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The Judge Rotenberg Center

1. What is the Judge Rotenberg Center (JRC)?

2. How does JRC differ from other special needs residential schools?

3. What is JRC's policy regarding psychotropic medication?

4. What is JRC's policy regarding behavioral counseling?

5. If there were no JRC, what are the alternatives for the JRC students?

Positive Programming

6. What categories of behaviors does JRC treat?

7. What reward systems does JRC use?

8. How are food rewards used in JRC's behavioral treatment?

9. How many of JRC students can be treated effectively with positive-only programming (i.e., rewards and educational procedures)?

10. How long is positive-only programming tried before supplementing it with skin shock?

11. Does JRC prepare its students to receive high school diplomas?

Supplementary Aversives at JRC

12. What is aversive therapy using the GED?

13. How is aversive defined and which aversives are considered acceptable?

14. What aversive does JRC use and with what policies?

15. What is GED and how is it used?

16. What behaviors are aversives used to treat at JRC?

17. How is skin shock used at JRC and what have the results been?

18. Is skin shock the same thing as electroconvulsive shock?

19. How effective is skin-shock as an aversive?

20. What percentage of JRC's population is treated with supplemental skin shock?

21. For those students who receive skin-shock, how often is the procedure used?

22. Does JRC's skin shock have any negative side effects?

23. What are the different treatment methods for using aversives?

24. What are behavior rehearsal procedures and what support is there for them?

25. What are programmed opportunities?

26. What is negative reinforcement?

27. What safeguards are in place to prevent skin-shock from being misused at JRC?

    1. Sample Court Authorized Treatment Plan

28. Is it true that some programs use "hidden aversives?"

29. Why is there so much opposition to the use of skin shock therapy?

30. Do positive-only schools expel students who are subsequently referred to JRC?

Common Objections regarding JRC's Use of Aversives

31. Does JRC's GED skin shock device cause burns?

32. Do students who receive skin-shock therapy ever "graduate" so that they no longer need this treatment?

33. Can JRC's students be treated in other programs without the use of aversives?

34. Contrast Skin Shock with Electroshock Therapy (ECT)

35. Does JRC analyze the causes (functions) of behaviors and base its treatment upon that analysis?

36. Is it true that JRC uses skin shock to punish minor behaviors?

37. Is the GED sometimes used when a student is restrained?

38. Should skin-shock be used only with lower functioning students?

39. How come all other programs manage without skin-shock?

40. Is JRC out of the mainstream?

41. Is the probate court process to approve skin shock at JRC a sham?

42. Is JRC's Human Rights Committee controlled by JRC?

43. Why has JRC not published on the GED in peer reviewed journals?

Common Objections regarding Skin Shock

44. Is skin shock overkill and are Positive Behavior Support procedures sufficient?

45. Why are not all the other residential programs for special needs children using skin shock aversives?

46. You would not use skin shock on a prisoner or a prisoner of war. Why use it on a handicapped child?

47. What do you say to people who say that the use of skin shock is inhumane?

Common Objections regarding Aversives in General

48. Is there disagreement on the effectiveness of aversives?

49. Can aversives be avoided by a skillful use of rewards?

50. Can the same results be achieved with positive-only procedures?

51. Are aversives only temporary in their effects?

52. Does IDEA require the use of positive behavior supports?

53. Have aversives been banned or restricted in other states?

54. What organizations support the right of parents to choose aversives?

Other Issues

55. Is JRC too expensive?

56. Is it true that five students have died at JRC?

57. What was the controversy regarding JRC's use of the term psychologist?

JRC's Current Controversy with New York State Education Department

58. On June 9, 2006 the New York State Education Department (NYSED) released a very negative report on JRC. Why?

    1. Three MA Agencies Review JRC and Find No Support for the Principle Accusations in the June 9, 2006 NYSED Report

59. Have the new NYSED regulations put a crimp in JRC's use of aversives?

"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 society.

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 at http://www.judgerc.org/parentletters.html.

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"Electric shock therapy used at JRC sounds barbaric -- 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 (ECT)

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 treatment approaches.

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 behaviors.

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 Massachusetts legislature.

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 problem behaviors.

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 GED again.

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 journals..."

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. Our own bibliography for example contains 111 separate papers on the topic, almost all of which are published in peer reviewed journals.

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. Dr. Israel 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 available a 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. Technical features of the GED behavioral skin shock device 2. Its success in treating one or two of our most difficult clients 3. Its effectiveness as compared with the SIBIS skin shock device  4. Its 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, several 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 – 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 of life. Click here to see proof in the form of before-and-after films and photos.

Fortunately, JRC's 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 behaviors."

There has 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[1] in Controversial Therapies for Developmental Disabilities in which they trace the history, contributions and harm done by this movement over the years. They write:

The nonaversive 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."[2]

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. 

The paper, Positive Behavior Support for People With Developmental Disabilities, ^[3] 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 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,"[4] 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.

• 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,"[5] 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."[6] 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[7].

A recent 2005 study^[8] 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:

1. 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!

2. 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 things:

   1. 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 warehousing.

   2.  They 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.

   3. 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.

   4. 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 punishment.

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.

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How 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 (1997).

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 judgment authorization.

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 procedure;

• 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 contract.

The medical safeguards in place for the Specialized Food Program include all of the safeguards for the Contingent Food Program plus the following:

• For 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;

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

• The student is offered unlimited amounts of fluids;

• The 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;

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

• 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.  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;

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

• The 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 loses, weight.

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 calories .

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:

1. Because 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 found here.
    

2. Many 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 found here.

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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:

1. psychotropic 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?
    

2. manual and 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.
    

3. warehousing. 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.
    

4. intense 1-1 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") philosophically.

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 Developmental Disabilities[1]," 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 programming.

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 goal.

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 more interesting is 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.

[1]  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 disabilities"

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 says.

In a recent book, Controversial Therapies for Developmental Disabilities,[1] 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:

(1) 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)

and later:

(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, p.57).

. . .There is no other reference even vaguely related to PBS in the law." [2]

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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[1] Jacobson, J.W., Foxx, R.M. and Mulick, J.A., Controversial Therapies for Developmental Disabilities,  Lawrence Erlbaum Associates, Publishers, 2005.

[2]  Ibid, p. 398

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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 here.

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 functioning students.

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.

"As the 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."[1]

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 do.

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 behaviors.

Crighton Newsom and Kimberly Kroeger make the same points in their review of the nonaversive treatment movement: (bracketed material supplied)

The original 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.[2]

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[1] Ibid, p. 107

[2]  Crighton Newsom and Kimberly Kroeger, "Nonaversive Treatment" in Jacobsen, J.W., Foxx, R.M. and Mulick, J.A., Controversial Therapies for Developmental Disabilities, 405-423

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"How 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.

1. 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 by 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, please 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 using aversives. 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 following claim:

     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.

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"What does JRC mean when they assert that most supposedly 'positive-only' programs make use of 'hidden aversives.'"

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 rooms.

"What are the safeguards that govern the use of the GED?"

SAFEGUARDS

Typically, 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.

JRC's use of supplemental aversives is carried out carefully, openly and with a maximum number of safeguards.

What are the safeguards?

1. 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 Care.

2. 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 videotaped.

3. 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.

4. 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.

5. 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 student's treatment plan, and if the parent accepts this recommendation, the use of these procedures is incorporated into the student's Educational Plan.

6. 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.

7. 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.

8.  Individual 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.

9. Daily oversight by clinician: The assigned clinician has the direct responsibility for the development and implementation of the student's treatment plan.  The clinician:

   1. 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.

   2. 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.

   3. 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.

   4. approve shifts of existing topographies from one behavior category to another and any changes in treatment, as a result of such shifts.

   5. approves treatment of new topographies of the problem behaviors with the categories of procedures that have been authorized by the Court.

   6. 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.

   7. 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.

   8. ensures, in conjunction with a consulting physician, that no treatment is used that is medically contraindicated for the student.

   Each clinician that oversees substituted judgments cases must complete at least 10 credit hours of continuing education credits, which are recognized by the Psychological Board Association.

10. 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.

11. 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

12. Nursing: One of their duties is to make sure that any supplementary aversives employed have no harmful effects. 

13. In-school monitoring 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 Charts.
    
    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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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 successfully.

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"Is it true that students at JRC can be punished with the GED for behaviors other than aggression, self-abuse or property destruction?"

Yes, for the following reasons.

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.

1. 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;

   1. 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.

   2. 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.

   3. 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.
       

2. 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 in frequency.

   1. 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.

   2. 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.

   3. 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.
    

3. 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 problematic.

   1. 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 development.

   2. 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 restaurant.

   3. 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.

4. 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.

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"1. 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?"

1. The 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 occasion.

• R.C. 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:

1. 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.

2. 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;

3. 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, please click here.

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.

The behavior rehearsal lesson is equivalent to "recreating the scene" described by Van Houten and Rolider (1988). The procedure is useful for low frequency - high 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 medical journals.

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.

References

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, 187-189.

Frawley, J. & Smith, J.W. (1990). 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. (1992). 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. (1993). 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. (1990). 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.

Swerissen, Hal; 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 retarded individuals.

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 zero rate.

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 suggested.

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 immobilization treatment.

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 validity.

Altmeyer, B.K., 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 states."

JRC has 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.

It is clearly not true that aversives are prohibited in either New York or New Jersey.

Some 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
New Jersey
Massachusetts
California
 

NEW YORK LAW ALLOWING THE USE OF AVERSIVE TREATMENT

The laws 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 aversives.

14 NYCRR § 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 § 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 § 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 § 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 § 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 § 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.

14 NYCRR § 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 §624.20 (n).  The definition specifically includes corporal punishment and electric shock.  

Aversive 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.

Aversive treatment is just that - it is treatment.  It is not a form of corporal punishment.  The New York state regulations define corporal punishment as "any 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 § 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.

8 NYCRR § 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.

The use 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. 

New York 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 § 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

New 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. 

N.J.S.A. 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.

N.J.S.A. 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 such procedures.

The New 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.  

DHS 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.

New 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.

MASSACHUSETTS LAW ALLOWING THE USE OF AVERSIVE TREATMENT

1. 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).   

II.                2005/2006 Massachusetts Legislation to Ban Aversive Treatment did not Advance

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 16^th, 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 15^th, 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 complete.

CALIFORNIA 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, §50800, et seq.  California's Department of Developmental Services, Civil Code Tit. 17, §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, §50802.

California's Department of Education allows the use of aversive treatment in public and private schools through a waiver process.  Cal. Educ. Code §§56520(a)(3), 56523(b)(1) and 5 CCR §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 §56101(a).  Cal. Educ. Code §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. 

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"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 aversive?
Which aversives are acceptable to use?
Definitions of Aversives used at JRC
 

What is an Aversive?

Most 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 aversive.

1. If 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.

2. If the 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.

A helpful 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 clicking here. 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:

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).

Using those 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 judgment authorization.

1. Differential reinforcement procedures
        Breaking a reward contract without a verbal reprimand

2. Differential reinforcement procedures with verbal reprimand
        Breaking a reward contract with a verbal NO and response cost,
             e.g., token/point/money fine
        *Food programs

3. Extinction
        Ignore

4. Response cost
        Token, point or money fine
        Loss of privileges

5. Overcorrection
        *Positive practice overcorrection
        *Restitutional overcorrection

6. Application of sensory punishment
        *Water spray

7. Application of physical punishment (includes movement limitation)
        *Helmet as punishment
        *Movement limitation as punishment

8. Contingent electric shock
        *Contingent electric shock

Other 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.:

3. Extinction
        Systematic desensitization
        Social extinction
        Social isolation

4. Seclusion timeout
        Locked seclusion with or with direct observation
        Seclusion without locked door with or without direct observation

5. Application of sensory punishment
        Aversive tastes
        Ice application
        Slap
        Airstream
        Oral hygiene
        Facial screening
        Visual screening

6. Application of physical punishment
        Aversive tickling
        Aversive pinches
        Thigh slap 
        Finger in jaw
        Spanks
        Muscle squeeze
        Protective equipment
        Mat rolling
        Corner holding timeout
    

Which Aversives are Acceptable to Use?

One purpose 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.

Michaels et al. explain 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 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.

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 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:

1. 10% of 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.

2. The PBS 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 results were:

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

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

   • 28% said they would use skin shock for behavior that "interferes with learning."

   • 28% said they 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 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

Movement 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.

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

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.

In certain cases, the caloric value of the items used as special food rewards in the form of treats and snacks may be counted toward the daily staple food calorie targets. The items that may be so counted, and the method of counting, are shown on the Food Recording Sheet.

Possible side effects of contingent food may be a temporary discomfort from increased hunger, lasting no more than a few hours. The student can avoid this temporary discomfort by not showing designated inappropriate behaviors, and thus earning the food portions that go with "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."

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

The Specialized Food Program, the student will not receive any make-up food at the end of the day unless the student has received less than 20% of 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 means.

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

 In addition, the following steps are taken:

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

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

iii. The student is offered unlimited amounts of fluids;

iv. The electrolyte content in the student's blood is measured prior to the time that 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;

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

vi. The nurse reports by telephone to JRC's consulting physician every other week (or more often, as necessary) once the specialized food program is instituted for the student, regarding the student's status. The nurse documents 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;

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

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

In most cases, if the student participating in the Specialized Food Program is under his red line weight or loses two pounds per day, or five pounds per week, or ten pounds overall, or ten percent of 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 contingencies.

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

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

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 or weeks.

This 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.

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"What aversives does JRC use, and what policies does JRC follow in using them?"

JRC Policy and Procedure on Aversive Therapy
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 the procedure.

Normally, 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.

Initial Requirements:

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 clinicians 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 Review Committee.

A 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.
 

Periodic Reviews and Reporting:

Every four 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.

Staff Training and Monitoring:

Every JRC 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 two weeks.

JRC is 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.

1. 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 problematic behavior.

2. 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 category.

3. 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 above, the 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.

1. Describe in detail the behavior that has been identified for a change in treatment.

2. Are the guardians aware of the proposed change and support the use Level 3 interventions to decelerate the behavior?

3. Describe how often the behavior is occurring.

4. Describe where and under what circumstances the behavior is occurring.

5. Have you reviewed and archived any Digital Video Recording footage of this behavior?

6. Describe what forms of treatment have been used to treat this behavior and the effectiveness of those forms of treatment.

7. Is there any other positive reinforcer or less restrictive negative consequence that could reasonably be expected to be effective?

8. How is this behavior causing serious disruption to the student's educational development?

9. How is this behavior causing serious disruption to the student's social development?

10. Give examples (including dates and times) of how this behavior has caused serious disruption to the student's education.

11. 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 clinician in 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:

1. 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

2. 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.

3. 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.

4. 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.

5. 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 effectively.
    

JRC Notice to the Court Procedures

When JRC intends to pursue a substituted judgment authorizing the use of Level III interventions it gives prior notice to the Department of Mental Retardation and the Receiver.

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 restraint.

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

Although 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. 

The Court Monitor, DMR, and Executive Director or his designee are notified if a student receives a misapplication of an electrical stimulation.

In 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.

Periodic 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 and DMR.
 

GED Fading Policy and Procedure 

For 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.

• If a 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). 

• If a 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).

• If a 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).

• In order for a student to resume the fading process it must be approved by all members of his treatment team.

For 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 weekends)

                     Step6:  faded for the evening on weekends

                     Step7:  faded during the overnight

                     Step8:  faded during transport/during fieldtrips
   

• There will be a minimum of two weeks between each step. 

• If a 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

These 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.
 

JRC Policy and Procedure on Peer Review Committee

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 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. 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 Committee

1. 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.

2. 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.

3. 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.

4. 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 § 104 CMR 20.07(5)."

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 description:

   1. participate in training programs for Human Rights Officers offered by the Massachusetts Department of Mental Retardation.

   2. serve as staff to the program's Human Rights Committee.

   3. develop and implement the means to do the following:

      1. inform students served by JRC, staff, and families of client's rights,

      2. train persons served by the program in the exercise of their rights, to the maximum extent of their capabilities and interests,

      3. 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,

      4. otherwise assist the program in the development of means to promote the human and civil rights of persons served by the program, and

      5. provide legal information and referral services to persons served by the program.

6. 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.

7. 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.

8. 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.

9. 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 by JRC.

10. ATTENDANCE.  The Committee may set attendance requirements. The committee will meet quarterly.

11. TERM.  The Term of members of the Committee shall be indefinite.

12. 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.

13. 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.

14. 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.

15. 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 to JRC.

16. 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

1. 42 of our current students are preparing for either MCAS or Regents exams.

   1. 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.

   2. 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).

2. 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 such students.

   1. 4 of the 25 obtained their high school diploma before leaving JRC.

   2. 2 of the 25 these have earned a GED diploma from their local high school

   3. 7 of the 25 have earned their diploma from their local high school

   4. 5 of the 25 are now enrolled in college

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"JRC's Human Rights Committee is controlled by JRC and therefore is useless as an oversight body."

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 JRC.

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?"

• National Institute of Health Consensus Report on Destructive Behaviors, 1989

• Statement on Aversives by the Association for Advancement of Behavior Therapy, 1982

• Autism Society of America: Options Policy Regarding Parent's Right to Choose Treatment, 1995

• Statement on the right to effective treatment by the Association for Behavior Analysis, 1987

• The Mental Retardation Division of the American Psychological Association's Guidelines for Effective Behavioral Treatment

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"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 Psychologists.

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 "psychologists." 

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 staff.

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, please click here.

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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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"The Probate Court 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 SUPPLEMENTARY AVERSIVES?

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:

• JRC Reply to Commissioner Mills

• JRC Reply to June 9, 2006 Report

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"JRC 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 Assessment

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.

1.     Review of the students' records.

2.     Interviews with the student on the day of admission and subsequently in the course of behavioral counseling sessions, chart sharing meetings, etc.;

3.     Interviews with parents, siblings or other family members;

4.     Interviews with staff who work with the student;

5.     Direct observations of the student's behaviors;

6.     Indirect measures of functions such as the Functional Assessment Screening Tool (FAST)

7.     Functional Analysis through direct analog assessment

8.     Observations via the digital video monitoring system which enables each clinician to observe the student in his classroom or residence at all times;

9.     Review of digital video recordings that are made in all areas of the school, residence and during transportation;

10. Review of the therapy notes of unusual behaviors and restraint forms -- notes which describe the problem behavior, the antecedent events, what followed the behavior, etc.;

11. 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;

12. 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 Functional Assessment

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 question.

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 "internal-rewarding-stimulation-producing."

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 desired activity.

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 Them

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[1] 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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[1]  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.

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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 self-abusive 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 "GED" In addition, JRC does not use traditional psychotherapy sessions and provides, instead, behavioral counseling.

Click here for a list of our key features.

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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 aversive?

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

1. How effective is the GED treatment?
   The following links will take the reader to evidence of its effectiveness:

   1. 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.

   2. Additional evidence may be found by clicking here.

   3. For a major detailed paper that Dr. Israel delivered at the EEAB (European Experimental Analysis of Behavior) Conference in 2001 in Amiens, France click here. 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.
       

2. 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. The results can be seen here.
    

3. 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. The 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 treatment.

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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 causes burns?

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

There are currently 65 adult residents at JRC. GED use for these residents is as follows:

2. Adult Residents

The total population of JRC is currently 219. GED use across all these individuals is as follows:

3. All Residents at JRC

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 shown below:

4. SCHOOL AGE STUDENTS WHO HAVE LEFT JRC DURING THE PAST FOUR YEARS

Looking at the experience of these 190 school-age students who left JRC during the past four years, we can say the following:

1. Only 59 (31%) were treated with the GED skin shock.

2. 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.

3. 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 5.

• For 90% the average (median) frequency of use per week was less than 10.

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