Long-term use of electrical aversion treatment with self-injurious behavior

Report of the ABAI Task Force on Contingent Electric Skin Shock

As a task force appointed by the Executive Council of the Association for Behavior Analysis International (ABAI), we investigated the clinical use of contingent electric skin shock (CESS) in behavior analytic treatments for severe problem behavior. We studied how CESS is used in contemporary behavior analysis, reinforcement-based alternatives to CESS, and current ethical and professional guidelines for applied behavior analysts. We recommended that ABAI uphold clients' right to receive CESS when it is restricted to extreme cases and used under rigorous professional and legal oversight. Our recommendation was rejected by a vote of the full members of ABAI, who instead endorsed an alternative recommendation, developed by members of the Executive Council, that opposed the use of CESS under any condition. Here we present for the record our report and initial recommendations, the formal statement that was rejected by the members of ABAI, and the statement that was endorsed.

Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key

PURPOSE OF REVIEW

Self-injurious behaviour (SIB) is a devastating condition frequently encountered in autism spectrum disorders (ASDs) that can lead to dangerous tissue injury and profound psychosocial difficulty. An increasing number of reports over the past decade have demonstrated the swift and well tolerated resolution of intractable SIB with electroconvulsive therapy (ECT) when psychopharmacological and behavioural interventions are ineffective. The current article provides a review of the salient literature, including the conceptualization of repetitive self-injury along the catatonia spectrum, and further clarifies the critical distinction between ECT and contingent electric shock.

RECENT FINDINGS

We searched electronically for literature regarding ECT for self-injurious behaviour from 1982 to present, as the first known report was published in 1982. Eleven reports were identified that presented ECT in the resolution of self-injury in autistic or intellectually disabled patients, and another five reports discussed such in typically developing individuals. These reports and related literature present such self-injury along the spectrum of agitated catatonia, with subsequent implications for ECT.

SUMMARY

Intractable self-injury remains a significant challenge in ASDs, especially when patients do not respond adequately to behavioural and psychopharmacological interventions. ECT is well tolerated and efficacious treatment for catatonia, and can confer marked reduction in SIB along the agitated catatonia spectrum.

Evaluation of electrical aversion therapy for inappropriate sexual behaviour after traumatic brain injury: a single case experimental design study

Inappropriate sexual behaviour after acquired brain injury is a severe complication. Evidence for effective treatment is not available. Electrical aversion therapy (EAT) is a behavioural therapeutic option used in persons with intellectual disabilities, which might be suitable for brain-injured individuals for whom other therapies are not effective. The effect of EAT in brain injury has not been investigated previously. A single case experimental design was used. In an ABBA (baseline-treatment-treatment-withdrawal) design the frequency of the target behaviour (ie, inappropriate sexual behaviour) in a 40-year-old man was measured daily. A total of 551 measurements were recorded. A significant reduction of the target behaviour was seen after the first treatment phase (baseline 12.18 (2.59) vs 3.15 (3.19) mean target behaviours daily); this reduction remained stable over time. We conclude that EAT was effective in this patient with inappropriate sexual behaviour due to severe brain injury. EAT can therefore be considered in therapy resistant inappropriate sexual behaviour in brain-injured patients.

Side effects of contingent shock treatment

In this study, the side effects of contingent shock (CS) treatment were addressed with a group of nine individuals, who showed severe forms of self-injurious behavior (SIB) and aggressive behavior. Side effects were assigned to one of the following four behavior categories; (a) positive verbal and nonverbal utterances, (b) negative verbal and nonverbal utterances, (c) socially appropriate behaviors, and (d) time off work. When treatment was compared to baseline measures, results showed that with all behavior categories, individuals either significantly improved, or did not show any change. Negative side effects failed to be found in this study.

Effects of single and repeated shock on perceived pain and startle response in healthy volunteers

Contingent shock (CS) has been used in a number of studies to suppress health-threatening self-injurious behavior of individuals with mental retardation and autism. As sustained suppression is an issue of concern, research into procedural variables of CS is needed. In this study, clinical evidence was used to infer a variable that might be of relevance for the application of clinical contingent shock, that is, to assess the effect of single versus repeated shock at a specific location on the body. With pain intensity and startle response as dependent variables, shocks were administered to 48 healthy volunteers. Electric shocks were identical to those that used in clinical practice. The second shock in succession to the same location of the body produced higher pain intensity ratings than the first shock and that the third shock in succession to the same location of the body produced higher pain intensity ratings than the second shock in succession. Startle responses, however, failed to be affected in this direction. The latter result is consistent with a previous study. Our data suggest that repeated shock to the same location is likely to be more effective to establish suppression than repeated shock to different locations.

Multiple factors in the long-term effectiveness of contingent electric shock treatment for self-injurious behavior: a case example

This report describes the effective treatment of self-injurious behavior (SIB) using contingent electric shock in an adolescent. Data are presented to document the initial dramatic reduction in SIB and the ongoing effectiveness of the treatment over a 5-year period. Positive side effects of the intervention are documented, as is information on the interaction of a medical condition (e.g., ear infections, fever), psychoactive medication status, and staff changes that served to effect the rate of SIB across 4 years of treatment. Recognizing and attending to these various factors has served to insure the success of the aversive intervention with very low rates of SIB and, consequently, very low rates of the administration of electric shock. Keeping the rate of administration of shock low serves to decrease the chances of habituation to the shock thereby emphasizing the importance of attending to the individual's total medical, social, and administrative environments.

On the status of knowledge for using punishment implications for treating behavior disorders

In this paper, we review basic and applied findings on punishment and discuss the importance of conducting further research in this area. The characteristics of responding during punishment and numerous factors that interact with basic processes are delineated in conjunction with implications for the treatment of behavior disorders in clinical populations. We conclude that further understanding of punishment processes is needed to develop a highly systematic, effective technology of behavior change, including strategies for improving the efficacy of less intrusive procedures and for successfully fading treatment.

A quasi-experimental study on the effect of electrical aversion treatment on imposed mechanical restraint for severe self-injurious behavior

Eight individuals with mental retardation and imposed mechanical restraints due to severe, life-threatening self-injurious behavior received electrical aversive treatment. Eight other individuals, who had been matched with the treatment group in terms of the degree of imposed mechanical restraint due to the above problem behavior, had not received electrical aversion treatment. A comparison of imposed mechanical restraint scores, as a measure of severity of self-injurious behavior, between both groups over a period of three years, revealed that electrical aversion treatment significantly reduces the degree of imposed mechanical restraint.

Positive behavioral support of adults with developmental disabilities: assessment of long-term adjustment and habilitation following restrictive treatment histories

The long-term maintenance of behavioral treatment effects is an important measure of clinical significance but is not reported with regularity in the published literature. The present report concerned therapeutic maintenance by evaluating five adults with developmental disabilities who had been exposed to multiple, restrictive procedures (food deprivation, mechanical restraint, electric shock) in a prior residential treatment facility and were transitioned to a new habilitation setting where these procedures were terminated in favor of alternative methods of behavior support. As revealed through a 24-month follow-up period, all of the participants were able to maintain clinically acceptable levels of challenging behaviors following the removal of the restrictive treatment procedures. Quality of life measures also revealed that the participants experienced greater independence, reduced supervision, and increased diversity in their living and work environments. These findings add to the limited studies on extended maintenance outcomes from behavioral intervention for serious clinical disorders in adults with developmental disabilities by demonstrating that positive adjustment can be sustained in the long-term without the continuation of restrictive treatment procedures.

Focusing versus distraction and the response to clinical electric shocks

This study pertains to assessing the effects of electric shocks that are used in the treatment of severe self-injurious behavior. With pain sensation and startle response as the dependent variables and focusing versus distraction of recipient's attention to the electric shocks as the independent variable, these stimuli were administered to 60 paid volunteers. Using ANOVA, no significant effect of the independent variable was found on either measure. However, repeated administration of the electric shock produced a significant increment of pain sensation, with a concomitant significant decrease of magnitude of the startle response. No interaction effect was found.

The treatment of severe self-injurious behavior by the systematic fading of restraints: effects on self-injury, self-restraint, adaptive behavior, and behavioral correlates of affect

Severe self-injurious behavior (SIB) in people with mental retardation is difficult to treat when dangerously frequent or intense responding rules out functional analysis and interventions that permit free responding. This situation is common when restrictive devices, such as straight arm splints, are used. In this study, the effects of introducing flexion into a straight-arm splint, on SIB, self-restraint, adaptive behavior, and behavioral correlates of affect were examined for three individuals with severe mental retardation. Using single-case design methodology, for two individuals self-injury was reduced to zero, while the overall level of restriction was also significantly reduced. From the observed behavioral correlates of affect, there was no evidence of an increase in negative affect with the introduction of the new splint and the fading procedure, but there was evidence of an increase in positive vocalizations. Engagement in activities and social contact were not affected by the introduction of the new splint. The reasons for a decrease in SIB with a corresponding decrease in restriction in the absence of any manipulation of contingencies for SIB are discussed, with particular reference to stimulus control.

An inventory method for assessing the degree of restraint imposed by others

An inventory for assessing the degree of mechanical restraint imposed by others to prevent individuals from inflicting physical injuries to themselves or to others, the Imposed Mechanical Restraint Inventory (IMRI), was developed. The inventory was administered to pairs of residential direct-care staff members to assess 113 individuals with mental retardation who showed self-injurious behavior while various sorts of mechanical restraint were imposed on them. The results indicate that the inventory showed acceptable levels of interobserver reliability, intraobserver reliability, and accuracy.