EverNotes from a Radical Behaviorist on Judge Rotenberg Center

JRC is a special needs school in Canton, Massachusetts serving ages 3-adult. For 41 years JRC has provided very effective education and treatment to both emotionally disturbed students with conduct, behavior, emotional, and/or psychiatric problems and developmentally delayed students with autistic-like behaviors. Read more to hear about Dr. Malott's recent visit!

1)    The scene at JRC is absolutely amazing, in a very positive sense, and along many dimensions. If you haven't been here, you have no idea. Will talk about a few of their residents, people with problems even most of us BCBAs will have no idea about. 

2)    One  resident just celebrated his 50th birthday, been at JRC 29 years. For him, by far the best game in town.

3)    Fifty-five kids read the book, Basketball Junkie. Then the author gave a talk to them. He received a big check from JRC for his presentation. He said, "Thanks, but I can't take this. Use it to do something for the kids," and then handed it back to Glenda, the CEO.

4)    One woman, back in the day, pulled out all of her own hair, one of the first to receive contingent shock.

5)    Back in the day, a 55 pound guy, bit off his tongue, came to JRC. He's the guy who for whom the shock device was developed. Also a big-time vomiter. He's still at JRC, still needs the contingent shock; when the shock pack is removed, he starts destroying himself. For this fellow to be in a traditional psychiatric facility, it would cost $500,000 to $1,000,000 per year, as opposed to $250,000 per year at JRC, which isn't a small amount, but this is a much bigger deal than the $125,000 per year for a 4-year-old, 40 hr/week, non-residential kid with autism. 

6)    One of their graduates from last year is now at U. Mass, Dartmouth, with a 3.7 GPA. He went there, rather than back to the hood, because he was afraid he'd fall off the cool behavior wagon. Now wants to work a few hours a week at JRC, while going to college.

7)    Quite a few of their alumni came in with such violent behavior that they had to use shock punishment, got it eliminated, graduated, and are now in the real world doing well.   

8)    But the message we all need to be tuned into, whether it's for our 5-year-old kid with autism, or the 20-year-old kid who no longer has life-threatening behavior, we need to provide an external monitoring and support system once they leave our intense, behavioral interventions. Otherwise, the odds are too high that things will fall apart.  

9)    Clinical Meeting: Case Studies

a)    Tough Case: Boy here since September. He had attacked his mother and ripped out a large portion of her hair, while she was driving, because he didn't want to go there. 18 years old. Autism & DD. Epileptic seizures. Had high-quality early intensive behavioral intervention services. On a fair number of meds until December at JRC, where the anti-psychotics have been eliminated. Now he can go a couple weeks without aggression, but he'll occasionally have a dozen instances of aggression in one hour, including a couple times, pulling out staff members' hair. His aggression doesn't have any obvious antecedents. 

i)      He came in with a "PECS" system with 100's of icons, which meant nothing to him. Now they're working on getting a 5-icon traditional PECS system to work. Only has a couple vocal words. 

c)    Not An Easy Case: 20-year-old girl who's been at JRC for 8 years, after multiple hospitalizations, and multiplle settings. Now, moderate MR and schizophrenia. Contingent shock pretty much eliminated her aggression, but  returned to around 1000 episodes/month, for six years, after they've been required to remove the shock punishment. Then a combination of an antipsychotic with highly structured behavioral interventions, has brought her aggression back down to around 10/month.

d)    Teenage boy. Severe MR, autism, etc. Non-verbal. Sever self-injury. Aggression and self-injury. When the contingent shock is removed, the behaviors increase from 10 to 100 per week. So the punishment contingency is now back in place and still used almost daily, but it helps a lot, decreasing the dangerous behavior to clinically significant lower level. Without the shock pack, it takes 3-4 staff to restrain him from his dangerous behavior. 

i)      Unfortunately, the staff currently need to be directly supervised by a liscenced professional to deliver the shock, which requires at least 15-60 seconds; longer than 60 seconds, they don't do it. If the shock could be immediate, they might be able to drop it down to 0 per week.  

f)     Male. Older teen. Average IQ. Highly verbal. Been in many institutions prior to JRC, of course. At JRC about 3 years. Biting the face and nose of staff. Also serious self-injury. Naked, barking like a dog. Sent several staff to the hospital. One of the most violent clients they've had. 2 to 1 staffing. Drugs didn't help. A lot of performance contracts. The drug, abilify, only when combined with  behavioral intervention seems to be helping a lot, and now he's studying for his regents exam. (Abilify in the absence of the performance management didn't work, and more or less vise versa.) He asked to be put back on a tighter performance contracting system. His aggressive behaviors have been eliminated. Now he has peer relations for the first time. 

 i)      (They only have a half dozen cases out of 230 where that are being maintained on psychotropic drugs.)

h)    Teenage boy. Bright, very verbal guy. At JRC for 3 years. Psych hospitals couldn't handle him. Violent behavior from 100 to 1000 per week.  Aggression: hitting, biting, stabbing with a pen, etc. Destroying property. Stores metal like screws in his mouth, threatening to swallow them, which then produces a lot of attention, but they don't want to risk his swallowing the metal. He can go a couple weeks with no aggression, and then do up to 500/day. He's very much into socials, like attention, with which they may do a DRO.  

i)      Man, mid-twenties, very verbal, all sorts of psychiatric labels, MR, before he came in. At JRC about 4 years. Aggression causing injury. Isolatied, anti-social. Phased out his high levels of psychiatric drugs, down to two. Going from 100 violent behaviors (e.g., scratching people's faces) per month to only one violent behavior in last 13 months.  Now he has a lot of friends and even flirts a little.

 i)      He is Haitian, but he hates Haitians; they're working on that.

k)    Male, 17. Average intellectual skills. Aggression, health dangerous behaviors, disruption. Alternates between several weeks with no aggressions to 100 per  day. Another guy who puts dangerous objects in his mouth, reinforced by attention and bargaining, though only a few times per year. Threatening to swallow, but never has. They've been using extinction. Got his major behavior problems from around 1,000 per week, down to around 100, sometimes several weeks at zero, but not out of the woods. Takes 7 grown men to control him when he becomes aggressive, which may hurt the staff, and thus challenges the integrity of the interventions; this may be why the aggressions don't stay at zero. He's a biter, and a computer thrower. He lives in the group home that's staffed with high-crisis staffing, guys who know how to handle it. They use their level system, from 1 to 13, with level 1 being essentially no privileges to 13 being almost continuous party time in the community, contingent on a high frequency of positive behaviors and a low frequency of negative behaviors. A joy to be around when he's cool; otherwise a terror. 

l)      Male, almost 30, mild DD but very verbal. 2.5 years at JRC, banned from the city, 3 assault and battery criminal cases, been to many institutions. Major problems are aggression and health dangerous behaviors. JRC emoted has most of his psychiatric meds since JRC.  Most restraints would take 6 to 10 people. But when he was restrained he would get into heavy head banging. Problem behavior started when he was around 12. Eventually, his problem behaviors abruptly fell from, maxing at 100 per week to 0 per week. He got a girl friend, about the time he got his violence under control. Not sure what caused what. He went from 2 to 1 staffing to going for a job in the community in the summer. 

i)      (Interruption: Someone just yelled, "Help in room E," and immediately 7 clinical staff ran from our meeting room to room E. Wow! False alarm, and they were back in our meeting in two minutes.) 

n)    Male, early twenties, at JRC about 8 years, non-verbal, autism, MR moderate to severe. Been on many meds. Seizure disorder (which is not unusual here). Behaviors, biting himself and others. Even when the staff wear heavy arm guards, he can seriously bruise up and down a staff member's arm. Even when he's having fun, he may become non-compliant and then dangerously aggressive. With electric shock punishment, dangerous behaviors fell from 5000/ month to 50 /month. But when they were no longer allowed to use shock punishment, the dangerous behavior returned to baseline. During the punishment contingency, he was a happy boy, making big academic progress, and then all regressed, when the punishment contingency was removed.  Planned intervention involves getting hyper-safe cloths on both the client and the staff, and then training him with various triggering events, using heavy reinforcement for violating the dead-man test (i.e. not aggressing), in other words punishment by the prevention of presentation of powerful reinforcers. 

 i)      (Incidentally, some of the clients prefer to have the shock pack on because it will prevent them from hurting themselves. One girl would hit herself in the head as a mand to force the staff to put the shock pack back on.)

11) Amazing scene--amazing problems, amazing successes. Nothing's easy.

12) Full disclosure: I'm honored to be a member of the JRC board.