Use of Electroconvulsive Therapy to Treat Self-Injurious Behavior in Adults With Autism Spectrum Disorders
Phase: NA
Conditions: Autism Spectrum Disorder, Self-Injurious Behavior
Sponsor: Eastern Virginia Medical School

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Use of Electroconvulsive Therapy to Treat Self-Injurious Behavior in Adults with Autism 
Spectrum Disorders 
I. Overview:  
Self-injurious behavior (SIB) is one of the strongest predictors of psychiatric hospitalization 
among children with Autism Spectrum Disorder (ASD) aged 5 to 21 years. While self-injury in 
some patients is operant-based, involuntary self-injury can be a presentation of catatonia. When 
psychopharmocologic interventions fail, electroconvulsive therapy (ECT) is a safe and highly 
effective alternative to treating catatonia and major depression.  Given that catatonia may present 
as SIB, especially in patients with ASD, several case studies have used ECT to minimize the 
self-injury in treatment-resistant patients. This study will use formal measures, including the 
Aberrant Behavior Checklist (ABC), Repetitive Behavior Scale (RBS), and the Self-Injury 
Trauma (SIT) Scale to monitor the outcome of using ECT to treat SIB in patients with ASD, for 
whom psychotropic medication has not worked. This study will be fundamentally different from 
the previously published literature on the subject in that this will be a prospective study which 
will aim to recruit multiple participants in an open label study.  
 
 
II. Specific Aims and Hypotheses: 
SIB in ASD is both physically and emotionally damaging to patients. Many patients with SIB 
who have ASD are treatment resistant in regard to psychopharmacologic treatment. ECT has 
been reported as an effective treatment for SIB in ASD but only through case reports. The major 
aim of this research study is to provide prospective research data of the efficacy of ECT in this 
population. 
Specific Aim 1: Clarification, verification,  and characterization of the presence of SIB in ASD 
subjects prior to ECT, through the use of the Self Injury Trauma Scale and daily caregiver 
assessments of self-injurious behavior.  
Specific Aim 2: To measure the efficacy  of ECT  on SIB by comparing clinical, physical, and 
psychological signs and symptoms pre and post ECT using the Self-injury Trauma Scale, 
Repetitive Behavior Scale-Revised, Aberrant Behavior Checklist, ASD Diagnostic Checklist, 
and the caregiver’s daily diary card. 
Hypothesis 2:  ECT will be an effective treatment for SIB as measured by improvements in the 
Self-injury Trauma Scale, Repetitive Behavior Scale-Revised, Aberrant Behavior Checklist, and 
the daily diary card, kept by the caregiver. ECT will not lead to significant changes in the ASD 
Diagnostic Checklist.  
Specific aim 3: Monitor and evaluate the side effect profile of ECT in this population of subjects. 
Hypothesis 3: ECT will have no additional side effects in this population other than those seen in 
any psychiatric population receiving ECT. 
 
 

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III. Background, Rationale, and Significance of the Study: 
Persons diagnosed with Autism Spectrum Disorder (ASD) are more likely to have a comorbid 
psychiatric disorder than their neurotypical peers.1 As many as 11% of children with ASD in the 
United States have been admitted to a psychiatric hospital by the time they turn 21 years old. 
Moreover, self-injurious behavior (SIB) is one of the strongest predictors of psychiatric 
hospitalization among children with ASD aged 5 to 21 years.2 Tate and Baroff define SIB as any 
behavior which “produces injury to the individual’s own body.”3 According to the Self-Injury 
Trauma Scale, SIB categories include: forceful contract with head or face; forceful contact with 
other body part; scratching, picking, rubbing skin; biting; eye gouging; ingestion of inedible 
materials; vomiting or rumination; air swallowing; and hair pulling4.  
While self-injury can be operant-based, SIB in some patients is a presentation of catatonia.5 
Indeed, a plethora of cases of self-injury and catatonia have been reported in the past century.5 
Involuntary self-injury can be a form of the motor stereotypies diagnostic of catatonia.5 
Unfortunately, the frequency of comorbidity of ASD and catatonia is unknown due to the 
similarities in presentation, and thus a likely underdiagnosis of catatonia in persons with autism. 
Shared symptoms of autism and catatonia include posturing, grimacing, negativism, motor-
stereotypies, and purposeless agitation.6 According to the DSM-5, catatonia is not recognized as 
an independent class. It may occur in the context of neurodevelopmental, psychotic, bipolar, and 
depressive disorders. A catatonia specifier is used when there is a marked psychomotor 
disturbance involving at least 3 of the 12 diagnostic features of catatonia (stupor, catalepsy, waxy 
flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, 
echolalia, and echopraxia). The DSM-5 also recognizes catatonia due to another medical 
condition and unspecified catatonia, where the nature of an underlying disorder is unclear. In the 
literature, ASD with co-morbid catatonia has been proposed to be its own subtype of autism.8 
Alternatively, it has been hypothesized that autism may be an early stage of catatonia.9 Autism 
Spectrum Disorders, catatonia, and some forms of SIB have been postulated to have the same 
neurochemical basis. GABA receptor abnormalities has been implicated in all three 
pychopathologies.7 Additionally, GABA and its subunit genes are encoded on chromosome 
15q11-13, the same loci that have been implicated in catatonia and autism.10  
A subgroup of patients with both ASD and self-injurious behavior have been found to be 
“treatment-resistant”. In these individuals neither behavioral interventions nor psychotropic 
medications have been found to be effective in controlling the SIB.  Electroconvulsive therapy 
(ECT) is highly effective at treating catatonia and severe depression. In life-threatening 
catatonia, ECT is considered a first-line treatment due to its speed and efficacy in treating the 
life-threatening emergency. ECT has been shown to have an efficacy of at least 80% in the 
resolution of catatonia among patients who have been treatment-resistant, with higher rates of 
efficacy r shown for the resolution of primary catatonic symptoms.11,12 Because self-injurious 
behavior can be a presentation of catatonia, several case-studies have been published that show 
the efficacy of using ECT to minimize or resolve SIB in children and young adults with 
ASD.13,14,15,16,17 However, all studies to date have been retrospective in nature and there were few 
formal outcome measures.18 
 

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Significance 
 
This study will use formal measures, including the Aberrant Behavior Checklist (ABC), 
Repetitive Behavior Scale (RBS), and the Self-Injury Trauma (SIT) Scale to monitor the 
outcome of using ECT to treat SIB in patients with ASD, for whom psychotropic medication has 
not worked. This study will be fundamentally different from the previously published literature 
on the subject in that this will be a prospective study which will aim to recruit multiple 
participants in an open label study rather than the previously reported case studies.13,14,15,16,17 
 
IV. Research Methods and Procedures 
 
Inclusion and exclusion criteria 
 
For this study, all adult individuals presenting to EVMS Psychiatry and Behavioral Sciences will 
be considered for this clinical treatment study if they have a documented ASD diagnosis by a 
psychiatrist or psychologist. Participants (N=20) must be over the age of 18, and must have an 
LAR who can consent to medical treatment and attend all appointments with the participant. 
Only the participant’s LAR may consent to treatment (no participants in this study will be 
permitted to self-consent). Those individuals considered wards of the state will be considered for 
the study as long as they meet all inclusion/exclusion criteria and are able to follow through with 
all steps of the protocol (e.g., guardianship, consent, transportation, etc.). Additionally, the 
participant must have a present history of self-injurious behavior (SIB) that significantly impacts 
their quality of life, for which they have tried and failed at least four other treatment methods in 
the past. SIB is any behavior “which produces injury to the individual’s own body.” (Tate and 
Baroff, 1966). All subjects must be medically cleared per the clinical ECT protocol already in 
place, which includes obtaining an EKG, Chest X-Ray (CXR), Complete Metabolic Panel 
(CMP), and Complete Blood Count (CBC). Subjects must also obtain a head CT scan. All 
studies must be less than 6 months old. Additionally, subjects must receive a full clinical 
psychiatric evaluation with the principal investigators: Dr. Shriti Patel, MD to evaluate for 
appropriateness for and response to ECT and Dr. Maria Urbano, MD to evaluate for ASD 
symptoms in subjects prior to, during, and at follow-up. 
 
Study Design 
 This study design is single subject design over multiple participants. Any patient who is enrolled 
for ECT with a diagnosis of ASD and SIB that meets inclusion and exclusion criteria will be 
entered into the study if their guardian/subject provides consent/assent. All ECT procedures will 
be performed at the SNGH outpatient surgical suite. 
 
Procedure 
After the individual has been screened and is determined to meet the inclusion and exclusion 
criteria they will be scheduled for two pre-treatment appointments and sent a consent form to 
review ahead of time. As part of the inclusion and exclusion criteria, the participant must have an 
appointment with their primary care provider or a hospital internist to complete a physical exam 
and required tests (EKG, CXR, CMP, CBC, and head CT scan). At the first pre-treatment 
appointment (Visit 1), the participant and their legal guardian will go over the consent form with 
the investigator. In addition to the consent form, to be signed by the legal guardian, the 

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participant will receive an assent of the cognitively impaired. After giving consent, the legal 
guardian will be given a Sentara release of medical information form so that investigators will 
have access to the ECT-performing physician’s medical notes. The guardian or other caregiver 
will then fill out the ASD Diagnostic Checklist, Repetitive Behavior Scale- Revised, and the 
Aberrant Behavior Checklist. The physician will complete the Self-Injury Trauma Scale, which 
documents the number, type, and severity of unhealed self-injury traumas. At the end of the Visit 
1, the guardian/ caregiver will receive a Subject Diary Card to record the number of self-injury 
episodes per day, the number of aggressive episodes per day, and the perceived severity of 
episodes that day. The Diary Card also has space to record the medication taken by the 
participant every day.  
 
The second pre-treatment appointment (Visit 2) will consist of a complete psychiatric evaluation 
with review of all medical evaluations. The subject must receive medical clearance as defined by 
Sentara Norfolk General Hospital to undergo ECT treatment. The first Diary Card will be 
collected at this time, and a second Diary Card will be given.  
 
After receiving medical clearance, or “low risk” to undergo ECT, participants (accompanied by 
their guardians/ caregiver) will begin to receive ECT treatments. They will receive ECT 3 times 
a week for 4 weeks, for a total of 12 treatments (Visits 3- 14).  All ECT treatments will take 
place in the Outpatient Surgery and Diagnostic Unit of Sentara Norfolk General, and will be 
performed by Dr. Shriti Patel or Dr. Justin Petri. All subjects will receive bilateral “brief” ECT, 
based on the potential risk that self-injurious behavior holds. Participants will be placed under 
general anesthesia (Etomidate) and after it is determined that the anesthesia is in effect they will 
be given a primary muscle relaxant (Succinylcholine). Patients will receive one bag of IV NS 
fluids. An anesthesiologist or nurse anesthetist will hyperventilate the patient to lower their 
seizure threshold. Two electrodes will be placed bi-temporally. An electric current will pass 
through the electrodes to the brain through a process of conduction. During initial treatment 
(Visit 3), the total amount of energy will be titrated until a short seizure is produced, which is 
called seizure threshold. During subsequent visits (Visits 4-14), the settings will be adjusted to a 
total energy of 2.5 x seizure threshold, as determined by the ECT provider. Electrical activity in 
the brain, including seizure quality, duration, and post-ictal suppression of seizure, will be 
determined by electroencephalogram (EEG). Throughout the procedure, the provider will be 
monitoring blood pressure, heart rate, and oxygen saturation. While asleep, the participant will 
be given oxygen through an oxygen mask and a bite block will be placed to protect the teeth and 
tongue during stimulation. Following the procedure, the patient will recover in the Post 
Anesthesia Care Unit.  
 
Throughout the course of the treatment, guardians/ caregiver will continue filling out the Diary 
Card. Once treatment begins, guardians/ caregiver will be asked to also include any side effects 
of the treatment noted by themselves or the participant. Guardians/ caregiver will turn in and 
receive new Diary Cards at Visit 3, Visit 6, Visit 9, and Visit 12. After Visit 14, patients will 
begin to receive maintenance ECT as prescribed by the ECT physician.   
 
After acute ECT treatment is complete, patients and their guardians/ caregiver will return to 
EVMS Department of Psychiatry and Behavioral Sciences for post-treatment appointments 
(Visits 15-18). At these post-treatment appointment guardians/ caregiver will complete the ASD 

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Diagnostic Checklist, Repetitive Behavior Scale- Revised, and the Aberrant Behavior Checklist. 
The physician will complete a second Self-Injury Trauma Scale. At this time the Diary Card will 
be collected and subjects will receive Diary Cards for 1 month.  Visits 15-18 will occur at 1 
month, 2 months, 6 months, and 12 months post – acute ECT treatment.  See the next page for a 
timeline summary of visits. 
 
 
 
Measures 
  
Appointment Type 
To-Do 
Diary Card 
Week 1 
Visit 1 
Pre- ECT 
Appointment 
Consent and  Assent forms,  
Release of Medical 
Information, ADC, RBS-R, 
ABC, Self-Injury Trauma 
Scale 
Receive Diary Card 1 
Week 2 
Visit 2 
Pre- ECT 
Appointment 
Psychiatric Evaluation, 
Medical Clearance 
Return DC 1, Receive DC 2 
Week 3 
Visit 3 
ECT 
Determine Seizure Threshold Return DC 2; Receive DC 3 
Visit 4 
ECT 
Treatment  
  
Visit 5 
ECT 
Treatment  
  
Week 4 
Visit 6 
ECT 
Treatment  
Return DC 3; Receive DC 4 
Visit 7 
ECT 
Treatment  
  
Visit 8 
ECT 
Treatment  
  
Week 5 
Visit 9 
ECT 
Treatment  
Return DC 4; Receive DC 5 
Visit 10 
ECT 
Treatment  
  
Visit 11 
ECT 
Treatment  
  
Week 6 
Visit 12 
ECT 
Treatment  
Return DC 5; Receive DC 6 
Visit 13 
ECT 
Treatment  
  
Visit 14 
ECT 
Treatment  
  
Week 7 
Visit 15 
Post- ECT  visit 
ADC, RBS-R, ABC, Self-
Injury Trauma Scale 
Return DC 6; Receive DC 
7, 8, 9, 10 
Week 11 
Visit 16 
Post- ECT  visit 
ADC, RBS-R, ABC, Self-
Injury Trauma Scale 
Return DC 7, 8, 9, 10 
6 
Months 
Visit 17 
Follow-up visit 
ADC, RBS-R, ABC, Self-
Injury Trauma Scale 
  
12 
Months 
Visit 18 
Follow-up visit 
ADC, RBS-R, ABC, Self-
Injury Trauma Scale 
  

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Self-Injury Trauma Scale (SIT) allows differentiation and quantification of self-injury. In 
conjunction with a complete medical assessment, the physician records location of injury, type of 
injury, number of injuries, and an estimate of severity. Given these findings a Number Index, 
Severity Index, and Estimate of Current Risk can be calculated. The scale has been shown to 
have high interrater reliability.4  
ASD Diagnostic Checklist (ADC) was designed after the ADOS, ADI-R, and DSM-V criteria for 
autism. It is a 25 item instrument, completed by the caregiver, used to assess, (1) qualitative 
impairment in social interaction, (2) difficulties in communication, and (3) restricted, repetitive, 
and stereotyped patterns of behavior. It is a tool that will be used as verification that the subject 
qualifies for an ASD diagnosis in addition to providing the density of ASD symptoms present 
specific to each patient..  
Repetitive Behavior Scale-Revised (RBS-R) is a 43 item instrument completed by caregivers that 
is rated on a four-point Likert scale ranging from “behavior does not occur” to “behavior occurs 
and is a severe problem”. The revised scale is specifically intended to assess the variety of RRBs 
in individuals with ASDs. It is grouped into 5 subscales:  1) stereotyped behavior, 2) self-
injurious behavior, 3) compulsive behavior, 4) ritualistic/sameness behavior and 5) restricted 
behavior. Cronbach’s alpha ranged from 0.78 for the restricted interest subscale to 0.91 for the 
ritualistic/sameness behavior subscale.19  
Aberrant Behavior Checklist (ABC), is useful for evaluating inappropriate and maladaptive 
behavior. It is normed from childhood to adulthood and has 58 items rated on a Likert scale. 
Separate factor analyses result in five-factor subscales: 1) Irritability, Agitation, Crying; 2) 
Lethargy, Social Withdrawal; 3) Stereotypic Behavior; 4) Hyperactivity, Noncompliance; and 5) 
Inappropriate Speech20,21. The ABC has had confirmatory and exploratory factor analyses in 
1893 children evaluated as part of the Autism Treatment Network which supported the 
convergent and divergent validity of the ABC as a measure of behavior problems in ASD.22 In 
practice, the ABC has the option to be completed by a parent, teacher, supervisor, or other 
guardian/ caregiver. In this study, the ABC will be completed only by a guardian/LAR/ caregiver 
or by the participant.  
 
Human Subjects Protection  
 
Data collection will be in accordance with an IRB approved protocol. This research project 
involves the collection of psychological data under the direction of the principal investigator Dr. 
Shriti Patel, MD.  All tests and measures have been widely and safely used with diverse 
populations. All written research material will be kept in a locked file cabinet in a locked room, 
and will be identified only with numerical codes (rather than name) to protect confidentiality. 
Data containing a link between the participants’ numerical code and their names will be accessed 
via password entry only.  Data will be reported as group data and will not be identifiable as 
individual responses. 
 
Risks to the Subject 
Electroconvulsive Therapy (ECT), like any other medical or surgical procedure, involves a 
certain amount of risk. Careful medical evaluation of each case will be completed to ensure that 

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there are no overriding medical contraindications to the treatment. Fatalities are extremely rare, 
but may occur due to heart problems or a prolonged seizure. Risk of mortality is 1 in 10,000-
80,000. Cardiovascular complications such as cardiac arrest, arrhythmias, ischemia, 
hypertension, and hypotension are rare but may occur. Prolonged seizures or status epilepticus 
are two other rare possible sources of morbidity. Complications, although infrequent, may 
include fractures and/or dislocations or adverse reactions to intravenous medications. Oral or 
dental trauma may occur as a result of the seizure. In some patients with bipolar disorder, manic 
symptoms may emerge or worsen with ECT.  
Headache, mild muscle soreness, or nausea sometimes occurs, but these are infrequent and 
usually respond to symptomatic management. As the treatments progress, short term memory 
impairment (anterograde and retrograde) may gradually occur. This is usually transitory and 
should return to baseline within weeks to months after completing treatments. There are 
occasional residual areas of memory impairment, but this is not common. Inadvertent release of 
PHI is a potential risk to the subject. 
Protection against Risks 
Information concerning the potential side effects of ECT will be discussed with the subject/legal 
guardian/ caregiver so that the subject has sufficient understanding. All subjects and guardians/ 
caregiver will be given information on how to contact the co-investigators should they have any 
questions or problems concerning ECT side effects. All interviews and questionnaires have been 
widely and safely used with diverse populations. All questionnaires and written research 
materials will be kept in a locked file room. All information will be identified only with 
numerical codes (rather than identifying information such as a name). To protect against risks, all 
subjects must be medically cleared per the clinical ECT protocol already in place, which includes 
obtaining an EKG, Chest X-Ray (CXR), Complete Metabolic Panel (CMP), and Complete Blood 
Count (CBC). Subjects must also obtain a head CT scan. These tests will help determine if a 
subject is at an increased risk for an adverse effect. Patients with preexisting cardiac illness, 
compromised pulmonary status, a history of brain insult or medical complications after earlier 
courses of anesthesia are likely to be at an increased risk, but will not be excluded from the study 
as none of these complications are absolute contraindications. The treatment team will be 
capable of managing the major classes of cardiovascular complications, including cardiac arrest, 
arrhythmias, ischemia, hypertension, and hypotension. To protect against prolonged seizures, the 
first treatment will determine the seizure threshold of the patient and following treatments the 
patient will receive the lowest affective dose. The team will be capable of dealing with instances 
of prolonged apnea, prolonged or tardive seizures, and status epilepticus. Participants will be 
monitored on an electroencephalogram (EEG) during the procedure. Vital signs will be 
continually monitored before, during and after each ECT procedure, and patients will only leave 
the recovery area once the vital signs are stable. Muscle relaxants are administered to protect the 
subject from fractures or dislocations. A mouth guard will be placed in the participant’s mouth 
prior to induction of the seizure to protect against oral/dental trauma. At every treatment patients 
and their caregivers will be questioned by the psychiatrist to determine that ECT treatment is not 
exacerbating any psychological symptoms, such as mania. Given the nature of the risks, all 

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subjects must have tried and failed at least four alternative treatments for their self-injurious 
behavior before being considered for this study.  
 
Data and Safety Monitoring Plan 
Research Staff Training 
Each member of the research staff is required to complete and pass all EVMS IRB required 
courses in human subject protection before they are permitted to conduct research.  These 
courses emphasize essential issues of patient confidentiality and informed consent procedures.  
The senior investigators also instruct and supervise staff on appropriate research conduct and 
monitor the staff’s ongoing activities to ensure adherence to the guidelines.  
 
Data Management 
Data are collected exclusively for the purpose of research.  All procedures will be conducted in 
compliance with HIPAA.  Patients provide information through interviews (e.g., clinical 
assessments, medication side effect assessments), through medical examination (e.g., lab values), 
and by guardian/ caregiver -performed questionnaires.  All data obtained from the patient are 
coded with a study identification number (not the patient’s social security number) and 
maintained in paper form in a Case Report Form booklet.  The Case Report Forms are stored in a 
locked file cabinet and kept in a locked research office.  The data will also be entered and stored 
in a computerized database on computers that are password protected.  Dr. Patel and the project 
manager maintain the master list that matches the patient’s name with the study identification 
number.  This list is secured in paper form in a locked file cabinet and in a computer file on a 
computer that is password-protected; both are kept in a locked research office.  The informed 
consent that includes the patient’s name is secured in a separate file in a locked file cabinet in a 
locked research office. Any identifying information on the test measures will be blacked out and 
replaced with the participant’s assigned subject number. The investigators monitor and verify 
that informed consent is obtained before any data collection activities, and that all data are coded 
and maintained with the proper study identification number.    
 
Reporting of Serious Adverse Events 
Drs. Maria Urbano and Shriti Patel will evaluate side effects, laboratory examination, EKG and 
physical examination data. They will assess the relationship of all serious adverse ECT side 
effects to the administration of treatments. All SAEs will be reported immediately (i.e., when 
investigator or members of investigational staff becomes aware of SAE) to the IRB.  The 
immediate reports will be followed by detailed written reports within 72 hours to the IRB.  
Assessment of the relationship of the SAE to the study ECT treatments will be made using the 
following categories: Not Related, Doubtful, Possible, Probable and Very Likely.  Subject 
information on the SAE report will include the patient’s study identification number and not their 
name, personal identification number or address.  All initial SAE reports will report the outcome 
of the SAE (e.g., recovered without sequelae, recovered with sequelae, not yet recovered, death).  

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If SAE is ongoing, then a final follow-up report will be submitted to applicable regulatory 
authorities (e.g., IRB, FDA). 
 
 
 
 
V.  References 
1. Leyfer OT. Comorbid Psychiatric Disorders in Children with Autism: Interview Deve. 2014 
 
2. Mandell. Psychiatric Hospitalization Among Children with Autism Spectrum Disord. 2014 
 
3. Tate BG; Baroff GS. Aversive control of self-injurious behavior in a psychotic boy. Behav 
Res Ther. 1966;4(4):281-7. 
 
4. Iwata BA; Pace GM; Kissel RC; Nau PA; Farber JM. The Self-Injury Trauma (SIT) Scale: a 
method for quantifying surface tissue damage caused by self-injurious behavior. J Appl 
Behav Anal. 1990;23(1):99-110. 
 
5. Wachtel LE; Dhossche DM. Self-injury in autism as an alternate sign of catatonia: 
implications for electroconvulsive therapy. Med Hypotheses. 2010;75(1):111-4. 
 
6. Dhossche DM; Reti IM; Wachtel LE. Catatonia and autism: a historical review, with 
implications for electroconvulsive therapy. J ect. 2009;25(1):19-22 
 
7. Dhossche DM; Carroll BT; Carroll TD. Is there a common neuronal basis for autism and 
catatonia? Int Rev Neurobiol. 2006;72:151-64 
 
8. Ghaziuddin M; Quinlan P; Ghaziuddin N. Catatonia in autism: a distinct subtype? J Intellect 
Disabil Res. 2005;49(Pt 1):102-5. 
 
9. Dhossche DM. Autism as early expression of catatonia. Med Sci Monit. 2004;10(3):Ra31-9. 
 
10. Chagnon YC. Shared susceptibility region on chromosome 15 between autism and catatonia. 
Int Rev Neurobiol. 2006;72:165-78. 
 
11. Hawkins JM; Archer KJ; Strakowski SM; Keck PE. Somatic treatment of catatonia. Int J 
Psychiatry Med. 1995;25(4):345-69. 
 
12. Rohland BM; Carroll BT; Jacoby RG. ECT in the treatment of the catatonic syndrome. J 
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13. Haq AU; Ghaziuddin N. Maintenance electroconvulsive therapy for aggression and self-
injurious behavior in two adolescents with autism and catatonia. J Neuropsychiatry Clin 
Neurosci. 2014;26(1):64-72. 
 
14. Wachtel LE; Contrucci-Kuhn SA; Griffin M; Thompson A; Dhossche DM; Reti IM. ECT for 
self-injury in an autistic boy. Eur Child Adolesc Psychiatry. 2009;18(7):458-63. 
 
15. Wachtel LE; Griffin M; Reti IM. Electroconvulsive therapy in a man with autism 
experiencing severe depression, catatonia, and self-injury. J ect. 2010;26(1):70-3. 
 
16. Wachtel LE; Schuldt S; Ghaziuddin N; Shorter E. The potential role of electroconvulsive 
therapy in the 'Iron Triangle' of pediatric catatonia, autism, and psychosis. Acta Psychiatr 
Scand. 2013;128(5):408-9. 
 
17. Zaw FK; Bates GD; Murali V; Bentham P. Catatonia, autism, and ECT. Dev Med Child 
Neurol. 1999;41(12):843-5. 
 
18. Dejong H; Bunton P; Hare DJ. A Systematic Review of Interventions Used to Treat 
Catatonic Symptoms in People with Autistic Spectrum Disorders. J Autism Dev Disord. 2014 
 
19. Lam KSL, Aman MG. The Repetitive Behavior Scale-Revised: independent validation in 
individuals with autism spectrum disorders. J Autism Dev Disord. 2007. 37(5): p. 855–866.  
 
20. Aman MG, Singh NN, Stewart AW, Field CJ. The aberrant behavior checklist: a behavior 
rating scale for the assessment of treatment effects. Am J Ment Defic. 1985. 89(5): p. 485–
491. 
 
21. Aman MG, Kasper W, Manos G, et al. Line-item analysis of the Aberrant Behavior 
Checklist: results from two studies of aripiprazole in the treatment of irritability associated 
with autistic disorder. J Child Adolesc Psychopharmacol. 2010. 20(5): p. 415–422.  
 
22. Kaat AJ, Lecavalier L, Aman MG. Validity of the Aberrant Behavior Checklist in Children 
with Autism Spectrum Disorder. J Autism Dev Disord. 2013.