosis, Pervasive Developmental Disorder, and Mild Mental Retardation.

EF was a 19 year old whose dangerous aggressive and self-injurious behaviors had been successfully treated with contingent electrical stimulation. He was continuing to display rapid-cycling periods of extremely high-rate verbal behaviors interspersed with very low-rate periods. This confirmed his diagnosis of Bipolar Disorder I with Rapid Cycling.

All three students were treated with psychoactive medication by a psychiatrist following accepted protocols for the introduction or termination of these medications. Treatment decisions were aided by JRC’s standard 24-hour data collection system in the form of frequency counts, and from the input of each student’s treatment team.

All three were concurrently treated with a highly structured reward system in the form of DRO contracts and special contracts. Major violent behaviors were managed with emergency physical restraint for ER and BS. EF’s violent behaviors were treated with court-authorized contingent electrical stimulation.

4) Results

All charts are semi-log, with totals on the y-axis and time in the form of months, weeks, or days on the x-axis.

Figure 1 shows that when ER’s Ativan and Risperdal were discontinued his aggressive behavior increased over the course of several months to a level of over 100 per month. With the re-introduction of Ativan and Risperdal, the monthly totals of aggression gradually decreased to under 10 per month and finally to a zero level.

Figure 2 shows that a trial of Neurontin was not effective in reducing BS’s aggression. Seroquel had been tried at first, but was discontinued because it produced agitation. Although there were two weeks of zero while on Neurontin, aggression jumped back up to over 200, leading to the institution of a Risperdal trial. On Risperdal aggression dropped precipitously to zero per week where it remained.

Figures 3, 4, and 5 show daily frequencies of inappropriate verbal behavior for EF. The left half of Figure 3 shows nine weeks of data while on no medication, clearly demonstrating the rapid-cycling nature of his behavior.

The right half of Figure 3 shows the results of a Neurontin trial.  This seemed to result in a drastic reduction of the peak frequencies, but the cyclicity is still apparent.

The left half of Figure 4 shows a period of time on 1500 mg. per day of Depakote.  The peaks are a little higher than when he was on Neurontin, and the cycles are still there.  However, the peak parts of the cycles are noticeably narrower than when on Neurontin or on no medication at all.

The right half of Figure 4 picks up several months later when the dosage of Depakote was increased to 1750 mg. per day.  Overall, the peaks become even narrower, closer together, then followed by periods with more days of very low frequencies. 

Figure 5 simply shows a continuation of this trend, ultimately reaching a point in which frequencies are mostly zero, and there is a very occasional narrow spike.

5) Discussion

We have presented three cases in which data, in the form of 24-hour daily frequency counts, have provided a clear-cut basis for psychiatric decision-making regarding the efficacy of psychoactive medication treatment. Often, prior to a student’s admission to JRC, it has been the case that decisions have been made on the basis of anecdotal information or rating-scale data. Frequency counts provide better information for decision-making, and in some cases they can provide firm evidence for a diagnosis that can more accurately and efficiently guide one to a proper treatment. This practice aids JRC in helping to avoid the unnecessary use or overuse of medications, while, at the same time, it allows us to provide an appropriately therapeutic use of medication when indicated.