- Email: [email protected]
Behavioral monitoring of pharmacological interventions for self-injury
Applied Primed
Research in Menrol Rerordarion. in the USA. All rights reserved.
Vol. 5. pp. 161-170.
1984 Copyright
0270-3092/84 0 1984 Pergamon
f3.00+ .oO Press Ltd.
Behavioral Monitoring of Pharmacological Interventions for Self-Injury Nirbhay
N. Singh
University New
of Canterbury Zealand
Alan
S. W. Winton
Massey New
University Zealand
Pharmacological interventions are often the treatment of choice for controlling fhe maladaptive behavior of institutionalized tnentally retarded children. However, the efficacy of various psychotropic drugs for controlling the behavior of given individuals has not been well established. Further, it is not always clear that decisions IO alter a drug regimen are based on actual changes in the behavior of interesr. The present study illustrates the use of behavioral observation to assess the effects of various drugs prescribed for the self-injurious behavior of a profoundly mentally retarded I5 year old male. The clinical effectiveness of various dosages of carbamazepine (Tegretol), thioridazine (Melleril), and chlorpromazine (Largactil) was assessed. Except for Melleril 100 mg. rid, when a marked down ward trend in the daily role was observed, no significani reduction in self-injury occurred. Subsequently overcorrection (forced arm exercise) made contingent on each response reduced self-injury to near zero, but only when the last prescribed drug, Tegretol200 mg, rid. had been withdrawn for several days.
It is well established that a large number of mentally retarded persons receive psychotropic drugs for behavior problems (see Aman & Singh, 1983). However, the clinical efficacy of most psychotropic drugs for controlling the behavior problems of such residents is still subject to much controversy. Clinical decisions concerning medication for behavior problems are usually based
Requests for reprints may be addressed to Nirbhay sity of Canterbury, Christchurch, New Zealand.
161
Singh,
Department
of Psychology,
Univer-
162
N. N. Singh and A. S. W. Winton
on informal global assesments. Prescribing physicians appear to change medication and dosage on the basis of ward reports, informal observations of nursing staff and their own overall judgement. Reliable behavioral data obtained from monitoring the effects of drugs prescribed specifically for behavioral disorders are typically lacking. In the present study the self-injurious behavior of a profoundly mentally retarded boy was monitored while he received drugs to treat the self-injury. Of interest was whether changes in the drug regimen correlated with changes in the behavior being treated. Subsequently, a behavioral treatment was used to eliminate the continuing incidence of self-injury. METHOD
Subject and Setting The subject was a 15year-old, institutionalized, profoundly mentally retarded boy. His weight was 45 kg. The etiology of his retardation was not known. His clinical records indicated a long-standing problem of face-rubbing which resulted in broken facial skin and bleeding. No behavioral programs had been instituted at any time to control his face-rubbing. The subject had been on a 6-month course of haloperidol for self-injury when he was 13 years old. Since then he had been drug free (with the exception of antibiotics) for 18 months. During the pharmacological intervention phases, observations were scheduled in all areas of the subject’s residential ward. During the behavioral intervention phases, observation and treatment sessions were scheduled only in the dayroom of this ward. However, treatment and observations were scheduled throughout the ward during the maintenance phase. Recording
and Definition
Four observers were given extensive individual and group training prior to, and throughout the study. Baseline observations were initiated only when interobserver agreement between randomly assigned partners was consistently above 85% during training. The principal data were collected by one observer, randomly assigned on a daily basis and reliability checks were made by a second observer during some of the sessions. The dependent measure was a frequency count of self-injury. Self-injury was defined as any rubbing of the face by the subject with each up-down or circular motion counting as a separate response. Typically the subject made two or three self-injurious responses at a time.
Pharmacological Intervention Monitoring
163
Reliability During reliability checks a measure of agreement between the two observers was obtained by dividing the two frequencies, the smaller by the larger, and multiplying by 100. During pharmacological treatment, the mean interobserver agreement was 96.8% (range = 87-100%) and during the behavioral intervention, the mean was 93.0% (range = SS-lOOOr0). Pharmacological
Intervention
The prescribing physician and the nurse in-charge of the ward were responsible for the decisions about medication. Neither the experimenter nor the observers were aware of the actual drug, the dosage, or changes in the drug regimen during the intervention. In effect, the intervention constituted an observational study of clinical-decision making on the effects of psychoactive drugs on self-injury. Two physicians were involved in this study; one was the prescribing physician and the other a consultant to the study. Both discussed the study with the experimenter (NNS) and agreed to participate. The prescribing physician was told that while several children under his care would be observed for behavior problems, only one would be the subject of this study. However, with his consent, he was not informed who or from which ward the subject was chosen. The data from the study were discussed with the prescribing physician at the termination of the pharmacological intervention phase, before the behavioral program was instituted. The consultant physician was involved in the study throughout and reviewed the data with the experimenter at weekly intervals. With the exception of the ward charge, all nurses were unaware of the purpose of the study which was discussed with the ward charge, and her approval obtained before the study was initiated. She was not informed which child on her ward would be studied. She was debriefed together with the physician when the pharmacological intervention was terminated. Experimental
Procedure
Drugs were administered throughout either twice a day (bd) or three times a day (tid) except during baseline. The pharmacological intervention consisted of 10 experimental phases conducted over 145 days: (a) baseline (drug free), 5 days; (b) Tegretol 200 mg, bd, 6 days; (c) Tegretol 200 mg, tid, 30 days; (d) Melleril 100 mg, tid, 17 days; (e) Melleril50 mg, tid, 14 days; (f) baseline (drug free), 16 days; (g) Largactil25 mg, tid, 6 days; (h) Largactil50 mg, tid, 8 days; (i) Largactil, 100 mg, tid, 31 days; and (j) Tegretol 200 mg, tid, 12
N. N. Singh and A. S. W. Winton
164
days. The length of each phase was determined by the physician and this depended in part on two things, 1) the global impressions of the ward staff on the effects of medication or lack of, in each phase, and 2) the titration sequence followed for determining the clinically optimal dosage. For example, a shorter duration may have been used for dosages below the optimum if the dosage was being increased. Observations were scheduled daily during the first 10 minutes of each hour from 9 a.m. to 8 p.m. Behavioral
Intervention
At the request of the prescribing physician and the ward charge, a behavioral intervention was initiated while the subject was medicated (Tegretol200 mg/tid). Experimental
Procedure
The behavioral intervention consisted of four experimental phases conducted over 60 consecutive days, followed by a 6-month maintenance phase. The experimental phases were: (a) medication plus overcorrection, 10 days; (b) overcorrection, 20 days; (c) withdrawal, 10 days; and (d) overcorrection, 20 days. Observations were made during daily one hour sessions conducted three hours after breakfast. Medication plus overcorrection. The subject received Tegretol 200 mg, tid, at mealtimes. The behavioral treatment was an adaptation of the Foxx and Azrin (1973) overcorrection procedure which has been used to treat self-injury in mentally retarded persons (de Catanzaro & Baldwin, 1978; Singh, Dawson & Gregory, 1980). The therapist (a ward nurse) was instructed to catch the subject’s wrist just before his fingers made contact with his face, hold his arm straight and fully extended to the side of the subject, and gently “pump” up and down at approximately one up-and-down movement per second. If the subject resisted treatment, his arm was to be held firmly without any movement and the overcorrection procedure implemented once he was calm. Each attempt at or instance of self-injury resulted in the overcorrection procedure being carried out for 10 seconds (i.e., 10 up and down arm movements). Overcorrection. In this phase, only overcorrection was used. The subject was off medication during this and subsequent phases. Withdrawal. The overcorrection procedure was withdrawn during this phase and no other experimental manipulations were in effect.
Pharmacological Intervention Monitoring Overcorrection. in this phase.
165
The overcorrection procedure for self-injury was reinstituted
Maintenance. All ward staff were given training with the overcorrection procedure before the maintenance phase was initiated, and each attempt at or instance of self-injury was consequated with overcorrection for 10 seconds. Therapy was conducted by ward staff on an g-hour-per-day basis. Instances of self-injury and consequent use of overcorrection were recorded. During this phase, the subject spent the majority of his time in nonstructured activities. RESULTS
Pharmacological
Intervention
Figure 1 presents the data from the pharmacological intervention phases. The graphs on the left of the figure show the daily means of the number of self-injurious responses per minute recorded during the 13 lo-minute observation sessions. The graphs on the right show the hourly means of the number of self-injurious responses per minute over the whole of each phase. During baseline, the mean daily rate of self-injury was 2.1 responses per minute. The highest rate of self-injury was observed between 11 a.m. and 1 p.m. with the lowest rate between 6 and 7 p.m. The rate increased with the introduction of Tegretol200 mg, bd, to a mean of 3.7 responses per minute although with considerable daily variation. The hourly pattern also changed, with more self-injury now being observed between 9 a.m. and 12 noon. With an increase in daily dosage of Tegretol to 200 mg, tid, the mean daily rate decreased to 3.0 responses but again there were considerable daily variations. The hourly rates show that this was mainly due to reduced self-injury during the mornings, although the morning rates were still somewhat higher than in the afternoon. With a change in medication to Melleril 100 mg, tid, the mean daily rate decreased to 2.0 responses per minute. As seen in Figure 1, there was a clear downward trend in the daily rate over this phase. Self-injury still tended to occur more often in the mornings although the highest rates were noted after 6 p.m. When the daily dosage was halved to 50 mg, tid, the mean daily rate increased to 2.9 responses per minute. There was a gradual but clear upward trend in daily rates across this phase. Again, the rate was higher during the mornings than at any other time, but with no increase at day’s end. Withdrawal of all drugs resulted in a rapid decrease of self-injury to 1.6 responses per minute, although there was an unexplained sharp increase in the daily rate over the last four days of the phase following two days absence
N. N. Singh and A. S. W. Winfon
166
43 2
itXnmrr lo
I
L?!!I
0
I4 Nov
TEGRETOL
7t
20013-q
bd
6 5 4 3 2
sy’
1 I
TEGRETOL
2oomg
b;
-
7
-
6
-
5
-
4
.
3 2 I 0
tid
0
21 Jan
5Ja1
MELLERIL
Ot.Jm 22
Jal311
Mmg
tld
I
4Feb DAYS
TIME
FIGURE 1. The daily means of the number of self-injurious responses in the graphs on the left. The hourly means of the number of self-injurious
Cf
DAY
per minute responses
are shown per minute
Pharmacological Intervention Monitoring
167
L-l 4
3 2
1
m‘
0
SF&
22 Feb
7
LARGACTIL
25mg
tid
LARGACTIL
100mg
tid
6 5 4 3 2 1 $ E
O
23Feb
28Feb
5
8
31 I April
TEGRETDL
7
6
z00rng
tid
t
9 April
2oA$nil DAYS
over daily
the whole of each phase during the first 10.min
are shown in the graphs on the right. of each hour from 8 am to 8 pm.
TIME
DF DAY
Observations
were
scheduled
N, N. Singh and A. S. W. Winton
I68
from the institution. Similar to that shown in the first no-drug phase the mean hourly rate showed less downward trend over the day, although maximal rates occurred around 12 noon. The introduction of Largactil25 mg, tid, resulted in an immediate increase and greater variability in the daily rate. However, there was a sharp reduction in the mean daily rate to 2.4 responses per minute when the dosage was doubled, although there was still considerable variability. The mean hourly rates showed a clear downward trend across the day with small variability about this trend. When the dosage was doubled again to 100 mg, tid, the mean daily rate increased slightly to 2.7 responses per minute and continued to show marked variability. Again the mean hourly rates showed a clear, though less steep, downward trend throughout the day with little variability. Withdrawal of Largactil 100 mg, tid, and the reintroduction of Tegretol 200 mg, tid, resulted in a slight decrease in the mean daily rate to 2.6 responses per minute. The pattern of self-injury across the day was similar to that shown in the last two phases under Largactil except for the very high rate shown at 8 a.m. A comparable high rate early in the morning had been shown when Tegretol was first given, during the second phase. Behavioral
Intervention
Figure 2 shows the rate of self-injurious responses (resp./min) in each of the behavioral intervention phases. During treatment time spent in overcorrection was subtracted from the total observation time before rates were calculated. The maintenance data show the mean rate for each month measured over the eight hours each day. The mean rate of self-injury during the first treatment phase (Tegretol200 mg, tid, plus overcorrection) was 2.9 responses per minute (range = 0.5-5.1). The mean rate decreased to 1.8 responses per minute (range = 0.2-4.8) in the next phase when the medication was withdrawn. However, mean rate during the first half of this phase (2.6 responses per minute) still approximated mean rate of the previous phase. Withdrawal of the overcorrection treatment resulted in an increase in the mean rate to 2.4 responses per minute (range = 1.2-4.7). Reintroduction of overcorrection rapidly decreased the mean rate to 0.3 response per minute (range = 0.0-l .5), with no instances of self-injury being recorded during 8 of the 20 treatment sessions. During maintenance, the total number of selfinjurious responses recorded each successive month was 20, 24, 15, 2, 10, and 7, respectively. DISCUSSION
In general, both pharmacotherapy and behavior modification affected this subject’s behavior; however, with the exception of Melleril 100 mg, tid, only
Pharmacological Intervention Monitoring
FIGURE maintenance.
2.
Number
of self-injurious
responses
per minute
across
experimental
conditions
and
the behavioral intervention systematically decreased his self-injurious behavior. Tegretol was prescribed presumably for its purported psychotropic effects rather than for its anticonvulsant properties. The current data show quite clearly that, when compared to the initial drug-free baseline the rate of selfinjury actually increased during the period when the subject was on Tegretol. Self-injury decreased gradually when Melleril 100 mg, tid, was introduced but when the dosage was halved it gradually increased. It seems that for the present subject the higher dosage was more appropriate for controlling self-injurious behavior. Largactil also failed to reduce the rate of self-injury from that in the second drug-free period. The return to Tegretol in the final drug phase was initially followed by a decrease in self-injury but later in the phase self-injury increased to levels comparable to those shown in the earlier phases under Tegretol. The way the drugs were prescribed during the pharmacological intervention raises difficulties for an unequivocal interpretation of the data on selfinjury. In particular, phase changes occurred after only a few days on some phases (e.g., the initial baseline and the first Tegretol phase) which may not have been sufficient to ensure stability. Furthermore, phase changes were sometimes made when there was a clear trend in the data (e.g., during the two Melleril phases). Of equal importance was that a return to a no-drug baseline occurred only once. This finding is of particular importance with drug interventions where effects from a drug may persist for some time after it is discontinued, and so cause a possible interactive effect with the next drug. When the overcorrection procedure was added in the final drug phase the rate of self-injury showed some overall increase but decreased in a subsequent overcorrection only phase. The present results support previous findings (de Catanzaro & Baldwin, 1978; Singh et al., 1980) that the overcorrection pro-
170
N. N.
Singh
and
A. S. W.
Winton
cedure is effective in treating self-injury. Also, unlike the procedure used in earlier studies, effectiveness was demonstrated when no differential reinforcement contingencies were concurrently used. The present study presents naturalistic observations of the behavioral response of the subject to changes in medication. The data suggest that decisions to change drug prescriptions were often not based on related changes in the target behavior. It may be useful for physicians to require that such data be collected so that changes in the drug regimen can be based on data on the clinically-relevant behavior instead of the global impressions of the ward personnel. The present approach could also be expanded to concurrently monitor other behaviors, both appropriate and inappropriate, to obtain a more detailed assessment of the behavioral effects of any drugs prescribed. AcknowledgementPreparation of this manuscript was supported by Grants HP1805 and #82-591 from the New Zealand Labor Department. We would like to thank Judy Singh, Robin Phillips and Lyonne Dailey for assistance in the preparation of the manuscript.
REFERENCES Aman, M. G., & Singh, N. N. Pharmacological intervention. In J. L. Matson&J. A. Mulick (Eds.), Handbook of menfol rerurdufion. New York: Pergamon Press, 1983. de Catanzaro. D., & Baldwin, G. Effective treatment of self-injurious behavior through a forced arm exercise. American Journal of Mental Deficiency, 1978, 82, 433-439. Foxx, R. M., & Azrin. N. H. The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 1973, 6, l-14. Marholin, D., Touchette, P. E., & Stewart, R. M. Withdrawal of chronic chlorpromazine medication: An experimental analysis. Journal of Applied Behavior Analysis, 1979, 12, 159-171. Singh, N. N., Dawson, M. J., &Gregory, P. R. Self-injury in the profoundly retarded: Clinically significant versus therapeutic control. Journal of Mental De/ciency Research, 1980,24,87-97.
Research in Menrol Rerordarion. in the USA. All rights reserved.
Vol. 5. pp. 161-170.
1984 Copyright
0270-3092/84 0 1984 Pergamon
f3.00+ .oO Press Ltd.
Behavioral Monitoring of Pharmacological Interventions for Self-Injury Nirbhay
N. Singh
University New
of Canterbury Zealand
Alan
S. W. Winton
Massey New
University Zealand
Pharmacological interventions are often the treatment of choice for controlling fhe maladaptive behavior of institutionalized tnentally retarded children. However, the efficacy of various psychotropic drugs for controlling the behavior of given individuals has not been well established. Further, it is not always clear that decisions IO alter a drug regimen are based on actual changes in the behavior of interesr. The present study illustrates the use of behavioral observation to assess the effects of various drugs prescribed for the self-injurious behavior of a profoundly mentally retarded I5 year old male. The clinical effectiveness of various dosages of carbamazepine (Tegretol), thioridazine (Melleril), and chlorpromazine (Largactil) was assessed. Except for Melleril 100 mg. rid, when a marked down ward trend in the daily role was observed, no significani reduction in self-injury occurred. Subsequently overcorrection (forced arm exercise) made contingent on each response reduced self-injury to near zero, but only when the last prescribed drug, Tegretol200 mg, rid. had been withdrawn for several days.
It is well established that a large number of mentally retarded persons receive psychotropic drugs for behavior problems (see Aman & Singh, 1983). However, the clinical efficacy of most psychotropic drugs for controlling the behavior problems of such residents is still subject to much controversy. Clinical decisions concerning medication for behavior problems are usually based
Requests for reprints may be addressed to Nirbhay sity of Canterbury, Christchurch, New Zealand.
161
Singh,
Department
of Psychology,
Univer-
162
N. N. Singh and A. S. W. Winton
on informal global assesments. Prescribing physicians appear to change medication and dosage on the basis of ward reports, informal observations of nursing staff and their own overall judgement. Reliable behavioral data obtained from monitoring the effects of drugs prescribed specifically for behavioral disorders are typically lacking. In the present study the self-injurious behavior of a profoundly mentally retarded boy was monitored while he received drugs to treat the self-injury. Of interest was whether changes in the drug regimen correlated with changes in the behavior being treated. Subsequently, a behavioral treatment was used to eliminate the continuing incidence of self-injury. METHOD
Subject and Setting The subject was a 15year-old, institutionalized, profoundly mentally retarded boy. His weight was 45 kg. The etiology of his retardation was not known. His clinical records indicated a long-standing problem of face-rubbing which resulted in broken facial skin and bleeding. No behavioral programs had been instituted at any time to control his face-rubbing. The subject had been on a 6-month course of haloperidol for self-injury when he was 13 years old. Since then he had been drug free (with the exception of antibiotics) for 18 months. During the pharmacological intervention phases, observations were scheduled in all areas of the subject’s residential ward. During the behavioral intervention phases, observation and treatment sessions were scheduled only in the dayroom of this ward. However, treatment and observations were scheduled throughout the ward during the maintenance phase. Recording
and Definition
Four observers were given extensive individual and group training prior to, and throughout the study. Baseline observations were initiated only when interobserver agreement between randomly assigned partners was consistently above 85% during training. The principal data were collected by one observer, randomly assigned on a daily basis and reliability checks were made by a second observer during some of the sessions. The dependent measure was a frequency count of self-injury. Self-injury was defined as any rubbing of the face by the subject with each up-down or circular motion counting as a separate response. Typically the subject made two or three self-injurious responses at a time.
Pharmacological Intervention Monitoring
163
Reliability During reliability checks a measure of agreement between the two observers was obtained by dividing the two frequencies, the smaller by the larger, and multiplying by 100. During pharmacological treatment, the mean interobserver agreement was 96.8% (range = 87-100%) and during the behavioral intervention, the mean was 93.0% (range = SS-lOOOr0). Pharmacological
Intervention
The prescribing physician and the nurse in-charge of the ward were responsible for the decisions about medication. Neither the experimenter nor the observers were aware of the actual drug, the dosage, or changes in the drug regimen during the intervention. In effect, the intervention constituted an observational study of clinical-decision making on the effects of psychoactive drugs on self-injury. Two physicians were involved in this study; one was the prescribing physician and the other a consultant to the study. Both discussed the study with the experimenter (NNS) and agreed to participate. The prescribing physician was told that while several children under his care would be observed for behavior problems, only one would be the subject of this study. However, with his consent, he was not informed who or from which ward the subject was chosen. The data from the study were discussed with the prescribing physician at the termination of the pharmacological intervention phase, before the behavioral program was instituted. The consultant physician was involved in the study throughout and reviewed the data with the experimenter at weekly intervals. With the exception of the ward charge, all nurses were unaware of the purpose of the study which was discussed with the ward charge, and her approval obtained before the study was initiated. She was not informed which child on her ward would be studied. She was debriefed together with the physician when the pharmacological intervention was terminated. Experimental
Procedure
Drugs were administered throughout either twice a day (bd) or three times a day (tid) except during baseline. The pharmacological intervention consisted of 10 experimental phases conducted over 145 days: (a) baseline (drug free), 5 days; (b) Tegretol 200 mg, bd, 6 days; (c) Tegretol 200 mg, tid, 30 days; (d) Melleril 100 mg, tid, 17 days; (e) Melleril50 mg, tid, 14 days; (f) baseline (drug free), 16 days; (g) Largactil25 mg, tid, 6 days; (h) Largactil50 mg, tid, 8 days; (i) Largactil, 100 mg, tid, 31 days; and (j) Tegretol 200 mg, tid, 12
N. N. Singh and A. S. W. Winton
164
days. The length of each phase was determined by the physician and this depended in part on two things, 1) the global impressions of the ward staff on the effects of medication or lack of, in each phase, and 2) the titration sequence followed for determining the clinically optimal dosage. For example, a shorter duration may have been used for dosages below the optimum if the dosage was being increased. Observations were scheduled daily during the first 10 minutes of each hour from 9 a.m. to 8 p.m. Behavioral
Intervention
At the request of the prescribing physician and the ward charge, a behavioral intervention was initiated while the subject was medicated (Tegretol200 mg/tid). Experimental
Procedure
The behavioral intervention consisted of four experimental phases conducted over 60 consecutive days, followed by a 6-month maintenance phase. The experimental phases were: (a) medication plus overcorrection, 10 days; (b) overcorrection, 20 days; (c) withdrawal, 10 days; and (d) overcorrection, 20 days. Observations were made during daily one hour sessions conducted three hours after breakfast. Medication plus overcorrection. The subject received Tegretol 200 mg, tid, at mealtimes. The behavioral treatment was an adaptation of the Foxx and Azrin (1973) overcorrection procedure which has been used to treat self-injury in mentally retarded persons (de Catanzaro & Baldwin, 1978; Singh, Dawson & Gregory, 1980). The therapist (a ward nurse) was instructed to catch the subject’s wrist just before his fingers made contact with his face, hold his arm straight and fully extended to the side of the subject, and gently “pump” up and down at approximately one up-and-down movement per second. If the subject resisted treatment, his arm was to be held firmly without any movement and the overcorrection procedure implemented once he was calm. Each attempt at or instance of self-injury resulted in the overcorrection procedure being carried out for 10 seconds (i.e., 10 up and down arm movements). Overcorrection. In this phase, only overcorrection was used. The subject was off medication during this and subsequent phases. Withdrawal. The overcorrection procedure was withdrawn during this phase and no other experimental manipulations were in effect.
Pharmacological Intervention Monitoring Overcorrection. in this phase.
165
The overcorrection procedure for self-injury was reinstituted
Maintenance. All ward staff were given training with the overcorrection procedure before the maintenance phase was initiated, and each attempt at or instance of self-injury was consequated with overcorrection for 10 seconds. Therapy was conducted by ward staff on an g-hour-per-day basis. Instances of self-injury and consequent use of overcorrection were recorded. During this phase, the subject spent the majority of his time in nonstructured activities. RESULTS
Pharmacological
Intervention
Figure 1 presents the data from the pharmacological intervention phases. The graphs on the left of the figure show the daily means of the number of self-injurious responses per minute recorded during the 13 lo-minute observation sessions. The graphs on the right show the hourly means of the number of self-injurious responses per minute over the whole of each phase. During baseline, the mean daily rate of self-injury was 2.1 responses per minute. The highest rate of self-injury was observed between 11 a.m. and 1 p.m. with the lowest rate between 6 and 7 p.m. The rate increased with the introduction of Tegretol200 mg, bd, to a mean of 3.7 responses per minute although with considerable daily variation. The hourly pattern also changed, with more self-injury now being observed between 9 a.m. and 12 noon. With an increase in daily dosage of Tegretol to 200 mg, tid, the mean daily rate decreased to 3.0 responses but again there were considerable daily variations. The hourly rates show that this was mainly due to reduced self-injury during the mornings, although the morning rates were still somewhat higher than in the afternoon. With a change in medication to Melleril 100 mg, tid, the mean daily rate decreased to 2.0 responses per minute. As seen in Figure 1, there was a clear downward trend in the daily rate over this phase. Self-injury still tended to occur more often in the mornings although the highest rates were noted after 6 p.m. When the daily dosage was halved to 50 mg, tid, the mean daily rate increased to 2.9 responses per minute. There was a gradual but clear upward trend in daily rates across this phase. Again, the rate was higher during the mornings than at any other time, but with no increase at day’s end. Withdrawal of all drugs resulted in a rapid decrease of self-injury to 1.6 responses per minute, although there was an unexplained sharp increase in the daily rate over the last four days of the phase following two days absence
N. N. Singh and A. S. W. Winfon
166
43 2
itXnmrr lo
I
L?!!I
0
I4 Nov
TEGRETOL
7t
20013-q
bd
6 5 4 3 2
sy’
1 I
TEGRETOL
2oomg
b;
-
7
-
6
-
5
-
4
.
3 2 I 0
tid
0
21 Jan
5Ja1
MELLERIL
Ot.Jm 22
Jal311
Mmg
tld
I
4Feb DAYS
TIME
FIGURE 1. The daily means of the number of self-injurious responses in the graphs on the left. The hourly means of the number of self-injurious
Cf
DAY
per minute responses
are shown per minute
Pharmacological Intervention Monitoring
167
L-l 4
3 2
1
m‘
0
SF&
22 Feb
7
LARGACTIL
25mg
tid
LARGACTIL
100mg
tid
6 5 4 3 2 1 $ E
O
23Feb
28Feb
5
8
31 I April
TEGRETDL
7
6
z00rng
tid
t
9 April
2oA$nil DAYS
over daily
the whole of each phase during the first 10.min
are shown in the graphs on the right. of each hour from 8 am to 8 pm.
TIME
DF DAY
Observations
were
scheduled
N, N. Singh and A. S. W. Winton
I68
from the institution. Similar to that shown in the first no-drug phase the mean hourly rate showed less downward trend over the day, although maximal rates occurred around 12 noon. The introduction of Largactil25 mg, tid, resulted in an immediate increase and greater variability in the daily rate. However, there was a sharp reduction in the mean daily rate to 2.4 responses per minute when the dosage was doubled, although there was still considerable variability. The mean hourly rates showed a clear downward trend across the day with small variability about this trend. When the dosage was doubled again to 100 mg, tid, the mean daily rate increased slightly to 2.7 responses per minute and continued to show marked variability. Again the mean hourly rates showed a clear, though less steep, downward trend throughout the day with little variability. Withdrawal of Largactil 100 mg, tid, and the reintroduction of Tegretol 200 mg, tid, resulted in a slight decrease in the mean daily rate to 2.6 responses per minute. The pattern of self-injury across the day was similar to that shown in the last two phases under Largactil except for the very high rate shown at 8 a.m. A comparable high rate early in the morning had been shown when Tegretol was first given, during the second phase. Behavioral
Intervention
Figure 2 shows the rate of self-injurious responses (resp./min) in each of the behavioral intervention phases. During treatment time spent in overcorrection was subtracted from the total observation time before rates were calculated. The maintenance data show the mean rate for each month measured over the eight hours each day. The mean rate of self-injury during the first treatment phase (Tegretol200 mg, tid, plus overcorrection) was 2.9 responses per minute (range = 0.5-5.1). The mean rate decreased to 1.8 responses per minute (range = 0.2-4.8) in the next phase when the medication was withdrawn. However, mean rate during the first half of this phase (2.6 responses per minute) still approximated mean rate of the previous phase. Withdrawal of the overcorrection treatment resulted in an increase in the mean rate to 2.4 responses per minute (range = 1.2-4.7). Reintroduction of overcorrection rapidly decreased the mean rate to 0.3 response per minute (range = 0.0-l .5), with no instances of self-injury being recorded during 8 of the 20 treatment sessions. During maintenance, the total number of selfinjurious responses recorded each successive month was 20, 24, 15, 2, 10, and 7, respectively. DISCUSSION
In general, both pharmacotherapy and behavior modification affected this subject’s behavior; however, with the exception of Melleril 100 mg, tid, only
Pharmacological Intervention Monitoring
FIGURE maintenance.
2.
Number
of self-injurious
responses
per minute
across
experimental
conditions
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the behavioral intervention systematically decreased his self-injurious behavior. Tegretol was prescribed presumably for its purported psychotropic effects rather than for its anticonvulsant properties. The current data show quite clearly that, when compared to the initial drug-free baseline the rate of selfinjury actually increased during the period when the subject was on Tegretol. Self-injury decreased gradually when Melleril 100 mg, tid, was introduced but when the dosage was halved it gradually increased. It seems that for the present subject the higher dosage was more appropriate for controlling self-injurious behavior. Largactil also failed to reduce the rate of self-injury from that in the second drug-free period. The return to Tegretol in the final drug phase was initially followed by a decrease in self-injury but later in the phase self-injury increased to levels comparable to those shown in the earlier phases under Tegretol. The way the drugs were prescribed during the pharmacological intervention raises difficulties for an unequivocal interpretation of the data on selfinjury. In particular, phase changes occurred after only a few days on some phases (e.g., the initial baseline and the first Tegretol phase) which may not have been sufficient to ensure stability. Furthermore, phase changes were sometimes made when there was a clear trend in the data (e.g., during the two Melleril phases). Of equal importance was that a return to a no-drug baseline occurred only once. This finding is of particular importance with drug interventions where effects from a drug may persist for some time after it is discontinued, and so cause a possible interactive effect with the next drug. When the overcorrection procedure was added in the final drug phase the rate of self-injury showed some overall increase but decreased in a subsequent overcorrection only phase. The present results support previous findings (de Catanzaro & Baldwin, 1978; Singh et al., 1980) that the overcorrection pro-
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cedure is effective in treating self-injury. Also, unlike the procedure used in earlier studies, effectiveness was demonstrated when no differential reinforcement contingencies were concurrently used. The present study presents naturalistic observations of the behavioral response of the subject to changes in medication. The data suggest that decisions to change drug prescriptions were often not based on related changes in the target behavior. It may be useful for physicians to require that such data be collected so that changes in the drug regimen can be based on data on the clinically-relevant behavior instead of the global impressions of the ward personnel. The present approach could also be expanded to concurrently monitor other behaviors, both appropriate and inappropriate, to obtain a more detailed assessment of the behavioral effects of any drugs prescribed. AcknowledgementPreparation of this manuscript was supported by Grants HP1805 and #82-591 from the New Zealand Labor Department. We would like to thank Judy Singh, Robin Phillips and Lyonne Dailey for assistance in the preparation of the manuscript.
REFERENCES Aman, M. G., & Singh, N. N. Pharmacological intervention. In J. L. Matson&J. A. Mulick (Eds.), Handbook of menfol rerurdufion. New York: Pergamon Press, 1983. de Catanzaro. D., & Baldwin, G. Effective treatment of self-injurious behavior through a forced arm exercise. American Journal of Mental Deficiency, 1978, 82, 433-439. Foxx, R. M., & Azrin. N. H. The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 1973, 6, l-14. Marholin, D., Touchette, P. E., & Stewart, R. M. Withdrawal of chronic chlorpromazine medication: An experimental analysis. Journal of Applied Behavior Analysis, 1979, 12, 159-171. Singh, N. N., Dawson, M. J., &Gregory, P. R. Self-injury in the profoundly retarded: Clinically significant versus therapeutic control. Journal of Mental De/ciency Research, 1980,24,87-97.