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Many persons argue that severe behavior problems can be effectively treated using positive-only treatment procedures. It would be nice if this were true, but unfortunately it is not. Here is why.

• The assertion that nonaversive treatment can treat severe problem behaviors is a myth. Opposition to a strictly scientific approach to the treatment of behavior disorders, including the use of aversives when required, began in the 1980’s. This movement was pioneered by agencies such as TASH (The Association for the Severely Handicapped), which tended to place ideological commitment to the avoidance of aversives above anything else and which viewed itself as a kind of civil rights advocacy organization.

  Those who believed in what was then called “nonaversive treatment” were unwilling (and are still unwilling) to weigh the risks and benefits of using aversives. Even if a person’s life could be saved by the use of aversives, and even if a person could be prevented from mutilating him/herself, those opposed to aversives were reluctant to allow them to be employed under any conditions. For them, aversives were simply Wrong with a capital “W” for moral reasons. Their opposition to aversives was similar in tone to that which is found in persons opposed to abortion and to animal experimentation. The history of this nonaversive movement is told in a balanced manner in a paper by Crighton Newson and Kimberly Kroeger, called “Nonaversive Treatment.”[1] The full text of this paper is available by clicking here.
   

• In the 1990’s those who supported nonaversive treatment began to call their approach “Positive Behavior Support.” This field is essentially a mixture of certain ideologies such as nonaversive treatment, social role valorization, person-centered planning, full inclusion, etc., with certain scientific procedures from the field of applied behavior analysis. Unfortunately, the scientific procedures are subordinated to, and placed in the service of, these ideologies. This is well explained by Jim Mulick and Eric Butter in their paper, “Positive Behavior Support: A Paternalistic Utopian Delusion[2].” Again the full text of this paper is available by clicking here.
   

• The proponents of Positive Behavior Supports have been successful in getting some state agencies to adopt their approach. They have also been successful in obtaining federal grants to support their research and in lobbying against any developments that have affected them adversely. An example of the latter is the National Institute of Health 1989 Consensus Conference On Destructive behaviors, a conference that found that decelerative procedures, including the use of skin shock, were supported in the published professional literature. The Positive Behavior Support people, through their lobbying efforts, managed to keep this report from being published for two years after the conclusion of the conference. The full story is told well by Richard Foxx in his chapter, “The National Institutes of Health Consensus Development Conference on the Treatment of Destructive Behaviors: A Study in Professional Politics” in Controversial Therapies for Developmental Disabilities.[14]
   

• Those who espouse Positive Behavior Support have asserted that it is possible to treat all severe behavior disorders without the use of aversives. As is noted below, there is no scientific support for this statement. An examination of those papers that report the success of positive-only procedures in treating “problematic” behaviors shows that the behaviors treated in these studies were, in many cases, not the same type of severe, case-hardened behaviors that are treated by those who employ aversives. In one oft-cited case in which the behavior was severe self-abuse, the author failed to report that an increase in the dosage of thorazine could have been the cause of the decrease in the problematic behavior, and not the non-aversive procedures[3]. These issues are well explained by Richard Foxx (who himself has used skin shock very successfully in treating developmentally disabled persons) in his paper, “Severe Aggressive and Self-Destructive Behavior”[4]. The full text of this paper is available by clicking here.

·         The assertion that all problem behaviors can be treated effectively with nonaversive means has never had any scientific support. In 1990, Edward Carr and his associates (Carr is a respected leader in the Positive Behavior Support movement) reviewed the available published professional studies (95 research papers from 21 journals, covering 1969-1988) which had used positive-only procedures to assess whether they had been effective. A study was judged to be “effective” if, by using it, the authors had been able to reduce the frequency of the problem behaviors by 90 percent from its level prior to the treatment. Carr presented the results of his research at the 1989 National Institute of Health Consensus Conference on Destructive Behaviors[5]. Carr and associates found that such procedures were effective in only 37% of the cases where self-abuse was involved and in only 35% of the cases of aggression.

In 1999 Carr and associates once again did a review[6] of the more recent literature on positive-only programming, this time covering 109 articles published between 1985 and 1996.. This paper, “Positive Behavior Support for People With Developmental Disabilities,” [9] 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. This paper is available in full text by clicking here.

 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 positive 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.

Even the 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," [10] 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 full text of Dr. Foxx's article is available here.

·         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.

·         Positive 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," [11] 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." [12] 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 [13].

• In 2005 Michaels et al[7] conducted a survey of 73 experts in the field of Positive Behavior Supports. They asked the experts to say what decelerative treatment procedures, if any, they would consider using in certain circumstances.

  Michaels et al. began by classifying different types of decelerative procedures into the following categories;

  1. differential reinforcement procedures (with extinction or redirection of disruptive behavior);

  2. differential reinforcement procedures (with mild reprimand or response cost for disruptive behavior);

  3. extinction (i.e. withholding reinforcement for a previously reinforced behavior);

  4. response cost (i.e. withdrawal of a reinforcer or reinforcing event contingent on the behavior’s occurrence);

  5. overcorrection (i.e. forced engagement in behavior that more than corrects the effects of the inappropriate behavior);

  6. seclusion timeout (i.e. removing the individual from the setting to an area of total social isolation);

  7. application of sensory punishment (e.g. ammonia vapor, foul tasting substances, loud or harsh sounds);

  8. application of physical punishment (e.g. spanking, pinches, restraint as punishment); and

  9. contingent electric shock (i.e. application of electrical stimulation for engagement in targeted behavior).

  Michaels et al. explained how they chose their experts as follows:

  “Experts 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 Disabilities (RPSD).”

  Seventy-three experts completed and returned the survey. 88% of the experts had doctorate-level degrees. On the average, the experts had 27 years experience in the field of developmental disabilities.

  Potential responders to the survey were assured that “all responses would be confidential and that data would be analyzed and reported in aggregate form only.”

  The findings of this survey that are relevant to JRC’s use of the GED skin shock procedure are as follows:

  1. 10% of the PBS experts said they would use contingent electric shock “under certain circumstances or conditions.” This was a higher percentage than the percentage that said they would use two of the other aversives that the experts were asked to consider--Sensory punishment (7% said they would use that under certain circumstances) and physical punishment (4% said they would use it under certain circumstances). 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.
      

  2. The experts were asked to say under what circumstances they would consider using the procedures they said they would use. Of those who said they would use skin shock under certain circumstances, the breakdown was as follows:

     • 100% of them would use skin shock if the person or others are “at risk for harm.”

     • 57% would use skin shock if other procedures were ineffective

     • 28% would use skin shock for behavior that “interferes with learning.”

     • 28% would use skin shock for behavior that is “socially stigmatizing, preventing inclusion

  Michaels et 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)

  In other words psychologists, including experts in Positive Behavior Supports, who work with severe and complex problem behaviors, tend to believe that a full range of decelerative procedures should be made available, including skin shock.

  The Michaels and Brown paper[8] is available in full text by clicking here.

[1] Jacobson et al, Controversial Therapies for Developmental Disabilities, Lawrence Erlbaum Associates, 2005, pages 405-423.

[2] Ibid, pp. 385-405.

[3] Berkman, K.A., & Meyer, L.H. (1988) Going "all out" nonaversively. Journal of the Association for Persons with Severe Handicaps, 13, 76-86.

[4] Jacobson et al, Controversial Therapies for Developmental Disabilities, Lawrence Erlbaum Associates, 2005, page 295-310.

[5] Carr, E.G., Robinson, F., Taylor, J. & Carlson, J. (1990). Positive approaches to the treatment of severe behavior problems in persons with developmental disabilities. In: National Institutes of Mental Health Consensus Development Conference. (NIH Publication No. 91-2410), 231-341.

[6] 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, D.C.: American Association of Mental Retardation.

[7] One of the authors of this paper, Fredda Brown, is a strong supporter of Positive Behavior Support. She has visited JRC and testified in opposition to the treatment plan that JRC proposed for one of its students. She was a key consultant in the unfortunate case of James Velez, a former student from JRC who, when he was "rescued" from JRC by proponents of Positive Behavior Support and normalization, died from self-scratching (bone and blood poisoning) within 17 months of being placed in a Positive Behavior Support program. His story is told elsewhere on this site.

[8] Michaels, C., Brown, F. & Mirabella (2005). Personal paradigm shifts in PBS Experts: Perceptions of treatment acceptability of decelerative consequence-based behavioral procedures. Journal of Positive Behavioral Interventions, 7(2), 93-108.

[9]  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.

[10] In Jacobson, J.W., Foxx, R.M. and Mulick, J.A., Controversial Therapies for Developmental Disabilities,  Lawrence Erlbaum Associates, Publishers,2005. pp 295-313.