Professionals' perceptions of psychotropic medication in residential facilities for individuals with mental retardation.

Professional staff in four state facilities for individuals with mental retardation were surveyed to determine their perceptions, knowledge and opinions regarding the use of psychotropic medication. A large majority of the 377 respondents indicated that the physicians in their facilities were primarily responsible for medication-related decisions. Under ideal conditions, however, all professional staff and parents were seen as having a greater influence in the decision-making process. Aggression, delusions and hallucinations, self-injury, other psychiatric disorders, and anxiety were rated as disorders most likely to result in medication therapy. Behaviour modification was viewed as a suitable alternative to drug treatment for acting out and aggression. The professionals indicated that behavioural observation was the most influential assessment technique in current usage, followed by global impressions and informal diaries. Over 80% of the respondents perceived their preservice and inservice training on issues related to the use of psychotropic medication to treat behaviour problems as inadequate, with 96% of them desiring continuing education. These findings were compared to data from similar studies of populations with other disabilities, and suggestions for modifications in the current decision-making processes related to the use of psychotropic medication in institutionalized individuals with mental retardation are discussed.

Effects on individuals with mental retardation of changing Depakote to Depakene.

This study was conducted to determine whether Depakene could be substituted for Depakote, which would represent a significant financial savings, without sacrificing symptom control or drug tolerance. Over an 8-week period of intensive monitoring, we changed 77 patients from Depakote to Depakene. Results showed no change in seizure control, no adverse upper gastrointestinal side effect, no weight change, no sleep disturbance, no change in aberrant behavior, and no change in appetite. Patients were less less lethargic on Depakene than on Depakote. However, there was some increase in diarrhea, of uncertain cause. Some changes in psychiatric symptoms were also noted. Overall, this drug change was well-tolerated.

Clinical effects of buspirone on intractable self-injury in adults with mental retardation.

OBJECTIVE: The efficacy of buspirone in controlling self-injurious behavior was examined in five individuals with mental retardation. Buspirone was used alone in two individuals and as an adjunct to thioridazine in the other three. METHOD: Standard behavioral observation methods were used to collect data on the number of self-injurious responses of the individuals during baseline and several doses of buspirone in an open trial. RESULTS: When compared with baseline levels, all five individuals showed some response to buspirone, with reductions in self-injury ranging from 13% to 72%, depending on the dose. The most effective dose of buspirone was 30 mg/day for three individuals and 52.5 mg/day for the other two. These individuals were maintained for 6 to 33 weeks on their most effective dose. Coexistent symptoms of anxiety did not predict a favorable response to buspirone therapy. CONCLUSIONS: Buspirone showed a mixed but generally favorable response in controlling intractable self-injury in this and four previous studies reporting similar cases. However, the drug should not be endorsed as a proved treatment for self-injury until similar results have been obtained from well-controlled studies of its efficacy.

The social validity of an argument supporting a ban on aversive procedures.

There is currently a controversy regarding the use of non-aversive and aversive procedures in the treatment of severe behaviour problems in individuals with mental retardation. One specific criticism directed at professionals who support the non-aversive position is that they have taken quotations from scientific articles out of context in order to give the impression of empirical support for their position. The present authors addressed this issue by assessing the social validity of references made to selected scientific articles in support of a specific argument in a monograph by Guess et al. (1987). Three groups of individuals were surveyed in this study: (1) psychologists working with individuals with mental retardation at six state schools in Texas (Group I); (2) selected professionals with expertise in the area of self-injurious behaviour and in the use of behaviour modification techniques with individuals who are mentally retarded (Group II); and (3) the authors of the six journal articles that were selected for the present study (Group III). The study focused on references made to journal articles in support of the 'depersonalization hypothesis' that aversive therapies serve to depersonalize the recipients of these treatments. Results indicate that the authors of the monograph were not completely accurate in their references to the six articles. Sixty per cent of the respondents from Group I, 71% of respondents from Group II, and two out of the three respondents from Group III rated the citations made in the monograph as inaccurate. In addition, the respondents rated the articles as not supportive of the depersonalization hypothesis for which they were cited. Over half of Group I respondents, and all respondents from Groups II and III rated the articles as non-supportive of the depersonalization hypothesis. These findings suggest that the authors of the monograph have used references selectively and incorrectly in support of their views in at least some instances. This emphasizes the importance of critical reading and hypotheses based on bodies of knowledge rather than selected sources. Furthermore, this study indicates the need for operationally defined hypotheses which may be examined empirically.

Fluoxetine treatment of severe self-injury in young adults with mental retardation.

Dysfunction of the serotonergic system has been implicated in the development and maintenance of self-injury in some persons with mental retardation. Several preliminary reports have suggested that fluoxetine, a drug that blocks the reuptake of serotonin, may decrease self-injury in these individuals. Of the 44 cases of self-injury treated with fluoxetine and previously reported in the literature, 42 demonstrated a beneficial response to the drug. We report four additional cases of adults with mental retardation whose self-injury was treated with fluoxetine. Each of these individuals benefited from fluoxetine to some extent, with average decreases in self-injury ranging from 20% to 88% when compared with baseline levels. These findings, combined with those from previously published case studies, emphasize the need for well-controlled studies to more adequately assess the effects of fluoxetine on self-injury.

A 4-year follow-up of treatment of self-injury.

Data on the long-term effectiveness of behavioral treatment for self-injurious behavior in individuals with mental retardation is rare. We present 4-year follow-up data on a 28-year-old man whose severe self-injurious behavior was treated with brief contingent electric stimulation via the Self-Injurious Behavior Inhibiting System (SIBIS). Event data collected throughout follow-up showed reductions in head-hitting and head-banging from over 2,600 responses per hour to approximately 1 response per hour during much of the first 31 months of treatment. However, the rate of head-banging began increasing thereafter, with the SIBIS losing its effectiveness to such an extent that it was no longer clinically useful.

Clinical evaluation of the self-injurious behavior inhibiting system (SIBIS).

Five cases involving the treatment of longstanding, severe, and previously unmanageable self-injurious behavior are presented. In each case, the behavior was forceful contact with the head or face, and treatment consisted of mild and brief contingent electrical stimulation, delivered automatically or by a therapist, via the Self-Injurious Behavior Inhibiting System. Results of reversal and/or multiple baseline designs, in which sessions ranged in duration from 10 min to all day across a variety of settings, showed that the effects of the system were immediate and produced almost complete elimination of the self-injurious behavior. Controlled and anecdotal follow-up data for four of the five cases suggest continuing benefits and the absence of detrimental side effects associated with treatment. Potential applications of the device, as well as extensions and limitations, are discussed.

A community survey of self-injurious behavior among developmentally disabled children and adolescents.

The extent, nature, and treatment of self-injurious behavior was surveyed among 2,663 developmentally disabled children and adolescents in a large metropolitan school district during the 1984-85 school year. Sixty-nine, or 2.6 percent, of the students exhibited at least one type of self-injurious behavior during the preceding 12 months; 59 percent of these students were males and 41 percent were females. Most of the self-injurious students were either severely or profoundly retarded, and their mean age was 10.2 years. Although almost three-quarters of the students exhibited self-injurious behavior at least daily, only a third were engaged in formal treatment programs for the problem. More than half (53.6 percent) had been restrained during the preceding 12 months for such behavior, and 8.7 percent had received psychotropic medications. The authors believe that the development of effective treatment strategies for self-injurious individuals living in the community may help them avoid institutionalization.

Treatment strategies for self-injurious behavior in a large service-delivery network.

Despite pressures in recent years to discourage reliance upon pharmacological interventions, psychoactive drugs continue to be utilized extensively with institutionalized mentally retarded persons. In the present study the scope and pattern of psychoactive drug use within a state-wide institutional service-delivery network were examined, with a focus upon its role in the treatment of self-injurious behavior (SIB) and other aberrant behavior patterns. Correlates to psychoactive drugs and alternative intervention approaches were examined. Lack of treatment, insufficient utilization of behavioral technology, and use of physical and chemical restraints as adjuncts to positive behavioral programs were indicated.