The Judge Rotenberg Center
What is the Judge
Rotenberg Center (JRC)?
How does JRC
differ from other special needs residential schools?
What is JRC's
policy regarding psychotropic medication?
What is JRC's
policy regarding behavioral counseling?
If there were no
JRC, what are the alternatives for the JRC students?
What categories of behaviors does JRC treat?
What reward systems does JRC use?
How are food rewards used in
JRC's behavioral treatment?
How many of JRC
students can be treated effectively with positive-only programming (i.e.,
rewards and educational procedures)?
How long is
positive-only programming tried before supplementing it with skin shock?
Does JRC prepare its
students to receive high school diplomas?
Supplementary Aversives at JRC
aversive therapy using the GED?
How is aversive
defined and which aversives are considered acceptable?
What aversive does
JRC use and with what policies?
What is GED and
how is it used?
behaviors are aversives used to treat at JRC?
How is skin shock used at JRC and what have the results
Is skin shock the same thing as electroconvulsive
How effective is
skin-shock as an aversive?
What percentage of JRC's population is treated
with supplemental skin shock?
For those students who
receive skin-shock, how often is the procedure used?
skin shock have any negative side effects?
What are the different treatment methods for using
What are behavior rehearsal
procedures and what support is there for them?
What safeguards are in place
to prevent skin-shock from being misused at JRC?
Authorized Treatment Plan
Is it true
that some programs use "hidden aversives?"
Why is there so
much opposition to the use of skin shock therapy?
Do positive-only schools expel students who are
subsequently referred to JRC?
Common Objections regarding JRC's Use of Aversives
Does JRC's GED skin
shock device cause burns?
Do students who receive
skin-shock therapy ever "graduate" so that they no longer need this
Can JRC's students be
treated in other programs without the use of aversives?
Contrast Skin Shock with Electroshock Therapy (ECT)
Does JRC analyze the
causes (functions) of behaviors and base its treatment upon that analysis?
Is it true that JRC
uses skin shock to punish minor behaviors?
Is the GED sometimes
used when a student is restrained?
Should skin-shock be
used only with lower functioning students?
How come all other programs
manage without skin-shock?
Is JRC out of the mainstream?
Is the probate court process
to approve skin shock at JRC a sham?
Is JRC's Human
Rights Committee controlled by JRC?
Why has JRC not published on
the GED in peer reviewed journals?
Common Objections regarding Skin Shock
Is skin shock overkill and are
Positive Behavior Support procedures sufficient?
Why are not all the
other residential programs for special needs children using skin shock
You would not use skin shock on a
prisoner or a prisoner of war. Why use it on a handicapped child?
What do you say to people
who say that the use of skin shock is inhumane?
Common Objections regarding Aversives in General
Is there disagreement on
the effectiveness of aversives?
Can aversives be avoided by
a skillful use of rewards?
Can the same results
be achieved with positive-only procedures?
Are aversives only temporary
in their effects?
Does IDEA require the use
of positive behavior supports?
Have aversives been
banned or restricted in other states?
support the right of parents to choose aversives?
Is JRC too expensive?
Is it true that five students
have died at JRC?
What was the
controversy regarding JRC's use of the term psychologist?
JRC's Current Controversy with New York State
On June 9, 2006 the
New York State Education Department (NYSED) released a very negative
report on JRC. Why?
Agencies Review JRC and Find No Support for the Principle Accusations in
the June 9, 2006 NYSED Report
Have the new NYSED regulations put a crimp in JRC's use
"You would not do this to a prisoner or a prisoner of war.
Why, then, should this be done to a handicapped child?"
JRC is a highly specialized and very
successful behavioral treatment program, not a prison. It is entirely
appropriate to treat persons in a treatment center differently from the
way they are treated in a prison. For example, it is perfectly legal
when hospitals inject handicapped children with haldol, thorazine or
other potent anti-psychotic medications when they are prescribed by a
psychiatrist; however, it would not be legal to inject prisoners with
these same medications as part of a person's prison sentence. Many of
these anti-psychotic medications are much more intrusive than JRC's
aversive procedures and have serious and sometimes permanent
side-effects. JRC's treatment has no serious side-effects and has a
record of treatment success for severe behavior disorders that far
exceeds that of anti-psychotic medications.
Society is responsible for providing
effective treatment and education to children with severe behavior
disorders to help them overcome their handicapping problematic
behaviors. This is particularly true when those behaviors are harming
the students' bodies and/or their future development. This
responsibility is recognized in the federal law that mandates school
systems to provide an appropriate education for all children, including
those whose handicaps take the form of behavior problems.
When children are given anti-psychotic
medications to treat their behavior disorders the only result is to drug
the children to the point of near-sedation. This can sometimes (but not
always) stop their severe aggressive and health dangerous behaviors but
it also severely dulls their minds, rendering them unable to learn. Such
drugs have never been approved for use with children, have known harmful
side effects and sometimes have unknown, harmful, permanent and
irreversible side effects that do not appear until years later.
By contrast, aversive therapy, when used as
a supplement to positive and educational programming, has no significant
harmful side effects, is an effective treatment that is often required
only temporarily, and works without clouding the student's mind and body
with harmful drugs. Aversive therapy, used in this way, is a recognized
professional treatment that can save, extend and enrich the lives of
many children with severe behavior disorders. Parents should have the
right to choose this form of treatment for their child if they think
that this is the most effective, least intrusive treatment available.
This is particularly true when a parent prefers a non-drug, behavioral
treatment to the common alternatives of warehousing, heavy psychotropic
medication, seclusion, restraint and takedowns.
A procedure is not inhumane simply because
it involves the application of something uncomfortable or painful.
Inoculations, dentistry, medications and surgery all involve procedures
that may be quite uncomfortable or painful. We judge those procedures to
be humane, however, because when one weighs the future benefits against
the current risks and intrusiveness, the future benefits normally far
outweigh the temporary pain and discomfort that is involved. Aversive
therapy needs to be seen in the same light. Its intrusiveness needs to
be weighed against its significant benefits in the same way.
Unfortunately, those who wish to ban
aversives appear to be unwilling to measure aversives in this way. They
are unwilling to weigh the benefits of aversives against their
intrusiveness. They prefer to simply oppose aversives in a dogmatic,
philosophical manner. Aversives, in their view, are just WRONG with a
capital "W." They prefer to see these children living in psychiatric
hospitals in a drug-induced stupor.
One reason for their unwillingness to apply
a risks/benefits analysis may be that aversives are still relatively new
as a treatment and have not been as widely accepted as have
inoculations, dentistry and surgery. JRC is one of the few programs in
the country that offers this form of therapy. In addition, many persons
are still confused as to the difference between the use of a temporary,
mild electric skin shock as a behavioral treatment to decelerate
specific problem behaviors, on the one hand, and electroconvulsive shock
therapy as a psychiatric procedure to induce brain seizures and treat
mental problems such as depression, on the other. They also seem to
think that JRC applies skin-shock to the students randomly and do not
understand that the skin-shock is only applied as an immediate response
to specifically targeted aggressive, self-abusive or other serious
problematic behaviors that are threatening the individuals' physical
well-being or seriously interfering with their education or access to
The present lack of information and
understanding about the use of skin-shock aversives among the population
at large means that opposing the use of such aversives is currently more
or less "politically correct." When one goes to the emergency room with
a life-threatening problem, one wants the most effective, least
intrusive treatment possible, regardless of whether or not that
treatment is considered to be politically correct. In the same way, when
the parent of a handicapped child finds that his/her child has
life-threatening problematic behaviors, that parent should be able to
select the most effective, least intrusive behavioral treatment,
regardless of whether or not certain uninformed and dogmatic persons
consider the treatment to be politically incorrect or even "inhumane."
Usually the persons who oppose the use of
aversives do not have children with behaviors as severely problematic as
do those parents who wish to keep aversives available as a treatment
option. Usually the opponents of aversives do not have children who are
routinely rejected from, or even expelled from, treatment programs that
employ positive-only treatment procedures. For a better understanding of
what it is like to be a parent of a child with severe behavior problems
that cannot be effectively treated with drugs or positive-only
procedures, please see the group of letters from parents that are found
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"Electric shock therapy used at JRC
-- like "One Flew Over the Cuckoo's Nest."
In a recent news paper article a New York
state official was quoted as saying something to the effect, "Electric shock
therapy [used at JRC] sounds barbaric -- like 'One Flew Over the Cuckoo's
Nest.'" This reflects a common confusion that exists in many people regarding
two very different treatment procedures.
Electroconvulsive therapy, is a psychiatric
procedure used for individuals with severe depression, psychotic depressions,
intractable mania, or people who are not able to take anti-depressants. This
procedure involves putting a patient to sleep with a barbiturate and
administering a drug to temporarily paralyze the muscles so they do not
contract during the treatment. An electrode is then placed above one or both
of the temples and another in the middle of the forehead and a small electric
current is passed through the brain of an individual for approximately 1
second in order to cause a localized seizure that can last from 30 seconds to
more than a minute. As you can imagine this procedure is done as a last
resort and only under the direct supervision of trained medical professionals.
ECT is the type of therapy used in the movie "One Flew Over the Cuckoo's Nest,"
although it has improved dramatically in its administration, safety, and
effectiveness since the movie was released back in 1975.
Behavioral Skin Shock
Behavioral skin shock is sometimes added as a
supplement to a very common form of treatment referred to as behavior
modification, which is based on behavioral psychology. Behavior
modification in various forms is used every day by parents and teachers to
help children learn good behaviors and achieve in education. Simply telling a
child that he/she will earn a special reward if he/she stops tantruming or if
he/she earns a good grade, is a simple form of behavior modification. For
people who engage in life threatening forms of self-abuse and/or aggression
which have been resistant to all other forms of treatment such as psychotropic
medication and in-patient counseling, then safe forms of skin shock or other
aversive techniques such as time-out, can be added to a reward-based
behavioral treatment program. At JRC, for instance, the student is normally
weaned off of psychotropic medication before behavioral skin shock is
employed. It has been very successfully used at JRC as a last resort for the
treatment of case-hardened problem behaviors that have not responded
successfully to heavy and prolonged dosages of psychotropic drugs or other
The behavioral skin shock procedure employed
at JRC involves the passage of a relatively weak electric current through a
small portion of the skin of an arm or leg for two seconds. It is used as a
consequence for certain pre-defined major problem behaviors that have been
targeted for treatment as part of a behavior modification plan. It causes a
level of pain that has been compared to that of a bee sting. It is used as one
component of a behavior modification treatment plan for treating major problem
behaviors displayed by autistic children and children with other problem
The student is first given rewards for not
showing the problem behavior to be treated, rewards for engaging in behaviors
that are incompatible with the problem behavior, and educational procedures to
teach the student how to appropriately and acceptably obtain the things that
he/she might otherwise have to engage in problem behaviors in order to obtain.
Typically, a student is treated, using only these rewards and educational
procedures, for several months to a year before supplementary skin shock is
considered. If these rewards- and education-based procedures are not
sufficiently effective to treat the behaviors, behavioral skin shock the
parent is given the option of adding behavioral skin shock as a supplement to
that ongoing reward/educational program. At JRC, 50% of its population is
successfully treated with rewards and educational procedures alone, without
having to use the skin-shock procedure.
The purpose of using behavioral skin-shock is
to help decrease the frequency of certain target behaviors. Data on the
frequency of the behavior(s) in question are collected and charted to
measure and evaluate its effectiveness. The procedure is done under the
direction of a behavioral clinician.
At JRC, behavioral skin shock is a voluntary
procedure that is employed only at the option of a parent. Prior to using the
procedure, JRC obtains the written informed consent of the parent and the
individualized as well as prior approval of a Massachusetts Probate Court
judge. The procedure is incorporated into the individual's Individual
Education Plan and into a treatment plan that is approved by the Probate
Court. JRC has been licensed to use this treatment by the Massachusetts
Department of Mental Retardation and the Massachusetts Department of Early
Education and Care. JRC's program is also approved by the Massachusetts
Department of Education and is approved as an out-of-state placement for
children by the New York State Department of Education.
The procedure is safe and effective. It has no
side effects. Often it is only needed for a short period. The need for it
diminishes as the frequency of the problem behavior decreases. For many
students, this treatment has been life-saving. Many students at JRC have been
able to be "weaned" off of the treatment procedure and graduate from JRC to
live a normal and productive life. Parents of students at JRC whose children
have benefited from the procedure are strong supporters of the program.
Recently current and former JRC students, who had benefited in their own
treatment by the use of behavioral skin shock, testified movingly on its
effectiveness and value to their own lives before a committee of the
To distinguish between these two procedures it
is helpful to refer to the first procedure as electro-convulsive therapy
and to the procedure employed at the Judge Rotenberg Center as behavioral
skin-shock, or aversion therapy.
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"The JRC students have to wear the GED device for the
rest of their lives, so what's the point?"
In many cases,
particularly for students who function cognitively at a medium or high
level, the GED is required only temporarily, to suppress the frequency
of major problem behaviors. Once those behaviors have been decreased in
frequency, the student is much more likely to display and be rewarded
for desired behaviors, and much more capable of receive instruction. The
new behaviors that the student is able to show, as a result, may now
begin to generate for him/her some of the same attention and other
satisfactions that he or she previously could obtain only by engaging in
As the student's behavior
improves in this way, JRC's clinicians arrange to "fade out" the use of
the GED in gradual steps. Numerous graduates of JRC have left JRC and
gone on to college and work environments and have never had to use the
There are some
lower-functioning students, however, with whom it may be necessary to
keep the GED available over a long period of time. In such cases, the
GED tends to be needed only very rarely and its use is somewhat similar
in function and value to that of an artificial limb or a pair of
eyeglasses. With the GED, the student is able to enjoy a quality of life
that is far superior than that which the student would have had if the
GED were not to remain available.
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"...neither...Israel or his school has ever submitted data on the success of any of these therapies to peer review
The use of skin shock as a
decelerative procedure for inappropriate behaviors is one of the most widely
published behavior modification techniques in the psychological literature.
bibliography for example contains 111 separate papers on the topic, almost
all of which are published in peer reviewed
The behavioral skin shock
device that JRC uses (called the Graduated Electronic Decelerator, or GED) is
simply a another device that administers a 2-second shock to the surface of
the skin. It was designed to be an improvement on the SIBIS device, which has
numerous publications in the professional peer-reviewed literature.
has written a paper that explains its advantages over the SIBIS device.
JRC's primary mission is
not the conduct and publication of peer-reviewed research, but the application
to education and treatment of basic principles and technological strategies
that are already well founded in the professional literature. Indeed, for JRC
to spend its funds on doing and publishing research would be a disallowed
expense under the Massachusetts rules for schools such as JRC.
Most practicing physicians
apply the results of research performed by research biologists, physiologists
and research physicians. Similarly, JRC is devoted to the practice of
behavioral treatment, rather than the conduct of the basic research that
practitioners rely on.
JRC has, however, made
number of papers that
describe our treatment procedures, in great detail and that report the data we
have obtained. For example, our website includes papers that describe the
following aspects of our use of the GED skin shock device: 1.
features of the GED behavioral skin shock device
Its success in
treating one or two of our most difficult clients
Its effectiveness as compared with the SIBIS skin shock device
overall effectiveness in treating the last 36
students who were authorized for its use.
Our website also contains
the following: 1. The full text of
14 professional papers,
of them from peer reviewed journals
dealing with electric shock 2.
A complete bibliography of 111 of
articles documenting the effectiveness of skin shock 3.
A copy of a summary of
the 1987 National Institute of Health Consensus Conference Report,
acknowledging that skin shock was a legitimate decelerative procedure with
professional support in the literature.
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"Aversives are only
temporary in their effect. When you stop using them, they lose their
effect. So why bother, if the behavior returns as soon as the procedure is
no longer used?"
This statement faults
aversives for failing to do something they were never intended to do â€“
i.e., to produce not only response reduction, but also long-term
generalization and maintenance. We should first note that many
educational and medical procedures do not produce long-term effects
that remain in place long after the procedure is removed. For example,
reward procedures produce an increase in the frequency of the behavior
that is rewarded; however, if the rewards are removed, the behavior will
return to the frequency it was at prior to the introduction of the
reward procedures, (unless some other rewards have come into play to
keep the behavior going). For another example, drugs cause certain
effects while they are taken. Those effects rarely, if ever, continue
long after the drug is discontinued.
The fact that a
procedure may be needed on a long term basis, does not mean it is
useless. Artificial limbs, eye glasses and hearing aids may be needed on
a long-term basis, but this does not make them useless. When a person
uses them, a major improvement in the person's quality of life becomes
possible. As a result, most persons consider that the benefits that
these prosthetic devices confer far outweighs the inconvenience involved
in wearing them. The same is true for the use of aversives with some
lower functioning self-abusive and self-mutilating children. Without
them, the child is often in danger of losing his or her life or of
suffering self-mutilation. With the occasional use of them, however,
lives and limbs can be saved and the student can have a decent quality
Click here to see proof in the form of before-and-after films and
experience shows that in most cases the need of aversives gradually
diminishes over time, even in the case of such lower functioning
self-abusive children. In most cases fewer and fewer applications of the
aversives are required as time goes on. For evidence of this, see the
charts we show of students who were started on the GED at some point
during the period 2003-2005. These charts show that as time goes
on, the number of GED skin-shock applications gradually diminishes to
zero or near-zero.
Even though an aversive
may reduce a behavior only while the aversive is being applied, this is
still a very significant effect, because it creates a window of
opportunity for strengthening certain other behaviors which may produce
their own natural rewards and therefore keep going after the aversive is
removed. For example, consider the case of a student who has been
refusing to attend school or cooperate with a teacher, and has been
languishing at home or in a psychiatric hospital before coming to JRC.
This might, for example, be the case of a student who is so aggressive
that he fights all the time, and has been excluded from school because
of his aggressiveness. If he is enrolled at JRC, and aversives are used
to get him to attend school, stop fighting with others, and cooperate
with the teacher, the student may, for the first time in his life, begin
to acquire new skills in reading, math, self-care, vocational skills,
playing new games and sports, socialization, etc. When the student
acquires these new skills, he may begin to be able to do useful and
enjoyable things that were never before possible. These new skills, in
turn produce their own rewards and therefore may keep going even without
any help from aversives. In effect, the student's whole life can be
turned around in a positive direction. He or she acquires self-esteem,
pride in his accomplishments and hope and optimism for his future. His
parents become proud of his accomplishments and begin to enjoy his
company and his home visits for the first time ever. If one reads the
letters to the New York legislators and Board of Regents that the JRC
parents have written as part of their campaign to keep New York
legislators from banning aversives and the Board or Regents from
removing JRC from New York's approved list of out-of-state schools,
one sees the pattern that I have described here occurring over and over.
In other words,
aversives, even if they only produce behavior reduction while they are
employed, have an effect similar to training wheels on a bicycle. They
can play the role of a temporary support device that enables a student
to start acquiring behaviors that were impossible to acquire until the
excessive anti-social behaviors were reduced.
This pattern of a
student changing his entire orientation to life once aversives have
helped him control his excessive anti-social behaviors is particularly
found when aversives are employed with higher functioning students.
These students can be changed from students who are headed for a wasted,
warehoused life in mental hospitals or prisons into productive
taxpayers. This is why Deputy Commissioner Cort's objection to JRC's use
of aversives with higher functioning students, in her
memo to the Board of Regents is particularly unfortunate. To
hear some of our higher functioning students tell you how aversives have
helped them to turn their lives around,
please click here.
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"There is no need for
aversives because positive programming can successfully treat problem
been controversy surrounding the use of aversive procedures for some time.
The most recent chapter in this controversy began in 1981 when an
organization called The Association for Persons with Severe Handicaps (now
called by its acronym TASH) adopted a resolution banning the use of all
aversive procedures. Creighton Newsom and Kimberly Kroeger have written a
chapter called Nonaversive Treatment
in Controversial Therapies for Developmental Disabilities in which
they trace the history, contributions and harm done by this movement over
the years. They write:
movement has led directly to school and provider policies in many communities of
excessive consumer choice and "hands-off behavior support," policies that over
time can and have produced individuals who become increasingly self-injurious,
routinely damage their homes or classrooms, or intimidate and injure peers and
staff. In the name of treating such individuals with "respect and dignity," such
providers are condemning them to certain institutionalization or incarceration.
Examples of misguided policies occur frequently at meetings about adult clients'
problem behaviors in community settings, usually in the context of discharging
the client. At one such meeting recently the workshop supervisor mentioned that
their new behavior support policy classifies "telling a consumer not do to do
something they want to do" as aversive because there's this big push to give
people choices and let them do whatever they want to do regardless. The issue
under discussion was whether or not the client should be allowed to run out of
the workshop into a busy street. The group home manager stated, "We have no
consequences. If a person needs hands-on to control his behavior, he's not
appropriate for our program." As a result, unintended consequences of
excessive client choice and hands-off policies are often the increased use of
psychotropic drugs and the frequent use of hospital emergency rooms or
developmental centers to deal with crises."
During the early 1980's the leaders in the field of Positive Behavior Supports
managed to secure a large multi-year grant from the Department of Education
that is now a national network of Rehabilitation Research and Training Centers
on Positive Behavioral Support. Many of the professionals and advocates who
oppose the use of aversives call their field "Positive Behavior Supports"
(PBS). Positive Behavior Supports are sometimes cited as a desirable
alternative to punishment procedures such as the GED skin shock used at JRC.
Positive Behavior Support for People With Developmental Disabilities,
published by the American Association on Mental Retardation in 1999, is the
most comprehensive review of the literature on Positive Behavior Supports that
has ever been done. The authors of the paper are among the most distinguished
names in the field of positive programming. The paper reports on a review of
216 published studies, in each of which positive programming was used, and
which appeared in 36 different journals.
The bottom line finding was that
programming was effective in 50% of the cases.
Effective was defined as decreasing the frequency of the behavior by 90% from
its "baseline" level (the level it was at prior to the start of treatment).
This is commendable, but it raises the question, "What about the other 50% of
the cases in which the treatment does not work?" That is where programs such
as JRC come in. JRC serves the cases where positive programming alone fails to
treat behaviors effectively.
assertion that the positive programming in these studies was effective in 50%
of the cases probably gives an exaggerated impression of just how effective
the treatment really was, because:
As Dr. Foxx
has shown in his chapter entitled "Severe Aggressive and Self-Destructive
Behavior: The Myth of the Nonaversive Treatment of Severe Behavior,"
the types of behaviors that the Positive Behavior Support persons do their
studies on are generally nowhere near as severe as the case-hardened
self-abuse and aggression that JRC is required to treat.
The standard of effectiveness used - reducing the problem behavior by 90%
from its baseline level -- is not really an adequate standard for clinical
work with dangerous behaviors. For example, suppose a student was engaging
in life-threatening head-banging at the rate of 1000 head bangs per day
prior to the treatment and this is reduced to only 100 head bangs per day as
a result of the treatment. This would meet the study's criterion of a 90%
reduction from baseline; however, from a clinical point of view it would not
be rated a success.
Behavior Supports is not really a scientific discipline. It is a group of
persons who are ideologically committed to opposing the use of aversives and
supporting certain other related ideologies such as normalization,
inclusion, person-centered planning, etc. In a chapter entitled, "Positive
Behavior Support: A Paternalistic Utopian Delusion,"
by Dr. James Mulick and Eric Butter, the authors note that the field of
Positive Behavior Supports is a mixture of three sources: applied behavior
analysis (which is a science) plus the two ideologies of the normalization
movement in human services and what are called "person-centered values." The
authors summarize their findings as follows: ". . .whatever else it may be,
PBS[Positive Behavior Support] is not science, but rather a form of illusion
that leads to dangerously biased decision making."
Because of the ideological allegiance that PBS journals demand of both its
authors and reviewers, the quality of peer review that PBS articles receive
is not up to standards of the non-ideological journals in the mainstream
behavior analysis field.
A recent 2005
by several prominent PBS practitioners surveyed the opinions of 134 experts in
the field of Positive Behavior Supports. The experts were asked what treatment
procedures they considered to be acceptable. Surprisingly, 10% of the Positive
Behavior Support experts considered contingent skin shock to be an acceptable
procedure. All of those who considered it to be acceptable did so because they
viewed it as "effective."
We at JRC really wish it
were true that there was a technology of positive-only interventions that was
so effective that JRC would not need to use its GED procedure any more. If
there were such a technology, JRC would certainly want to use it and stop
using the GED. After all, why would we want to risk the future of JRC every
single day, by using such a controversial procedure as the GED skin shock, if
there were a more politically correct and non-controversial way of treating
the same behaviors? Wouldn't we be dummies to be continuing to use the GED?
Unfortunately, a careful
look at the facilities and programs that profess to use positive behavior
supports to control behavior tends to reveal the following:
Often, such programs
are just not dealing with the level of case-hardened problem behaviors that
JRC deals with. And when they do come across such students they sometimes
refer them to JRC!
In cases where such
positive-only programs are dealing with students with difficult
behavior problems, they tend to be doing one or more of the following
They may just
substitute a lot of extra staff to hover near the student at all times,
ready to jump in and prevent problem behaviors from occurring when they
start. But this is not treatment; it is more like guard duty and
may not be putting any demands on the student to work, study, or
cooperate. They may just let the student do nothing all day. The
philosophy is, "If he doesn't bother us, we won't bother him." The result,
again, is warehousing.
They may give the
student so much psychotropic medication that the individual is in a kind
of stupor, is sleepy and has little energy to do anything. Heavy
medication that produces that result is not real treatment. It is, again,
a kind of pernicious warehousing.
They may be using
aversives, but hiding them under nice-sounding names. Five staff members
grabbing the student and forcing him to the floor each time he/she is
aggressive is called a "reactive procedure" or "containment" or "required
relaxation," and is definitely not called a "punishment." Isolating the
student in a room alone as a consequence is called "cooling off" or "time
out" and is not recognized as the punishment that it often is. Grabbing
the student harshly on the shoulder or arm, and squeezing it hard, when
the student does something inappropriate is called "redirection" rather
than the punishing consequence that it really is. You are safer to have
your child in a program that calls a spade a spade and a punishment a
JRC's professional staff
are fully familiar with the techniques that comprise the field of Positive
Behavior Supports. Those techniques are essentially the same positive
programming procedures that JRC employs when a student first enters JRC. In
fact, we know of no program that goes to greater lengths to create a powerful
set of positive procedures. Witness our Big Reward Store, the little reward
stores in many of our classrooms, the weekly Reward Afternoon, the reward
boxes in many of the classrooms, the two Contract Stores, the variety of
behavioral contracts that are used simultaneously, the computer based
educational system with self-instructional software, etc. It is only if and
when such positive and educative procedures are insufficiently effective, by
themselves, in decreasing problematic behaviors that JRC supplements them with aversives such as the GED skin shock.
Those professionals who
publish in the Journal of Positive Behavior Supports are largely the same
behavioral psychologists who have long been in philosophical opposition to the
use of aversives. Behavioral psychologists come in many different flavors.
Some of them, like many advocates, are simply unwilling to weigh the risks and
benefits of the use of aversives and reject their use on philosophical
grounds. Others simply realize that their professional life will be a lot
smoother if they do not go down the road of using aversives, even if they know
in their heart that a combination of rewards and effective aversives may be
the most efficient way to treat serious problem behaviors.
The use of aversives is
so controversial that JRC is just about the only program that uses them
openly. The controversy has also had an impact on what is published in the
journals. Very few articles are now published in the area of aversives and on
skin shock. JRC's treatment is so effective, powerful, and humane, however,
that we are loathe to give it up in favor of something more politically
correct. It has been around since the 1960's and it has enormous support in
the professional literature (111 papers in our bibliography for example). It
may not be the flavor of the month, but it works marvelously well and saves
and enriches the lives of our students.
Carr, E. G., Horner, R. H.,
Turnbull, A. P., Marquis, J. G., Magito McLaughlin, D., McAtee, M. L.,
Smith, C. E., Anderson Ryan, K., Ruef, M. B., & Doolabh, A. (1999).
Positive behavior support for people with developmental disabilities: A
research synthesis. Washington, DC: American Association on Mental
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are food rewards used in JRC's behavioral treatment?
First, let me point out that our
food programs, which will be explained below, are used with students who have
extremely dangerous, often life-threatening, or bodily-injurious behaviors.
B.S. is a case in point. Some of the problematic behaviors that he brought to
JRC were these: biting off parts of his tongue; biting his cheek to the point
of opening a hole in his cheek; refusing to eat or swallow his medication; and
ruminating (regurgitating food from his stomach) and the projectile vomiting
of this food at others. The biggest problem with the projectile vomiting is
that as a result of it, B.S. brought himself close to the point of starvation
through the loss of weight.
Behaviors such as those that B.S.
showed have sometimes proven to be resistant to all other forms of treatment
offered outside of JRC, such as drugs, educational procedures, counseling, and
medical treatment. For example, at one point we sent B.S. for two weeks to
Boston Children's Hospital to see if the physicians there could find any
medical solution to his life-threatening behavior problems. They could not.
The facts of B.S.'s case were summarized by the Massachusetts Supreme Judicial
Court in its opinion affirming the lower court's decision to approve continued
use of JRC treatment program. The opinion can be found at 424 Mass. 482
A common behavioral tool for the
treatment of such problem behaviors is to make a "behavioral contract" with
the student in which, if he is able to show certain desired behaviors (e.g.,
not banging his head against hard objects) for a certain period of time, the
student earns a reward. For some low-functioning students, the usual rewards
that you or I might work to earn, such as money, good grades, etc., may not be
effective. B.S. is a case in point. For such a student the mealtime food may
be the most effective reward that one can offer.
When JRC employs mealtime food to
motivate the students to change their behaviors, the food is used under either
of two alternative treatment programs--the
Contingent Food Program (in which
all food missed through contracts is made up at the end of the day) or the
Specialized Food Program (in which
the make up procedure is more restrictive).
Neither of these programs can be used unless JRC obtains prior
informed consent by the parent, prior approval from a physician and prior
authorization by the Probate Court as part of an individualized substituted
Out of our 245 students we are
employing the Contingent Food Program with only 22 students (9%) and the
Specialized Food Program with only 3 students (1%).
When food is used as a reward,
under either the Contingent Food Program or the Specialized Food Program, the
student's breakfast, lunch and dinner are divided into "mini-meals" small
portions of food that are earned one at a time. Successive "behavioral
contracts" are then set for the student, in which, if he can go for a certain
period of time without showing some problem behavior, he can earn a mini-meal.
For example, we might set a 5 minute contract for not hitting one's head. At
the end of 5 minutes, and providing the student has not hit his head during
those 5 minutes, the student would earn one portion of his breakfast. After he
eats that portion a second 5 minute contract would be set. The student can
then earn that second portion of breakfast by going for another 5 minutes
without displaying the self-injurious behavior. And so on. These contracts
would continue to be set, one after another, throughout the morning. Lunch and
dinner would also be divided into mini-meals and handled in the same manner.
In effect, the contracts are carried out continuously throughout the day. In a
16-hour day there would be a large number of contracts set for the student,
the actual number depending on the length of the contract.
In order for these contracts to
be effective, the student must be prevented from obtaining food by any method
other than by passing his contract to not hit his head during the 5 minute
period. Obviously, if the student were allowed to eat all of his normal three
meals at the usual times, regardless of whether or not he was showing any
problem behaviors, he would not be motivated by food and he would have no
incentive to try to pass any of the contracts by stopping the banging of his
head. He would continue to bang his head.
If the student passes each of the
behavioral contracts that are set for him, he will earn all of what otherwise
would have been served to him at his breakfast, lunch and dinner meals. In
other words, he will earn 100% of the amount of calories that would have been
offered to him at those three meals.
If the student fails to "pass"
one or more of his contracts, he is not given the food portion(s) that is(are)
the potential reward(s) for that contract(s). Whether or not the food that was
missed, as a result of those failures to pass contracts, will be made up later
in the day depends on whether the student is on the
Contingent Food Program or the
Specialized Food Program.
The Contingent Food Program
At the end of the day, we offer
to students who are on the Contingent Food Program a make-up meal that is
composed of chicken and mashed potatoes with liver powder sprinkled on top and
that will make up all the calories that the student will have missed by not
passing one or more of his contracts earlier in the day. This make-up food is
deliberately intended to be an unattractive option, however, because we want
the student to be motivated to earn the portions of real mealtime food that
can be earned by passing the behavioral contracts.
Despite these procedures, we occasionally find one or two students who seem to
prefer the make-up food to the regular menu food that they can earn by passing
their contracts. They appear not to mind failing their contracts and then
eating one large meal at the end of the day. When this occurs, we cease using
this food program and, if we have the parent and court authorization to do so,
we switch to the use of the Specialized Food Program described below.
There are a variety of safeguards
that are in place before the Contingent Food Program can be employed,
including the following:
The procedures must be approved
by the parent (informed consent) prior to their use;
JRC's consulting physician
examines the students and must give medical clearance for use of this
The procedures must approved,
prior to use, by a probate court as part of an individualized treatment plan
that is authorized for that student;
The student's daily caloric
requirements are determined by a registered dietician in consultation with
JRC's medical staff;
The student's menu is designed
by a nutritionist;
The number of calories consumed
by the student each day is recorded;
The students are examined
periodically by JRC's nursing staff; and
The students are weighed daily.
The Specialized Food Program
For students on the Specialized Food Program
(currently it is being used with only 3 out of our 245 students) we do not
offer make-up food to compensate for food that the student missed by failing
to pass his contracts unless he has eaten 25% or less of his normal daily
caloric target. If he has eaten 25% or less, he is offered make-up food to
bring him up to the 25% level. Normally this provision is never brought into
play for two reasons: (1) the typical student passes the vast majority of
his contracts during the day; and (2) if the student fails to pass a
significant number of his contracts, the clinician may shorten the length
of the contract period, thereby it easier for the student to pass the
The medical safeguards in place
for the Specialized Food Program include all of the safeguards for the
Contingent Food Program plus the following:
each student at JRC, the medical staff determines the student's ideal weight
based on the student's body frame and height. To do this, the medical staff
refers to standardized charts which provide ideal weights based on body
frame and height. The ideal weight range is defined as the range from 90% to
110% of the "ideal weight." All students are maintained 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.
Baseline blood work is done for the student prior to the initiation of the
specialized food program;
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 his/her recommended daily caloric intake;
(b) if a member of the JRC medical staff determines that such a test is
student is offered unlimited amounts of fluids;
electrolyte content in the student's blood is measured prior to the time
that he or she enters 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 they might
be measured when there is a major change in the student's medical status;
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;
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. 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
forwards the status of the student's weight to the consulting physician,
each week; and
food program is suspended or otherwise appropriately altered if a student's
weight dips below the red line value.
We have been employing these food make-up
procedures for almost 20 years and have not experienced any problems with
their use. One of our clinicians has done a careful study of the
Specialized Food Program. He found that the average student on this programs
gains, rather than
As noted, the students tend to pass most of their
contracts. If a student is having difficulty passing his contracts, the
clinician may shorten the duration of the contract to make
passage easier (e.g., he could, for example, diminish the period of the
contract from 5 minutes to 1 minute). I cannot recall a single case in which a
student passed so few of his contracts that we had to bring into play the
provisions of the Specialized Food Program that involve the need to bring a
student, through the provision of makeup food, to 25% of his normal daily
The overall purpose of these food
programs is to make sure that the student is adequately motivated to earn the
food that is used in the behavioral contracts. This in turn creates a very
effective reward which JRC has used quite successfully to eliminate dangerous
forms of health dangerous and aggressive behavior. These are often dangerous
behaviors that were resistant to all previous forms of treatment such as
psychotherapy and drugs. We regard the use of both of the Contingent Food
Program and the Specialized Food Program as less intrusive than the use of our
skin-shock punishment procedure. The more effective that we can make our
behavioral contracts, through the use of such food programs, the less often we
need to employ the skin-shock procedure. In other words, the behavioral
contracts, coupled with the two food programs, are part of our strategy to
minimize our need to rely on the use of the skin-shock procedure.
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"The program is too expensive"
JRC is a kind of
behavioral hospital and has many of the same costs that any hospital has in
order to function 24 hours, 7 days per week, 365 days per year. We pay the
highest level of wages to our direct care staff of any comparable program in
our area in order to ensure that we can have a carefully selected, well
trained and supervised treatment and education staff. We employ 1170 staff
members for 255 students and maintain 4 office buildings 48 residences, a
fleet of vans and trucks, etc. The physical plant of our buildings and
residences is unmatched in its beauty, decoration and cleanliness. We have 35
staff members whose only duty is to ensure quality control. For all of this,
our tuition is much less than the cost of keeping an individual in a
psychiatric facility and is about average for intensively staffed residential
treatment programs of our kind.
There are two ways in
which, although our tuition is substantial, placing a child with us can save a
school district money:
our treatment is so effective, we have better control over our students'
behaviors than most programs have. As a result, we are able to dispense with
the costs of extra 1-1 staffing that many schools and programs of our kind
charge when they accept difficult-to-treat students. During the 2005 year we
calculated the amount of money we were able to save for the programs that
place children with us. The total savings were $783,288.
A table showing how this figure was calculated is
students go through a succession of ineffective residential placements
before they get placed at JRC. If they had been placed with us at the
beginning of their placement history, our ability to accomplish rapid and
effective change in the students' behaviors could have saved many years of
costs of the prior ineffective residential placements. Recently we
calculated the savings that could have been accomplished for one of our
successful graduates of our GED treatment.
The table showing the savings is
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"Skin shock is cruel and inhumane."
The GED behavioral
skin shock treatment procedure is dramatically effective in saving lives and
in rapidly turning around the lives of our students so that they can be
happier, healthier and more productive. In some cases it enables them to
return to public school, to competitive job or to being able to live normally
in an independent fashion. The procedure involves 2 seconds of discomfort and
the average student receives one two-second application per week. There are
absolutely no negative side effects. The principal side effects are that the
student behaves better and better, makes more of his behavioral contracts,
enjoys more rewards, becomes happier and develops a better self-concept. What
is cruel or inhumane about that?
What is really cruel
and inhumane are the alternatives to the use of the GED skin-shock, which tend
to be these:
medication. For the students that are referred to JRC such medication
has not worked. If it had, the student would never have been referred to
JRC. If you fill a student with enough medication, he/she can become a kind
of drooling zombie, with little energy and with a tendency to sleep much of
the time. The medication may also have permanently disabling effects on the
body, including on the nervous system. To us at JRC, that is cruel and
inhumane. Why are the anti-aversive advocates so upset about a harmless
skin-shock but hardly upset at all at largely ineffective and permanently
injurious psychotropic medication?
mechanical restraint. Some problem behaviors can be controlled and
prevented by putting the student into continual manual or mechanical
restraint. To manually restrain a vigorous young man can take the efforts of
many staff members and is inevitably a dangerous exercise. Putting a student
in continuing restraints is much more cruel than changing his/her behavior
quickly with a powerful positive reward program that is supplemented with
occasional two-second skin shocks.
It is important to note that there are some behaviors that cannot be
prevented even with manual or mechanical restraint. For example, the
behavior of biting off parts of one's tongue, biting a hole through one's
cheek with one's teeth, refusing to swallow food or medication, breaking one's own arm, and rubbing a leg against the inside of a plaster cast until
the skin is infected, are all behaviors that cannot be controlled with
manual or mechanical restraint. They are, however behaviors that can be (and
have been, at JRC) successfully treated with the GED treatment program of
rewards supplemented with skin shock.
Another alternative that is used frequently is to simply not place any
demands on the student at all. Just leave the student alone, feed and house
him/her, but do not try to get the student to do anything that he/she does
not want to do. Don't try to teach the student new skills and don't try to
decrease the problem behaviors. This abdication of any responsibility to
provide education or treatment and is clearly inhumane, because it treats
the individual in some respects like a caged animal.
staffing. A very popular alternative is to assign one or two persons to
stay close to the individual at all times, ready to jump in and prevent any
problem behaviors when they start to occur. This strategy may temporarily
prevent problems, but it is also an abdication of the responsibility to
provide education and treatment. Throwing a lot of staff into a room into
close proximity with a student who has major problem behaviors is not the
same as treating those behaviors so that they no longer are problematic.
There have always been
persons of good will and good intentions who are strongly opposed to aversives.
They oppose aversives with the same passion and mission as those who strongly
oppose the use of animals in research (animal rights advocates) and the
procedure of abortion. A notable characteristic of those who oppose aversives,
whom some have termed the "anti-aversive advozealots," is that they are
unwilling to evaluate aversives by scientifically weighing their pros and
cons, or by evaluating their benefits against their risks. They believe that
these practices, regardless of what practical benefits they may give to
individuals or to mankind, are simply Wrong (with a capital "W")
Even if one were to point out the fact that the use of aversives treatment
procedures, as a supplement to other reward procedures, have saved persons'
lives that otherwise would have been lost (something that is clearly true),
that would not convince such persons to allow aversives to be used.
Conversely, even if the removal of aversives leads to a child's death, that
would not be enough to convince them that there might be a legitimate place
for the careful, controlled judicious use of aversives in such severe cases.
In fact we had just such
a case at JRC. A severe self-abusive student who had
come to us in a wheelchair had, with the help of aversives, as a supplement to
his program that was otherwise overwhelmingly positive in nature, managed to
stop his scratching and even attend public high school in Attleboro Mass.
However, the anti-aversive advozealots managed to convince the young man's
mother to remove the student from our care and to allow her son to be
transferred to an anti-aversive service organization who placed the young man
in an apartment in Brooklyn that he shared with another student. (The story of
this young man, named James Velez, was told by reporter Sonny Kleinfeld on two
straight major front page articles in the New York Times.) Within about 9
months of James' departure from JRC, however, I was reading the obituary of
this young man in the same New York Times. He had scratched himself to death
(the scratching had led to blood poisoning and eventually, to paralysis).
Nonetheless the anti-aversive advozealots still claimed that they had
"liberated" him from JRC and to this day probably still believe that he
represented a shining example of the fact that handicapped persons can live a
normal life and do not have to be treated with aversives.
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"Aversives and the GED
skin-shock are overkill. Recent developments in the field
of Positive Behavior Supports show that even severe behaviors can be
successfully treated with positive programming only."
Positive programming is often
cited as an alternative to punishment procedures such as the GED skin shock
used at JRC. The paper, "Positive Behavior Support for People With
published by the American Association on Mental Retardation in 1999, is the
most comprehensive review of the literature on positive programming that has
ever been done. It is a review of 216 articles in which positive programming
was used, and which appeared in 36 different journals. The authors of the
review are among the most distinguished names in the field of positive
The basic finding of this paper,
however, was that positive programming was effective for only 50% of the
cases. The question is, "What about the other 50% of the cases that cannot
be treated successfully with positive programming?" Other treatment options
must be available that can reduce the frequency of dangerous behaviors to a
level where the individual is no longer a danger to him/herself or others.
Behavioral skin shock is a well established treatment that can accomplish this
At JRC, we employ all of the
available positive programming methods in an attempt to decelerate problem
behaviors. We believe that our positive only programming is stronger and more
varied than can be found in any other program in the country. Witness our big
reward store, contract stores, classroom reward stores, reward boxes in
classrooms and reward activities (such as field days). Positive only methods
are used continuously throughout treatment, even when supplementary aversives
are part of an individual's treatment plan.
In 2005 an article appeared in the
Journal of Positive Interventions -- a key journal of those who support
positive-only interventions reporting a survey that was taken among 134
persons who are considered to be experts in positive programming. These
experts were asked to evaluate the acceptability of a number of treatment
techniques. The paper
reported the surprising
result that 10% of these experts
in positive programming found the use of behavioral skin shock to be an
acceptable form of treatment.
What makes this result even
re the fact
that the 134 experts were gathered from fields that would be the least likely
to support intrusive procedures. Indeed one of the authors has testified in
two of JRC's
court hearings against ever using contingent shock for anyone and is a member
of TASH, is an organization that would like to close our facility.
Carr, E. G., Horner, R. H., Turnbull, A. P., Marquis, J. G., Magito
McLaughlin, D., McAtee, M. L., Smith, C. E., Anderson Ryan, K., Ruef, M. B., &
Doolabh, A. (1999). Positive behavior support for people with developmental
disabilities: A research synthesis. Washington, DC: American
Association on Mental Retardation.
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"In 1997 the Individuals with Disabilities Education Act
(IDEA) was amended to explicitly require the
use of positive behavioral supports and services for students with
The above statement that IDEA "explicitly requires the use of positive
behavioral supports and services" implies that aversives are prohibited by
IDEA. However, that is a serious misrepresentation of what the IDEA really
In a recent
book, Controversial Therapies for Developmental Disabilities,
James Mulick and Eric Butter wrote an excellent chapter entitled, "Positive
Behavior Support: A Paternalistic Utopian Delusion." They write that:
"PBS [Positive Behavior Support -- my insertion] leaders even managed to use
their inside status with the U.S. Department of Education to insert a vague
and somewhat ungrammatical reference to the following in the 1997
reauthorization of IDEA (Public Law 105-17, p.57):
(B) CONSIDERATION OF
SPECIAL FACTORS- The IEP Team shall:
in the case of a child whose behavior impedes his or her learning or that of
others, consider, when appropriate, strategies, including positive
behavioral interventions, strategies and supports [italics added] to
address that behavior (Public Law 105-17, p.57)
(C) REQUIREMENT WITH
RESPECT TO REGULAR EDUCATION TEACHER--
The regular education teacher of the child, as a member of the IEP Team,
shall, to the extent appropriate, participate in the development of the IEP
of the child, including the determination of appropriate positive
interventions and strategies [italics added] and the determination of
supplementary aids and services, program modifications, and support for
school personnel consistent with paragraph (1)(A)(iii). (Public Law 105-17,
. . .There
is no other reference even vaguely related to PBS in the law."
Note that in section B, dealing with the IEP team, positive behavior supports
are not mandated. What is mandated is simply that the IEP team should consider
them. Also notice that the phrase "positive behavioral interventions,
strategies and supports" are said to be included in what are referred to
simply as "strategies," implying that there might be other types of strategies
to be considered as well. Also note that there is absolutely no prohibition
against the use of aversive therapy procedures.
Note that in section C, positive behavior supports again are not mandated. The
regular education teacher is simply to participate in determining the
"appropriate positive interventions and strategies." The regular education
teacher is also to participate in determining "supplementary aids and
services, program modifications, and support." Supplementary aversives could
easily be considered to be included in "supplementary aids and services,
program modifications, and support." Again, there is no prohibition against
aversive therapy procedures.
There is nothing problematic for JRC in the fact that the 1997 reauthorization
of the law encourages positive programming. JRC believes in positive
programming and has an unusually strong component of positive programming. JRC
tries positive programming first, usually for a substantial period of time,
before considering the adding of supplementary aversives. Fifty percent of
JRC's students are successfully treated with positive programming alone.
JRC received a very favorable
review after a 2 day visit by NYSED staff in September, 2005. No mention was
made in that report of any concerns that JRC was violating the IDEA due to its
use . Similarly, an extensive review of JRC was done by NYSED in 1999, at the
conclusion of which JRC continued to be fully approved. No mention was made in
the report associated with that visit, either, that JRC was in any violation
of the IDEA.
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"The GED skin shock
may be alright to use with lower functioning students but should not be used
with students who have higher levels of cognitive functioning."
JRC's belief is that if a treatment procedure is effective, JRC should make
it available to the parents of all of our students who wish it for their child
and not limit its availability to those who function at a low cognitive level.
To do so would be to discriminate against the higher functioning students.
The GED skin-shock procedure, when applied to higher functioning students is
even more effective than it is with lower functioning students. Dr. Israel,
JRC's Executive Director, reported this in a paper he presented at the 2002
annual convention of the Association for Behavior Analysis. The paper is
can be found
As noted there, in some cases higher functioning students stop their
problematic behaviors as soon as they are informed that we have secured court
approval for the use of the GED, and we never actually have to make an
application. In other cases, the behavior decreases in frequency much faster
and more precipitously than it does when the GED is applied to lower
Higher functioning students sometimes even request that the GED skin shock be
added to their treatment programs. This is because they clearly see how much
it has helped other students who function at their level, and who have
obviously benefited once they started on the treatment. They see that other
students (who have started GED treatment) do one or more of the following
things: avoid being restrained; advance from spending time in one of our Small
Conference Rooms, or in one of our Alternative Learning Centers, to being able
to work in a regular classroom; earn more rewards; go on field trips; advance
to a higher level residence with fewer staff and more privileges; and
generally be happier and have a higher quality of life.
Higher functioning students are able to tell others how much it has benefited
them. The testimony of such students at a recent legislative hearing for an
anti-aversives bill in Massachusetts was extremely compelling. Two of the
higher functioning students who testified were former students who had
benefited from GED treatment while they were enrolled at JRC and who appeared
at the hearing voluntarily to help JRC deal with the proposed legislation.
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"there is extensive research and disagreement
as to the efficacy of the use of aversives."
This is not true. An event, when used as a consequence for behavior, is called
an aversive if it decreases the future frequency with which that
behavior occurs. If it does not, it is not even called an aversive. Aversives,
in other words, are by definition effective in decreasing the frequency of the
behaviors they are used to consequate.
Even supporters of nonaversive treatment acknowledge the effectiveness of
aversives when used to decrease the frequency of problem behaviors. Michaels,
Brown and Mirabella, in their important review article surveying what
procedures are acceptable to a group of nonaversive experts, all of whom were
strong supporters of nonaversive treatment, acknowledge that the professional
literature shows that both nonaversive and aversive treatments are effective.
literature base reveals, there is supportive literature demonstrating the
effectiveness of the full range of decelerative consequence-based procedures
(e.g., Ricketts, Goza, & Matese, 1992; Wiliams, Kirpatrick-Sanchez & Iwata,
1993), and literature that supports the use of alternative [nonaversive]
procedures (e.g., Horner et al., 1990; Jackson & Panyan, 2002; Koegel,
Koegel, & Dunlap, 1996). If the literature is available to support any
position, then likely other factors contribute to professionals' decisions
concerning the use of the procedures."
Critics of aversive procedures sometimes acknowledge that aversives are
effective when used to decrease the frequency of a behavior. But, they point
out, the behavior sometimes returns to its pre-treatment level when the
aversives are withdrawn from use. The problem with this argument is that it is
faulting aversives for something they were never intended to be able to do
"i.e., to continue to cause a behavior to be low in frequency long after they
are no longer used as consequences for behaviors. As I have pointed out in my
Letter to Bob Frank behavior tends to adjust to whatever the current
contingencies are in the individual's environment. Expecting an aversive
consequence to keep having its effect long after we have stopped using it is
to criticize aversives for something that we have no right to expect them to
The same criticism can be made of positive rewards. They, too, can be said to
be temporary in their effect. They increase the frequency of a behavior when
they are used; however, when they are discontinued, we do not expect them to
keep having their accelerative effect long after we have stopped using them.
I have also pointed out in my letter to Bob Frank that letter that even
though aversives may be temporary in their effect, they nonetheless can create
a window of opportunity during which rewards and educative procedures can be
used to teach new skills. If those new skills produce their own rewarding
consequences and therefore keep going, then the aversives have played a very
important role in making permanent changes in the student's repertoire of
Crighton Newsom and Kimberly Kroeger make the same points in their review of
the nonaversive treatment movement: (bracketed material supplied)
TASH [The Association for the Severely Handicapped] resolution [banning
aversives] was based in part on the board's belief that evidence for the
effectiveness of aversive interventions was 'questionable' and 'on the
observations among board members that these procedures were being both
abused and misused in a variety of settings that serve persons with
disabilities.' (Guess, 1990). However, even Guess own literature review
(Guess, Helmstetter, Turnbull & Knowlton, 1987) like those of other
reviewers, actually showed that punishment procedures were generally
effective in reducing behaviors. The evidence was 'questionable' only in the
sense that punishment was faulted for failing to do more than it was ever
intended to do, that is, produce not only response reduction but also
long-term maintenance and generalization. (There was, however, no
acknowledgment that reinforcement also does not automatically produce
maintenance and generalization of treatment gains.) The main issue was
actually the second mentioned, the misuse of punishment procedures. But
instead of addressing what is a regulatory, credentialing , training and
oversight problem with a proposal for better controls, the TASH board chose
to eliminate aversives as an option altogether.
Return to top
come all the other [treatment centers] in the
country are able to manage without [the use of skin shock]?" (Question asked by Ed Carr, Ph.D.
Professor of Psychology SUNY Stony Brook, in an article about JRC in
People Magazine, April 17.
Many of the programs Dr.
Carr refers to have handled their difficult-to-treat students without skin
shock in a simple way. They have referred them to JRC.
We have compiled a list of all prior placements of all of our current
students who are receiving treatment with the GED skin shock. An examination
of the list, which is shown
clicking here, shows the following:
Students usually come
to JRC only after they have been tried in several other programs. The
average student has been in 3.23 other programs before being referred to
JRC. In one case a student was in 18 different programs before coming to
JRC. He was re-admitted to a few of those programs on multiple occasions.
So actually he had a total of 29 separate admissions before he was placed
at JRC. For a student-by-student analysis showing how many programs each
student was in before coming to JRC,
click here. Although students
sometime leave a program for reasons other than the program's lack of
effectiveness, in most cases if a program is serving a student
effectively, he will remain in that program.
The programs listed
here include many well known programs that have reputations for not
Click here to view the list of these programs and number of
current GED students who attended each.
Click here to view
the same information given
here but displays it in alphabetical order by
name of program.
On the recent CNN
program about JRC's treatment, psychiatrist Bennett Leventhal made the
There are centers, for example, such as the
Kennedy Krieger Institute at Johns Hopkins which uses a positive
reinforcement center and in six to eight weeks has children reduce these
very behaviors. They disappear, the patients are discharged, and rarely
need to be continued with the treatments like -- and never need to use
aversives like shock treatment.
The information on
this page proves this to be false. Two of JRC
current GED students were treated at Kennedy Krieger before being placed
at JRC. A third case, who is not on this list because this list includes
only current students, was James Velez, whose unfortunate story is told on
the JRC website (click on the button
"A Fatal 'Experiment' in Positive
Behavior Support" on the JRC home page). Moreover, contrary to Dr. Leventhal's statement, it was not true that Kennedy Krieger did not use aversives with this student. One of the procedures they tried with James
was the use of ice on the skin as an aversive.
Return to top
JRC mean when they assert that most supposedly 'positive-only'
programs make use of 'hidden
Although, the term
aversive is now largely used to refer to JRC's use of skin-shock, it is
important to understand that every program that works with children with
behavior problems does use one or more aversives. The term aversive
refers to a procedure which, when used as a punitive consequence for a
behavior, has the effect of decreasing the future frequency of that
behavior. Every program has to have certain procedures that accomplish that
result; however, to maintain their political correctness, they do not call
those procedures aversives.
For example if, whenever a student is aggressive, 5-6 staff members
forcefully grab the student, take him to the floor and hold him there until
he stops struggling, that will be called something like "required
relaxation" or an "emergency cooling off." If, whenever a student engages in
property destruction, a student is placed alone for a period of time in a
small bare room, with nothing to do, as a punitive consequence, this is
called "time out" or a "de-escalation procedure." If, whenever a students
starts to run out of the classroom, the student is grabbed and squeezed
forcefully by the arm and moved back to a certain area or position, this is
likely to be called merely a "physical prompt." If, whenever a student
refuses to make his bed, two staff members force him to do so 5 straight
times, by hand over hand manipulation of his arms and hands, this might be
called "overcorrection" or even "positive practice." And so on. In other
words, there is a whole field that might well be called "hidden aversives."
Two important differences between programs that do
this and JRC are these:
JRC is open and
above-board in calling a spade a spade. Which is the better practice one
that hides the aversives from the world, or one that is open about it,
securing court, parental and agency permission for their use?
JRC's aversives are
much safer in that they require much less manual physical force by staff
members against the student. Because other programs do not use a procedure
like the GED skin shock, in those programs the student is exposed to many
more hours of dangerous and confrontational physical struggles with staff
members and of many more hours of wasted time in restraint and isolation
"What are the safeguards that govern the use
of the GED?"
a student is treated, using only rewards and educational procedures, for
several months to a year before supplementary skin shock is considered. If
these rewards- and education-based procedures are not sufficiently effective
to treat the behaviors, the clinician (person with masters or
doctoral level degree in psychology or allied field) must present the student's behavior program and the effectiveness to the Admission Team. The
purpose of the presentation is to ensure that the clinician
has exhausted all positive procedures and interventions before discussion with
the parent/guardian takes place. If it is agreed that the parent/guardian
should be approached regarding supplemental alternative treatments, the
parent/guardian will be invited to meet with the clinician and
other members of the treatment team. At which time the parent/guardian will
be given the option of adding behavioral skin shock as a supplement to their child's ongoing reward/educational program.
of supplemental aversives is carried out carefully, openly and with a maximum
number of safeguards.
What are the safeguards?
Certification required: JRC has to be specially
certified by the Massachusetts Department of Mental Retardation to use
aversives and the certification is renewed every two years. JRC is
regulated and overseen by the Massachusetts Department of Education,
Department of Mental Retardation, and Department of Early Education and
Parental consent: No aversive is employed
without prior written, informed consent by the parent or guardian. Consent
forms for each aversive procedure are thoroughly reviewed in detail with the
parent or guardian to ensure that there are no questions. The
parent/guardian is invited to apply the GED device to him/herself. All
written consent forms with the detailed explanation of the procedure are
signed and dated by the parent/guardian. The parent or guardian may also
revoke this approval at any time. The informed consent session is
Clinician designs treatment plan:
The plan contains, first, a detailed account of the history of treatments,
placements, medications, etc. that have been used unsuccessfully in the past
and an explanation of the urgent need for effective treatment. The plan also
includes: a record of the student's most recent competency evaluation;
functional analysis; reward preferences; contracts; IEP/ISP/IHP Goals; the
target behavior categories and the sample topographies that are proposed to
be treated; and the proposed supplemental aversive procedure that is
proposed for the treatment of each behavior category.
Medical pre-approval: A physician examines
each student whose treatment plan includes supplementary aversives. These
procedures are employed only if the physician certifies, after the physical
examination and a review of the student's records, that there are no medical
contraindications to their use with that particular student. If applicable,
a psychiatrist, cardiologist, and/or neurologist must also examine the
student and find no contraindications to the use of supplementary aversives
before they can be used with that student.
Inclusion in the student's Individual Education
Program (IEP), Individual Service Plan (ISP), or Individual Habilitation
Plan (IHP): If JRC recommends the addition of aversives to a
treatment plan, and if the parent accepts this recommendation, the use of
these procedures is incorporated into the student's Educational Plan.
Review by Peer Review Committee: The treating
clinician presents the treatment plan and relevant
information to committee members, which includes (but is not limited to) the student's behaviors, characteristics, behavior charts, functional analysis,
prior treatment, and any other pertinent information. Committee members may
ask questions at any time. When all questions have been answered and
discussion is at an end a vote is taken to accept or reject the treatment
plan. If the presenting clinician is a member of the
committee, he or she must abstain from voting. The committee meets based on
the need to review new treatment plans or new aversive interventions
proposed for a student already being treated with aversives.
Human Rights Committee approval:
JRC has a human rights committee that is composed of parents of students at
JRC and other outside lay and professional persons such as a nurse, an
attorney, a psychologist or clinician, etc. This committee reviews each
proposed treatment plan that involves the use of supplementary aversives,
and must grant its approval to the treatment that is proposed. Once a
student has a court approved treatment plan the committee must review
the treatment program of the student on an annual basis.
court approval: Individualized authorization by a Massachusetts Probate
Court. No aversive is employed at JRC unless authorized by a Probate
Court through a "substituted judgment" petition. This process has two
components. First, the court decides if the individual is competent to make
his or her own medical or treatment judgments. Second, the court decides
whether the individual would have chosen aversives if he or she had been
competent to decide.
The process begins when JRC submits a proposed treatment plan to the court.
Click here to see an example
of a treatment plan. The plan is a detailed account of the behaviors JRC proposes to treat and
the supplementary aversives that JRC requests authorization to use. The
court appoints an attorney to represent the rights of the student (as
distinct from the rights of the parent or of the school). This attorney may
retain an expert psychologist or clinician to evaluate the treatment plan
that JRC proposes. The court ultimately decides how much of JRC's proposed
treatment plan will be allowed. Depending on the case, the court will
decide to approve a temporary order which is good for 90 days or a permanent
order which typically is good for 12 - 18 months.
Daily oversight by clinician:
The assigned clinician has the direct responsibility for the
development and implementation of the student's treatment plan. The
prescribes and personally authorizes 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.
is responsible for setting 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
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 student's clinical record.
ensures 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.
approve shifts of existing topographies from one
behavior category to another and any changes in treatment, as a result of
approves treatment of new topographies of the
problem behaviors with the categories of procedures that have been
authorized by the Court.
ensures 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.
ensures that before aversive or restrictive
consequences are used for non-aggressive, non-destructive, or
non-self-injurious behavior there is evidence that: the behavior
significantly interferes with educational development; or the behavior
significantly interferes with social development; or the behavior is an
antecedent to aggressive, self-injurious or destructive behaviors; or the
behavior is a weaker, shaped-down or incipient version of an aggressive,
self-injurious or destructive behavior; or the behavior is an attempt to
execute an aggressive, self-injurious, or destructive behavior.
ensures, in conjunction with a consulting physician,
that no treatment is used that is medically contraindicated for the
Each clinician that oversees
substituted judgments cases must complete at least 10 credit hours of
continuing education credits, which are recognized by the Psychological
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 analyses in formulating each narrative report.
Copies of these materials need not be attached to the report but shall be
made available to counsel and Court Monitor upon their request. JRC sends
copies of this report to the Court, parent, the student's counsel, Court
Monitor, and DMR.
Yearly reviews by court: A review of the case
is held prior to the expiration of the order and annually thereafter to
insure that the treatment is working and that it should be allowed to
continue. The court takes into consideration: the quarterly progress
reports; the behavior and academic charts; and reports by JRC treatment
staff, court assigned counsel and clinicians, and independent clinicians
Nursing: One of their duties is to make sure
that any supplementary aversives employed have no harmful effects.
of overall plan: behaviors
are recorded as tally marks on a daily recording sheet, which accompanies
the student 24 hours a day. Additional information on this sheet, relevant
to the 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 or her. 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 are graphically represented on
daily, weekly, and monthly Standard Behavior Charts. Positive behavior
frequencies are recorded and may also be plotted on Standard Behavior
Program implementation is monitored from an online digital video streaming
system within the school building and residence. Supervisors and
clinicians who frequently visit classrooms and residences
also monitor the program implementation. The clinician, in
many cases monitors student's progress on a daily basis, but in any case
does so at least weekly. The clinician reviews the student's
treatment for effectiveness at least weekly and records his/her assessment
of the plan's effectiveness in achieving the stated goals.
Staff training: Each staff member undergoes 2
weeks of pre-service training and additional in-service training thereafter.
JRC does not hire temporary workers from employment agencies. All JRC direct
care staff members are full or part time employees of JRC and are trained by
JRC's Training Department.
Staff monitoring: Each staff member is
supervised and monitored by quality control supervisors and by digital
video monitoring supervisors. The performance of each direct care staff
member is evaluated on each shift and the staff member is given appropriate
positive or negative feedback. Direct care staff members are also given an
evaluation of their performance every two weeks. If a staff member is not
performing his or her duties correctly, JRC takes immediate disciplinary or
other appropriate remedial action to promote proper performance at all
times. Staff members are rewarded for desired performance and receive
disciplinary actions for performances that do not meet JRC's standards.
Weekly chart share review: Once each week the
clinicians, teachers, nursing, case managers and
programming staff conduct a "Chart Share" at which they review the charts of
approximately 10-15 students to ensure that all students are progressing and
that all are benefiting from the collective experience and expertise of our
professional staff. These Chart Shares are usually attended by the Executive
Director and one or more Assistant Executive Directors.
Case-conferences: Meetings are held for
students that have had Level III aversives in their treatment program for
three or more years. These students are separated into four groups. Group
One consists of students that have been on Level III aversives the longest,
Group Two the next longest, and so on. Attending the Case Conferences are:
the independent clinicians who provide independent evaluative services for
the client, JRC's consulting psychiatrist, JRC's treating clinician, the classroom teacher, the parent or guardian, the JRC nurse, and
the case manager. A tentative date is chosen and the Director of Student
Services coordinates a case conference to discuss the progress of a
particular student with all of the above-mentioned attendees. The treating
clinician presents background information, discusses past
treatment procedures, presents the current treatment procedures, reviews the
behavior charts and discusses the effectiveness of Level III procedures.
Input is sought from all attendees. The independent clinician that is
assigned to that student will write a report addressing the continuation of
Level III procedures. The final report is placed in the student's file and
forwarded to the court, the court monitor, the parent or guardian, the IEP/IHP/ISP
contact and the student's counsel.
Fading the GED: A great many students at JRC,
both in the lower functioning levels and in the higher functioning levels,
are able to graduate from the use of the GED and function without it in
society. As treatment proceeds the target behaviors decrease in frequency
and eventually often reach a zero level. At that point the students are no
longer receiving any applications of the GED device. When the behaviors have
been at a zero level for 3 months or so, we begin to "fade" the device. This
means we remove the device for a short period of time each day and then
gradually increase the length of this period of time. Eventually the student
is not wearing the device at all.
Success criteria: A particular intervention
will 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 problem 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. 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
Return to top
"Is it true that students at JRC can be
punished with the GED for behaviors other than aggression, self-abuse or
Yes, for the following
The typical student
entering JRC engages in many types of behaviors that are extraordinary
difficult and significantly interfere with appropriate behavior or learning
and are thereby causing serious harm to the student. They also engage in
patterns of behaviors that lead to extremely dangerous behaviors. One cannot
judge the appropriateness of a given treatment procedure without understanding
the entire treatment context. Sometimes something that seems innocuous when
looked at in isolation is quite different if you understand the full context.
In such cases, if positive only treatment is unsuccessful by itself in
controlling such behaviors, it is wise to consider the possibility of using
the GED procedure. JRC observes each student carefully and designs an
individual treatment plan for each student that targets the problematic
behaviors particular to that student. Here are some examples.
The behavior by itself
seems innocuous, but it is an antecedent, an attempt or threat to execute,
some much more serious behavior. Sometimes a behavior, while not
dangerous in and of itself, or when looked at without knowing the full
context, is the first part of a chain of behaviors that ends in a dangerous
behavior. For example;
If reaching for a knife
is almost always an "antecedent" to attacking someone with a knife - i.e.,
, then it is wise to treat the antecedent in order to keep the rest of the
sequence from occurring.
If swearing in class is
the first step in a sequence that almost always leads to the student's
attacking someone else with his fists, then it is wise to treat the
antecedent swearing behavior.
If bolting out of one's
seat is the first step in attacking the teacher, it may be necessary to
treat the behavior of bolting out of one's seat.
The behavior in and of
itself seems harmless, but actually is a reduced version of some more
significant and dangerous behavior that is in the process of being reduced
When the frequency of a
behavior is decreasing, the form of that behavior may also undergo
changes. For example, when one treats punching with an aversive
consequence, and when punching begins to decrease in frequency as a
result, it also may change its form. The student could, for instance begin
to "pull his punches" - i.e., act as though he is punching, but just touch
the other person with his fist. We sometimes refer to these as being
"shaped-down" versions of the full-scale behavior. When these shaped-down
versions are displayed, the proper treatment procedure may be to continue
to treat the "pulled" punching with the same aversive that one has been
using for the full-fledged punching. If one does not, the "pulled" punches
can grow back to become full fledged injurious punches. A student faces
the same serious problems with education and socialization whether he is
hitting people or putting people in fear of being hit.
In the effective
treatment of hair pulling (pulling out one's own hair), as the behavior
decreases in frequency, it may change its form. For example, the student
may start to simply touch the hair rather than actually pull it out.
Again, in the successful treatment of this problem it would be important
to apply the same consequence to the touching of the hair that one has
already been applying to the pulling out of the hair.
Another example could
be loud screaming that goes on constantly and which makes it impossible
for the student himself, or any other student to work in the classroom.
When such loud screams are treated, they may not only decrease in
frequency but also in loudness. In such cases, it may be necessary to
continue to treat reduced-loudness screams with the same treatment
consequence that one is employing with the full-blown screams.
The principle that is at
work in these examples is similar to the one that causes physicians to tell
their patients to take their medication until all symptoms of the medical
problem are ended and not just until the major symptoms are reduced.
One instance of the
behavior in itself is innocuous, but displaying that same behavior at a high
and excessive frequency, without stopping, makes it into something much more
A single failure to
stay in one's seat during classroom instruction would be innocuous, but
getting out of one's seat every minute all day long, in cases where that
behavior cannot be effectively treated with less restrictive procedures,
could significantly interfere with a student's educational and social
A single swear may seem
innocuous, but if it goes on at all times in all places this might prevent
a student from ever being invited to enter a public library or a nice
A single deliberate
wrong answer may seem innocuous, but if the student does this to every
academic problem presented to him, he/she will never learn anything.
Some behaviors, while
not physically dangerous in and of themselves, can be extremely harmful to
the students' social and education development. For example suppose that
every time a teacher asks a student to do something that he does not want to
do, the student says "F*ck you!" and refuses to comply. Such a student will
very likely be soon be kicked out of school and may never receive an
education. On the other hand, if the student can be taught to comply with
the reasonable requests of a teacher, and to respond appropriately and
without swearing when the teacher makes requests of the student, then the
student will be able to stay in school, to learn useful skills such as how
to read and write, and to get an education.
At JRC we consider such
behaviors -ones that seriously interfere with a student's ability to get an
education -to be significantly harmful. If positive procedures are unable to
change such behaviors, and if we can succeed by using a parent-and
court-approved, 2-second harmless shock to the surface of a small patch of
skin, once a week on average and eventually removed when the behavior changes,
we believe that the use of such a procedure may be justified.
Return to top
Is it true that at JRC a staff member
will sometimes prompt a student to begin to engage in a problem behavior
and then arrange an aversive for that? 2. Is there any professional
support in the literature for that procedure?"
Yes. The practice is called
behavior rehearsal lessons. The procedure requires individual and prior court
approval. Behavior rehearsal lessons, when used with aversives, are used to
address dangerous behaviors that occur at a low frequency (i.e. once per month
or once per year) but one more occurrence of the behavior would likely result
in death, blindness or dismemberment. In these cases the typical behavioral
procedure of delivering the aversive consequence immediately after the
occurrence of the dangerous behavior, and thus reducing and eventually
eliminating the behavior, does not work because the behavior is not occurring
except on rare occasions.
There are certain behaviors
that are so dangerous to the student or to others that one wants to prevent
them from occurring even one more time, if one can. Examples of
behaviors we have treated with behavior rehearsal lessons at JRC are these:
G.M. had the behaviors of
swallowing utensils which had to be surgically removed from his stomach on
numerous occasions. He also engaged in punching his eyes with his fist. When
he was enrolled in JRC, he had already blinded himself in one eye and was in
danger of losing sight in his other eye. Shortly after G.M. enrolled in JRC,
behavior rehearsal lessons were given to him for both swallowing utensils
and punching his eyes. He has never shown either behavior even on one
had the behaviors of putting his arm through windows and of cutting his arm
with a knife. His arm had been sutured so frequently that the skin of his
arm had become extremely tough- so tough that it was now almost too tough to
be sutured any more. RC had had 3-1 coverage at his previous placement and
despite this the program could not keep him from engaging in these
behaviors. behavior rehearsal lessons were administered to him as soon as he
was enrolled at JRC. As a result, he never showed these behaviors at all
while enrolled at JRC.
This treatment procedure is
employed if there is some good reason to believe that the student might engage
in this behavior in the future, based on how the student has behaved in the
past. For example, it was used with GM and with RC because their record showed
that they had actually engaged in these dangerous behaviors.
In such situations behavior
rehearsal lessons are applied as follows. One prompts the student to engage in
the first phase of the behavior. For example one prompts a student to pick up
a knife and begin to direct it toward his arm as though to cut it with the
knife. Then one arranges an aversive stimulus, for example one administers a
GED skin shock. This is called a behavior rehearsal lesson. The student
is prompted (against his will if necessary) to begin the undesired behavior
(i.e., to move the knife in the direction of the arm) and is then receives an
aversive stimulus while engaging in that beginning phase of the behavior.
The purpose of the
procedure is to transfer some of the aversive properties of the GED stimulus
to the internal stimuli that are generated by the beginning phase of the
behavior. This transfer is accomplished by the pairing the beginning phase of
the behavior with the GED stimulation. The intention is that if this can be
done, then the following will happen: when, on a future occasion, the student
begins to engage in the problem behavior, the beginning phase of the behavior
will automatically generate conditioned aversive properties and the student
will then terminate these conditioned aversive properties by refraining from
engaging in the behavior. Typically the student will be given a certain number
- say 3 or 4 - such lessons during a week at random times. Then as the student
progresses, the frequency is diminished to a zero level.
There are a number of
papers in the field of behavior modification that support this procedure. The
are listed below. Sometimes the procedure is given a different name by the
author. For example, in a paper by Dr. Ron Van Houten, he refers to the
procedure as "recreating the scene."
The same basic approach
that is used in behavior rehearsal lessons has often been used in the field of
behavior therapy. Here are some examples:
In the treatment of sex
offenders a visual stimulus (relating to some inappropriate behavior that we
wish to treat) may be presented to deliberately arouse the patient and then
an aversive stimulus is arranged.
In the treatment of
alcoholism, an emetic substance such as atropine is mixed with an alcoholic
drink. The patient is required to ingest the drink which then causes him to
vomit. The noxious stimulation associated with vomiting is thus paired with
the behavior of ingesting alcohol;
In the treatment of
cigarette smoking one procedure is to have a smoker reach for a cigarette
and receive a skin shock, or to start to inhale and receive a skin shock. A
related procedure is called rapid smoking. The smoker is asked to smoke one
cigarette after another until he becomes sick of doing so. The unpleasant
sensation that is thus generated is thereby paired with the act of smoking.
For more information on how
this procedure has been used at JRC, and its effectiveness,
2. Professional Support
Behavior rehearsal lessons
(BRL's), utilizing aversive stimuli, are used to treat a wide variety of
problem behaviors including aggression, self-injury, pica, substance abuse and
deviant sexual arousal. There is considerable research devoted to the
treatment of these behaviors in the professional literature.
rehearsal lesson is equivalent to "recreating the scene" described by Van Houten and Rolider (1988). The procedure is useful for low frequency
intensity behaviors that have been resistant to other forms of treatment. Van Houten and Rolider used manual guidance and prompting to guide the individuals
to engage in a problem behavior that previously occurred. Following the
procedure, some form of aversive stimulus was applied. This procedure was
effective in reducing biting and stealing behaviors emitted by the children
involved in the study.
Skin shock has been used as an aversive stimulus in
behavior rehearsal lessons to eliminate aggressive and self-injurious
behaviors. The effectiveness of this procedure in eliminating problem behavior
has been demonstrated in six professional papers. For example, Ribes-Inesta &
Guzman (1974) successfully eliminated pica behaviors by administering
punishment after manual guidance was used to bring inedibles to the mouth of
the patient. Foxx, McMorrow, Bittle & Bechtel (1986) arranged the environment
to elicit aggressive behavior which was immediately followed by contingent
shock. Brandsma & Stein (1973), created scripts that when read were known to
occasion problem behavior. Other authors have used similar procedures with
similar success (McFarlain, Scott & Wheatly, 1975; Duker, 1976; Alexander,
Chai, Creer, Miklich, Renne & Cordosa, 1973).
Behavior rehearsal lessons are
also used to treat people with substance abuse problems. The Schick Shadel
Hospital in Seattle, WA has been treating individuals with substance abuse
problems for over 60 years and their slogan - "We have the #1 success rate for
alcoholism" - is based on valid scientific method research done by an
independent and reputable research firm. Schick Shadel Hospital has known for
decades that its treatment does indeed work for about 70 percent of its
patients (66%-80%) and has allowed many to stay clean and sober for life - not
just a year. They have achieved these results by using aversive stimuli such
as faradic stimulation (another word for skin shock) and Emetine (a drug that
produces nausea). Schick Shadel researchers, led by Dr. James Smith have
contributed dozens of articles on addiction and aversion therapy to leading
Finally, behavior rehearsal procedures have been used to
treat deviant sexual arousal in juvenile sex offenders. Weinrott, Riggan &
Frothingham (1997) presented juvenile offenders with inappropriate arousal
cues followed by aversive stimuli that portrayed the negative social,
emotional, physical and legal consequences of offending. This intervention
resulted in decreased arousal to inappropriate sexual stimuli.
Alexander, A., Chai, H.,
Creer, T., Miklich, D., Renne, C., & Cardoso, R. (1973). The Elimination of
Chronic Cough by Response Suppression Shaping. Journal of Behavior Therapy and
Experimental Psychiatry, 4, 75-80.
Brandsma, J. M., & Stein,
L. I. (1973). The use of punishment as a treatment modality: A case report.
The Journal of Nervous and Mental Disease, 156(1), 30-37.
Duker, P. C. (1976).
Remotely applied punishment versus avoidance conditioning in the treatment of
self-injurious behaviours. European Journal of Behavioural Analysis and
Modification, 3 (3), 179-185.
Foxx, R. M., McMorrow, M.
J., & Bittle, R. G. (1986). Increasing staff accountability in shock programs:
simple and inexpensive shock device modifications. Behavior Therapy, 17,
Frawley, J. & Smith, J.W.
Chemical Aversion Therapy in the Treatment of Cocaine Dependence as
Part of a Multimodal Treatment Program: Treatment Outcome, Journal of
Substance Abuse Treatment, Vol. 7, pp. 21-29.
Frawly, J. & Smith, J.
One-Year Follow-Up After Multimodal Inpatient Treatment for Cocaine
and Methamphetamine Dependencies, Journal of Substance Abuse Treatment, Vol.
9, pp. 271-286.
McFarlain, R., Scott, J., &
Wheatley, M. (1975). Suppression of headbanging on the ward. Psychological
Reports, 36, 315-321.
Ribes-Inesta, E., & Guzman,
E. (1974). Effectiveness of several suppression procedures in eliminating a
high-probability response in a severly brain-damaged child. Interamerican
Journal of Psychology, 8, 1-2.
Smith, J.W. (1982).
Treatment of alcoholism in aversion conditioning hospitals, Chapter 72.
Encyclopedic handbook of alcoholism. E. M. Pattison & E. Kaufman (Eds.), New
York: Gardner Press.
Smith, J.W. & Frawley, P.J.
Treatment Outcome of 600 Chemically Dependent Patients Treated in a
Multimodal Inpatient Program Including Aversion Therapy and Pentothal
Interviews, Journal of Substance Abuse Treatment, Vol. 10, pp. 359-369.
Smith, J.W. (1988).
Long-Term Outcome of Clients Treated in a Commercial Stop Smoking Program,
Journal of Substance Abuse Treatment, Vol. 5, pp. 33-36.
Smith, J.W., Frawley, J., &
Polissar, L. (1991).
Six- and Twelve-Month Abstinence Rates in Inpatient
Alcoholics Treated with Aversion Therapy Compared with Matched Inpatients from
a Treatment Registry, Alcoholism: Clinical and Experimental Research, Vol. 15,
No. 5, Sept/Oct.
Smith, J.W. & Frawley, J.
Long-Term Abstinence From Alcohol in Patients Receiving Aversion
Therapy as Part of a Multimodal Inpatient Program, Journal of Substance Abuse
Treatment, Vol. 7, pp. 77-82.
Van Houten, R., & Rolider,
A. (1988). Recreating the scene: An effective way to provide delayed
punishment for inappropriate motor behavior. Journal of Applied Behavior
Analysis, 21, 187-192.
Weinrott, M., Riggan, M., and Frothingham, S. 1997.
Reducing deviant arousal in juvenile sex offenders using vicarious
sensitization. Journal of Interpersonal Violence 12(5):704-728.
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"Is it true that one of the consequences JRC uses is to administer several GED applications, over a half-hour period during which a student may be
restrained on a restraint board?"
Yes. This court-approved
procedure combines two court approved aversives - the use of multiple
applications of the GED skin shock, and the use of restraint as an aversive.
Multiple applications of
the GED skin shock.
As in any therapeutic
procedure, some individuals and behaviors require a more intensive consequence
than others. In the prescription of drugs, the amount of the dosage prescribed
for a person needs to be individualized by the physician. Sometimes a stronger
dosage of a drug will work where a weaker one will not. Sometimes a person
will adapt to a certain dose of a drug and will then need a stronger dosage.
The same principles require that the GED be
available in more than a single dosage. Normally the consequence for a
problem behavior is one application per behavior. In certain cases, however,
it may become clear that one application is not aversive enough to
accomplish the desired deceleration of the problem behaviors. In those cases
the clinician may specify that two or more applications be made
as a consequence for a single behavior. Similarly, in certain cases, it may
become clear, through the data we collect, that the student has "adapted" to
the GED and needs a stronger stimulation. In such cases we may either use
multiple applications of the GED, or we may shift, with court authorization,
to the use of the GED-4, which delivers a stimulation that is judged to be two
or three times more aversive.
In some cases a student may
be able to remove a device and thereby defeat the application of the GED
consequence or may engage in dangerous struggling while the stimulus is
applied. In such cases, the safest method for administering the consequence is
to restrain the student before administering the GED consequence.
The Use of Restraint as
an Aversive Consequence
When a student engages in
dangerous aggressive, self-abusive or destructive behavior, and if it is a
student for whom JRC does not have a court-authorized treatment plan that
includes the use of mechanical restraint, JRC makes use of what is known as
emergency restraint. Emergency restraint is carried out manually in some
cases. In other cases, a special waiver is obtained to make use of mechanical
devices to carry out the emergency restraint.
For those students for whom
JRC obtains a court-authorized treatment plan, JRC is able to use periods of
restraint as an aversive consequence. There is strong support in the
professional literature for the use of restraint as an aversive consequence as
is related in the following material.
Ramm, Sheela. The use
of the duvet (quilt) for the treatment of autistic, violent behaviors (an
experiential account). Journal of Autism and Developmental Disorders. Vol
20(2) Jun 1990, 279-280. Describes the use of a restraining technique
used successfully to discourage behaviors often displayed by autistic
children (e.g., head-banging, throwing, and persistent screaming). The child
is rolled in a quilt, and kept in it for the shortest time possible, until
he/she is calm enough to return to the previous classroom activity.
Matson, Johnny L;
Keyes, Joseph B. A comparison of DRO to movement suppression time-out and
DRO with two self-injurious and aggressive mentally retarded adults.
Research in Developmental Disabilities. Vol 11(1) 1990, 111-120.
Movement Suppression Time-Out (MSTO) is a variant of physical restraint that
may have applicability for serious behavior problems of developmentally
disabled persons. This study evaluated reinforcement of (1) other behavior (DRO)
and verbal reprimands and (2) MSTO, DRO, and verbal reprimands with 2
severely mentally retarded males (aged 35 and 39 yrs). Using a multiple
baseline design, self-injury was studied across setting with 1 S and across
self-injury and aggression with the 2nd S. Improvements were only apparent
when MSTO was paired with verbal reprimands and DRO. With 1 S effects were
maintained at an 8-mo follow-up.
Konarski, Edward A;
Johnson, Moses R. The use of brief restraint plus reinforcement to treat
self-injurious behavior. Behavioral Residential Treatment. Vol 4(1) Jan
1989, 45-52. Evaluated the use of brief arm restraint plus differential
reinforcement of alternative behavior to treat the self-injurious behavior
(SIB) of 1 31-yr-old female and 1 19-yr-old male nursing home resident with
multiple handicaps and profound mental retardation. The 1st S's responding
appeared to be associated with the presence of the treatment program as
supported by the multiple baseline across inappropriate behaviors (IABs) and
by the unintended withdrawal and subsequent reinstatement of the treatment.
The 2nd S's IABs and appropriate behaviors were positively influenced by
introduction of the treatment procedures. Results indicate that the
treatment effectively reduced Ss' SIBs and IABs, replicating an earlier
study (N. H. Azrin et al, 1982) that used similar procedures to reduce SIB.
Carruthers, Janine. The use of a physical restraint procedure to reduce a
severely intellectually disabled child's tantrums. Behaviour Change. Vol
4(1) 1987, 34-38. Used a brief physical restraint procedure combined
with differential reinforcement of incompatible behavior to reduce the
tantrum behavior of a 5-yr-old severely developmentally disabled girl in a
classroom setting. Daily frequency recording of tantrum behavior
demonstrated a marked reduction of tantrums following intervention, which
was maintained at follow-up. Staff reported concomitant increases in S's
participation in class activities. Spontaneous generalization of reductions
in tantrum behavior to nonprogrammed settings and staff was not found.
Singh, Nirbhay N;
Bakker, Leon W. Suppression of pica by overcorrection and physical
restraint: A comparative analysis. Journal of Autism and Developmental
Disorders. Vol 14(3) Sep 1984, 331-341. Overcorrection and physical
restraint procedure have been shown to be effective in controlling certain
classes of maladaptive behavior in mentally retarded persons. In the present
study, an alternating treatments design was used to measure the differential
effects of overcorrection and physical restraint procedures in the treatment
of pica in 2 profoundly retarded females, aged 20 and 21 yrs, with IQs below
20. Changes in collateral behaviors were also monitored. Each occurrence of
pica was followed by either an overcorrection procedure or a physical
restraint procedure. Although both procedures reduced the occurrence of pica
and had a similar effect on the occurrence of collateral behaviors, physical
restraint was clinically more effective in terms of immediate response
reduction. Results confirm the efficacy of brief response-contingent
physical restraint for controlling the maladaptive behaviors of mentally
Hamad, Charles D;
Isley, Ellen; Lowry, Michael. The use of mechanical restraint and response
incompatibility to modify self-injurious behavior: A case study. Mental
Retardation. Mechanical restraint and a contingent "stand-up" procedure
were used to treat self-injurious behavior (SIB) of a profoundly mentally
retarded, institutionalized 41-yr-old male. The restraint device was
continuously and gradually withdrawn until the S was restraint-free.
Treatment consisted of gradually increasing the amount of time out of
restraint, providing a high density of reinforcement for not engaging in SIB
while unrestrained, and a brief time-out/physical-hold procedure made
contingent on the occurrence of SIB. SIB was gradually reduced to a near
Richmond, Glenn; Bell,
James C. Analysis of a treatment package to reduce a hand-mouthing
stereotypy. Behavior Therapy. Vol 14(4) Sep 1983, 576-581. Treated 4
profoundly retarded 24-yr-old women who mouthed their hands, using a
treatment package that included DRO and response interruption/physical
restraint. The 2 components were evaluated separately and together. A
single-S reversal design was replicated across Ss to evaluate each
individual component. The order of treatment was counterbalanced to control
for order effects. No reduction in hand mouthing occurred with DRO. A
reduction was obtained with response interruption/physical restraint alone.
Combining the 2 components resulted in the greatest reduction.
Winton, Alan S; Singh,
N. N. Suppression of pica using brief-duration physical restraint. Journal
of Mental Deficiency Research. Vol 27(2) Jun 1983, 93-103. Results of an
experiment with 2 nonverbal, profoundly retarded (IQs below 20) males (aged
12 and 19 yrs) support the finding of B. Buches et al (see record
1976-30295-001) that physical restraint can control pica, the ingestion of
inedible substances. However, unlike the earlier study, which additionally
used a verbal reprimand, physical restraint alone was shown to be effective.
While all 3 durations of physical restraint suppressed pica, the duration of
10 sec was more effective than either 30 sec used with 1 S, or 3 sec used
with the other in alternating treatment designs. The procedure proved simple
to use, took minimal staff training time, and required no equipment. During
treatment some increase in pica was observed in settings where treatment had
not yet been applied, but later treatment in these settings quickly
controlled the behavior. Collateral behaviors were largely unaffected except
for picking and handling, a precursor for pica, which showed variable
changes but tended to be reduced.
Bitgood, Stephen C;
Peters, R. Douglas; Jones, Michael L; Hathorn, Nancy. Reducing out-of-seat
behavior in developmentally disabled children through brief immobilization.
Education & Treatment of Children. Vol 5(3) Sum 1982, 249-260. Three
developmentally disabled children who exhibited a number of deviant
behaviors received 15 sec of contingent immobilization for out-of-seat
behavior (OSB) during training sessions. In Exp I, environmental
restriction, time-out, and immobilization were compared in a reversal design
with a 5-yr-old male diagnosed as retarded, brain-damaged, and autistic.
Immobilization reduced OSB significantly more than environmental
restriction, while time-out produced an increased percentage of OSB. In Exp
II, the effectiveness of brief immobilization was demonstrated in a
combination reversal and multiple-baseline across 2 Ss--8-yr-old males
diagnosed as hyperkinetic and autistic, and schizophrenic and hyperactive.
The OSB of both Ss was substantially reduced by the application of brief
immobilization. Ethical guidelines for the use of immobilization are
Luiselli, James K.
Evaluation of a response-contingent immobilization procedure for the
classroom management of self-stimulation in developmentally disabled
children. Behavior Research of Severe Developmental Disabilities. Vol 2(1)
Sep 1981, 67-78. The control of self-stimulatory behavior is frequently
a prerequisite for effective teaching of developmentally disabled children.
The present study evaluated the practicality of a brief immobilization
technique with 2 children exhibiting high rates of hand self-stimulation. In
Study 1, self-stimulatory responses of a 9-yr-old mentally retarded female
were reduced to low levels by holding her hands by the sides of her body
whenever she self-stimulated. This method proved to be more effective than
differential reinforcement alone or a procedure to increase contact with
task materials. In Study 2, a finger-flicking response of a 15-yr-old
severely retarded female who was also visually- and hearing-impaired was
eliminated by contingently immobilizing her hands on a desk top. The
procedure was also shown to be more effective than reinforcement methods
alone. For both Ss, no deleterious side effects were associated with
Persel, Craig S;
Persel, C. H; Ashley, M. J; Krych, D. K. The use of noncontingent
reinforcement and contingent restraint to reduce physical aggression and
self-injurious behaviour in a traumatically brain injured adult. Brain
Injury. Vol 11(10) Oct 1997, 751-760. Many different intervention
programmes for reducing undesirable behavior with people with traumatic
brain injury (TBI) have been investigated in recent years. The purpose of
this study was to examine the potential of using noncontingent reinforcement
(NCR) in combination with contingent restraint to reduce severe behavior.
The subject (E.L.) was a 40-yr-old male with TBI admitted to a
rehabilitation long-term care programme. E.L. had a history of physical
aggression (PA) and selfinjurious behavior (SIB). Assessment conditions
included a descriptive analysis, response scatterplot and Self-Injury Trauma
(SIT) Scale. Attention was identified as the maintaining positive
reinforcement for PA and SIB. Treatment conditions were compared using a
reversal (ABAB) design. Attention (NCR) was delivered on a fixed-time
schedule that was not dependent on the subject's behavior. Contingent
restraint was applied when E.L. exhibited PA or SIB that was dangerous to
himself or others. During treatment, PA occurred over 4 times less often and
SIB over 2.5 times less often. Results demonstrated that PA and SIB were
sensitive to NCR. NCR can be an effective procedure for reducing severe
behavior maintained by socially-mediated positive reinforcement.
Hagopian, L. P.,
Fisher, W. W., Sullivan, M. T., Acquisto, J., & LeBlanc, L. A. (1998).
Effectiveness of functional communication training with and without
extinction and punishment: A summary of 21 inpatient cases. Journal of
Applied Behavior Analysis, 31, 211-235. used a 60 second basket hold as
a decelerative procedure for some participants.
Gregory P. Hanley,
Cathleen C. Piazza, Wayne W. Fisher, & Kristen A. Maglieri (2005). On the
effectiveness of and preference for punishment and extinction components of
function-based interventions. Journal of Applied Behavior Analysis, 38,
51-65. 30 second hands down procedure with visual screen. The
participant's hands were forced to the table and their vision was shielded
for 30 seconds.
Dura, J.R. (1991).
Controlling extremely dangerous aggressive outbursts when functional
analysis fails. Psychological Reports, 69, 451-459. This article
describes and illustrates a treatment program aimed at addressing
intermittent extremely dangerous aggressive behavior in an 11-year-old girl
who was blind, multiply handicapped, and profoundly mentally retarded. In
the month preceding treatment she had injured a peer, a paid careprovider,
and her mother. Functional analysis produced no clear antecedents to
aggression. Punishment was used to introduce a superordinate contingency.
Differential reinforcement of alternative behavior combined with contingent
restraint reduced, then eliminated aggression. Follow-up at an age
equivalent of 4 years, 6 months indicated a continued absence of aggression.
Results are discussed in regards to the balance between research
methodology, agency policy, right to effective treatment, and social
Williams, D.E. & Sams, V. (1985). Treatment of self-injurious and aggressive
biting. Journal of Behavior Therapy and Experimental Psychiatry,
June; 16(2): 169-172. The treatment of a 16-year-old severely mentally
retarded and blind female client exhibiting severe biting of self and others
consisted of the contingent application of an aversive gustatory stimulus
(Tabasco Sauce), brief timeout, DRO, and contingent restraint against biting
while in time-out. This is the first use of Tabasco as the aversive stimulus
against biting. Deceleration of biting was rapid and maintained for 20
months after initiation of treatment.
Rolider, A., & Van
Houten, R. (1985). Movement suppression time-out for undesirable behavior in
psychotic and severely developmentally delayed children. Journal of
Applied Behavior Analysis, 18, 275-288. The effects of a movement
suppression time-out, which involved punishing any movement or verbalization
while a client is in the time-out area, were evaluated in four experiments.
The first experiment examined the effects of a DRO procedure and movement
suppression plus DRO in suppressing self-injurious behavior in a psychotic
child in three different situations. In Experiment 2, the results of the
previous experiment were replicated with two dangerous behaviors in a second
psychotic child. In a third experiment, movement suppression plus DRO was
compared with contingent restraint in reducing inappropriate poking behavior
in two settings. The movement suppression procedure eliminated poking
whereas contingent restraint had little effect. In the final experiment,
movement suppression time-out alone was compared with exclusionary time-out
alone and simple corner time-out alone. Self-stimulation occurred at high
levels during the exclusionary and simple corner time-out procedures.
Self-stimulation was either suppressed or reduced during movement
suppression time-out. The movement suppression time-out procedure produced a
larger reduction in the target behavior in all three children. The
effectiveness of the movement suppression procedure was explained in terms
of the suppression of self-stimulation while the time-out procedure was
being applied. In this study, movement suppression was defined as forcing
the child into a corner, holding his hand behind his back and applying
further pressure contingent upon any movement.
Multiple Applications of
GED Combined with Restraint as an Aversive
This procedure is used, but
only rarely, for certain extremely violent and personally dangerous behaviors,
where all other forms of positive interventions and aversives were not
effective in eliminate extremely violent behavior and where often the only
feasible alternative would be to expel the student from JRC, which would
likely send the student back to a psychiatric hospital. Life-threatening
behavior must be effectively treated before a student can safely be given the
opportunity to learn in a regular classroom and experience interactions with
other JRC students and the community.
Sometimes a student may
engage in a behavior so calculated and violent that it constitutes,
essentially, a felony assault on either a staff member or another student. For
example, we once had a student who overpowered a staff member and beat him
unconscious, with a lamp. Most programs would, as their consequence, call the
police and insist that the student be charged with assault, and demand the
immediate removal of the student from their program.
Because JRC has a near-zero
expulsion policy, and because we see our mission to treat individuals with
severe behavior behaviors and not simply to throw the student into the
criminal justice system (which will no doubt make the student worse) we use a
stronger consequence than the normal one application of the GED. Typically
that consequence involves a period (e.g. a half-hour) during which several GED
stimulations are applied at unpredictable intervals during the time period.
The safest way to do this is to use mechanical restraint to contain the
student, in a prone position, on a flexible plastic restraint platform that
has been specially designed for the purpose. JRC currently uses this procedure
with eight of its students. In each case the procedure was used with the
student less than 1.4 times on average and in each case resulted in dramatic
improvement for the student.
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"I hear that aversives are banned in other
begun some research to find out the legal status of the use of aversives in
other states. Below are some documents that report on the status in
Massachusetts, New York, New Jersey and a few other states.
clearly not true that aversives are prohibited in either New York or New
states that have regulations restricting the use of aversives may nonetheless
allow them if a parent secures a waiver. For example, California has a
regulation that restricts the use of aversives for school-age children;
however parents have been able to obtain waivers of this regulation both to
allow skin shock to be used within California and to allow aversives with a
student at JRC who was sent by a California school district.
NEW YORK LAW ALLOWING THE USE
OF AVERSIVE TREATMENT
of the state of New York do not prohibit the use of aversive treatment. There
is no statute or regulation in New York which prohibits aversive treatment
when approved by a Court. Thus, school districts in New York do not violate
any laws when they send students to JRC and the student receives supplemental
Â§ 681.13 (Section 681.13), entitled "Informed consent for service plans
which involve untoward risk to a individual's protection or rights when the
individual is a resident of an ICF/DD", speaks directly to the issue of
treating individuals with behavioral disorders pursuant to a treatment plan
containing aversives. Section 681.13 states that:
No service plan (see Glossary, section 681.99 of this
Part) which involves an untoward risk to an individual's protection or rights,
including those designed to manage inappropriate behavior and inclusive or
those employing medication for such purposes, shall be implemented until
informed consent is obtained in conformance with this section.
14 NYCRR Â§ 681.13(a)(2).
The Glossary describes service plans which
constitute an untoward risk to an individual's protection or rights as:
plans, including those designed to manage
inappropriate behavior, which may impact negatively upon the rights or
protection afforded individuals in an ICF/DD, including, but not limited to,
the use of time-out rooms, physical restraints, medication, and the
application of painful or noxious stimuli.
14 NYCRR Â§ 681.99(p). The definition of a
service plan which constitutes an untoward risk to an individual's protection
or rights specifically includes a service plan which provides for the use of
painful stimuli, an example of which is the
Graduated Electronic Decelerator (GED).
According to Section 681.13, a service plan which
contains the use of painful stimuli, such as the GED, to manage inappropriate
behaviors may be implemented once informed consent is obtained. JRC and the parents of a JRC student while the student
is on a home visit in New York use GED treatment only if the treatment has
been approved by a Human Rights Committee and Peer Review Committee under
procedures outlined by the Massachusetts Department of Mental Retardation,
approved by the Massachusetts Probate Court and consented to by the student,
or the student's parent or guardian if the student is a minor or deemed
incompetent by the Probate Court in Massachusetts. Section 681.13 clearly
contemplates that under certain circumstances, when informed consent is
obtained, a facility may use the GED on an individual pursuant to the individual's service plan. This provides further support that the use of
aversive treatment, here in the form of GED, is not prohibited in New York.
14 NYCRR Â§ 624 (Section 624) confirms that the use of
aversive treatment is not prohibited by New York law. Section 624 applies
to persons receiving services in any facility operated or certified by the New
York Office of Mental Retardation and Developmental Disabilities (OMRDD).
14 NYCRR Â§ 624.1. Section 624 pertains to the reporting and investigating of
certain events and situations for the purpose of enhancing the quality of care
provided to persons with developmental disabilities who are in facilities, to
protect them from harm and ensure they are free from mental and physical
abuse. 14 NYCRR Â§ 624.2.
Section 624.4, entitled "Reportable incidents, serious
reportable incidents, abuse, defined" relates to aversive treatment. This
section describes the types of incidents that are to be reported, reviewed and
investigated to safeguard the well-being of persons receiving services.
Subsection (c) describes abuse and includes the following:
(6) The unauthorized or inappropriate use of aversive
conditioning (see "Conditioning, Aversive" in Glossary). The use of aversive
conditioning without appropriate permissions is the unauthorized use of
aversive conditioning. Inappropriate use of aversive conditioning shall
include, but not be limited to, the use of the technique for convenience, as a
substitute for programming, or for disciplinary (punishment) purposes.
Â§ 624.4 (c)(6). The Glossary defines aversive conditioning as follows:
"Contingent upon a person's behavior, the application to a person's body of a
physical stimulus to modify or change behavior with such stimulus being
reasonably considered extremely uncomfortable or painful, or which may be
noxious to the person." 14 NYCRR Â§624.20 (n). The definition specifically
includes corporal punishment and electric shock.
conditioning is defined as "abuse" only if its use is "unauthorized or
inappropriate." Here, JRC and the parents of a JRC student while the student
is on a home visit in New York use aversive conditioning only if the treatment
has been approved by a Human Rights Committee and Peer Review Committee under
procedures outlined by the Massachusetts Department of Mental Retardation,
approved by the Massachusetts Probate Court and consented to by the student's
parent or guardian. Also, the use of aversive treatment is closely monitored
and regulated. The use of aversive treatment under these circumstances cannot
be characterized as unauthorized or inappropriate. Therefore, this regulation
strengthens the argument that the use of aversive treatment is not prohibited
by New York law.
treatment is just that - it is treatment. It is not a form of corporal
punishment. The New York state regulations define corporal punishment as
act of physical force upon a pupil for the purpose of punishing that pupil,
except as otherwise provided in subdivision (c) of this section." 8 NYCRR Â§
19.5(b). Aversive treatment is not administered for the purpose of punishing
the students. Rather, it is a Court-approved treatment for behavioral
disorders that have not been corrected through other types of treatment.
Therefore, it does not fall within the definition of corporal punishment under
New York law or regulations.
Furthermore, subdivision (c) reads as follows:
(c) In situations in which alternative procedures
and methods not involving the use of physical force cannot reasonably be
employed, nothing contained in this section shall be construed to prohibit the
use of reasonable physical force for the following purposes:
(1) to protect oneself
from physical injury;
(2) to protect another pupil or teacher or any person from physical injury;
(3) to protect the
property of the school or others; or
(4) to restrain or remove a pupil whose behavior is interfering with the
orderly exercise and performance of school district functions, powers and
duties, if that pupil has refused to comply with a request to refrain from
further disruptive acts.
Â§ 19.5(c). Aversive treatment is only used when alternative procedures cannot
reasonably be employed since prior to the approval of aversive treatment,
other treatments were shown to be insufficient for that student. Thus, the
use of aversive treatment does not contravene any law or regulation of the
state of New York.
of aversive treatment by parents of students at JRC when those students are on
home visits in New York does not violate any civil or criminal statute. The
Supreme Judicial Court of Massachusetts has affirmed JRC's right to implement
treatment plans that include supplemental aversives and has affirmed the
Massachusetts Probate Court's approval of treatment plans that include the
supplemental aversives. See, Guardianship of Brandon Sanchez, 424
Mass. 482 (1997); JRC v. DMR, 424 Mass. 430 (1997). Since aversive
treatment under these circumstances are not prohibited by any law in New York,
this use by parents is completely legal.
parents cannot be criminally prosecuted for allowing their children to be
treated with aversives, and specifically for allowing the GED device to be
placed on their children within the state of New York. Under New York Penal
Law, a parent or guardian can be found criminally liable if he or she fails to
prevent the child from becoming an "abused child" or a "neglected child." The
definition of "neglected child" includes a child whose parent has
"unreasonably" inflicted harm on them, including the unreasonable infliction
of "excessive corporal punishment." Corporal punishment is something that is
inflicted to punish the child. In the case of students at JRC, those
who are on aversive therapy are on the program because it has been deemed
beneficial to the treatment of their behavioral disorders, and the treatment
was approved by the student's physicians and by the court. Aversive
treatment, particularly with the safeguards implemented by JRC and the
Massachusetts Courts, is not unreasonable nor excessive and is in accord with
a Court-approved treatment plan while the child is on home visits. Therefore,
the use of aversive treatment by parents on JRC students when the students are
on home visits in New York is not prohibited by New York law.
Furthermore, New York law explicitly permits the use of physical force by a
parent, guardian or teacher "when and to the extent that he reasonably
believes it necessary to maintain discipline or to promote the welfare" of the
child or student. NY CLS Penal Â§ 35.10. This parental privilege deems such
force to be legal, not criminal. Thus, even if the use of aversive treatment
is deemed to be punishment and physical force, the parents are protected by
this privilege, codified by statute, and they cannot be criminally prosecuted
in this circumstance.
NEW JERSEY LAW ALLOWING THE USE OF AVERSIVE TREATMENT
Jersey specifically allows the use of aversive treatment and treatment with
skin shock. New Jersey recognizes the use and benefit of aversive treatment
and the use of skin shock as part of a treatment plan. New Jersey statutes
N.J.S.A 30:4-24.2 and 30:6D-5 detail the rights of patients and
developmentally disabled persons receiving services at facilities and provide
for the use of skin shock treatment in certain circumstances.
30:6D-5 states that a person receiving services for the developmentally
disabled at any facility has the right not to:
(4) be subjected to shock treatment, psychosurgery,
sterilization or medical behavioral or pharmacological research without the
express and informed consent of such person, if a competent adult, or of such
person's guardian ad litem specifically appointed by a court for the matter of
consent to the proceedings, if a minor or an incompetent adult or a person
administratively determined to be mentally deficient. Such consent shall be
placed in such person's record.
30:4-24.2 similarly states patients have the following right:
(2) Not to be subjected to experimental research, shock
treatment, psychosurgery or sterilization, without the express and informed
consent of the patient after consultation with counsel or interested party of
the patient's choice. Such consent shall be made in writing, a copy of which
shall be placed in the patient's treatment record. If the patient has been
adjudicated incompetent a court of competent jurisdiction shall hold a hearing
to determine the necessity of such procedure at which the client is physically
present, represented by counsel, and provided the right and opportunity to be
confronted with and to cross-examine all witnesses alleging the necessity of
Jersey Department of Human Services (DHS) has enacted regulations that
permit the use of aversive techniques, including skin shock, as part of an
Individualized Habilitation Plan (IHP) of a person with developmental
disabilities. NJ ADC 10:47-7.4. DHS has categorized permissible behavior
modification techniques into three categories - Level I, II and III - with
Level III techniques including, but not limited to, "aversive stimulation,
manual restraint, meal modification, mechanical restraint, overcorrection with
or without positive practice, response cost including personal property or
community activities, sensory masking, time out utilizing any techniques not
found in Levels I and II, and time out from positive reinforcement in a
designated room." NJ ADC 10:47-7.4.
regulations further detail specific requirements for the use of Level III
techniques. See NJ ADC 10:47-7.4 through 10:47-7.7. A Behavior Management
Plan (BMP) containing Level III techniques must be approved by an
Interdisciplinary Team (IDT) (which includes the person receiving services,
the legal guardian(s), those working most closely with the person and the
professionals involved in developing the person's program) and, upon approval,
incorporated into the person's IHP. See NJ ADC 10:47-7.5(a). The BMP must
then be approved by a Behavior Management Committee (BMC) (individuals who
have clinical expertise and administrative authority within the DHS Division
of Developmental Disabilities or the provider agency), a Human Rights
Committee (HRC), and the Chief Executive Officer (CEO) of the provider
agency as well as receive medical certification from a physician. See NJ ADC
10:47-7.5(c)(2). The use of Level III techniques also requires the informed
written consent of the person, if competent, or the parent/guardian of the
person, if deemed incompetent. See NJ ADC 10:47-7.7.
Additionally, New Jersey courts have acknowledged the need for and benefit of
skin shock treatment. The New Jersey Superior Court in In re J.M., 292
N.J.Super. 225 (1996), permitted a New Jersey student who was receiving skin
shock treatment with the Self-Injurious Behavior Inhibiting System (SIBIS)
in Rhode Island, because such treatment was not available in New Jersey, to
receive the SIBIS treatment in New Jersey when a new school offering the SIBIS
treatment opened in New Jersey. The court held that the student's condition
necessitated the use of skin shock treatment, detailing the remarkable
progress the student had made since its implementation as a treatment
procedure and found that the student's developmental progress would not have
been possible without the skin shock treatment. The court determined that
that there was clear and convincing evidence of the need for skin shock
treatment and permitted the student to receive such treatment in New Jersey.
Jersey law clearly allows for the use of Level III techniques, including
treatment with skin shock, and the use of Level III techniques is based upon
individual need and informed consent.
LAW ALLOWING THE USE OF AVERSIVE TREATMENT
Massachusetts Legal Procedure for Implementing
Behavioral Treatment Plans containing Aversives
The implementation of aversive treatment by JRC is closely
regulated and monitored. Behavior modification techniques involving the use
of physical aversives are regulated in Massachusetts by the Massachusetts
Department of Mental Retardation (MA DMR) and Massachusetts Department of
Early Education and Care (MA EEC). The MA DMR has promulgated detailed
regulations requiring these treatment techniques to always be used in a safe,
well-documented manner, and performed as treatment and not for the purpose of
punishment. See 115 CMR 5.14. To employ aversive techniques, a
provider must specifically be certified by the MA DMR and JRC is certified by
the MA DMR to use aversive procedures.
The use of aversive techniques also requires special consent
procedures before they may be implemented. A written behavior modification
plan detailing a treatment's rationale, duration, conditions, and goals and a
detailed monitoring plan for evaluating the treatment's efficacy must be
created. See 115 CMR 5.14(4)(c). The plan must be approved by both a
Human Rights Committee and Peer Review Committee under procedures outlined by
the MA DMR. See 115 CMR 5.14(4)(d). In addition, aversive techniques
cannot be implemented until a state court, specifically the Massachusetts
Probate Court, approves their use under "substituted judgment" criteria
designed to protect the interests of persons not able to make informed
treatment decisions on their own behalf. See 115 CMR 5.14(4)(e).
Moreover, a guardian/family member must first sign a detailed aversive therapy
consent form before JRC will incorporate such procedures in a student's
treatment plan and the aversive treatment is included and made part of an individual's Individualized Education Plan or Individualized Service Plan.
One particular aversive intervention developed by JRC is an
electrical stimulation device that JRC manufactures called the Graduated
Electronic Decelerator (GED). The GED unit consists of a transmitter
operated by a JRC staff member and a receiver worn by the student. The
receiver delivers a low-level surface application of electrical current to the student's skin upon command from the transmitter, as part of a designed
behavioral treatment. The GED device is adjustable in intensity and duration
of the electrical current. There are no harmful side effects. Minor side
effects may consist of reddening of the skin and, on rare occasions, a small
blister may appear if the device is not making full contact with the skin.
The Supreme Judicial Court of Massachusetts has affirmed a Probate Court order
authorizing the use of GED at JRC as an appropriate intervention. See,
Guardianship of Brandon Sanchez, 424 Mass. 482 (1997); see also JRC
v. DMR, 424 Mass. 430 (1997).
2005/2006 Massachusetts Legislation to Ban Aversive Treatment did
Two identical pieces of legislation proposing a ban on
the use of aversive therapy were considered by Massachusetts legislators this
session. Similar bills had been introduced since 1986. House Bill 1120 was
proposed by Rep. Barbara LaItalien. The Senate version, Senate Bill 376, was
submitted by Sen. Jarrett Barrios. Both bills were submitted to the Joint
Committee on Children and Families.
A public hearing was held on September 27, 2005 to address these bills.
Parents, students, and
clinicians testified in
opposition to these bills. Also testifying in opposition of these bills was
Rep. Jeffrey Sanchez whose nephew attends JRC. Rep. Sanchez described how his
nephew would be extremely harmed if aversive therapy were not available in his
treatment plan. Rep. John Scibak, who is a behavioral psychologist with
personal experience using aversive therapy and a member of the Joint Committee
on Children and Families, spoke in opposition to these bills as well. The
Committee members graciously commended the students for sharing their personal
stories and they seemed moved by the students' testimony about their
progress. Throughout the next few months, JRC students visited the Committee
members at their offices in the State House.
An Executive Session of the Joint Committee on Children
and Families was held on January 25, 2006. It was anticipated that the
Committee members would discuss and vote on these bills. However Chairperson
Shirley Owens-Hicks announced that a second Public Hearing would be schedule
because one of the sponsors of the bills felt she did not have enough time to
present her testimony.
On February 16th, 2006 a second hearing on
House Bill 1120 took place at the State House. Several JRC students who have
benefited from aversive therapy spoke passionately to the Committee members.
The JRC students pointed out that other treatments such as the prescription of
psychotropic medications and counseling had been tried with poor results.
Many of the JRC students stated that they had requested this therapy because
they witnessed progress made by other students and wanted to improve
themselves. A few of the Committee members experienced a brief skin shock
application delivered by one of JRC's clinicians. The Committee members
commented that it was not as painful as they had imagined. Once again, Reps. Scibak and Sanchez testified in opposition to these bills. Many JRC parents
recounted their experiences with their children being drugged senselessly,
precluding their children from participating in academic and social
opportunities. JRC parents mentioned the improved quality of life for their
children and entire families since the aversive therapy was implemented.
JRC's clinicians enlightened the Committee members on the Court process
required before using the treatment. They described the safeguards and school
policies which are in place to protect students.
The Joint Committee on Children and Families met for an
Executive Session on March 15th, 2006 to vote on these bills. The
Senate Chairperson Shirley Owen-Hicks motioned to place these bills into
study. Co-Chairperson Senator Karen Spilka commented that she believes that
parents have a right to choose this treatment for their disabled children.
She called for an oral vote on the motion. The votes in support of the motion
prevailed and the bills were placed into study. Placing the bills into study
ends the legislative review of the bills and a study can take years to
LAW ALLOWING THE USE OF AVERSIVE TREATMENT
California law recognizes the use and benefit of aversive therapy in
certain circumstances and created specific regulations permitting the
use of such treatment. See Civil Code Tit. 17, Â§50800, et seq.
California's Department of Developmental Services, Civil Code Tit. 17,
Â§50800, et seq., entitled "Peer Review of Behavior Modification
Interventions That Cause Pain or Trauma, and Electroconvulsive Therapy"
allows the use of aversive treatment in certain circumstances. The
regulations provide that:
All care providers shall be prohibited from using
any form of behavior modification that may cause pain or trauma upon the
client unless this behavior modification has been developed into a
program that is fully described in a treatment plan proposed by the
Interdisciplinary Team and either endorsed for implementation by a
qualified professional pursuant to Article 2, or approved by a Behavior
Modification Review Committee pursuant to Article 3.
Civil Code Tit. 17, Â§50802.
California's Department of Education allows the use of aversive
treatment in public and private schools through a waiver process. Cal.
Educ. Code Â§Â§56520(a)(3), 56523(b)(1) and 5 CCR Â§3052(5) provide that
behavioral interventions shall not include interventions which cause
pain or trauma. However, the provisions of the Education Code which
prohibit the use of behavior interventions that "cause pain or trauma"
are subject to waiver under Cal. Educ. Code Â§56101(a). Cal. Educ. Code
Â§56101(a) provides a waiver process whereby various provisions of the
Education Code or regulations adopted under the Education Code may be
waived upon request. It states in pertinent part:
Any district, special education local plan area,
county office, or public education agency, as defined in Section 56500,
may request the board to grant a waiver of any provision of this code or
regulations adopted pursuant to that provision if the waiver is
necessary or beneficial to the content and implementation of the pupil's
individualized education program and does not abrogate any right
provided individuals with exceptional needs and their parents or
guardians under the Individuals with Disabilities Education Act . . . ,
or to the compliance of a district, special educations local plan area,
or county office with the Individuals with Disabilities Educations Act .
. . Section 504 of, the Rehabilitation Act of 1973, and federal
regulations relating thereto.
These waivers have been granted for the use of skin-shock, including a
waiver granted for a California student who is currently enrolled at
JRC. In Kate School v. Department of Health, (1979) 156 Cal.
Rptr. 529, the Court acknowledges that aversive treatment may be allowed
in accordance with specific waiver procedures as provided by the then
existing Department of Health regulations. See Kate School, 156
Cal. Rptr. at 538 (it must be kept in mind that the Department does not
seek to forbid all behavioral modification therapy but only to regulate
the circumstances and conditions under which such therapy may be
used). The Court in Kate School recognizes that California does
allow a means to permit alternative procedures to be implemented in
school, as long as it is closely monitored and restricted.
Return to top
"What is the
definition of an aversive? Which aversives are considered by
professionals to be appropriate to use?"
WHAT ARE AVERSIVES AND
WHEN ARE THEY ACCEPTABLE TO USE?
What is an
Which aversives are acceptable to use?
Definitions of Aversives used at JRC
What is an Aversive?
broadly defined an aversive is an event that is defined by its effect on
behavior. There are two equally good ways to determine if an event is an
event, when it is arranged as a consequence, decreases the frequency of a
behavior, it qualifies as an aversive. For example, if child punches
his sister and is given a spank, and if the spank causes punching his sister
to occur less often, then the spank qualifies as a decelerating consequence,
or an aversive.
escape or avoidance of an event increases the frequency of the behavior that
escaped or avoided it, then the event qualifies as an aversive. For
example, if a child's hand-removal-from-a-hot stove increases when that
removal terminates contact with a hot stove, then skin-touching-a-hot stove
qualifies as an aversive.
classification of aversives was given in a 2005 article by Michaels, et al.,
entitled "Personal Paradigm Shifts in PBS [Positive Behavior Support] Exports"
(bracketed material inserted) in the Journal of Positive Interventions,
Volume 7, Number 2, Spring 2005, pages 93-108. A copy of the full text of this
paper may be found at by
Michaels et al. suggested grouping decelerative consequences into the following
nine categories of "decelerative consequence-based behavior strategies used in
relation to individuals who engage in dangerous behavior." The nine categories
were as follows:
differential reinforcement procedures
(with extinction or redirection of disruptive behavior);
differential reinforcement procedures
(with mild reprimand or response cost for disruptive behavior);
extinction (i.e. withholding reinforcement
for a previously reinforced behavior);
response cost (i.e. withdrawal of a
reinforcer or reinforcing event contingent on the behavior's occurrence);
overcorrection (i.e. forced engagement in
behavior that more than corrects the effects of the inappropriate behavior);
seclusion timeout (i.e. removing the
individual from the setting to an area of total social isolation);
application of sensory punishment (e.g.
ammonia vapor, foul tasting substances, loud or harsh sounds);
application of physical punishment (e.g.
spanking, pinches, restraint as punishment); and
contingent electric shock (i.e.
application of electrical stimulation for engagement in targeted behavior).
definitions of the various categories, JRC currently uses the following
decelerative procedures. Each procedure that is asterisked is one for which JRC
seeks authorization from a probate court to use, in the context of a substituted
Differential reinforcement procedures
Breaking a reward contract
without a verbal reprimand
Differential reinforcement procedures with verbal
Breaking a reward contract
with a verbal NO and response cost,
e.g., token/point/money fine
Token, point or money fine
Loss of privileges
Application of sensory punishment
Application of physical punishment (includes movement
*Helmet as punishment
*Movement limitation as
Contingent electric shock
*Contingent electric shock
procedures not in use at JRC but reported and supported in the
professional literature include the following. Again we have used the
classification given by Michaels et al.:
Locked seclusion with or with
Seclusion without locked door with or without direct
Application of sensory punishment
Application of physical punishment
Finger in jaw
Corner holding timeout
Aversives are Acceptable to Use?
of the study by Michaels et al. was to survey experts in the field of Positive
Behavior Supports (PBS) to find out what procedures they considered to be
acceptable to use in certain circumstances.
al. explain how they chose their experts as follows:
within the field of positive behavior supports was operationally defined
based on two primary attributes: (a) leadership within the field of PBS (i.e.,
public policy and advocacy work) and (b) scholarship within the field of PBS
(i.e., publication record and editorial board work).
The total sample (N = 134) was drawn from four sources: (a) selected state
contacts to the Rehabilitation Research and Training Center on Positive Behavior
Supports (RRTC-PBS, n=27), members of the editorial board of the
journal of Positive Behavior Interventions (JPBI, n=59), members of
TASH's subcommittee on Positive Behavior Supports (n=21), and (d) members
of the editorial board of Research and Practice for Persons with Severe
Seventy-three persons completed and returned the survey. 88% of the responders
had doctorate-level degrees. On the average, the responders had 27 years
experience in the field of developmental disabilities.
responders to the survey were assured that "all responses would be confidential
and that data would be analyzed and reported in aggregate form only."
following findings of this survey are relevant to the recent proposal by NYSED
to remove JRC from its list of approved schools and to the current proposed bill
in the New York Legislature that would ban the use of aversive procedures:
the PBS experts would use contingent electric shock "under certain
circumstances or conditions." This was a higher percentage than the percentage
of experts that would use Sensory punishment (7%) and physical punishment
(4%). That as many as 10% of the top experts in Positive Behavior Supports
would use contingent electric shock in certain circumstances is an astounding
finding. Of those who said that skin shock was appropriate in certain
circumstances. 100% of these said that skin shock was effective, and 83% said
it was supported in the literature.
experts who said they would use skin shock in certain circumstances were also
asked to say under what circumstances they would consider using it. The
them said they would use skin shock if the person or others are "at risk for
said they would use skin shock if other procedures were ineffective
said they would use skin shock for behavior that "interferes with learning."
said they would use skin shock for behavior that is "socially stigmatizing,
al express their surprise at their results in the following statement:
"Interestingly, a small number of PBS experts indicated that they would still
use the full range of decelerative procedures (sensory punishment, physical
punishment, and contingent shock) under certain conditions. This range of
treatment acceptability among PBS experts was somewhat surprising to us and
likely is a result of a variety of factors, including training, background,
and current and past clinical experiences. Both Keyes et al. (1988) and Spreat
and Walsh (1994) found differences in treatment acceptability according to
discipline (i.e., psychologists were more likely to support certain behavioral
procedures and less likely to support position statements against the use of
decelerative strategies), and much of the research in treatment acceptability
acknowledges the influence of the severity of the problem on perception of
acceptability. This may be pertinent to the experts, who, as a function of
their expertise, have worked and continue to work with individuals who have
the most severe and complex problem behaviors." (page 106)
words, psychologists and PBS experts who work with severe and complex problem
behaviors tend to support the need to have a wide range of aversives
available, including skin shock.
Definitions of Court-Authorized
Supplementary Aversives Used at JRC
Limitation: (DMR Level
III) Either of two forms of movement limitation might be used for treatment
purposes: (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, arm splints, arm tubes, or helmet. 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 the student 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 the student 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 problematic behaviors so that the student will be able
to engage in positive reinforcement programs; to decelerate student's
problematic behaviors so that he/she 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/her 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 her 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.
(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.
Contingent food program: (DMR Level III) If the student does not exhibit
certain targeted behaviors for a specified period of time he 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 preferred staple-food menu is
designed by the nutritionist and the food is prepared by the kitchen staff or a
caterer. The total calories per day of preferred staple food is determined by
the nutritionist in consultation with the medical staff, as necessary to meet
the student's daily calorie requirements. (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 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 contracts. If the minimum daily total of calories has not been earned by
7:00 P.M., then the balance necessary to bring the total staple food calories
eaten to the total calories will be dispensed to the student, in the form of
non-preferred staple food, starting at 7:00 P.M. (preferably contingent upon
passage 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 the health and well being of the
student are not jeopardized. This includes daily weighing by the staff and daily
nursing inspections to insure that his weight remains at his target weight, as
established by the medical staff. In addition to recording in the medical record
the weighing and daily nursing inspection, a qualified nutritionist shall
provide a consultation on a regular basis.
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.
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 "making" their contracts. Any food missed by
failing to make a contract is made up in a pre-bedtime meal.
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 which 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."
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.
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 his 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 his other food through various task completions, the
exhibition of "supergoodie" behaviors, and the passage of contracts, among other
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.
the following steps are taken:
i. A baseline
blood work of the student prior to the initiation of the specialized food
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 his recommended daily caloric intake; (b) if a member of
the JRC medical staff determines that such a test is necessary;
student is offered unlimited amounts of fluids;
electrolyte content in the student's blood is measured prior to the time that he
enters 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;
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 in the student's
record that the report was made. 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;
forwards the status of the student's weight to the consulting physician, each
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 his 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 his daily calorie goal, without respect to any behavioral
Monitor shall be informed whenever the student receives no more than twenty
(20%) percent of the daily caloric goal for two consecutive weeks.
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.
Behavior Rehearsal Lessons
(Recreating the Scene): The staff member presents a stimulus for some
targeted inappropriate behavior that the student has shown or may show. The
staff member then prompts the student to engage in the initial phase(s) of the
behavior or some attempt to exhibit the behavior, and arranges some planned
aversive. This procedure is arranged to be carried out at pre-specified times of
the day, which may be randomized and carried out over a specified number of days
procedure is particularly useful to treat behaviors with a low frequency of
occurrence, where even one natural occurrence of the inappropriate behavior
could have serious consequences for the student or others; however, it also may
be used to treat behaviors of medium or high frequency.
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 an average
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 range from
approximately 1% to 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 seconds. One or more electrical stimulations are
administered to a student after he engages in a targeted behavior. The GED
devices also have remote 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 reddening of the skin and, on rare occasions, a small
blister may appear if the device is not making full contact with the skin.
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.
Return to top
"What aversives does JRC use, and what
policies does JRC follow in using them?"
JRC Policy and Procedure on
Policy on What Problem Behaviors may be Treated with Level III Procedures
JRC Notice to the Court Procedures
GED Fading Policy and Procedure
JRC Policy and Procedure on Peer Review Committee
JRC Procedures Followed by JRC's Human Rights Committee
JRC Policy and Procedure
on Court-Authorized Supplementary Aversives (Level II and III Interventions)
If positive programming by itself proves insufficiently
effective to accomplish a student's treatment goals, parents/guardians of JRC
students are given the option of supplementing JRC's positive programming
procedures with the use of one or more supplementary, court-authorized aversives.
Aversives are used only if appropriate parental, medical, psychiatric, human
rights, peer review and court approvals are obtained.
At JRC, the
primary aversive used is a brief (2-second) application of a skin-shock to the
surface of the skin, typically on the arm or leg, and is applied, as soon after
the occurrence of a problem behavior as is possible and practical. This
procedure is very effective, is generally required only in the initial phase of
treatment, has no significant adverse side effects and is a considerably less
intrusive and more effective alternative than psychotropic drugs. For some
higher functioning students, when the student realizes that this treatment will
soon be available for use in his/her program, major behavior changes may take
place in the student's repertoire even without JRC's having to actually employ
positive programming is tried for a period of time before the option of
supplementing the treatment with aversive procedures is considered. Looking at
the JRC population as a whole (which includes both students who have been at JRC
for a longer time as well as recent admissions), at any given time only about
55% of JRC's population have court-authorized aversive procedures as part of
their treatment programs. The other 45% are being successfully treated using
positive programming alone.
If the JRC
professional staff proposes the addition of court-authorized aversive procedures
to a student's program, parents have the option to decline. If they do so, and
if the student can be kept at JRC while maintaining the safety of the student
and those around him, the student simply remains at JRC and may then make
substantially less progress than might otherwise be possible. If, however, the
student cannot be kept safely without the use of such procedures, and if the
parents decline permission for them, the parent and sending agency may seek an
alternative placement for the child.
In the event that
supplemental aversives is proposed for use with a student, JRC will obtain
informed consent from the parent or guardian. Supplementary aversives are only
employed at JRC after they has been approved by the parents, and authorized by a
Massachusetts Probate Court pursuant to a substituted judgment petition.
In each substituted judgment case, counsel is appointed for the student.
Full hearings are held on each petition for the appointment of temporary or
permanent guardianships. A clinician with the necessary qualifications to oversee a
behavioral treatment program, supervises the treatment of all students for whom
supplementary court-authorized aversives are used. The plans are developed by
JRC's clinicians, including the
clinician that will be overseeing the implementation of the plan. All
plans are reviewed and approved by
designated by the Executive Director. All interventions are approved for use
with a student by a physician and, if indicated, by a psychiatrist, neurologist
and/or cardiologist. All programs are also reviewed by a Human Rights and a Peer
clinician oversees each
student's treatment program with the assistance of a treatment team that
includes a case manager, the teacher, the special education supervisor and the
residential coordinators. Additional input is obtained from medical consultants,
psychiatrists, nursing staff, speech therapists, etc. as required. The design of
each student's program, as well as each substantive change in that program, must
be reviewed and approved by a doctoral-level clinician.
Reviews and Reporting:
months JRC submits a progress report, which consists of a narrative analysis by
the student's attending clinician of the progress
since the last report. The clinician considers behavior charts, tally sheets, and functional analyses in
formulating each narrative analysis. For students who have had supplementary
court-authorized aversives for three years, a case conference review is done on
the student. Attending these case conferences are an independent clinician,
appointed by Massachusetts Department of Mental Retardation "DMR," a
consulting psychiatrist, the treating clinician, the classroom teacher, the parent
and/or guardian, a nurse, and the case manager. A report is written and
submitted to the Probate Court and DMR by the independent clinician which
includes the rationale for continuing or discontinuing the court-authorized
supplementary aversives. A copy of this report is sent to the Court, the ward's
counsel, the Court Monitor, the Parent/Guardian and DMR. Each treatment plan
with court-authorized supplementary aversives is reviewed periodically by JRC's
Human Rights Committee.
Training and Monitoring:
staff member who is responsible for implementing a student's treatment plan
undergoes a two-week intensive pre-service training period, which is mandatory.
In addition, there is monthly mandatory in-service training for all staff.
Advanced training is available and encouraged. In-service training is constant
and ongoing, using, among other procedures, the following: (1) feedback is
provided to staff by those monitoring the implementation of treatment procedures
through the television monitors in each classroom and video monitoring at the
residences; (2) observations are made in the classroom and residences, feedback
is given by the supervisors, including the quality control supervisor(s); (3) a
system is in place (PIO/PC system) in which supervisees and supervisors provide
positive and negative feedback for desired and undesired staff performance; and
(4) formal evaluations of all direct-care staff performances are conducted every
certified by the Massachusetts Department of Mental Retardation to use
supplementary court-authorized aversives (level III procedures).
Policy on What Problem Behaviors may be
Treated with "Level III" Procedures
In order for a behavior to be treated with the GED or any
other level 3 procedure, that behavior category must be approved for the GED or
level 3 procedures.
There are three general circumstances where the JRC clinician may be involved in seeking to apply a level 3 consequence to a
behavior that, if viewed out of context, and if viewed only in one instance,
might seem inappropriate for the receipt of a level 3 treatment procedure.
Where the topography of the behavior is an antecedent
to, an attempt to execute, the first member of a chain that ends in, a
shaped-down version of, or a threat to execute some other obviously serious
problematic behavior. JRC's treatment plans allow the
clinician to add
such topographies to the behavior category of the obviously serious
Where the behavior occurs so frequently, within some
short period of time (e.g., where some behavior occurs n or more times
within x minutes), that it functions as a verbal tantrum or a
nonverbal tantrum that is a major disruptive behavior. In such cases, the
clinician may wish to identify the behavior as a verbal or nonverbal
tantrum and to add this to the list of topographies in the Major Disruptive
Where a topography becomes more disruptive or
otherwise more frequent and/or intense so that it meets the definition of one
of the five categories of major behaviors (e.g., Aggression, Health Dangerous,
etc.) and as a result will be treated with a Level 3 procedure.
For circumstance 1 above, the
clinician must be able to support the notion that the behavior is an
antecedent to, attempt to execute, an initial step in a chain that ends in,
etc., some other obviously serious problematic behavior. For circumstance 2
clinician should be
prepared to show that the verbal or nonverbal tantrum significantly interferes
with the student's social or educational development. For circumstance 3
above, the clinician needs to be able to show that the topography does belong in the
new category to which he/she wishes to transfer the behavior.
In considering all three of these circumstances, the following checklist must be
considered by the clinician in making his/her case.
Describe in detail the behavior that has been identified
for a change in treatment.
Are the guardians aware of the proposed change and
support the use Level 3 interventions to decelerate the behavior?
Describe how often the behavior is occurring.
Describe where and under what circumstances the behavior
Have you reviewed and archived any Digital Video
Recording footage of this behavior?
Describe what forms of treatment have been used to treat
this behavior and the effectiveness of those forms of treatment.
Is there any other positive reinforcer or less
restrictive negative consequence that could reasonably be expected to be
How is this behavior causing serious disruption to the
student's educational development?
How is this behavior causing serious disruption to the
student's social development?
Give examples (including dates and times) of how this
behavior has caused serious disruption to the student's education.
Give examples (including dates and times) of how this
behavior has caused serious disruption to the student's social development.
All of this supporting information will not be needed in
every single case. Much depends on how obvious is the relation of the seemingly
innocuous behavior and the obviously problematic behavior. An additional
important factor is how serious is the obviously problematic behavior.
The Programming Office will assist the
assembling the needed information to complete this set of questions. Any of
these types of changes to a student's treatment plan must be accompanied by a
detailed clinician note explaining the clinical reasons for the change.
It is JRC's policy to treat each and every problematic
behavior effectively, even if these behaviors may, when considered in isolation
or out of context, seem non-threatening. For many of our current treatment
plans, the plan allows level 3 procedures for Aggression, Health Dangerous
Behaviors, Property Destruction, Noncompliance and Major Disruptive categories.
Some behaviors, however, if viewed out of the total
treatment context of the individual, and if only one instance is viewed, may
seem to be too innocuous to be worthy of being addressed with a level 3
procedure such as the GED. For example:
A nag might be innocuous, but if it goes on 24/7 and
cannot be treated by less restrictive procedures, it can completely interfere
with a student's educational and social development
A mumble may seem innocuous, but if it goes on at all
times in all places might prevent a student from ever being able to enjoy a
public library or a nice restaurant.
A deliberate wrong answer may seem innocuous, but if the
student deliberately does this to every academic problem presented to him,
he/she will never learn anything.
A tap on the head may seem innocuous, but if this is a
shaped-down version of very dangerous self-abusive head-hitting, it may need
to be treated.
Getting out one's seat without permission may seem
innocuous, but if this is the first component of a behavior chain that leads
to life-and-limb-threatening aggressive behaviors; it may need to be treated
intends to pursue a substituted judgment authorizing the use of Level III
interventions it gives prior notice to the Department of Mental Retardation and
When any type
of emergency exists, such as a student going to the hospital emergency room or
police involvement, the Court Monitor (currently Dr. John Daignault), DMR, and
treating clinician are notified.
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 the clinicians and
the student's clinician must approve of 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. In addition, restraint
checks are performed every 15 minutes and recorded on the student's recording
sheet every time movement limitation is used for a student with court authorized
Notifications to the Court Monitor re: Specialized Food Program
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 his 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 her or her 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. JRC's treatment program is so effective and successful that
this notification is never needed.
Notifications to the Court Monitor re: GED Applications
rarely if ever triggered, 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 the skin on a
regular basis 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.
Monitor, DMR, and Executive Director or his designee are notified if a student
receives a misapplication of an electrical stimulation.
addition, a student's treating clinician is notified in person, by phone, or by
beeper when a student reaches a total of 10 electrical stimulations within a
24-hour period. The clinician is also notified when a student's electrical
stimulation total reaches each subsequent multiple of 10.
Progress Reports and Case Conferences
Every four months JRC shall
submit a progress report, which will consist of a narrative analysis by his/his
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. For students who
have received Level III interventions for three years, a case conference review
is done on the student. Attending these case-conferences are the independent
clinicians, appointed by DMR, JRC's consulting psychiatrist, treating
clinician, classroom teacher, parent and/or guardian, nurse, and case
manager. A report is written and submitted by the independent clinician which
includes the rationale for continuing or discontinuing Level III interventions.
The copies of these materials need not be attached to the analysis but shall be
made available to counsel, and Monitor upon their request. JRC shall send copies
of this report to the Court, the ward's counsel, Court Monitor, Parent/Guardian
GED Fading Policy and
students who have been identified as Highly Aggressive by the treatment team the
following procedures will be followed when fading the GED:
GED fading will not occur until
the student has gone a minimum of 1 year with no major behaviors.
The clinician will discuss the student with the programming
department to make sure everyone on the treatment team is in agreement.
student has been faded from devices and they exhibit a serious behavior the
student will then be placed back into GED devices for a period of 6 months - 1
year (student specific).
student has been faded from devices and shows 3 or more serious interfering
behaviors within 1 hour, the student will go back into GED devices for a
period of 1 week - 3 months (student specific).
student has been faded from devices and shows 5 or more serious interfering
behaviors within a day, the student will go back into GED devices for a period
of 1 week - 3 months (student specific).
for a student to resume the fading process it must be approved by all members
of his treatment team.
students who have not been identified as Highly Aggressive by the treatment team
the following procedures will be followed when fading the GED:
Once a student has been on the
GED for two weeks-one month, the topic of fading can be addressed.
Students must then go a minimum of 3 months without exhibiting any MTD
behaviors. Students will also have to have a minimum of 10 (can be set
differently by treatment team) interfering behaviors per day throughout that
3 month period. The clinician will discuss the student with all
members of the treatment team for the initial approval. Most students will
follow these fading steps (The treatment team may decide to go in a different
order depending on the student):
Step1: faded during self care
Step2: faded 9-12 M-F
Step3: faded 9-3 M-F
Step4: faded for the school day M-F
Step5: faded for the school day all week (including
Step6: faded for the evening on weekends
Step7: faded during the overnight
Step8: faded during transport/during fieldtrips
will be a minimum of two weeks between each step.
student breaks his MTD or exceeds the criteria for their interfering behaviors
they will be placed back into the devices. The treatment team will determine
when a student is ready to start the fading process again and which step the
student will start on
are minimum guidelines and can be extended whenever necessary. Case managers
must complete a DPD for all changes (including dropping the fading). These
DPD's must be signed and activated BEFORE fading can start.
When a treatment plan is written containing any Level II or III interventions,
the treating clinician makes a request to the
chairperson of the Peer Review Committee (PRC) to schedule a meeting. The
meeting is scheduled at an agreed upon time. The treating
the treatment plan and relevant information to committee members, which includes
(but is not limited to) the student's behaviors, characteristics, behavior
charts, functional analysis, prior treatment, and any other pertinent
information. Committee members may ask questions at any time. When all questions
have been answered and discussion is at an end a vote is taken to accept or
reject the treatment plan. If the presenting clinician is a member of the
committee, he or she must abstain from voting. A signature sheet is passed
around for a written documentation of the vote. Minutes from the meeting are
tape recorded. These notes along with signature sheets and notes taken by the
chairperson are given to the Student Services Department. Copies of the
signature sheets are placed in the Student File. Notes and audiotapes are kept
in the Student Services Department. The minutes of the meeting are typed and
kept on file at JRC.
The committee meets based on the need to review new
treatment plans or new aversive interventions proposed for a student already
being treated with aversive.
In addition to the Peer Review Committee, JRC also conducts weekly behavior
chart shares in an effort to review and discuss treatment decisions.
Participating staff may include the Executive Director, one or more Assistant
Executive Directors, Clinicians, Director of Education,
Programming, Case Managers, and a member from the Nursing department.
JRC Procedures Followed by JRC's Human Rights
REVIEW AND APPROVE ALL INDIVIDUAL TREATMENT PLANS
SUBMITTED TO THE PROBATE COURT. JRC will submit to the Human Rights
Committee (HRC), for its review all programs that JRC has submitted, or which
JRC plans to submit, for approval by a probate court. The goal of the Human
Rights Committee (HRC) will be to make available to JRC the standards and
opinions of the lay community, so as to ensure that the behavior modification
techniques used at JRC are not only effective, but also are acceptable, as
measured by community standards.
REVIEW AND APPROVE OTHER HUMAN RIGHTS-RELATED ISSUES
AND ACTIVITIES. JRC will submit to the Committee, for its review, any
other program activities or issues that concern the protection of the rights
of the students and their families.
UNBIASED COMMUNICATION TO OTHERS ABOUT THE JRC
PROGRAM The committee is available to receive questions from others, both
outside and inside JRC concerning the ethics, humaneness, and appropriateness
of the procedures.
REVIEW, MONITOR AND INVESTIGATE THE ACTIVITIES OF THE
PROGRAM WITH REGARD TO HUMAN AND CIVIL RIGHTS OF THE STUDENTS SERVED. The
Committee shall review, monitor and investigate the activities of the program
with regard to the human and civil rights of persons served by the program.
The Committee shall take such action as it determines is required to protect
such human and civil rights. The committee shall have the authority to
investigate grievances and allegations of client mistreatment, harm, or
violation of a client's rights. "Any such action taken by the Committee
shall not remove the responsibility of the program and the Department to
conduct a formal investigation where required under Â§ 104 CMR 20.07(5)."
INFORM AND TRAIN PERSONS SERVED BY THE PROGRAM OF
THEIR RIGHTS AND HOW TO EXERCISE THOSE RIGHTS THROUGH THE ACTIVITIES OF THE
JRC HUMAN RIGHTS OFFICER. JRC will designate and empower a member of its
staff to serve as the program's Human Rights Officer and to undertake the
following responsibilities as a formal component of his or her job
participate in training programs for Human Rights
Officers offered by the Massachusetts Department of Mental Retardation.
serve as staff to the program's Human Rights
develop and implement the means to do the following:
inform students served by JRC, staff, and families
of client's rights,
train persons served by the program in the exercise
of their rights, to the maximum extent of their capabilities and
provide persons served by the program with
opportunities to exercise their rights to the fullest extent of their
capabilities and interests and the right to go to the Human Rights
Committee on any issue involving human rights,
otherwise assist the program in the development of
means to promote the human and civil rights of persons served by the
provide legal information and referral services to
persons served by the program.
CONSULTATION WITH EXPERTS AS REQUIRED. The
Human Rights Committee members are not expected to have the expertise to
propose treatment procedures. However, the Committee members may consult with
JRC's Peer Review Committee Members for assistance.
ORGANIZATION. The Committee will elect its own
chairperson, and will conduct business-like meetings. Each meeting will have
an agenda, and minutes, which summarize the proceedings will be prepared. On
any topics on which decisions are required, a vote of the Committee will be
taken and recorded in the minutes.
INVITATION. Potential members will be invited to
participate on the Committee by either JRC or the Committee. JRC will make the
final decision with respect to membership on the Committee, in consultation
with the existing membership of the Committee.
TRIAL MEMBERSHIPS. The first six months of
membership will be a trial membership. At the end of the year, a trial member
may be admitted to permanent membership by vote of the Committee and approval
ATTENDANCE. The Committee may set attendance
requirements. The committee will meet quarterly.
TERM. The Term of members of the Committee shall
DUTIES. The duties of the Committee shall be as
described in Paragraphs 1 through 5 above. Such duties shall not
include monitoring of the JRC program or communicating with licensing and
approval authorities. Each member of the Committee agrees that frank and
candid discussion between JRC staff and members of the Committee is essential
to the successful operation of the Committee.
REMOVAL FROM THE COMMITTEE. JRC may remove a
member from the Committee for just cause or for violation of any of the terms
of this policy.
COMPLIANCE WITH STATE REGULATIONS. This
Committee shall operate in full compliance with the provisions of 104 CMR
20.14. To the extent that any of the provisions of this policy are
inconsistent with state regulations or laws, the remaining provisions of this
policy shall be in full force and effect.
CONFIDENTIALITY. Committee members agree to keep
confidential all documents and other information provided to them at Human
Rights Committee meetings, except as may be required in order to carry out
their official duties. When documents or other information is disclosed to
others, in the course of carrying out a Committee member's official duties,
the fact of the disclosure and the contents disclosed should be communicated
VOTING and QUORUM REQUIREMENTS. The requirements
shall be a quorum of four Committee members. Decision to approve a treatment
plan shall be by majority vote. In emergency situations the committee members
may be contacted by the Human Rights Officer for approval of a court
authorized treatment plan. The plan will be given further consideration at the
next scheduled Human Rights Meeting.
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"Does JRC prepare its students to achieve
high school diplomas?"
Because JRC has
very effective treatment procedures, we are able to bring students problematic
behaviors under control relatively quickly. This then allows students who have
never previously cooperated with their teachers, or taken an interest in,
academic studies to start to do their schoolwork and enjoy the rewards that
come from doing well in school and learning new skills.
JRC has a system in
which as the student does better and better in his/her behaviors and
academics, the student gains more privileges, lives in less restrictive
settings, begins to do part-time jobs, work toward receiving a high school
diploma, etc. Wherever possible, the goal is to return the student back to
his/her local school system.
As of April 25,
2006, here is what our students and graduates had been able to accomplish with
respect to obtaining a high school diploma or GED diploma.
Academic Accomplishments of JRC Students
As of April 26,2006
42 of our current
students are preparing for either MCAS or Regents exams.
Four of these
42 students have passed either all or most of their MCAS or Regents
requirements. One of these four will receive a high school diploma from
his high school this June and may receive a Regents diploma if he passes
his Regents' examination.
One of these 42
students plans to sit for his GED test once he has left JRC. (Students are
not eligible to take the GED test while they are still students at JRC).
As of 4/25/06 we
have collected information for all students who have been transitioned back
to their local school system or otherwise graduated from JRC due to the
improvement in their behaviors since Jan. 1, 2000. There are a total of 25
4 of the 25
obtained their high school diploma before leaving JRC.
2 of the 25
these have earned a GED diploma from their local high school
7 of the 25
have earned their diploma from their local high school
5 of the 25 are
now enrolled in college
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Rights Committee is controlled by JRC and therefore is useless as an
None of the members of
JRC's Human rights committee are employed by JRC. All of the members are
either parents of current or past JRC students or volunteer members of
the community. New members are appointed by the committee and not by
From time to time state
agencies have placed representatives on the committee. Both the
Massachusetts Department of Education and the New York Department of
Education have placed representatives on the Human Rights Committee in
past years. The New York Department of Education has recently notified
JRC that it will be resuming that practice.
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"What organizations support the right of
parents to choose aversives for their child?"
Return to top
"What was the
controversy re JRC's use of the term "psychologist?"
Consistent with the provisions of
Massachusetts state law and other applicable regulations, the Judge
Rotenberg Center, Inc. (JRC) has long employed clinical staff with
training and graduate degrees (masters and doctorates) in psychology.
These professionals provide diagnostic evaluations and develop and
implement behavioral treatment plans. Some, but not all of these
professionals, also held licenses issued by the Massachusetts Board of
Registration of Psychologists, and a licensed psychologist oversaw and
directed the work of these professionals at all times.
For over twenty years prior to May of 2006,
consistent with our understanding of the law, JRC assigned the title of
"psychologist" to all of these professionals even though some of them
were not licensed as
psychologists by the Massachusetts Board of Registration of
In 1996, the Massachusetts Legislature
amended existing law to limit the use of the title "psychologist" to
only those holding a Massachusetts license irrespective of their
education and training and notwithstanding the continued existence of
the state's own conflicting contracting rules and practices. That
legislative change did not limit or alter the authority and ability of
those appropriately educated and trained professionals, though not
licensed, to continue to provide diagnostic, counseling and treatment
services in schools such as JRC that have been licensed and approved by
the Departments of Education, Mental Retardation, and Early Education
and Care. In other words, although these same individuals could no
longer call themselves "psychologists," the 1996 amendment did not
restrict them from continuing to do exactly the same work they had
always done at schools such as JRC.
Significantly, despite the 1996 change in
the law, Massachusetts state contracting rules and practices continued
to provide that those with graduate degrees in psychology be called
Unaware of the 1996 amendment, JRC
continued to use the title "psychologists" for staff holding graduate
degrees in psychology or related fields who were providing diagnostic,
counseling and treatment services. Many other special education schools
in Massachusetts were, like JRC, also unaware of the statutory change
and continued to use the title of psychologist for their professional
JRC and its attorneys first became aware of
the change in the law in April, 2006 when the Board of Registration of
Psychologists brought it to our attention. At that time JRC immediately
changed the title of those members of its professional staff who did not
hold a Massachusetts license to "JRC clinicians." Although the job title
of these persons changed at that point, their duties and
responsibilities did not.
Those of our professionals who do not hold
a license from the Massachusetts Board of Registration of Psychologists
have entered into a consent agreement with the Board giving their
assurance that they will not use the title of "psychologist" unless and
until they are licensed. By their terms, the consent agreements are
neither punitive nor an adjudication, determination or an admission of
wrongdoing. JRC has accepted full responsibility for this
administrative oversight, and has paid an administrative assessment on
behalf of the clinicians as part of the voluntary resolution of this
matter. JRC also agreed to send the attached letter to parents
notifying them of the change in job title.
The intent of the 1996 amendment was no
doubt to protect consumers from purchasing services from individuals
holding themselves out as psychologists - who are not sufficiently
trained in the field. Since the law did not change the substance of the
work of the professional staff at specialty schools like ours.
JRC believes that we and our staff were singled out because of
a bias against aversive therapy, and not because of the egregiousness of
our mistake. Dozens of professionals employed at other schools made
exactly the same honest mistake and, to this day, have not faced either
criticism or sanction. Further, at no time - over the ten-year period
that the new law had been in effect - did the Psychology Board or any
other Massachusetts authority notify schools such as ours of the change
in the law, despite constant interaction between these schools and the
Commonwealth, and dozens of references to professional staff members as
"psychologists" in documents filed with state agencies. Indeed, it was
only upon the suggestion of JRC counsel that the Commonwealth ultimately
did send a directive to schools, urging staff to correct their titles to
be in compliance with the 1996 amendment.
For the consent agreement that was entered into between the JRC
clinicians and the Board of Registration of Psychology in Massachusetts
please click here. For a copy of JRC's news release at the time of the
settlement of this issue (October 2006), please
click here. For the report of
this settlement, found on the website of the Board of Registration,
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"Is it true that five students have died at JRC?"
Yes. Each died from natural causes that had nothing to do with our use of
aversives. JRC's policy has always been willing to admit students even
though they may have pre-existing life-threatening medical conditions. JRC
has an excellent record of maintaining the health and safety of its
students over JRC's 34 year history. JRC is proud of this record because
JRC accepts the most physically and mentally disabled students in the
nation and maintains their safety regardless of their age and physical
condition upon admission and despite the fact that many of these students
suffer severe behavior disorders that cause them to try to inflict mortal
injury to themselves. Any program that operates for as long as JRC has
under these conditions will have at least some students who die from
natural causes. No program can prevent that.
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approval process is a sham because JRC always receives approval for the aversives that it seeks authorization for."
WHY IS JRC SUCCESSFUL IN
ITS PETITIONS TO THE MASSACHUSETTS PROBATE COURT FOR THE USE OF
Every student who comes to JRC is suffering
from a life-threatening or other major behavior disorder which has been
resistant to all other forms of treatment such as heavy dosages of
anti-psychotic and other medications. The student is usually suffering
from harm inflicted by his own self-abusive, aggressive or other
behaviors and is in dire need of some form of more effective treatment.
That is the nature of type of students that JRC accepts and treats.
Typically, the basic options tend to be
these: (1) a more intensive 24 hour application of positive behavioral
programming than has been offered up to that point of time; (2)
psychotropic medication; and/or (3) intensive positive behavioral
programming supplemented by aversives. As to more effective positive
programming, the student has usually been exposed to positive
programming in all of his/her previous placements and it has been
ineffective because of inconsistent application, lack of potent rewards,
lack of properly trained staff, and/or an inability to respond to
life-threatening behaviors and keep the student safe while the
behavioral treatment is administered.
As to psychotropic medication, usually this
has also been tried exhaustively before the student comes to JRC and has
also been found to be ineffective. In some cases such medication causes
the student to suffer severe and debilitating side-effects such as
lethargy, obesity, paranoia, uncontrolled shaking, potential liver and
kidney damage, etc. No school system would send a student to a
residential special needs program such as JRC if a simple and less
expensive solution, such as psychotropic medication, were effective.
By the time a student comes to JRC, it is
often the case that the only untried major treatment options are a more
consistent and intensive application of 24-hour positive behavioral
programming and, if that is not sufficient, the adding of supplemental
aversives. In many cases parents place their child with JRC with the
explicit understanding that aversives may need to be used if JRC's
intensive positive-only behavioral programming is not successful. JRC
positive-only programming alone is successful for about 40% of the
school-age students admitted to JRC; therefore, for that group, JRC
would have no need or interest in proposing an aversive treatment plan
to the court. By the time the other 60% of the students are presented to
the court for the authorization of a treatment program involving aversives, an average of 11 months have been spent in trying,
unsuccessfully, to employ a powerful and consistent application of
positive programming. The question then becomes not only whether
aversives should be used at all, but even more critically, which
aversives and for what behaviors. At that point there are simply no
other treatment options left.
JRC has been seeking court authorizations
for the use of supplementary aversives since 1986. During that time we
have learned what elements are needed in order to justify a successful
application to the Probate Court for authorization of aversives. It has
been our policy not to seek an authorization for skin shock aversives
unless we are confident that we can meet all of the court's
requirements. In addition, when JRC is asked to make modifications to
the treatment plan by the attorney appointed by the court to represent
the student, and/or the attorney's court-funded independent expert, JRC
will work with them to try to present a treatment plan to the court that
is acceptable to all parties.
The types of requests made by the students'
counsel to JRC include the following: a request that some other type of
treatment be tried first; a request that the student receive a special
psychiatric examination before aversives are used; a request that
certain behaviors not be treated with aversives; a request that certain
aversive(s) be removed from a treatment plan; a request for a
psychiatric consult to consider the possible use of psychotropic drugs
before using aversives; etc. In these cases, we either accept the
limitation or try to work out an acceptable compromise. For example, in
certain cases where the opposing attorney objects to a certain
procedure, we have had to forgo obtaining that procedure and a further
hearing has been scheduled to review the matter in three months. We
would always rather have some plan approved, even if it is not our ideal
plan, than no plan at all.
There have been many cases in which the
parties cannot agree to a treatment plan, the judge has not approved the
treatment plan submitted by JRC and the judge has ordered JRC to
implement alternative procedures. Often the court will then schedule a
review to be held in three or six months, and hold a hearing at that
time to consider the effectiveness of the treatment that was approved
and to consider proposals to change the treatment. It is our observation
that the court's focus is always on the treatment needs of the student
and not on which party has proposed the treatment.
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"New York State
Education Department released a very negative report on JRC on June 9,
2006. What is JRC's response?"
Please see the following items:
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does not give enough attention to functional assessment. If it did, it would not need to use aversives."
JRC's approach to
functional assessment is described below. JRC's approach to functional
assessment has three parts: First, JRC uses traditional means to make
an initial functional assessment when a student enrolls at JRC. Second,
uses "Direct, Continual In-vivo Functional Assessment" throughout the
period the student is enrolled. Third, JRC uses "Redundant Programming
to Cover the Principal Possible Functions" in which treatment systems
are designed to cope with whatever function or functions a problem
behavior may have.
1. At Intake: Traditional Functional
When a student is first enrolled at JRC,
JRC's clinicians use a variety of methods to collect information about
the student, using one or more of the following sources, depending on
the needs of the student.
Review of the students' records.
Interviews with the student on the
day of admission and subsequently in the course of behavioral counseling
sessions, chart sharing meetings, etc.;
Interviews with parents, siblings or
other family members;
Interviews with staff who work with
Direct observations of the student's
Indirect measures of functions such
as the Functional Assessment Screening Tool (FAST)
Functional Analysis through direct
Observations via the digital video
monitoring system which enables each clinician to observe the student in
his classroom or residence at all times;
Review of digital video recordings
that are made in all areas of the school, residence and during
Review of the therapy notes of
unusual behaviors and restraint forms -- notes which describe the
problem behavior, the antecedent events, what followed the behavior,
If the student is receiving the GED
skin-shock procedure as part of his/her treatment, review of the GED
recording sheets that specify what the student was doing, where the GED
targeted behavior occurred and at what time;
Ongoing review of daily, weekly and
monthly charted behavior frequencies and evaluation of how interventions
are affecting these frequencies.
The information derived from one or more of
these procedures enables JRC's clinicians to develop hypotheses as to
what functions the student's problem behaviors have been serving as well
as what functions the behavior's antecedent and subsequent events have
been playing. Although JRC clinicians do this type of traditional
functional assessment for each student who enters the program, JRC also
does two other things (listed in 2 and 3 below) that make the findings
of a traditional functional assessment largely irrelevant.
2. Throughout a Student's Enrollment: Direct, Ongoing, In vivo
After the initial
assessment and throughout the course of a student's enrollment at JRC,
JRC clinicians can then test their hypotheses concerning the functions
of behaviors and events by making changes in the student's program and
observing what results they produce in the charted behavior data. This
can be conceptualized as a direct, ongoing, in vivo functional
assessment that is conducted by manipulating relevant stimuli and
consequences in order to test and redesign various hypotheses concerning
the possible functions of events that may be affecting the behaviors in
For example, if the
clinician suspects that a certain event is rewarding a problem behavior
the clinician can immediately remove that event from the student's
treatment program to see if the charted behavior shows a drop in
frequency as a result. Similarly, if the clinician thinks that a certain
event, if added to a treatment plan, can increase the effectiveness of
the reward program, the clinician can add it immediately and see how
that affects the behavior in question. The charted data, the direct
observations, and the digital video recording (DVR) monitoring system,
among other sources listed above, give the clinician the data to support
or reject various hypotheses about the functions of behaviors, stimuli
and of various interventions.
This approach has
significant advantages over relying solely on collecting data on the
functions (causes) of behaviors only at only at the start of a treatment
program (e.g., by doing some analog tests, rating scales, or analyses of
conditional probabilities) and then selecting an intervention on the
basis of those tests, rating scales or analyses. Instead, because of
JRC's behavior charting system, its ability to change treatments quickly
and constantly, and its control over its direct care staff, JRC
clinicians are able to collect behavior data daily and to use that data
to directly and continually assess the functions of behaviors, stimuli,
and various interventions.
3. Redundant Programming to Cover the Principal Possible
Functions: Designing Treatment Systems and Student Programs to Respond
Appropriately to the Problem Behavior Regardless of what its Current
Function May Be
The major possible
findings of a typical functional assessment are typically that a
behavior functions to produce certain inadvertent rewarding
consequences. There are four major types of inadvertent rewarding
consequences that we typically are concerned about: (a) attention; (b)
escape from certain ongoing demands; (c) access to certain tangible
items or activities; or (d) internal stimulation that may be
reinforcing. The result of a typical functional assessment is to be able
to characterize the student's behavior as having the function of
producing one or more of these consequences. In other words, after a
functional assessment, we hope to be able to characterize the student's
behavior as "attention-getting," "escape-producing," "tangible-item-or-activity-producing," or
And having so
characterized the behavior, the theory is that we can then better design
a treatment plan. We do this by making sure that it is designed so that
the problem behavior no longer generates the reward in question. For
example, if a problematic behavior is found to be "escape-producing" we
would make sure that that the consequence for the problem behavior is
not a time out procedure, a procedure that inevitably involves arranging
an escape from the ongoing activity.
JRC designs its treatment
systems and trains its staff in a manner that obviates the need to
characterize a student's behavior as "attention-getting,"
"escape-producing," "tangible-item-or-activity-producing," or "internal-rewarding-stimulation-producing." Instead, JRC designs all its
treatment systems so that each of these possible functions has already
been anticipated and planned for. In other words, we make the assumption
that at any given time a problem behavior may have any one or all of
these functions and we design the treatment environment in such a way to
minimize the extent to which any of these potentially rewarding events
will occur after the behavior has occurred.
To see what this means
more concretely, let us consider each of the possible inadvertent
rewards and see how each possibility is incorporated in the training of
staff and in the design of the treatment systems that are set up in
advance and that operate across all students.
1. Attention. We
design any procedures that must be implemented immediately after a
student has engaged in a problem behavior in such a way as to minimize
any inadvertent rewarding attention that those consequences or
procedures will produce for that student. For example, suppose that the
consequence that is planned for a student if he/she shows a certain
behavior is that the student will be removed from the room he is in and
transferred to a different smaller room. The JRC staff are trained to
do this while always minimizing the amount of attention they give to the
student. The staff members do not talk to or reprimand the student
while moving him and they do not ask him (at that particular time) why
he or she engaged in the behavior. They just remove him or her to the
alternative room that he or she must be moved to with a minimum of fuss,
emotion or attention.
Of course, it will be
pointed out that even having a staff member remove a student to another
room inevitably involves giving some attention to the student. True, the
student does inevitably generate a little attention by his or her
problematic behavior; however, to counteract the rewarding effect of
this attention, we add some aversive event to the overall set of
consequences. For example, we might fine the student a certain amount of
points and we might impose a period of "loss-of-privileges" for the
behavior that he or she just displayed, in addition to moving the
student to another room. As a result, whatever rewarding effects the student's behavior may generate in the form of attention, are outweighed
by the punishing effects of the point fine and the loss of privileges.
In other words, even though the student may succeed in generating a
certain amount of attention, the net effect of the problematic behavior
for the student will be, on balance, an undesirable one from his/her
point of view.
2. Escape from demands.
When a student engages in a self-abusive action staff member are trained
to make sure that the student does not escape from any ongoing demands
as a result of this, or that any brief escape that is inevitable is
minimized. For example, if the student is working on some math homework
and suddenly engages in a self-abusive behavior, JRC staff are trained
to administer whatever consequence has been programmed for that
particular behavior - for example, the consequence might be the
administration of a GED skin shock - and then immediately put the
student back to work on the same task that he was working on before
displaying the behavior.
As an added precaution,
the clinician may direct that when the student engages in a problem
behavior, not only should the staff make sure that any escape-from-work
be minimized, but also the demands should be increased after the
problem behavior is displayed. For example, after the self-abusive is
displayed, the clinician may require the student to do a task that is
even less preferable than the task he was working at the time he/she
displayed the self-abusive behavior.
3. Tangible item or
activity. Staff are trained to never give a desired item or activity
to a student right after a problem behavior is displayed. Desired items
or activities are given only as earned rewards, and such rewards are
dispensed only as consequences for desired behaviors.
4. Possible internal
stimulation that may be rewarding. There is really little that one
can do if a problem behavior is generating internal stimulation that is
rewarding because, by definition, the stimulation is internal and beyond
our reach. One thing that one can do to counteract the possibility of
such internal and rewarding stimulation is to make sure that the problem
behavior produces some external stimulation that is sufficiently
aversive so that, on balance, the net consequence to the individual, for
displaying the behavior, is negative rather than positive.
If we design the training
of one's staff and the treatment programs for the students in the manner
described above, then we will minimize any attention or escape from
demands, we will have avoided any possibility that the behavior will
produce desired rewarding items or activities and we will have covered
the possibility that the behavior produces some desirable internal
stimulation. Having done all that there will also be no particular value
in characterizing the student's behavior as "attention-getting,"
"escape-producing," "tangible-item-or-activity-producing," or "internal-rewarding-stimulation-producing." In other words, there will
be no need for doing a functional assessment in the traditional manner.
To put it another way, by
designing treatment systems and student programs in this way, it does
not matter what function (supposed rewarding events), or combination of
functions, a problem behavior may have at any given time. Regardless of
what the function happens to be, the JRC systems are prepared, in
advance to respond appropriately if the behavior has that function or
functions. The JRC systems will, in all cases, minimize the possibility
that the staff may arrange inadvertently rewarding events after a
problematic behavior has occurred - whether those potentially rewarding
events happen to be staff or peer attention, escape from ongoing
demands, and/or obtaining some desired tangible item or engaging in some
There continues to be a
need, however, to do the type of ongoing, in vivo functional assessment
that JRC does - i.e., the daily measurement of behavior frequencies, and
the constant evaluation and re-evaluation of the function of various
events and behaviors by making ongoing intervention changes and seeing
their effect on the charted behavior data.
For most of the students
who come to JRC, and who have had the traditional Functional Behavior
Assessments (FBA's) and/or Functional Analog Analyses performed in their
past, it has been determined that their behaviors were being maintained
by multiple functions. Therefore, planning treatment systems in advance
and training the staff to make sure that the staff do not arrange any
deliberate or inadvertent rewards for problem behaviors, regardless of
what the function of the behavior may happen to be on any given
occasion, is clearly indicated.
Using Attention, Escape and Tangibles as Rewards for Desired
Behaviors and Giving the Student Easy Means for Requesting and Obtaining
In addition to minimizing
the possible roles that escape, attention and obtaining tangible items
or activities can play in rewarding unwanted behaviors, JRC's clinicians
also try to use these same consequences to reward desired behaviors. A
lot of attention is deliberately given immediately after the student
displays desired positive behaviors. This occurs both as a result of an
intermittent schedule of momentary DRO attention-rewards that staff are
trained to implement throughout the day, and as result of the DRO
reward or work contracts in which the staff give the student
extravagant praise whenever the student passes a contract.
Students are able to
escape from the demands of their classroom in an appropriate manner.
After they pass a behavior or work contract, they can earn a chance to
leave their work station and relax in the "Classroom Reward Store" which
is an area of the classroom that has couches, TV and games. Students who
are nonverbal are taught to point to a pictorial menu on their computer
to request a break (or any other reward they wish). They are also taught
to exchange a photo-card containing a photograph of the reward they want
in order to obtain the designated item or activity.
Preferred tangible items
and activities are programmed as rewards that can be earned through
behavioral contracts and students are taught how to request these items
or activities in an appropriate manner. Behavior and work contracts are
initially set at a very easy level and/or a very short duration with a
large reward for completion, in order to reinforce staying on task and
reduce the chance that the student will engage in a problematic behavior
in order to escape demands. As the student progresses, more and more
behavior or work may be required. This scheme provides many of the same
benefits as does functional communication training.
Functional Assessment and the Aversives Controversy
Functional assessment is
largely promoted by those who are in the anti-aversives camp. Those who
espouse it tend to argue that if you do a functional assessment well
enough, you will not have to use aversives. Unfortunately, published
data disprove this. In a comprehensive review
of 10 years of published studies that used Positive Behavior Support
procedures (over 100 individual behavior modification results were
involved), the authors found that even when functional assessments had
been done, positive behavior support procedures were effective in only
60% of the cases.
Why Does JRC Use its Own Method of Conducting Functional Assessments?
The typical situation in
which a functional analysis is conducted may be described as follows.
The individual is in a school or other community environment in which
the caregivers are not aware of or using behavioral procedures to treat
the problem behavior. Behavior data is not being collected on a daily
basis. And different caregivers may have different philosophies of
treatment and may or may not be willing to follow any one consistent
approach. An expert psychologist or behavior analyst is invited to
consult on the matter. The expert does a functional assessment. He or
she may bring in some graduate students to help conduct the assessment.
The assessment is often done through information collected indirectly by
speaking to the individual him/herself or to caregivers, or by asking
caregivers to complete questionnaires or rating scales. Sometimes it is
conducted by direct observations made on the results of specially
designed analog treatment situations or of structured descriptive
analyses in which conditional probabilities of response-consequence
situations are determined. On the basis of the results of this analysis,
the expert recommends a treatment plan that contains certain procedures
to more effectively control the problem behavior and to generate,
instead desired behaviors.
JRC differs in that the
student is in a residential environment that is highly structured in
advance to prevent and treat problem behaviors with the use of
behavioral procedures. It is also an environment where behavior data (on
behavior frequencies) are collected and displayed in charted form on a
daily basis, where all staff follow directions as to what procedures to
implement and in which clinicians can make changes in the entire
environment easily and quickly to determine their effect. It is because
of these major differences in setting, JRC is able to conduct, in
addition to the traditional functional assessment done a the time of
intake, the ongoing, direct, in vivo functional analysis which is
described above and the redundant programming to cover the principal
possible functions, also described above.
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How does JRC differ from other
special needs residential schools?
We treat a broad range of severely disturbed
students and are the school of last resort for students expelled from
other programs because of failed treatments. We treat
behaviors such as head banging to the point of brain injury,
eye-punching to the point of blindness, projectile vomiting to the point
of starvation, scratching skin to the point of blood and bone infection,
eating one's own fingertips, breaking one's own arms, cutting one's ears,
etc. We also treat aggressive, psychotic, suicidal, depressive and other
harmful behaviors. Students come to JRC because their previous treatment
programs were unable to control life threatening behaviors. JRC has a
near-zero rejection and near-zero expulsion policy.
Unlike other residential schools, JRC uses
no or minimal psychotropic
medication Instead, JRC uses a highly structured and consistent
behavior modification therapy. A wide range of
reward and educational
procedures are tried first to change the student's behaviors. If those
positive procedures are not effective, however, JRC supplements them with
the use of a skin-shock aversive produced by a device known as the
In addition, JRC does not use traditional psychotherapy sessions and
provides, instead, behavioral counseling.
Click here for a list of our
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What is aversive therapy
using the GED?
JRC's skin-shock therapy (not to be confused
with the psychiatric procedure known as electroconvulsive shock therapy or
ECT) is a behavior modification procedure in which a mild current from
a battery operated device is passed for a two-second period through a
small area of the surface of the skin of an arm or leg. The sensation has
been compared to a bee sting with no after-sensation. It has no
significant negative side effects.
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How effective is skin-shock as an
Very. Problem behaviors sometimes decrease
by factors of 10-fold to 1000-fold within days or weeks of
implementing the treatment. Skin-shock is far more effective than
psychotropic drugs, which are sometimes so sedating that a student can
only sleep and cannot learn. Once JRC's skin-shock aversives have
decreased a student's problem behaviors to a point where those behaviors
no longer block out all other behaviors, a window of opportunity opens
that enables the student to learn and display positive behaviors and to be
rewarded for doing so. The overall result is that student's life has been
saved, his behavior improves dramatically and his family is able to enjoy
positive experiences with their child. A detailed summary of JRC's use of
skin shock and its results is available on the JRC website.
Immediate and Long Term Effectiveness of JRC Treatment
How effective is the GED treatment?
The following links will take the reader to evidence of its effectiveness:
Proof of its effectiveness can be seen in a set of charts that show the
effect of introducing the GED into the programs of 36 students during the
2003-2005 period. The results are shown for aggressive, health dangerous
and major disruptive behaviors in the form of 106 individual charts.
Click here to see these charts and a paper
that explains them.
Additional evidence may be
a major detailed paper that Dr. Israel delivered at the EEAB (European
Experimental Analysis of Behavior) Conference in 2001 in Amiens, France
In this paper, which was updated in 2002, Dr. Israel summarizes all of
JRC's experiences in the use of skin shock from 1990 through 2002.
How well do former GED students do after they leave JRC?
We recently surveyed every former GED student that we could make contact
with, to see how well he or she is doing. 76% are doing well.
can be seen here.
How well do JRC's graduates do when they leave JRC, irrespective of
whether they have had GED treatment while at JRC?
This is covered in the annual follow-up study that we do each year.
most recent follow-up study may be found here.
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If there were no JRC program, what
alternatives would the parents of these students have?
Heavy psychiatric medication: This can sometimes be so sedating that the
students sleep most of the day and cannot even recognize their parents.
This medication often does not work and sometimes has dangerous and
irreversible side effects. Some of the negative side effects of
psychiatric medications may not be discovered until years later when it is
too late to do anything about the damage it has done. Warehousing: The
student may have no program at all to go to, and may have to languish at
home, on the streets, in a state institution for the retarded or mentally
ill, in a psychiatric hospital or in jail. 10% of JRC's higher functioning
students were either sent to JRC from a correctional facility or were sent
to JRC as an alternative to one. Restraint: If students have aggressive,
self-abusive or disruptive behaviors, they may be subjected to frequent
restraint, isolation and physical take-down procedures. In comparison with
these alternatives, skin shock is far less intrusive and far more
effective. It is no wonder that the parents of our students are JRC's
strongest advocates. See, for example, some of their letters to
legislators and agency officials, their comments, and the comments both
former and current students who have benefited from the skin shock
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How many of JRC's
students can be treated effectively with positive-only programming
(rewards plus educational procedures)?
Approximately 40% of JRC's school-age students can be effectively treated
by the use of positive-only procedures such as rewards and the teaching of
new skills alone. The other 60 % require the addition of aversives to
their treatment programs.
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How long is positive-only
programming tried before supplementing it with skin shock?
For the 60% of JRC's students who require the addition of skin shock aversives in order to be treated effectively, the average student is tried
on positive-only procedures for 11 months before the decision is made to
request the use of skin-shock.
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For those students who receive
skin-shock, how often is the procedure used?
One two-second application is given per week, in the average case.
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Does the GED skin shock have any
negative side effects?
Skin-shock has no significant negative side effects. To the contrary, its
effects are very positive. Once it helps to treat a student's problematic
behaviors, the student earns more rewards, progresses academically, and is
happier, more relaxed and more confident. Contrast this with the
alternative to the GED, which is psychotropic medication. Many of these
drugs have irreversible negative side effects.
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Why is there so much opposition
to the use of skin-shock therapy?
This is a relatively new and rarely used procedure and most people are
unfamiliar with it. Many do not realize how extremely self-abusive or
aggressive some autistic or behavior disordered persons can be. Some
people are simply unwilling to weigh the intrusiveness of the procedure
against its many benefits.
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Is it true that JRC's skin shock
On occasion and with very few students an application causes a
superficial, harmless, and temporary reddening which is not a burn.
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On June 9, 2006 the New York State
Education Department (NYSED) released a very negative report on JRC. Why?
In the spring of 2006, NYSED proposed new emergency regulations
restricting the use of aversives. NYSED's most recent previous review of
JRC (November 2005), however, had resulted in a very positive report. In
March and April 2006, NYSED appointed several investigators who were
biased against aversives to make a new review of JRC that would justify
its assertion that the new emergency regulations were needed. JRC has
prepared a detailed response to this report.
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What percentage of JRC's population is treated
with supplemental skin shock?
What Percent of Current Residents are Being Treated with JRC's GED Skin
Shock Treatment as of August 14, 2007 (1)
There are currently 154 school age students attending JRC. GED use for
these students is as follows:
1. School-Age Students
Are currently receiving GED
Are doing so well that the GED has
been faded out and is no longer being used (no applications for
a year or more) because it is no longer needed.
Were authorized for GED treatment
at one time, but are not currently authorized to receive it for
various reasons (2)
Have never been authorized for or
received GED treatment
There are currently 65 adult residents at JRC. GED use for these residents
is as follows:
2. Adult Residents
Are currently receiving GED
Are doing so well that the GED has
been faded out and is no longer being used (no applications for
a year or more) because it is no longer needed.
Have never been authorized for or
received GED treatment
The total population of JRC is currently 219. GED use across all these
individuals is as follows:
3. All Residents at JRC
Are currently receiving GED
Are doing so well that the GED has
been faded out and is no longer being used (no applications for
a year or more) because it is no longer needed.
Were authorized for GED treatment
at one time, but are not currently authorized for various
Have never been authorized for or
received GED treatment
Only 43% of JRC's current school age population are receiving GED
treatment; however, if we consider the entire population of residents,
including JRC's adult residents, the percentage rises to 56%. The reason
for this difference is that JRC's adult population includes a number of
lower-functioning adults who have been attending JRC for many years and
most of whom (85%) tend to need the GED treatment on a long term basis.
What are the Chances that an Incoming School-Age Student
will be Placed on GED Treatment?
When a student starts at JRC, JRC tries to accomplish effective treatment
with what would be considered standard behavior modification procedures
at first. These are largely positive in nature. On average, JRC spends
11 months in trying to avoid the need for using the GED. Only if
positive procedures alone are insufficiently effective, (and only after
JRC secures parental, court, physician, psychiatrist, human rights
committee and peer review committee approval,) does JRC add the use of
the GED skin shock to a student's program. The average (median)
school-age student is enrolled at JRC for only 23 months. Such a student
has a much smaller chance of receiving GED treatment than the 43% figure
in Table 1 above would suggest.
We recently analyzed all of the school-age students who have attended JRC
during the past four years and who are no longer enrolled at JRC. There
were a total of 190 such former students who attended JRC while of
school age. The numbers who attended for different lengths of time, and
the number of those whose programs were supplemented with the GED, are
SCHOOL AGE STUDENTS WHO HAVE LEFT JRC DURING THE PAST FOUR YEARS
For those who attended for a period
that is between----------->
Total Number of Students who
attended for that period
Cumulative number who attended for
this period in question
Number of those Students who were
treated with GED
Cumulative number of students
treated with GED
For the students who were enrolled at
JRC for a period that was---------------------------->
Their chances of being treated with the
1/50 or 2%
10/101 or 10%
36/145 or 25%
44/167 or 26%
51/178 or 29%
59/190 or 31%
Average (median) period of
enrollment = 23 months
Looking at the experience of these 190 school-age students who left JRC
during the past four years, we can say the following:
Only 59 (31%) were treated with the GED skin shock.
The 50 who attended for less than a year and the 51 who attended for
a period of between 1 and 2 years add up to 101 students, which
amounts to a majority of the 190 students. Out of those 101
students, only 10 of them (10%) were treated with the GED. One of
these was a student who attended for less than one year. The other 9
were students who attended JRC for between 1 and 2 years.
The average (median) school age student stays at JRC for 23 months.
A student who stays for that length of time had only a 10% chance of
being treated with the GED.
For Those JRC Residents who are Currently Being Treated with Skin Shock,
How Often Does the Average Student Receive an Application?
To answer this question, we reviewed the five week period from July 1,
2007 to August 4, 2007, looking at all residents (both school age and
adult) who are currently receiving GED treatment. During that period the
average (median) student received only 1 application per week. During
the same period, the following was also true:
For 48% the average (median) frequency of use per week was 0.
For 80% the average (median) frequency of use per week was less than
For 90% the average (median) frequency of use per week was less than
The statistics in this paper are constantly changing. For information on
the most current data, please contact
Dr. Robert von Heyn at JRC.
The reasons include failures of the local school committees in New York to include
the use of aversives in the student's most recent IEP, decisions by the
parent or guardian to remove approval, and decision by a student who
becomes his/her own guardian to discontinue treatment.
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