February 15, 2005

COMMONWEALTH OF MASSACHUSETTS

BRISTOL, SS PROBATE AND FAMILY

COURT DEPARTMENT

DOCKET NO.

IN RE:

) PROPOSED

) BEHAVIOR

) MODIFICATION

JOHN SMITH ) TREATMENT PLAN

)

I. PERSONAL INFORMATION

John Smith is a 16-year-old young man from Bronx, New York, who is the second of four children. He was born on January 5, 1988. His legal guardian is his grandmother, Jane Smith. John has a long history of aggressive, health dangerous, oppositional, disruptive, destructive and impulsive behaviors. John was admitted to the Judge Rotenberg Educational Center (JRC) on June 15, 2004.

II. HISTORY OF PRIOR PLACEMENTS AND TREATMENTS

The following information was taken from John’s admission packet. John was adopted in early infancy by his mother. His biological mother has been incarcerated for the past twelve years (scheduled for release next year) due to drug related charges. He has visited with her on a regular basis until just recently when she was moved to a facility in upstate New York. John does not have contact with his biological father. There is little information available regarding his birth and development, however, a psychiatric evaluation conducted in 1999 suggests that developmental milestones were delayed. John has been receiving full-time special education services since pre-school for his behavioral difficulties. There is a significant history of behavior difficulty within the family.

John has a long standing history of aggressive behavior toward others and has been hospitalized numerous times due to his severe behaviors. He has a history of fire setting (in 1997 he set his bed and his clothing on fire), physical/verbal aggression, and indecent exposure. In addition, it was reported that he was the victim of sexual abuse by a peer. In 1998 he was hospitalized because of his agitated, aggressive, self abusive behavior, as well as suicidal ideation, and complaints of hearing a “constant buzzing”. In 2002, during an aggressive incident with his sister, he attempted to assault her with a knife. In the later part of that same year he was reported to have been involved in multiple fights at school. Ms. Smith reported that John was displaying violent behavior in the home. In August of 2003, he cursed and pushed his residential habilitation worker and had also become physically assaultive on the school bus.

In October of 2003, John was hospitalized for violent behavior after refusing to take his prescribed medication. Shortly after he was discharged, he was re-hospitalized following threats toward his grandfather with a knife. In December of 2003, it was noted that his behavior was deteriorating. He was observed masturbating at inappropriate times/places. He was banned from a local store for masturbating in the women’s bathroom. In addition, records indicate that John would masturbate in school (in the classroom), and once urinated on the floor in his classroom (in front of a female teacher). Later that month he assaulted his residential habilitation worker after the worker attempted to stop him from fighting with a family member. In January of 2004, John was arrested after stabbing his cousin in the wrist with a knife following an altercation. He was later released. In February of 2004, he was taken to a psychiatric emergency room following an aggressive episode toward his family members. During his physical assault, he obtained a serving fork and began threatening them with it.

John is described as being belligerent toward authority figures and tends to curse and make verbal threats toward them. He often refuses to go to school and his grandmother is unable to get him to attend because of his oppositional behavior. An increase in his aggressive, oppositional and volatile behavior has been noted during the 2003-2004 school year. Although he has been attending outpatient treatment through the Association for the Help of Retarded Children since 1999, it has not been successful in reducing the intensity or frequency of his behavior. His aggressive behavior towards others can be extremely dangerous in nature. John often acts in an unpredictable manner and although appears calm, he may be preparing to retaliate. It was noted that in January of 2004, John had a verbal/physical altercation with his cousin. After the situation had been brought under control and he had calmed down, he went to the kitchen to retrieve a knife and used it to cut his cousin’s wrist. John’s record indicates that “conduct disordered difficulties can be traced back for numerous years but have recently increased in frequency.”

School reports indicate significant behavioral difficulties including fights with peers, verbal threats, cursing, tantrums, and non-compliant behavior. Documentation states that when John would attend school he would often sleep in class resulting in little or no academic progress. Currently, he is failing all of his subjects. Teachers state that John will often tease and antagonize his peers in school. It is also noted that he would argue and refuse to be cooperative with his teachers. His aggressive behaviors were often directed toward his peers at school, however, on one occasion, he threw his calculator at his teacher. At home, Ms. Smith indicates that he does not interact with anyone in the household and tends to isolate himself. She states that he does not like his brother or his sister, and often fights with them. A psychiatric evaluation included in John’s admission record notes a history of abuse at the hands of his brother (brother urinated in John’s mouth). Ms. Smith feels that John is in need of a highly structured residential treatment facility, as his current educational setting, medication, and psychiatric treatment are not meeting his needs.

In the past, John has been treated with psychotropic medications such as Strattera, Risperdal, Ritalin, and Abilify, all of which have been unable to address his behavioral difficulties. Admission records indicate a history of febrile seizures, however, there is no documentation suggesting any current or former medical treatment.

John was administered the Wechsler Abbreviated Scale of Intelligence (WASI) on May 13, 2004. He obtained a Verbal IQ of 64, Performance IQ of 64 and Full Scale IQ of 61. These scores suggest evidence of significant deficits in cognitive functioning relative to John’s same-aged peers. John’s current IEP states that his cognitive and behavioral needs cannot be affectively addressed in a general education setting and that a 24 hour setting is required to address his needs.

III. DIAGNOSIS

By history, John has been diagnosed with Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Psychotic Disorder (Not Otherwise Specified), Dysthymic Disorder, and Mild Mental Retardation. After careful review of John’s records, input from his guardians, review of behavioral charts, and direct behavioral observation, and based on DSM IV criteria, the most appropriate diagnoses for John at present are Conduct Disorder, Childhood Onset, Dysthymic Disorder and Mild Mental Retardation.

IV. GENERAL STATEMENT OF THE TREATMENT APPROACH

The Judge Rotenberg Educational Center, Inc. ("JRC") is a school that offers education at all levels K through 12, and College (Post Graduate), along with a comprehensive behavioral program that treats behavior disorders. The goal is to decrease the frequency and intensity of the behavior problems so that the students may reach their potential within the social and educational opportunities offered by JRC, including enrollment in educational, social and employment settings within the vicinity of JRC. The typical JRC student is admitted to JRC after having been discharged and/or expelled from a treatment facility or school because of an uncontrollable behavior disorder ranging from refusing to cooperate with the program, up to life-threatening health dangerous or aggressive behavior. The typical JRC student has parents who have never been able to care for or manage the student at home, and who have been intimately involved with moving the student into and out of unsuccessful placements in an attempt to find a suitable and effective treatment for their child. Usually, the JRC student’s behavior disorder has prevented or extremely impaired the student’s ability to interact with or even spend any significant amount of time with his parents and family.

V. IDENTIFICATION OF PROBLEM BEHAVIORS

Below is a list of the problem behaviors that John presently exhibits, has exhibited in the past, or is reasonably likely to exhibit based on his history. Each category of behaviors is listed, together with example topographies. Each topography may include incipient versions of the behavior, shaped-down versions of the behavior, antecedents to the behavior, and attempts to execute the behavior. The behavior topographies are subject to change; those, which presently exist, may be extinguished and/or new problem behaviors may emerge.

With the approval of the attending clinician or educator, with the necessary qualifications to oversee a behavioral treatment program, existing topographies may be shifted from one behavior category to another, which may result in changes in treatment procedures. Should new topographies emerge, these may be treated with the categories of procedures that have been authorized by the Court, provided that such new topographies are identified by the assigned attending clinician. These changes shall be described by the attending clinician (with reference to the behavioral analysis data, where clinically appropriate) in the 120-day progress report concerning John. The progress report shall be forwarded to the Court, the Court Monitor, and counsel for John.

A. Definitions of Behaviors to Decelerate

John’s problematic behaviors include Aggressive, Health Dangerous, Destructive, Major Disruptive, Non-Compliant, Educationally/Socially Interfering and Inappropriate Verbal behaviors.

John’s Aggressive Behavior consists of physical aggression towards others (to include attempts), punch others, headbutt others, bite others, verbal threats to aggress, possession of potential weapons (i.e. sharp or heavy, blunt objects), spit at others, out of seat without permission (to exclude a rewarding setting, BRS, ERS, CRS, All Purpose Room), out of bed without permission (to exclude to use the bathroom).

John’s Health Dangerous Behavior consists of attempts to harm self, verbal threats to harm self, leave supervised area, attempts to run away, verbal threats to run away, take off seat belt while in transport.

John’s Destroying Behavior consists of property destruction (to include attempts), verbal threats to destroy, bang objects, throw objects, possession of any fire setting materials.

John’s Major Disruptive Behavior consists of swear (to exclude “hell” and “damn”), yell, scream, racial comments, sexual comments and/or gestures, steal, inappropriate urination or defecation, masturbate at inappropriate times, expose self (not to include in the bathroom taking self-care).

John’s Noncompliance Behavior consists of refuse to follow staff direction, blatant NO, attempt to remove restraints, attempt to remove/tamper with/destroy GED devices or electrodes.

John’s Educationally/Socially Interfering Behavior consists of stop work, personal space violation, mimic others, rude gestures, non-functional body movements, stare at others for move than 5 seconds, failure to follow student rules, refuse to do academics.

John’s Inappropriate Verbal Behavior consists of talkout, noises, interrupt others, nag, negative/rude comments, not minding own business, laugh at inappropriate times, argue with staff/students, use of slang, tease others.

B. Measurement

John’s problem behavior categories will be measured by daily frequency counts over a 24-hour period. These frequencies may be displayed graphically on daily, weekly and monthly Standard Behavior Charts.

C. Current Data (Behavior Frequency Totals: 7/30/04 – 1/29/05)

Totals

Aggressive Behavior 258

Health Dangerous Behavior 25

Destroying Behavior 130

Major Disruptive Behavior 629

Non-Compliance Behavior 546

Educationally/Socially Interfering Behavior 415

Inappropriate Verbal Behavior 3,509

VI. IDENTIFICATION OF POSITIVE BEHAVIORS

Below are the positive behaviors that JRC has identified as appropriate replacement or alternative behaviors for John. They will be rewarded with social praise, tokens, points, and/or other rewards as part of a reward system. This is not an exhaustive list, and it would be impossible to list and target every possible alternative positive behavior in a treatment plan. These behaviors are subject to change based on his progress and needs at a particular time. With the approval of the attending clinician or educator, existing behaviors may be dropped and new behaviors may be added.

Academic task completion

Passing transport contracts

Passing less-than-a-day contracts

Passing multi-day contracts

Participation in social events on school premises

Appropriate social exchanges/communication skills

Measurement — Most of the items in the above list are tallied by frequency or other appropriate recording method on the Daily Recording Sheet or Academic Recording Sheet. They are later entered into the JRC database kept by the charting department. The ones that are placed in the database may also be charted on daily Standard Behavior Charts.

VII. FUNCTIONAL ANALYSIS INFORMATION

Based on observations of John, a review of his records, and consultation with JRC treatment staff, and discussions with John’s grandmother, JRC has determined the functions of John’s behaviors to be the following:

Escape — In all of John’s five major inappropriate behavior categories (aggressive, destructive, health dangerous, major disruptive and non-compliant behaviors) escape from demands plays a part. John rebels against those trying to provide needed educational structure or anyone who tries to set limits on him. Such inappropriate behaviors are maintained by negative reinforcement contingencies involving escape from or postponement of less preferred tasks, including participating in his academic curriculum. For example, when asked to sit quietly and work on academic tasks, John has been observed by JRC staff to refuse to work (Noncompliance). Limit-setting regarding noncompliance often results in John exhibiting disruptive yelling or swearing, threats of aggression or attempting to destroy property. When John is physically prompted by staff members (which is often necessary, particularly at times of transition/transport), John has resisted, and escalated into aggression in order to attempt to escape this constraint on his behavior.

Social Attention – John will also exhibit inappropriate behaviors in order to manipulate, annoy, or get exasperated reactions from authority figures. He is reinforced by being openly defiant and eliciting frustrated reactions from staff. It is likely that a portion of John’s inappropriate behaviors are maintained by social approval from peers, as well as representing counter-control of adults who attempt to educate him or set limits. Other sources of social attention include John himself as both speaker and listener. When he makes exaggerated or false statements about other persons, this may provide a personal (inner) source of social reinforcement for his own verbal behavior that has been observed to occur in the absence of apparent extrinsic social contingencies.

From a stimulus control perspective, situations most likely to escalate into physical aggression and extremely disruptive behavior are when firm limits are set for exhibition of less intense inappropriate behavior (i.e. losing access to rewards for refusing to complete academics, or physical prompting by staff members in order to complete a necessary task or to move about the school or residence). John’s outbursts tend to be preceded by a period of noncompliant behavior, and appear to serve the primary function of attempting to defeat consequences and restrictions placed on his behavior.

In general, reward systems and specific rewards are selected in order to provide a strong incentive for John to withhold problematic behaviors, and exhibit appropriate behavior and cooperation with teaching efforts. His overall program components have been selected so that he: earns breaks from reasonable demands through cooperative task performance; receives token money for task and chore completion; does not escape demands through problem behaviors; receives a high rate of positive social attention and interaction with staff for good behavior and following directions; is allowed to make choices and have his way within reason and within the structure of the program; and earns reinforcement for proper social behaviors and cooperating with the educational, vocational and residential routines. Reinforcers have been selected in a way that maximizes the probability that they will be more powerful than what he gets from the problem behaviors.

The selection of aversive consequences presented in this plan was based on the fact that they have a reasonable likelihood of functioning as effective decelerators for John. Aversive consequences actually used to decelerate problem behaviors will be selected from those available in this plan, and the behavioral response to them will be monitored through daily charting to assure that they are functioning as decelerative consequences.

VIII. PROGRAM DESCRIPTION AND OBJECTIVES OF TREATMENT

A. General Statement of the Treatment Approach

Upon admission, JRC’s educational, psychological, and medical staff examined John, and a review of his records was done to determine his cognitive and functional abilities. JRC also examined John for the purposes of determining the rewards that would motivate him, and the consequences that might deter him from engaging in his problematic behaviors. JRC then designed a behavioral program using the rewards that have been identified to make “contracts” with John, which allow him to earn the rewards by not engaging in problematic behavior for specific periods of time. The goal is to decrease problematic behaviors by 100 % so John can experience the enjoyment of succeeding in educational, vocational, and social challenges, with the intended result that John engages in these instead of in the problematic behaviors of the past. As John’s problematic behaviors reduce in frequency and intensity, he will be able to earn a more extensive menu of rewards such as opportunities to purchase preferred items and weekly field day participation. The substitution of educational and social endeavors for the prior problematic behaviors will give John the opportunity to reach increasingly challenging goals, receive an education appropriate to his needs, and spend more time with family and friends

B. Consideration of Alternative Treatment Approaches

It is the opinion of the JRC clinical staff that a consistent behavioral approach would be the most effective form of treatment for John. The use of psychotropic medications in the past (Risperdal, Abilify, Ritalin and Strattera) did not successfully treat John’s inappropriate behaviors. While psychotropic medications may reduce the intensity of John’s agitation and the severity of his outbursts, they not only have not reduced his dangerous behaviors to an acceptable level, they are incapable of “un-learning” the functional relationships John has established between his inappropriate behavior and the reinforcements he is able to obtain through their exhibition. In addition, medications also have a strong potential for permanent negative side effects. Tardive dyskinesia is just one example of the permanent effects possible from long-term antipsychotic medication usage.

Due to John’s level of intellectual functioning he would not be a candidate for psychotherapy. John does not have the empathic capacity to see things from another person’s point of view, nor does he have the mental capacity for the kind of verbal reasoning, symbolic thinking, and drawing of analogies required in persons in order to benefit from psychotherapy. In addition, it is JRC’s position that traditional, non-behavioral psychotherapy is fundamentally inconsistent with a treatment program based on Skinnerian behaviorism, and that any verbally-mediated therapy or counseling that is provided to its students should be in the form of behavioral counseling or behavior therapy provided by JRC’s clinicians and other staff.

At this point in time a consistent behavioral approach offers John the most effective, least restrictive treatment alternative. Medications, counseling/psychotherapy, psychiatric hospitalizations, and non-intrusive behavior modification have proven to be insufficient for adequately treating John’s behavior disorder. A behavioral program, rich in positive reinforcers, together with a punishment component to rapidly decelerate inappropriate behaviors, produces no serious negative side effects. Due to John’s inappropriate behavior, JRC needed to apply for a mechanical restraint waiver from DMR to include other types of restraints to keep him and others safe.

IX. DESCRIPTIONS OF TREATMENT/EDUCATION PROGRAM

A. Educational Programming. JRC provides a complete educational/vocational program to John, focusing our objectives on what is decided in his annual IEP meeting. Specifically, these objectives will include teaching appropriate new skills that will serve to replace targeted inappropriate behaviors. Among these are residential and vocational skills selected to match his abilities. John will also participate in physical education classes and work on social integration skills by making trips into the community.

B. Behavioral Treatment Interventions. JRC provides a comprehensive behavioral treatment for the inappropriate behaviors, which John exhibits. In addition to the emphasis on educative procedures to teach new skills to replace targeted inappropriate behaviors, JRC has specifically arranged a comprehensive system of rewards for John, contingent on good behavior and academic performance. Rewards are administered as contracts are passed and as positive behaviors occur. If a particular problem behavior is treated with a particular aversive consequence, the consequence is administered contingent on the particular behavior. The reward procedures for John, which are described below, are subject to change. Certain procedures may be modified, discontinued, or applied to different treatment objectives. In addition, new reward procedures may be added.

1. Momentary DRO (DMR Level I) — John is rewarded when he is not showing one of his targeted behaviors. The reward consists of one or more of points, tokens, a smile, verbal praise, physical contact (such as a pat on the back, touch on the arm, or high five) or other reward. Points or tokens may be spent in a number of different ways, including in Classroom Reward Store, Big Reward Store, Contract Store, for field trips/outings, access to games, and supergoodies in accordance with John’s preference.

2. DRO Contracts — If John does not exhibit certain targeted behaviors for a specified length of time, he earns specific rewards. The amount and duration of these contracts and the behaviors targeted by them are subject to change, depending on his progress in the program. (DMR Level I; DMR Level III if contract involves staple food)

a) Less than a day Contract: No educationally and socially interfering behavior and no inappropriate verbal behavior for one hour earns a 15 minute break with a preferred reward activity. If John passes two consecutive LTD contracts, he earns a 50 calorie snack reward.

b) Multi-Day Contract: No aggressive, destructive, health dangerous, major disruptive, or noncompliant behaviors for 24 hours (2pm to 2pm) earns 250 points, 30 minutes of leisure time in Big Reward Store, and a vending machine reward.

c) Transport Contract: No aggressive, destructive, health dangerous, major disruptive or noncompliant behaviors during transport to and from the school building earns points and a 30 minute break upon arrival at the destination.

d) Overnight Contract: No aggressive, destructive, health dangerous, major disruptive, or noncompliant behaviors during the overnight hours, and completion of morning routine, earns points and leisure time until departure from the residence.

3. Rewards — JRC’s clinical staff have identified the following items as rewards for John and will endeavor to make them available to him contingent upon his appropriate behavior: This is not meant to be an exhaustive list, and staff are always looking for new and more effective rewards. Rewards for the student vary from student to student.

CD’s/Music Phone calls Sports

Breaks Leisure Time Riding bikes

Books TV/movies Snacks

4. When behavior problems warrant, JRC has arranged for certain procedures to be used with John when he exhibits one of the problem behaviors listed in section V of this treatment plan. The procedures that we have selected for availability in John’s treatment are the following:

a) Movement Limitation: (DMR Level III) Either of two forms of movement limitation might be used for treatment purposes for John: (1) movement limitation which is applied manually, or (2) movement limitation which is applied mechanically. With manual movement limitation, the student is immobilized by being physically held by a staff member. The student may be in a standing position (possibly in a corner), a sitting position, a prone position, or a supine position. With mechanical movement limitation, the student is placed in some form of mechanical restraint. This may include leg, waist or crossover restraints, an arm-free or four-point chair, four-point restraint board, harness, arm splints, arm tubes, helmet, or visual screen goggles. Movement limitation is used for the following treatment purposes: to enable contingent rewards to be used by preventing students from taking such rewards without earning them through behavioral contingencies; to enable John to receive medical, dental, educational and treatment procedures by preventing and/or decreasing problematic behaviors that would otherwise make such procedures unavailable; to decelerate targeted behavior(s); to keep John from removing or destroying a medical, dental, educational or treatment device that is essential to the provision of successful and effective medical or dental care or to effective education or treatment; to decelerate John’s problematic behaviors so that John will be able to engage in his positive reinforcement programs; to decelerate John’s problematic behaviors so that John is able to engage in educational, vocational, and social programming opportunities and learn positive behaviors and receive positive reinforcement; and to enhance the effectiveness of other interventions, including both positive reinforcers and aversive procedures. A "contingent release" may be used, requiring that the student be calm and participating in his behavioral program at the time of his release and for a specified period immediately prior to release. If the student fails to meet this contingency requirement, then the restraint may be extended until the student meets it. The clinician determines the duration of the restraint based upon a clinical assessment of a number of criteria including whether the student is calm and participating in his behavioral program, frequency of passing contracts, the frequency and intensity of his behaviors, the student’s overall demeanor and level of perceived agitation and tension, and the student’s treatment history. Typical side effects of movement limitation are occasional skin abrasions or reddening of the skin.

Notifications to the Court Monitor re: Movement Limitation: JRC will notify the Court Monitor if a student requires more than eight (8) continuous hours of movement limitation procedures in a twenty–four (24) hour period. Also, the Court Monitor will be notified if the student spends five (5) or more days in movement limitation in a seven-day period. Staff must notify and the student’s clinician must approve the initial use of restraint within one hour of the student being placed in movement limitation, and must review the use of movement limitation with the student each day. The clinician and nurse examine the student during school hours while in movement limitation each day. A physician determines in advance any individual cases in which movement limitation for certain students may be contraindicated.

b) Helmet: (DMR Level III) A specially designed helmet is placed on the student's head for a specified period of time as a consequence for a given inappropriate behavior. The helmet may be equipped with one or more of the following components: (1) a Plexiglas or grid-type face guard and (2) a mechanism, which prevents removal. The helmet may cause sweating or local skin irritations.

c) Water Spray I: (DMR Level II) The student is sprayed several times on the cheek or the back of the neck with water from a spray bottle. The water may be chilled by the insertion of ice in the bottle. Side effects are that the skin may get chafed from the student wiping it dry and the student’s shirt may become wet from water dripping down to his clothes. When this occurs, the student is given dry clothing.

d) Contingent food program: (DMR Level III) If the student does not exhibit certain targeted behaviors for a specified period of time; he/she will earn a portion of staple food.

Preferred staple food refers to the basic menu food that is offered to all students each day. The nutritionist designs the preferred staple food menu and the kitchen staff or caterer prepares the food. The student’s preferred staple food is comprised of a target number of calories per day, which meets their daily caloric requirements as determined by the nutritionist in consultation with the medical staff, as necessary (caloric targets may be changed depending on the student's overall condition, but are always supervised by the nutritionist, in consultation with the medical staff, as required). Non-preferred staple food currently refers to a plate of bland food consisting of mashed potatoes, chicken and spinach served at room temperature and garnished with liver powder.

The daily minimum target calories of 2000 will be dispensed to the student, in the form of preferred staple food, during the period from 7:30 A.M. through 7:00 P.M. upon successful completion of all less-than-a-day contracts. If the minimum daily total of 2000 calories has not been earned by 7:00 P.M., then the balance necessary to bring the total staple food calories eaten to the daily target of 2000 calories will be dispensed to the student, in the form of non-preferred staple food, starting at 7:00 P.M. (preferably contingent upon the student passing some simple contract, but if necessary, without conditions). If special treatment considerations require it, alterations in the time and manner of staple food make-up may be made, with the approval of a consulting physician. The Court Monitor shall be informed whenever the student has been required to consume the full calories in the form of non-preferred staple food after 7:00 P.M. for a period of two weeks.

The number of calories that the student earns both in the form of preferred staple food and in the form of non-preferred staple food, will be recorded daily in a Food Recording Sheet. JRC will provide all necessary medical safeguards to ensure that their health and well-being are not jeopardized. This includes weighing by the staff and periodic nursing inspections to insure that their weight remains at the target weight, as established by the medical staff. In addition to recording in the medical record the weighing and periodic nursing inspection, a qualified nutritionist may also provide a consultation on an as needed basis. In certain cases, the caloric value of the items used as special food rewards in the form of treats and snacks may be counted toward the daily staple food calorie targets. The items that may be so counted, and the method of counting, are shown on the Food Recording Sheet.

Possible side effects of contingent food may be a temporary discomfort from increased hunger, lasting no more than a few hours. The student can avoid this temporary discomfort by not showing designated inappropriate behaviors, and thus earning the food portions that go with achieving their contracts. Any food missed by failing to make a contract is made up in a pre-bedtime meal.

e) Specialized Food Program: (DMR Level III) If special treatment considerations require it, such as if the data indicate that a student has not responded to contingent food, or, when it is clinically judged that the specialized food program would increase the motivation to earn food more than the contingent food program, some students may participate in a Specialized Food Program. For each student at JRC, the medical staff determines the student's "ideal weight" and “ideal weight range.” The medical staff refers to standardized charts that provide ideal weights and ideal weight ranges based on body frame and height. The ideal weight range is considered to range from 90% to 110% of the “ideal weight.”

All students are presently maintained, if their eating habits permit, at or above a so–called "red line weight” which is 87.5% of their ideal weight— that is, 2.5% below the lower boundary of the ideal weight range.

With the Specialized Food Program, the student will not receive any make–up food at the end of the day unless the student has received less than 20% of their daily targeted calories. It is instituted with the approval of a consulting physician (and a neurologist if the student is seizure prone or a cardiologist if there are any cardiac problems) and the JRC medical and nursing staff. The student continues to be able to earn their other food through various task completions, the exhibition of "supergoodie" behaviors, and the passage of contracts, among other means.

Before JRC institutes the Specialized Food Program, the consulting physician is notified. The physician then reviews the student's records. The student is also personally examined by one of JRC's consulting physicians.

In addition, the following steps are taken:

i. A baseline blood work of the student prior to the initiation of the specialized food program;

ii. JRC conducts a urinalysis to test for positive ketones on every day that follows a twenty-four-hour period when either of the following occurs: (a) the student earned less than 80% of their recommended daily caloric intake; (b) if a member of the JRC medical staff determines that such a test is necessary;

iii. The student is offered unlimited amounts of fluids;

iv. The electrolyte content in the student's blood is measured prior to the time that they enter the specialized food program, to measure the chemical composition of the ions. The electrolyte content in the student's blood is measured every 6 months or more frequently as needed. For example, it might be measured when there is a major change in the student's medical status;

v. The student's vital signs are measured as needed, by the nursing staff. This includes a measurement of the student's heart rate, respiratory rate and blood pressure. This might be done, for example, when there is a major change in the student's medical status;

vi. The nurse reports by telephone to JRC's consulting physician every other week (or more often, as necessary) once the specialized food program is instituted for the student, regarding the student's status. The nurse documents that the report was made in the student’s records. Based on the report, the consulting physician determines whether an examination is necessary, and if so, the examination is also documented in the student's record;

vii. JRC forwards the status of the student's weight to the consulting physician, each week; and

viii. The Specialized Food Program is suspended or otherwise appropriately altered if a student's weight dips below the red line value.

In most cases, if the student participating in the Specialized Food Program is under his red line weight or loses two pounds per day, or five pounds per week, or ten pounds overall, or ten percent of their body weight, the Specialized Food Program is suspended or otherwise appropriately altered to assure adequate food intake as necessary. In other cases, it is continued with the approval of JRC's consulting physician, and notice to the Court, the ward’s counsel, and Court Monitor. A student on the Specialized Food Program is always offered at least twenty percent of their daily calorie goal, without respect to any behavioral contingencies.

The Court Monitor shall be informed whenever the student receives no more than twenty (20%) percent of the daily caloric goal for two consecutive weeks.

Possible side effects of specialized food may be discomfort from increased hunger, and a temporary and minor weight loss. The student can avoid the temporary discomfort of increased hunger by not showing designated inappropriate behaviors, and thus earning the food portions that go with “making” their contracts. Any weight loss is monitored daily by the nursing staff, and is immediately reversed (by adjusting the size of food portions, discontinuing of Specialized Food, etc.) whenever this is deemed desirable.

f) Electrical Stimulation: (DMR Level III) JRC uses the Graduated Electronic Decelerator --the "GED" and "GED-4" devices that are manufactured by JRC. The GED device consists of a transmitter operated by the JRC staff and a receiver worn by the JRC student. The receiver delivers a low–level surface application of electrical current to the student's skin upon command from the transmitter. The GED device is adjustable with a maximum intensity of 15.25 milliamperes RMS, a duration range from .2 seconds to 2 seconds, an average peak of 30.5 milliamperes, and a duty cycle of 25%. The GED 4 device has a maximum current of 45.0 milliamperes RMS, a duty cycle of 25%, an average peak of 91 milliamperes, and a maximum duration of 2.0 seconds. One or more electrical stimulations are administered to a student after they engage in a targeted behavior. The GED devices also have remote distanced electrodes. The distanced electrode configuration is a cloth Posey strap or other attachment with two standard round electrodes mounted thereon up to six inches apart. The use of the distanced electrode configuration does not, in any way, increase the output of the GED device and does not, in any way, compromise the safety of the device. The distanced electrode configuration delivers more effective applications, thereby increasing the GED's therapeutic value. Side effects may be temporary reddening of the skin and, on rare occasions, a small blister may appear.

g) Negative Reinforcement: Aversive procedures may be used in either a punishment paradigm or a negative reinforcement paradigm. If used in a negative reinforcement paradigm, the procedure may be given repeatedly until the student exhibits a pre–determined appropriate response to escape further applications. For example, a student who is aggressive may receive a series of GED’s, which would continue until the student went to his seat and sat down.

h) Automatic Negative Reinforcement: This refers to the use of electrical circuitry to: 1) automatically administer, as soon as a behavior starts, a series of aversives (e.g., skin shocks) at regular intervals (e.g., one every three seconds); 2) automatically terminate the series of aversives as soon as the behavior stops occurring.

i) Behavior Rehearsal Lessons (Recreating the Scene): The staff member presents a stimulus for some targeted inappropriate behavior that the student has shown. The staff member then prompts the student to engage in the initial phase(s) of the behavior, and arranges some planned aversive stimulus. This procedure is arranged to be carried out at pre-specified times of the day, and over a specified number of days or weeks.

The procedure is used to treat problem behaviors, such as pulling out the hair of others, biting others or self, and opening a car door while driving. It is particularly useful to treat behaviors with a low frequency of occurrence, such as eye gouging or life-threatening aggressive behavior, where even one natural occurrence of the inappropriate behavior could have serious consequences for the student or others.

j) For each procedure the clinician establishes, and may change as need arises, notification limits, at which time a programming representative is notified. For John, the attending clinician must be notified when John receives 10 GED applications, and when each additional 10 GED applications are made, within a 24 hour period.

Notifications to the Court Monitor re: GED Applications: All required notification limits imposed by the Court are also observed and carried out, including notification to the Court Monitor if more than fifty (50) electric stimulations are delivered to a student in a twenty–four (24) hour period. Also, the Court Monitor will be notified if the student receives two hundred and fifty (250) applications in seven days and at intervals of five hundred (500) thereafter. A nurse examines affected areas each day and a physician determines in advance any individual cases in which application of the procedure to certain students, or application of the procedure to certain areas of the body, may be contraindicated.

k) Positive Practice Overcorrection: (DMR Level II; III if force required) The student may be required to repeat a desired form of behavior several times. For example, if the student has the inappropriate behavior of ritualistically touching their belt each time they stand, the student might be required to stand up 5 times in a row without touching the belt. There are no side effects unless force is required; if so then side effects would be the same as those for restraint.

l) Restitutional Overcorrection: (DMR Level II; III if force required) The student is required to restore disrupted objects to their original condition, and then to engage in further effort to make the situation much better than it originally was. For example, if the student exhibits the inappropriate behavior of knocking a chair over, he might be required to pick it up, place it back where it was, and then straighten every chair in the room. There are no side effects unless force is required; if so then side effects would be the same as those for restraint.

5. For John, JRC requests court authorization to use the following treatment procedures:

a) Aggressive Behavior: physical aggression towards others (to include attempts), punch others, headbutt others, bite others, verbal threats to aggress, possession of potential weapons (i.e. sharp or heavy, blunt objects), spit at others, out of seat without permission (to exclude a rewarding setting, BRS, ERS, CRS, All Purpose Room), out of bed without permission (to exclude to use the bathroom).

Helmet, movement limitation, waterspray, contingent food program, specialized food program, GED and GED 4 with distanced electrodes, negative reinforcement, automatic negative reinforcement, behavior rehearsal lessons, positive practice overcorrection, restitutional overcorrection.

b) Health Dangerous Behavior: harm self, verbal threats to harm self, leave supervised area, attempts to run away, verbal threats to run away, take off seat belt while in transport.

c) Destroying Behavior: property destruction (to include attempts), verbal threats to destroy, bang objects, throw objects, possession of any fire setting materials.

d) Major Disruptive Behavior: swear (to exclude “hell” and “damn”), yell, scream, racial comments, sexual comments and/or gestures, steal, inappropriate urination or defecation, masturbate at inappropriate times, expose self (not to include in the bathroom taking self-care).

e) Non-Compliance Behavior: refuse to follow staff direction, blatant NO, attempt to remove restraints, attempt to remove/tamper with/destroy GED devices or electrodes.

f) Educationally/Socially Interfering Behavior: stop work, personal space violation, mimic others, rude gestures, non-functional body movements, stare at others for move than 5 seconds, failure to follow student rules, refuse to do academics.

Contingent food program.

g) Inappropriate Verbal Behavior: talkout, noises, interrupt others, nag, negative/rude comments, not minding own business, laugh at inappropriate times, argue with staff/students, use of slang, tease others.

Contingent food program.

6. Procedures added or deleted.

There are no additions or deletions at this time because this is the first proposed treatment plan for John.

7. Reasons for DMR Level III Interventions

The success of John’s overall treatment depends on a comprehensive approach, which has the flexibility to manage any potential problems that arise and the ability to deal with any behaviors which function to defeat the overall treatment. If any particular behaviors are allowed to get out of control, this can result in escalating sequence of inappropriate behavior. For example, if JRC does not properly manage his seemingly minor behaviors, this may lead to an increased likelihood of him becoming aggressive towards staff or students or attempting to injure himself. If this occurs, John would potentially require the use of protective restraint and one-to-one staffing 24 hours per day.

Verbal threats, yelling, swearing and getting out of his seat in the classroom without permission are direct antecedents to full-blown assaultive and major destructive behavior. If allowed to do this, John becomes extremely risky to self and others around him. John has been observed to exhibit these “antecedent” behaviors on numerous occasions since his admission to JRC, and these behaviors have been frequently noted as precursors to physical aggression and destructive behavior. John has also exposed himself and masturbated in public settings. Left untreated, such behaviors are also likely to lead to John’s exclusion from social and educational settings. If these behaviors are permitted to remain in John’s behavioral “repertoire,” he will likely continue to exhibit them, and due to their long history of being linked with more “overt,” dangerous actions, will likely facilitate a resumption of these dangerous and disruptive behaviors once constraints on John’s behavior are removed. In order to maximize his potential for sustained progress, and to provide him the opportunity to learn appropriate behaviors for seeking desired outcomes for himself, these antecedents must be directly targeted for rapid deceleration.

Running away or leaving a supervised area can be very dangerous. John does not have the ability to recognize potential danger and these behaviors could threaten his safety.

The effective treatment of refusing to follow directions is critical to the whole treatment and educational package. We are mandated to provide to John an education that is appropriate to meet his needs, as opposed to custodial supervisory care. Even if all other problematic behaviors were successfully reduced, refusal to comply with habilitative educational and residential programming would result in continued severe skill deficits for John, which would hamper him for the rest of his life. If he does not form habits of being able to comply with structure and authority during his remaining school years, he will have no hope for vocational success as an adult.

Although any of the above behaviors taken alone occurring at a low intensity would not necessarily indicate the use of DMR Level III procedures, taken in the context of John’s behavioral history and the dangerousness of what happens when these behaviors go untreated, the use of Level III procedures to treat them is supported. Any of these left untreated will be used by John to totally defeat his overall plan by creating a highly disruptive situation.

8. Success Criteria

John will always have some type of structured behavior modification treatment while at JRC. A particular intervention may be terminated if it is judged ineffective by the supervising clinician, or is not contributing to the overall success of the program. If an intervention has successfully reduced a behavior to zero for a period of three to six months, it might be terminated. However, if the behavior appears to return, the intervention may be re-instated to prevent regression.

It is not possible to state criteria for measuring the success of each individual intervention on each individual behavior in isolation, because of the following factors:

i. Progression or regression in one behavior area may be an expected result of, or may be balanced or outweighed by, progress or regression in one or more other behavior areas, and the overall result must be measured by a risk/benefit approach. For example, the frequency of John’s inappropriate behaviors may become higher when new educational or treatment demands are placed upon him. If, when this occurs, John learns important new skills, the learning results obtained may be worth the regression in inappropriate behaviors that may occur.

ii. The fundamental index of success is the overall quality of life, when evaluated against what it was in the past, and what it would be under other, alternative treatment approaches. For example, even though John may show little further reduction in his inappropriate behavior frequencies from their current level, simply maintaining their current level despite receiving a higher level of educational and social demands that might represent considerable success for John. Similarly, even if his inappropriate behaviors should show some increase from their current levels, if he still is able to function in a reasonably normal way, without having to take psychotropic medication that interferes with his ability to learn or function, or that affects his cognitive abilities and with minimal or no restraint, this might still be a major success for John.

iii. Whenever aversive procedures are used, one should be constantly wary of the ever-present possibility of adaptation to the aversive procedures. Consequently, simply avoiding this outcome, or avoiding it as long as possible, or even making adaptation occur as slowly as possible, may also represent very successful treatment for John.

To summarize, the ultimate measure of success of a behavior plan is not to be found in the effect of the plan on the frequency of a single individual behavior. Instead, success is measured by whether we have improved the quality of life over what it has been in the past, or over what it would likely be under other possible treatments, weighing the risks and benefits. By quality of life, we include, among other things the following: health, happiness, safety, emotional well-being, competencies in a large number of skills, ability to enjoy as many positive life experiences as possible, ability to cope with social, physical, and educational demands successfully.

As to the measure of the success of the behavior plan as a whole, there are clearly too many factors to create an exhaustive list of what will be taken into account. However, in general, we would be looking at factors such as John’s tendency to hurt himself and others, his level of disruptiveness, his degree of participation, the extent to which he is making his DRO contracts—all of which, as noted above, will need to be weighed, in terms of a risk/benefit approach against what these levels have been in the past under other treatments, what they would likely be under alternative treatments, and how they relate to his overall quality of life. The following behavioral goals are stated in John’s IEP.

Projected Goal

at 12 months

(median/week)

Behavior

Aggressive Behavior 1

Health Dangerous Behavior 1

Destructive Behavior 1

Major Disruptive Behavior 5

Noncompliant Behavior 5

Inappropriate Verbal Behavior 10

Educationally/Socially Interfering Behavior 10

XI. CLINICAL PRACTICES

A. Supervision by a Clinician

A clinician, currently Robert E. von Heyn, Ph.D., and under the direction of Matthew L. Israel, Ph.D., the Executive Director of JRC, has the direct responsibility for the development and implementation of John’s treatment plan. The clinician may change from time to time based on caseload re-assignments. Specifically, the clinician will do the following:

1) Design and sign off on the initial treatment plan.

2) Prescribe and personally authorize any change in a treatment procedure before it is implemented. Such written orders are documented and signed in the clinical record, and reported in the 120-day progress report to the Court. JRC has in place an on-call system at all times so that, in the event of the unavailability of the attending clinician, the on-call clinician will be consulted for the purpose of prescribing and personally authorizing any change in treatment procedure before it is implemented. The on-call clinician will have the responsibility of informing the assigned attending clinician of any changes at the earliest reasonably possible opportunity. In the event of an emergency, where approval of a clinician cannot be obtained, the prior authorization provisions of this paragraph shall not apply, provided that such changes are authorized by the current program supervisor and approval is sought from a clinician as soon as practicable. Likewise, the prior authorization provisions of this paragraph shall not apply in the event that the program description authorizes, for medical reasons, a pre-planned switch to another procedure once a certain limit is realized.

3) Set the numeric limits for administration of an aversive treatment (except for "No", Ignore, and Token Fine), beyond which he/she or the on-call clinician, will be directly consulted by the staff. The clinician will make a determination as to the clinical effectiveness of the procedure in question in order to further direct the staff. The staff may not implement aversive procedures beyond the set numeric limits, unless directly prescribed by the clinician. Such an order will be documented and signed in the ward’s clinical record. An on-call clinician will have the responsibility of informing the assigned attending clinician of the matter at the earliest reasonably possible opportunity. In the event of an emergency, where the approval of a clinician cannot be obtained, the prior authorization provision of this paragraph shall not apply, provided that such changes are authorized by the current program supervisor and approval is sought from a clinician as soon as practicable. Likewise the prior authorization provisions of this paragraph shall not apply in the event that the program description authorizes, for medical reasons, a pre-planned switch to another procedure once a certain limit is realized.

4) Insure that any change in treatment is based on the student's record and the behavioral analysis. The changes in treatment are based on, for example, the student's behaviors, charts, incident reports, and observations of the student and interviews with staff.

5) Approve shifts of existing topographies from one behavior category to another and any changes in treatment, as a result of the shifts.

6) Approve treatment of new topographies of the problem behaviors with the categories of procedures that have been authorized by the Court.

7) Insure that if a treatment other than Ignore, No, or Token Fine is used for any non-aggressive, non-destructive, or non-self-injurious behavior, appropriate strategies are developed to use positive, non-aversive interventions for these problem behaviors, that appropriate behavioral analysis is conducted, and that efforts are undertaken to teach appropriate behaviors to replace inappropriate behaviors, wherever clinically appropriate.

8) Insure that before aversive or restrictive consequences are used for non-aggressive, non-destructive, or non-self-injurious behavior there is evidence that:

a) the behavior significantly interferes with educational development; or

b) the behavior significantly interferes with social development; or

c) the behavior is an antecedent to aggressive, self-injurious or destructive behaviors; or

d) the behavior is a weaker, shaped-down or incipient version of an aggressive, self-injurious or destructive behavior; or

e) the behavior is an attempt to execute an aggressive, self-injurious, or destructive behavior.

9) Insure, in conjunction with a consulting physician, that no treatment is used that is medically contraindicated for the student.

10) John’s treatment plan will be prescribed and directly supervised by a clinician whose professional time commitment does not exceed a patient to full-time clinician ratio of 16:1. JRC will designate in the clinical record the name and credentials of the assigned attending clinician for the case, and will indicate whenever changes are made in the designation of the attending clinician. The inability of JRC to achieve the ratio prescribed by this paragraph shall not prevent JRC from rendering the treatment authorized by the Court provided that good faith efforts are being undertaken to retain additional clinicians.

B. Emphasis on Positive Non-Aversive Procedures

JRC applies positive non-aversive procedures to treat all problem behaviors, including those behaviors, which are non-aggressive, non-destructive, and non-self-injurious. JRC also attempts to exhaust such procedures, to a clinically appropriate degree, before treating problem behaviors with aversive procedures. JRC implements a stimulus control focus to enable John to learn that interfering behaviors can be acceptable in some settings, and teaches John to discriminate between appropriate and inappropriate settings for such behaviors.

C. Input From the Human Rights Committee and the Peer Review Committee

Prior to the implementation of any Level II or III procedures, the student's treatment plan in its entirety must be approved by the Human Rights and Peer Review Committees. Nothing in this paragraph will preclude the use of educative, reward and emergency manual restraint procedures, which are necessary or are implemented prior to Human Rights Committee and Peer Review Committee approval.

D. Reporting to the Court

Every four months JRC shall submit a progress report, which will consist of a narrative analysis by his/her attending clinician of the progress since the last report. The clinician must consider behavior charts, tally sheets, and functional analysis in formulating each narrative analysis. Copies of these materials need not be attached to the analysis but shall be made available to counsel and Court Monitor upon their request. JRC shall send copies of this report to the Court, the ward’s counsel, Court Monitor, and DMR.

E. In-School Monitoring of Overall Plan

Behaviors are recorded as tally marks on a daily recording sheet, which follows John 24 hours a day. Additional information on this sheet, if relevant to John’s specific treatment plan, may include calories eaten, periodic or as needed body checks by a nurse, times in restraint devices, contracts passed, counts of any aversive procedures used, and the names of any staff working with him. These daily recording sheets are processed by JRC’s charting department every day, with critical information being entered into the JRC database. All problematic behaviors may be graphically presented on daily, weekly, and monthly Standard Behavior Charts. Positive behavior frequencies are recorded and may also be plotted on Standard Behavior Charts.

Program implementation is monitored from an online video streaming system at the residences and school. Supervisors and clinicians who frequently visit classrooms and residences also monitor the program implementation. The clinician, in many cases monitors student success on a daily basis, but in any case does so at least weekly. The clinician reviews John’s treatment for effectiveness at least weekly and records his/her assessment of the plan’s effectiveness in achieving the stated goals. The clinician reviews daily records of the frequency of target behaviors, frequency of interventions, safety checks and reinforcement data.

XII. SUBSTITUTED JUDGMENT CRITERIA

The prognosis for John without effective behavioral treatment is poor. He was previously treated both on an outpatient and inpatient basis without sustained improvement. Without effective treatment his destructive and aggressive behaviors are likely to lead to severe injuries to himself and others, and/or to incarceration, without any further hope of vocational or educational progress.

Under the proposed treatment plan John has the potential to do better than ever before. The prognosis for John expected success at JRC is guardedly optimistic. Because adaptation to the GED is always a possibility with John, or with other students, we remain vigilant to this possibility. However, a judicious combination of rewards and aversives is essentially the only hope for John in terms of successful treatment and progress in educational and vocational activities.

There are no negative side effects to JRC’s treatment procedures except: skin chaffing from the movement limitation and temporary, superficial red mark on the skin or some mild scaling from the GED, and mild state of hunger from the food programs.