Electroconvulsive Therapy for Self-Injurious Behaviors?

By Sidney Baker, MD
Posted July 22, 2014

In my previous answer I said diet is the cornerstone to the most puzzling question – self-injurious behavior - faced by patients, parents and practitioners. More specifically, I said a diet free of sugars and starches. However, if your child’s life is controlled by self-injurious behavior, you may wish to consider Electroconvulsive Therapy (please consult with your child’s physician or a neurologist).

Response

Posted:  July 22, 2014 by Dr. Sidney Baker
 
Whether that diet comes in the form of (a) GAPS (Gut and Psychology Syndrome Diet), (b) SCD (Specific Carbohydrate Diet), (c) one more recently presented in the book Grain Brain by David Perlmutter MD, (d) Paleo Diet, or (e) SuperImmunity Diet presented by Joel Fuhrman MD, the common feature is restriction of carbohydrates. Disagreements about what is the right diet for everyone have been debated publicly and have produced confusion in all of us for the past half century, but a consensus has finally emerged.
 
I learned as a physician that changing how people eat – and especially how they feed their kids – is very difficult.  We are all willful about food. The result is that diet modification engages us in a battle of wills. For some of us food becomes a struggle between appetite and common sense. For parents it becomes a struggle that is complicated by children’s exclusive power over swallowing.
 
In other words, food puts us to the test.  Food is a test in another way that frames the entire question about treatments for children in the spectrum.  If we want to find out if a given diet or other treatment works for one particular child we can put it to the test. A new diet is never a treatment – at first – it is always a test, which I have referred to above as a “thumbs test”: try it for a couple of weeks. If it works – thumbs up. If it causes negative effects – thumbs down. If nothing happens – thumbs sideways; a mixture of good and bad effects – one thumb up, the other down. At the very least we learn something. What we learn will help decide on the next step. 
 
If you don’t think that restricting carbohydrates in your child has been proven to work, then you have the power to prove it. Doing the proof takes a strong intention on you part so it is a test not only of the effectiveness of the diet but of your intention. Parents, teachers, grandparents, practitioners who are unable to change a child’s diet are passing up the most potent therapy we have – certainly better than all the drugs. Understanding that should mobilize your intention at least to the point of proving the point for yourself.
 
Having reinforced my effort to persuade you that diet is the key to nearly all issues relating to health and behavior, let me turn to look in another direction. In that direction are those of you who confront such overwhelming self-injurious behavior problems that make talking about diet sounds ridiculous. A child who spends most of his or her time and energy slapping, banging or hitting calls for intervention matched to the drama of the risk.
 
I was stunned to discover such a treatment in my reading – never having heard of it from my many teachers: parents, researchers, and colleagues with a vast collective experience. Nor has any member requested it be included among the treatment options on Autism360. Electroconvulsive Therapy (ECT). 
 
If your child’s life is controlled by self-injurious behavior, defined as any act directed towards oneself that results in tissue damage, you may wish to bring the question of ECT up with your physician or consult with a neurologist.  Dr. Lee E. Wachtel, Medical Director of the Behavioral Unit at the Johns Hopkins School of Medicine in Baltimore, published the first report of the successful use of ECT in an 8-year old child.
 
“Self-injury included slapping and punching his head as well as banging his head on his knees and shoulders, with daily rates averaging 109.3 attempts hourly based on 24-h data collection.”  During the five years since the onset of this child’s self-injury, seventeen psychotropic drugs had failed to provide relief and two of them (sertraline and fluoxetine) made him worse. Only clomipramine and fluphenazine led to small reductions in self-injury.
 
The following interventions failed: “behavioral assessments and interventions including, but not limited to multiple functional analyses, antecedent analyses, preference assessments, reinforcement based interventions (i.e., functional communication training, differential reinforcement procedures, non-contingent reinforcement), response reduction procedures (i.e., brief physical holds, contingent application of helmet), and bilateral arm restraints and protective equipment (i.e., padding).”  
 
Dietary intervention was noticeably missing from the interventions reported in Dr. Wachtel’s research.
 
Given that ECT itself is an extreme measure, I wonder whether extreme dietary interventions might first deserve more serious consideration.  The model of extremity in dietary matters is fasting. Many children have been reported to calm down and or be relieved of various severe symptoms during abstinence from food. Preparation for radiological exams and surgery and loss of appetite during acute illness are widely recognized as having transient beneficial effects
 
Fasting requires abstinence from food all together – a practice with a long history in human experience and a recent upsurge of interest in its benefits. I believe that the resistance to the notion of fasting in children may be overcome by the comparative danger of some of the symptoms many children endure without relief from other interventions. Just as Dr. Wachtel was the first to try the extreme measure of trying ECT for an 8 year-old, another researcher or practitioner will try fasting a child with uncontrolled, continuous self-injurious behavior. 
 
If Autism360 members have experience in this regard, I would be glad to hear from you as my colleagues and I add to this series on self-injurious behavior with additional descriptions of therapeutic options.