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THE USE OF BEHAVIORAL INTERVENTIONS TO DECREASE THE FREQUENCY OF INAPPROPRIATE BEHAVIOR IN AN ADULT MALE SUFFERING FROM PARANOID SCHIZOPHRENIA:  AN EXTENSIVE CASE STUDY

Patricia M. Rivera, Ph.D., Robert von Heyn, Ph.D., and Matthew L. Israel, Ph.D.,

Judge Rotenberg Educational Center

Canton, MA

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 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

This extensive case study will present a review of behavioral interventions used to decrease the frequency of inappropriate behavior in a 44 year old male (ML) with paranoid schizophrenia.  A history which includes severe aggressive behavior, suicide attempts and other health dangerous behaviors, will be discussed. Prior interventions included the use of at least 15 different psychotropic medications, more than 25 psychiatric hospitalizations, months of Electroconvulsive Shock Therapy and placements in adult residential facilities, failed to produce significant changes in his behavior. Strict behavioral programming was implemented upon his admission to the Judge Rotenberg Center and he was slowly weaned off of his psychotropic medications. The use of positive programming included a standardized token system, DRO contracts of varied lengths, and an extensive reward program. After nearly 6 months of treatment, punishment, in the form of a court approved contingent skin shock was added to his program to decelerate his most problematic behaviors. Following the reduction of his major behaviors to near zero rates, Risperdal and Zyprexa were started to reduce his bizarre verbalizations and allowed for the weaning of the skin shock device.  Standard celeration charts showing significant deceleration in aggressive, health dangerous, destructive, major disruptive and non-compliant behaviors will also be presented. 

Introduction

Traditionally, hospital treatment and antipsychotic medications have been the treatment of choice for individuals diagnosed with Paranoid Schizophrenia (APA, 1997).  Carpenter. McGlashan, and Strauss  (1977) noted that millions of people diagnosed with Psychotic disorders are taking antipsychotic medications as the only important component of their treatment.  Recent research has focused on more community oriented interventions with minimal use of medication and found beneficial effects after 2 years (Bola, & Mosher, 2003).  Given that not all psychotic patients benefit from psychotropic drug treatment it seems imperative to explore other treatment modalities for individuals suffering from schizophrenia, especially when more traditional treatment has failed to produce significant results.

Subject

The subject (M.L.) was a Caucasian male diagnosed with Chronic Paranoid Schizophrenia.  He graduated from high school but began exhibiting self injurious behavior in the form of cutting and scraping his skin with sharp objects at age 18.  He was able to attend 2 years of art school before being admitted into the hospital at age 20 for alcohol abuse.  The course of his treatment history from 1983 until his admission to the Judge Rotenberg Center on February 14, 2002 is as follows:

Problem Behaviors

-          2 suicide attempts (putting a knife to his throat and cutting himself with sharp objects)

-          Unprovoked aggression (punching, hitting, kicking peers, family and staff)

-          Delusions (stated his desire to hurt others was a result of having a “spring in his back that made him want to hit”)

Treatment History

-          25 psychiatric hospitalizations for command hallucinations, as well as non-compliant, aggressive and self-abusive behavior

-          4 adult residential facilities

-          Dozens of ECT treatments over 3-4 months

-          4 point restraint 24 hours a day for 3 weeks

-          Numerous medications trials (Clozaril, Haldol, Klonopin, Risperdal, Seroquel, Loxitane, Lithium, Depakote, Topomax, Zyprexa, and Neurontin) with no significant or sustained improvement in his behavior.

Method 

M.L. was admitted to JRC directly from the psychiatric hospital on February 14, 2002.  He was 44 years old.  M.L. arrived by ambulance after spending the prior 3 weeks in 4 point restraint at his own request to keep him safe.    Upon admission M.L. was taking Klonopin (1mg), Clozaril (600 mg) and Haldol (2mg).

-          Positive programming including the use of various DRO contracts, a token economy system and loss of privileges was implemented.

-          Rewards included time by himself, cigarettes, preferred meals, arts and crafts.

-          Frequency data were recorded 24 hours a day and tally charts were converted to standard behavior charts in order to track behavior changes and adjust the length and time of contracts.

-          Medication was successfully faded without any increase in his major inappropriate behaviors (see Figure 1).

-          The Graduated Electronic Decelerator (GED) was implemented to target his major inappropriate behaviors (see Figure 2). 

-          Anti-psychotic medication was reintroduced to target his inappropriate verbal behaviors which were not being treated with the GED (see figure 3).

Results

The frequency of M.L’s major inappropriate behaviors, including aggression, health dangerous behaviors, destroy, major disruptive behaviors and non-compliance) decreased from a median of 113 per week prior to GED to a median of 6 once the GED was introduced into his program (see figure 4).  Although the trend of his major inappropriate behaviors appeared to be decelerating slowly prior to the implementation of the GED he was in an alternative learning classroom with very little demands placed on him.  Once the GED was implemented we were able to place many more demands on M.L., requiring him to complete his vocational tasks in order to earn his rewards and his behaviors continued to decelerate.  More specifically, the frequency of his aggressive behavior decreased from a median of 57.5 a week to a median of 0 (see Figure 5).  Finally, his inappropriate verbal behaviors which included bizarre speech and negative statements about self were on a decelerating trend following the re-introduction of the antipsychotic medication (see Figure 6).

Due to the overall improvement in M.L’s behaviors he also earned the following privileges:

-          move to a less restrictive residence

-          weekly community outings with peers

-          opportunity to earn money by completing contracted piece work

-          eventual fading of the GED and moving out of JRC

Discussion

Results of this study indicate that behavioral treatment replaced psychotropic medication and successfully reduced the frequency of M.L.’s major inappropriate behaviors including aggression.  This allowed the subject to reintegrate into the  community and resume semi-independent living outside of an institution.  M.L. now resides in a private apartment with a 1:1 paraprofessional aide 24 hours a day 7 days a week.  He does not have any paid employment at this time but is taking art classes at a local university.  M.L. is actually having his own art show at a local gallery this summer. He obtained his driver’s license but will only drive with his aide or a family member in the car.  He is able to go shopping, to the movies, out to eat and complete all of  his ADL’s.  M.L. has not required any psychiatric hospitalizations since his discharge and has not exhibited any aggressive behavior.  He has been successfully weaned off all of his medication without any acceleration in his inappropriate behavior.  He visits with his family frequently and interacts daily within his community.  Traditional treatment including several psychotropic medications, electroconvulsive shock therapy, and psychiatric hospitalizations failed to produce the results obtained by implementing a strict behavior treatment program. 

References

American Psychiatric Association (1997) Practice guidelines for the treatment of patients with schizophrenia.  American Journal of Psychiatry, 154 :1-63.

Bola, J.R, and Mosher, L. (2003) Treatment of acute psychosis without neuroleptics: Two year outcomes from the Soteria project.  The Journal of Nervous and Mental Disease, 191(4): 219-229.

Carpenter, W.T., McGlashan, T.H., Strauss, H.S. (1977) The treatment of acute schizophrenia without drugs: An investigation of some current assumptions.  American Journal of Psychiatry, 134: 14-20.