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Treatment of Severe Aggression and Self-Injury with Contingent Electric Shock

Robert E. von Heyn, Matthew L. Israel, Robert W. Worsham & Melissa Burns

Judge Rotenberg Educational Center

Canton, MA USA

Introduction

The Judge Rotenberg Educational Center operates day and residential programs for children and adults with behavior problems, including conduct disorders, emotional problems, brain injury or psychosis, autism and developmental disabilities. The basic approach taken at JRC is the use of behavioral psychology and its various technological applications, such as behavioral education, programmed instruction, precision teaching, behavior modification, behavior therapy, behavioral counseling, self-management of behavior and chart-sharing. The behavior modification treatment included court approved use of the Graduated Electronic Decelerator (GED), a contingent skin shock device, to decelerate specific targeted behaviors for some individuals. The present report describes the effectiveness of the GED with four individuals referred to the Judge Rotenberg Educational Center (JRC) for treatment of their intense aggression, self-injury and other disruptive behaviors such as property destruction and noncompliance. These individuals functioned between mild mental retardation and average intelligence and had received various psychiatric diagnoses. These individuals were not typical of those that have been treated with contingent electric shock as reported in the psychological literature. Most published articles have dealt with individuals with more severe cognitive impairments, developmental delays and/or autism. However, a common factor between these individuals and those described in the literature are their intense aggressive and self-injurious behaviors that had not responded to more traditional treatments. For these individuals, medications, positive-only behavior modification and traditional types of psychotherapy had failed to produce a significant impact on their interfering behaviors. In conjunction with the treatment to decelerate these inappropriate behaviors, academic education, daily living skills, social skills and community integration were taught. Information on previous treatments, number of placements, diagnoses and grade level are presented. Frequency data of targeted behaviors were collected hourly and plotted on daily, weekly and monthly charts. Other areas of improvement in these individuals’ living and working environments and development of new skills are also provided.

Method

All participants were initially treated with highly structured behavior plans that used a variety of Differential Reinforcement of Other Behaviors (DRO) contracting. Contract lengths varied between 5 minutes and 24 hours, depending on the frequency of the targeted behaviors. Reinforcers were individualized for each participant and based on their verbal preferences. A token economy, in the form of points or pennies, was also in place for each participant. Tokens were awarded for passing contracts, completing academics or exhibiting other defined prosocial behaviors. Points or pennies could be spent in a variety of ways to purchase preferred items or activities. A response cost system was also in place whereby tokens were deducted when targeted behaviors occurred.

When participants exhibited aggressive or self-injurious behaviors emergency physical or mechanical restraints were employed. Chemical restraint was never used. For more information on JRC’s programs visit www.judgerc.org.

For these individuals, the positive only approach did not produce a clinically significant improvement in their targeted behaviors. These behaviors interfered with their entire educational and habilitative programming and posed a significant risk of injury. Therefore, at various intervals after intake, JRC petitioned the Probate Court in Massachusetts for permission to use the Graduated Electronic Decelerator (GED) to treat their challenging behaviors. The GED is an FDA registered medical device that administers a 2-second skin shock when remotely activated by a therapist. The proposed treatment plan presented to the Court, written by a doctoral level psychologist or clinician, operationally defined the behavior topographies JRC requested for treatment with the GED. When GED treatment began the individual’s daily recording sheet described those topographies for which the clinician prescribed GED treatment. To insure reliable treatment, two therapists confirmed the existence of the targeted behavior on the individual’s daily recording sheet before the GED consequence was administered. Twenty-four hour a day videotaping and live monitoring also insured treatment consistency. For more information on the GED see www.effectivetreatment.org.

Participants

AS

• 19-year-old female admitted July 27, 2000.
• Previously in 2 foster homes, 4 residential placements, 4 psychiatric hospitalizations and 1 emergency respite program. Discharged from each due to continued aggression and self-injury and inability to keep her and others safe.
• Medications included: Klonopin, Lithium, Wellbutrin, Seroquel, Tegretol, Cogentin, Prozac, Ritalin, Thorazine, Naltrexone, Depakote, Clonidine, Zyprexa, Trilafon and Haldol.
• Past treatments included ‘intensive behavioral programming’, milieu therapy and group and individual therapy and physical and mechanical restraint.
• Diagnoses included: Impulse Control Disorder; Conduct Disorder, Post Traumatic Stress Disorder; Psychosis NOS; Rule out Bipolar Disorder; Rule out Mood Disorder; Major Depression, Recurrent, Severe; and Mental Disorder, not otherwise specified due to lead poisoning.
• Targeted behaviors included physical aggression and self-injurious behaviors including head banging, runaway, tying material around her neck, scratching open her skin with objects or fingernails and imbedding staples and paperclips under her skin.

 

TC

·        19-year-old female admitted to JRC on July 9, 2001.

·        Medications included Ritalin, Dextrostat, Risperdal, Paxil, Clonidine, Depakote, Seroquel, Luvox, Adderall and Buspar.

• Elementary school settings included 7 special education placements, 1 crisis intervention day program, 3 psychiatric hospitalizations and 1 out-of-state residential special education program. Discharged from each due to continued aggression and self-injurious behaviors.
• Past treatments included 1:1 staffing, a behavior support plan that included aversive interventions incorporating physical restraint and a locked timeout room.
• Diagnoses included: Attention Deficit Hyperactivity Disorder; Conduct Disorder; Oppositional Defiant Disorder; Depressive Disorder, NOS; Impulse Control Disorder, NOS; Panic Disorder; Borderline Personality Disorder; Disruptive Behavior Disorder and Mild Mental Retardation.
• Targeted behaviors included aggression and self-injurious behaviors that encompassed running away into traffic, breaking objects, injuring herself to the point of bleeding and climbing and jumping from trees causing injury.

JC

• 17 year-old female admitted on August 23, 2000.
• At age three a very detailed behavior management home program, 2 residential treatment programs, 2 day programs and 9 psychiatric hospitalizations. Discharged and readmitted to many of these placements due to the severity of her aggressive and self-injurious behaviors.

·        Medications included Ritalin, Trazadone, Tegretol, Thorazine, Depakote, Cogentin, Topamax, Risperdal and Olanzapine.

·        Past treatments included a behavior modification program, 1:1 staffing, individual psychotherapy and physical restraints.

·        Diagnoses included: Oppositional Defiant Disorder; Bipolar Disorder; Attention Deficit Hyperactivity Disorder, Combined Type; Dysthymia; Psychotic Disorder, NOS; Cognitive Disorder; Nonverbal Learning Disability; Intermittent Explosive Disorder and Organic Brain Syndrome.

·        Targeted behaviors included physical aggression and self-injurious behaviors that encompassed throwing herself down a flight of stairs, assaulting her siblings with scissors, biting herself, cutting her wrists, head-banging and pounding walls.

JE

• 16 year-old young male admitted on September 19, 1999.
• Beginning at age seven, 2 psychiatric day school programs, 4 psychiatric hospitals and 2 residential treatment centers. Discharged from all placements due to uncontrollable aggression and self-injurious behaviors.
• Past treatments included individualized psychotherapy, group therapy, family therapy and multiple physical and chemical restraints.

• Medications included Neurontin, Lithium, Zyprexa, Benadryl, Propranolol, Klonopin, Depakote, Mysoline, Zoloft, Ritalin and Clonidine.
• Diagnoses included: Generalized Anxiety Disorder; Post Traumatic Stress Disorder; Psychotic Disorder; Bipolar Disorder; Attention Deficit Hyperactivity Disorder; Schizoaffective Disorder; Pervasive Developmental Disorder; Partial-Complex Seizures and Mild Mental Retardation.
• Targeted behaviors included physical aggression and self-injurious behaviors that encompassed choking his sibling, slashing older sibling with a razor, jumping out of classroom windows, jumping out of a moving car, picking scabs and head banging.

Results and Discussion

Figures 1 through 4 contain the behavior charts of the combined frequencies of aggression and self-injurious behaviors and some of the positive effects of GED treatment. The data clearly indicate the efficacy of the behavioral treatment package in rapidly decelerating the rate of the targeted behaviors and the continued reduction to zero rates. The behavioral program, rich in positive reinforcers, together with a punishment component to rapidly decelerate inappropriate behaviors, produced no negative side effects and allowed medication and all restraint to be eliminated. As importantly, it allowed these individuals to actively engage in an educational curriculum, live in community-based apartments and, in some cases, become gainfully employed. In all of these cases they jumped two or more academic grade levels in less than a year. In many cases family contact was reestablished, and peer relationships improved. While this method may be considered intrusive, the individuals and their families welcomed this treatment and credit treatment success to it. With further research it may prove that this procedure is the most effective, least intrusive treatment available for individuals such as these who have only worsened under a myriad of medications, psychotherapy and weaker treatment programs.

Table 1

The Effect of GED on Aggressive and Self-Injurious Behaviors

Participants	Pre-GED Rate/week	Total GED Applications	Weeks of GED Treatment	Median GED/week		Immediate Effect of GED
AS	207	6	90	0	¸45
TC	248	7	31	0	¸60
JC	323	28	70	0	¸165
JE	723	6	62	0	¸2