Olanzapine for self-injurious, aggressive, and disruptive behaviors in intellectually disabled adults: a retrospective, open-label, naturalistic trial

BACKGROUND: The effectiveness of olanzapine in treating challenging behaviors in the intellectually disabled and its ability to substitute for conventional antipsychotic drugs were evaluated. METHOD: A total of 20 institutionalized adults with a mean age of 42.7 years (range, 18-55 years) with intellectual disability and aggression, self-injurious behavior, destructive/disruptive behavior, or combinations of these behaviors were studied. These individuals were receiving multiple psychotropic medications at baseline and were given additional treatment with the atypical antipsychotic agent olanzapine. The mean dose of olanzapine was 9.1 mg/day (range, 2.5-22.5 mg/day). Effectiveness was determined by retrospective review of the summaries of quarterly neuropsychiatric behavioral reviews and retrospective review of longitudinal behavioral graphs of target symptoms. Data were collected from 1995 to 2000. RESULTS: A significant decrease in global challenging behaviors and specific target behaviors (i.e., aggression, self-injurious behaviors, destructive/disruptive behaviors) occurred (p <.05). A numerical decrease in the dosage of concurrent conventional antipsychotic medications occurred over the course of the first 6 months of olanzapine therapy, and a statistically significant (p <.005) decrease from the start of olanzapine therapy occurred in those subjects who received olanzapine for longer than 6 months (mean = 20.3 months). A significant increase in weight occurred in the subject group during the first 6 months of olanzapine treatment (p <.006), and sedation and constipation were the other common side effects noted. CONCLUSIONS: Olanzapine was found to be effective in the treatment of challenging behaviors in the intellectually disabled and in part could be substituted for administration of conventional antipsychotic drugs.     

Severe self-injurious behavior associated with treatment-resistant schizophrenia: treatment with maintenance electroconvulsive therapy

A 35-year-old man with schizophrenia associated with a 10-year history of repetitive and often severe self-injurious behaviors was treated successfully with maintenance electroconvulsive therapy. Initially his condition did not respond to multiple psychotropic agents (including a year-long trial of clozapine), 27 hospitalizations, two courses of bilateral electroconvulsive therapy, and supportive psychotherapy with partial hospitalization. After the initiation of maintenance electroconvulsive therapy, this patient was able to tolerate residential placement and begin a work therapy program with only one instance of self-injurious behavior in the past 17 months.     

Suppression of repetitive self-injurious behavior by contingent inhalation of aromatic ammonia

Two institutionalized children who exhibited high rates of severely self-injurious behaviors were punished with aromatic ammonia inhalation on a response-contingent basis. This contingency was applied throughout all aspects of each child's institutional program which focused on teaching of self-help skills. Suppression of the self-injurious responses was both rapid and general. The contingency was maintained for 2 months, although there was no responding after the first 5 days. Follow-up sessions, conducted 4 months after the punishment contingency was removed, revealed that suppression effects were highly durable. Aromatic ammonia inhalation appears to be an effective alternative for decelerating extremely maladaptive behaviors that do not yield to more conventional nonaversive forms of therapy. However, the procedure should be used with great caution, for it may involve risk to the subject.This work was supported in part by PHS grant HD00973.     

Electroconvulsive therapy for psychotropic-refractory bipolar affective disorder and severe self-injury and aggression in an 11-year-old autistic boy

We report the successful use of electroconvulsive therapy in a 11-year-old boy with autism and a 4-year history of psychotropic-resistant bipolar affective disorder associated with dangerous episodes of self-injurious and aggressive behaviors placing his caregivers and himself at significant safety risk. Extensive behavioral and medication interventions in both inpatient and outpatient settings had been ineffective, and the boy was at risk for acute physical injury and restrictive out-of-home placement. An acute course of eight bilateral electroconvulsive therapies resulted in significant mood stabilization and significant improvement of self-injury and aggression. Maintenance electroconvulsive therapy and psychotropic interventions were then pursued.     

Modification of self-injury and self-mutilation behavior--analysis of a single case intervention study of a boy in a school for mentally retarded

The present study analysed the self-injurious, destructive behaviour of a mentally retarded boy, ten years of age which was generally noticed through his resistance to demands and because of his self-destructive behaviour and aggressions against others. This behaviour appeared in critical situations (following instructions; not getting something). It is maintained by positive (getting attention) and negative reinforcement (let off demands). The interventions followed the mediating concept, including both female teachers and the mother of the boy. They were instructed to set effective demands, to give positive reinforcement for following rules and to sanction deviant behaviour by over correction. The effects of the intervention were measured through four problem behaviours (oppositional defiant behaviour, self-injurious behaviour, aggressive behaviour against others, evading) with 80 measurements in a multiple baseline analysis (replication over behaviours). The interventions reduced the destructive behaviours of the boy. A follow-up after 10 months proved that no problem behaviours were noticeable anymore.     

ECT in a man with FG syndrome

We report on the use of electroconvulsive therapy (ECT) in a 20-year-old man with a history of FG syndrome and schizophrenia who demonstrated thought disorder and aggression refractory to pharmacological treatment. He received 71 ECT treatments over a period of 13 months and demonstrated a marked reduction in aggressive behavior. In the 14 months before beginning ECT, the patient spent 189 days in the hospital, whereas in the 13 months subsequent to his initial ECT series as an inpatient, he was able to be maintained in the community without psychiatric hospitalization. This case extends the findings of prior cases documenting the alleviation of aggressive behaviors with ECT.     

Buspirone therapy for maladaptive behavior and anxiety in developmentally disabled persons

The authors used buspirone, a new anxiolytic agent that has a low side effect profile, to treat 14 developmentally disabled individuals who demonstrated anxiety as well as aggressive and self-injurious behaviors. Nine of the 14 individuals responded favorably to the drug. The authors present case reports for 3 of the responders and discuss the clinical implications of buspirone therapy.     

精神科急诊患者自杀自伤行为相关因素的调查分析

目的:对精神科急诊患者自伤自杀行为发生及相关因素进行初步调查。方法:采用自杀危险因素评估表对精神专科医院急诊非取药患者1 325例进行评估,并根据评分将其分为自伤自杀组146例(评分≥21分)和非自伤自杀组1 179例(评分≤20分),分别对两组社会人口学及疾病学资料进行调查分析。结果:女性就诊者自伤自杀行为高于男性(χ2=6.158,P0.05),白天就诊者高于其他时间段就诊者(χ2=27.740,P0.001),父母关系不和的就诊者高于父母关系好的就诊者(χ2=9.771,P0.01),存在疾病诱因的就诊者高于无疾病诱因的就诊者(χ2=15.134,P0.01),多次发病的就诊者高于首次发病的就诊者(χ2=8.578,P0.05),临床诊断焦虑抑郁状态的就诊者高于其他临床诊断的就诊者(χ2=125.203,P0.001)及有躯体疾病的就诊者高于无躯体疾病的就诊者(χ2=9.039,P0.05)。结论:女性、发病诱因、发病次数、躯体疾病、父母关系、就诊时间及焦虑抑郁状态是精神科急诊患者发生自伤自杀行为的主要相关因素。     

The progression of severe behavior disorder in young children with intellectual and developmental disabilities

Behavior disorders, such as self-injurious, stereotypic, and aggressive behavior are common among individuals with intellectual or developmental disabilities. While we have learned much about those behaviors over the past few decades, longitudinal research that looks at developmental trajectory has been rare. This study was designed to examine the trajectory of these three forms of severe behavior disorders over a one year time period. The behaviors were measured on two dimensions: frequency of occurrence and severity. Participants were 160 infants and toddlers at risk for developmental delays in Lima, Peru. Using structural equation modeling, we found that the frequency of self-injury and stereotypic behavior and the severity of aggressive behavior remained stable over the 12-month period. Uni-directional structural models fit the data best for self-injurious and aggressive behavior (with frequency being a leading indicator of future severity of self-injury and severity being a leading indicator of future frequency for aggression). For stereotypic behavior, a cross-lagged autoregressive model fit the data best, with both dimensions of frequency and severity involved as leading indicators of each other. These models did not vary significantly across diagnostic groups, suggesting that toddlers exhibiting behavior disorders may be assisted with interventions that target the specific frequencies or severities of behaviors, regardless of diagnostic category.     

Progressive supranuclear palsy with agitation: response to trazodone but not to thiothixine or carbamazepine

A 66-year-old man with progressive supranuclear palsy is described. Although generally apathetic, withdrawn, and spontaneous in speech and behavior, he had sudden episodes of agitation, during which he was verbally threatening and physically abusive. Treatment with thiothixine and then with carbamazepine was ineffective in controlling his violent behavior. He responded temporarily to trazodone, and a recurrence of aggressive behavior was suppressed by increasing the dose of trazodone; this response may be related to trazodone's putative effect on the serotonin system. Although both carbamazepine and trazodone have been advocated for the control of aggression in organically impaired patients, they were not equally effective in this case.     

Effects of vibroacoustic music on challenging behaviors in individuals with autism and developmental disabilities

Vibroacoustic music has been proposed to be an effective treatment for individuals with developmental disorders and challenging behaviors. The present study experimentally tested the effects of vibroacoustic music on self-injurious, stereotypical, and aggressive destructive behaviors in 20 individuals with autism spectrum disorders and developmental disabilities. The participants were randomized into two groups in a randomized controlled trial evaluation. The first group received 10–20 min sessions with vibroacoustic music treatment for 5 weeks. Then the second group received the same treatment during the next 5 weeks. Behavior was assessed using the Behavior Problems Inventory in all participants before the treatment, after the first group had completed their treatment, and again after the second group had completed their treatment. In order to evaluate each session, the accompanying assistants assessed behavior on different scales after each session. In addition, the sessions were videotaped and analyzed minute by minute for challenging behaviors. The results revealed that vibroacoustic music reduced self-injurious, stereotypic, and aggressive destructive behaviors in the participants. In addition, the results indicated that the effect of vibroacoustic music was to some extent dependent on the participants’ diagnosis. Implications for vibroacoustic music theory and practice are discussed.     

Analysis of risk factors and early predictors of challenging behavior for children with autism spectrum disorder

The current study evaluated risk factors for the occurrence, frequency and severity of challenging behavior among a sample of individuals with a diagnosis of autism, under the age of eighteen, in Ireland. Age, gender, hours of intervention received, age at diagnosis, presence of challenging behavior at diagnosis and treatment type at diagnosis were not found to be significant predictors for the frequency or severity of challenging behavior. The participants’ IQ was found to be a significant predictor of the frequency and severity of the behaviors measured. Lower IQ predicted greater frequencies of stereotyped behavior, aggression and self-injurious behavior along with increased severity of stereotyped behavior and self-injurious behavior. The intervention participants were currently receiving was not significant in predicting the frequency of challenging behavior, nor the severity of aggressive or self-injurious behaviors. However, this variable was a significant predictor of severity of stereotyped behaviors with individuals currently in Applied Behavior Analysis interventions presenting with more severe stereotyped behavior than those currently in “eclectic” interventions. Additional findings and implications in relation to these variables are discussed.     

Psychiatric Hospitalization Among Children with Autism Spectrum Disorders

This study examined predictors of psychiatric hospitalization among children with autism spectrum disorders (ASD). Data were collected from 760 caregivers of children with ASD. Cox regression was used to determine factors associated with hospitalization. Almost 11% were hospitalized. Youth in single parent homes were more likely to be hospitalized (OR = 2.54), as were youth diagnosed at a later age (OR = 1.10). Engaging in self-injurious behavior (OR = 2.14), aggressive behavior (OR = 4.83), and being diagnosed with depression (OR = 2.48) or obsessive compulsive disorder (OR = 2.35) increased the odds of hospitalization. Risk for hospitalization increased with age and over time. The results suggest early diagnosis and community-based interventions for aggressive and self-injurious behaviors may reduce hospitalizations.     

Effect of divalproex sodium on aggression and self-injurious behaviour in adults with intellectual disability: a retrospective review

The aim of the present study was to evaluate the efficacy of divalproex sodium treatment in adults with intellectual disability, and aggressive or self-injurious behaviour. Twenty-eight adults aged between 20 and 63 years of age with severe, long-lasting behavioural problems were treated with divalproex sodium (dosage 500–4000 mg day − ¹). Clinical changes were assessed at 2–73 months into the pharmacological treatment utilizing the Clinical Global Impression Severity (CGI-S) scale, and monthly behavioural counts of aggressive and self-injurious acts. Seventy-one percent of subjects demonstrated a moderate or marked improvement on the CGI-S; another 21% demonstrated mild benefits. Among the patients for whom objective prospective behavioural counts were available, 88% showed a significant reduction in aggression and self-injurious behaviour, 46% had other psychotropic medications discontinued, and another 39% had psychotropic medications decreased. One patient had serious thrombocytopenia which required the discontinuation of divalproex sodium, and one other had vomiting and worsened aggression. The present preliminary, uncontrolled study suggests that adults with intellectual disability, and aggressive or self-injurious behaviour may respond to divalproex sodium, and that this drug is well-tolerated in the majority of subjects.     

Multifaceted behavior therapy of self-injurious behavior

Learning principles were used to overcome the severe self-injurious behavior eye-poking and lip- and tongue-biting) of a 20-yr-old male, diagnosed as schizophrenic. In individual treatment sessions, relaxation, thought-stopping and desensitization were used to render stimuli antecedent to self-injurious behavior ineffective. Withdrawal of reinforcement and covert sensitization were used directly to diminish self-injurious behavior. Reinforcement (overt and covert) and instruction were employed to teach appropriate behaviors. Three shifts of ward staff were instructed and monitored in the application of reinforcement principles. Self-injury ceased after 3 months. Nine months later the patient was discharged. A 2-yr follow-up indicates no recurrence of the maladaptive behavior and a normal adjustment.     

The relationship of self-injurious behavior and aggression to social skills in persons with severe and profound learning disability

In this study, we investigated differences in social skills among four groups of individuals with severe and profound learning disabilities. The comparison groups were composed of individuals engaging in self-injurious behavior, aggression, both behaviors, or neither of the behaviors. We measured social skills using the Matson Evaluation of Social Skills for Individuals with Severe Retardation, a standardized assessment of social skills in persons with severe or profound learning disability. The results indicated that individuals displaying maladaptive behaviors exhibited a restricted range of social behaviors compared to controls. Also, group membership based on self-injury and aggression was predicted based on profiles of scores on the Matson Evaluation of Social Skills for Individuals with Severe Retardation. These findings are consistent with reports in other studies that note social skills deficits in aggressive and self-injurious persons with learning disabilities. However, in this case a standardized assessment of these deficits was possible and specific skills problems were identified. Implications of the findings for identification and treatment of self-injury and aggression are discussed.     

Self-injurious behavior associated with clonidine withdrawal in a child with Tourette's disorder

A 7-year-old boy with Tourette's disorder, atypical pervasive developmental disorder, borderline mental retardation, and a history of self-injurious behavior was treated for 21 months with clonidine transdermal patches at doses ranging from 0.1 to 0.5 mg weekly. When withdrawn from clonidine over 4 weeks to assess the need for continued therapy, the patient developed multiple self-destructive behaviors involving the theme of suffocation. The importance of careful clinical monitoring of the behavior of patients undergoing withdrawal from prolonged treatment with high doses of clonidine is emphasized.     

Dopamine re-uptake inhibitor GBR-12909 induction of aberrant behaviors in animal models of dopamine dysfunction

Many individuals with mental retardation exhibit chronic aberrant behaviors (CABs) that includes hyperactive, stereotyped, aggressive, and self-injurious behaviors. Brain imaging studies have found that several of these individuals have abnormalities in their dopaminergic neurotransmitter systems that are thought to be responsible in part, for the development of these behaviors. The present study evaluated the effects of a selective dopamine re-uptake blocker, GBR-12909 in three animal models of varying striatal dopamine concentrations. The three animal models included the neonatal 6-hydroxydopamine (6-OHDA)-lesioned rat, a model of dopamine neuronal depletion, the prenatal methylazoxymethanol (MAM)-exposed rat, a model of hyper-dopaminergic innervation and control rats, a model of normal dopaminergic function. The animals were given five daily injections of GBR-12909 and videotaped observations were conducted immediately following the injections and 6h later. The results of the study indicate that the MAM-treated rats exhibited more hyperactive behaviors than either the 6-OHDA or the control animals in response to the GBR-12909 injections. However, the 6-OHDA and control rats exhibited more self-injurious behaviors than the MAM rats. Interestingly, the topography of the self-injurious behavior exhibited differed from that we have previously observed in 6-OHDA lesioned rats following dopamine agonists and resembles the mouthing behaviors seen in some individuals with mental retardation, in particular those with Rett syndrome. These findings indicate the models of varying dopaminergic function interact differently with a dopamine re-uptake blocker than dopamine agonists and that the partially dopamine depleted model may model the behaviors seen in individuals with Rett syndrome.     

Soles of the Feet: a mindfulness-based self-control intervention for aggression by an individual with mild mental retardation and mental illness

Uncontrolled low frequency, high intensity aggressive behavior is often a barrier to community living for individuals with developmental disabilities. Aggressive behaviors are typically treated with psychotropic medication, behavioral interventions or their combination; but often the behaviors persist at a level that is problematic for the individual as well as care providers. We developed a mindfulness-based, self-control strategy for an adult with mental retardation and mental illness whose aggression had precluded successful community placement. He was taught a simple meditation technique that required him to shift his attention and awareness from the anger-producing situation to a neutral point on his body, the soles of his feet. After practice he applied this technique fairly consistently in situations that would normally have elicited an aggressive response from him. The data show that he increased self-control over his aggressive behaviors, met the community provider's requirement for 6 months of aggression-free behavior in the inpatient facility before being transitioned to the community, and then successfully lived in the community without readmission to a facility. No aggressive behavior was seen during the 1-year follow-up after his community placement. Mindfulness-based intervention may offer a viable alternative to traditional interventions currently being used to treat behavioral challenges in children and adults with mild mental retardation.     

A behavioral/pharmacological intervention for the treatment of severe self-injurious behavior

The effects of haloperidol and a mild punishment on the severe self-injurious behavior and several collateral behaviors of a 17-year-old profoundly retarded male were assessed. A 12-month analysis using a withdrawal design suggested that neither the medication nor the behavioral intervention alone was effective in significantly reducing the frequency of self-injurious behavior. When combined, however, these interventions produced dramatic reductions in the subject's self-injurious behavior. The haloperidol may have acted as a “setting event”for the successful use of the punishment. Suppression of this behavior was maintained at 6 months and 1 year following the end of the analysis. The collateral behaviors were differentially affected by the behavioral and pharmacological interventions. Time spent in bed and the appearance of drooling increased with the introduction of the haloperidol, while percent correct on a fine-motor task increased only when the interventions were applied simultaneously. The results point out the importance of a careful behavioral analysis for both pharmacological and behavioral interventions and their possible combined actions.