Response to ABAI Task Force on the Use of Contingent Electric Skin Shock

Abstract

In this article, the authors provide their response to the Association for Behavior Analysis International (2022) position statement on the use of contingent electric skin shock (CESS). In this response, we address concerns raised by the task force regarding limitations of the Zarcone et al. (2020) review article in which both methodological and ethical concerns were raised about the quality of research in the use of CESS with people with disabilities in the treatment of challenging behavior. We note that with the exception of the Judge Rotenberg Center in Massachusetts, no state or country currently supports the use of CESS as it is not recognized as the standard of care in any other program, school, or facility.

Background

The International Association for the Scientific Study of Intellectual and Developmental Disabilities (IASSIDD) is an international group of researchers, clinicians, students, parents, and self-advocates that promotes worldwide research and exchange of information related to people with intellectual and developmental disabilities. In 2018, IASSIDD made a policy statement regarding their opposition to the use of contingent electric skin shock (CESS) with individuals with challenging behavior and intellectual and developmental disabilities. To support the statement, the available literature was reviewed to evaluate the efficacy, side effects, generalization, and long-term effectiveness of the procedure as an intervention for challenging behavior. This review was published in the Journal for Policy and Practice in Intellectual Disabilities (Zarcone et al., 2020). The review noted that, although CESS can decrease the frequency of challenging behavior, it comes at a cost in terms of physical and emotional side effects, and questions remain regarding the long-term effectiveness of the procedure. In addition, several ethical and methodological issues were raised that made research on the use of CESS concerning. In the review we concluded that studies with CESS are rare and use of CESS is limited to a single center. Given this, and that there are other treatments that have shown to be effective for severe challenging behavior, we recommended stopping the use of CESS.

The initial task force report for the Association for Behavior Analysis International (ABAI) supported the use of CESS under limited conditions (Association for Behavior Analysis International, 2022). The task force also reviewed the relevant literature and drew different conclusions than the Zarcone et al. (2020) review. Below are portions of a response that was written by the authors of Zarcone et al. as well as the IASSIDD Chair of the Challenging Behavior and Mental Health Special Interest and Research Group, in response to the initial task force report when they asked for public comments on the report.

Comments on the Initial ABAI Task Force Report

The use of CESS has been banned in all but one state in the United States and nearly all other countries. To be clear, the state of Massachusetts has made multiple attempts in court to obtain a ban on its use, but to date has not been completely successful (there is a ban in place since 2011 going forward but those who were receiving CESS at the time could continue to receive it). The U.S. Food and Drug Association has also attempted to ban the device, but these attempts to date have been unsuccessful. Although the initial ABAI task force recommendations attempted to narrowly limit the scope of its use, the recommendations for oversight were not feasible and for some individuals, the ability to obtain assent may be difficult (see comments below). Our position is that the use of CESS is unethical and morally unjustifiable, regardless of the targeted behavior or individual’s disability. We are deeply saddened that it is still being used at all today. Our group also felt it was important to respond to the initial task force statement because there were concerns shared about our review article (Zarcone et al., 2020). We felt that these criticisms were unwarranted. The manuscript went through an appropriate peer-review process prior to publication, and we stand by our conclusions.

In particular, in the report, the task force noted that there were some errors made in citing other articles. First, they found in their review that studies on long-term effectiveness showed that CESS continued to suppress problem behavior for up to 5 years for the majority of participants. Although we recognize that many of the studies cited demonstrated reductions in the targeted behavior, which was evaluated during sessions or over several weeks, there are few demonstrations that CESS remains effective for many months (Mudford et al., 1995; Williams et al., 1993, 1994), with each of these studies evaluating effects in a single participant. Moreover, there is one study that demonstrated that CESS lost its effectiveness over longer periods of time (Ricketts et al., 1993). Thus, one could conclude that there is a lack of research on the long-term effectiveness of CESS and those studies for whom it was evaluated found inconsistent effects. As a consequence, it cannot be concluded with certainty that CESS is effective and safe over the longer term. Such a conclusion could only be reached as a consequence of the completion of multiple well-designed randomized clinical trials involving many participants that allow for conclusions about causality and associated harms.

In the report, the task force also stated that we had not accurately described the side effects found in two studies. We recognize that although we did not correctly describe the side effects of the CESS in Linscheid et al. (1994) or the van Oorsouw et al. (2008) articles, it should be noted that Linscheid et al. did not report a decrease in negative vocalizations (i.e., side effects) as the task force reported, but rather these authors reported there to be “little change” across their conditions for their one participant. Moreover, there are additional limitations to these studies, not discussed in the task force report, that may have compromised the validity of their conclusions. For example, although van Oorsouw et al. found decreases in negative behaviors when CESS was implemented, they measured behaviors in 10-min random samples across the day both before and after CESS was implemented. To truly determine whether CESS was having any side effects, those observations should have been made during episodes of challenging behavior targeted by the CESS during baseline and after it was implemented. The place where the study was conducted (Judge Rotenberg Center; JRC) has a video monitoring system and the ability to gather these data, but instead the authors made observations at times that may or may not have been relevant to the individual’s treatment.

More concerning than the results of these two limited studies is the task force’s stance that there may not be any negative side effects associated with CESS at all. It is our perspective that most of the studies did not systematically assess side effects and those that did note effects were made anecdotally. In their discussion of psychotropic medication, the task force listed many of the known negative side effects of risperidone. These are known side effects because researchers via clinical trials have looked for them, and such evidence is lacking about CESS. When considering CESS, the task force focused entirely on immediate, observable side effects (e.g., whether a person cried when they were shocked), qualified all reports of negative side effects of CESS (e.g., they are temporary, only anecdotal), and made no comment on the possibility of long-term psychological effects. The lack of systematic data on potential negative side effects of CESS should not be taken as evidence that there are none and instead reflects the absence of methodologically robust studies that thoroughly examined harms.

Lastly, although a recommendation is offered that negative physical and behavioral side effects be monitored and reported, the task force provides less guidance on how one would specifically monitor them, particularly with individuals who may have significant communication difficulties. We stand by our assertion that our understanding of the short- and long-term negative side effects of CESS is incomplete and feel there is evidence (both within this literature and other studies of aversive interventions) that inflicting pain on others is likely to have a significant impact on those experiencing it (e.g., Heilmann et al., 2021).

The task force also indicated that Zarcone et al. (2020) unfairly criticized the research design used in several CESS studies. We stand by our assertation that Israel et al. (2008) and others used a methodologically weaker AB or nonconcurrent multiple baseline design in their studies. For example, van Oorsouw et al. (2008) characterized their study design as a “nonconcurrent quasi multiple baseline.” We assert that as a field we should consider this to be a weaker design and the tiered presentation of the nonconcurrent multiple baseline design implies that there are relationships across subjects that may not exist as they occur in varying points of time. Although a concurrent multiple baseline design may be useful to evaluate generalization, the nonconcurrent design is weaker when implemented across participants (Johnston et al., 2019). It should be noted, however, that like repeated AB designs, it does control for some threats to internal validity (Slocum et al., 2022). Much larger and well-designed studies are needed to fully examine the short and long term effects of CESS, if the field felt that from a scientific perspective better data are needed. Finally, although the Zarcone et al. article did note several methodological concerns with the research supporting the use of CESS, we felt that the ethical and moral concerns outweighed the fact that CESS (like other forms of punishment) does reduce behavior. But at what cost?

Additional Concerns

In addition to the concerns raised by the task force regarding the quality of our review, we would like to share several concerns we had with the conclusions and recommendations that they made. First, the authors noted that they interviewed several other programs that serve a similar group of individuals but do not use CESS. Data on the effectiveness of alternative interventions from these programs should be shared. It is worth pointing out that the National Institute for Health and Care Excellence (NICE) in the United Kingdom thoroughly reviewed interventions for challenging behavior and made recommendations as to how treatment should be delivered (National Institute for Health & Care Excellence, 2015). Comment from the task force as to how their conclusions align or conflict with NICE Guidance would be welcomed.

Further, it is our view that there should be more emphasis placed on the fact that no other inpatient units, outpatient clinics, or educational programs in the United States nor internationally use CESS and yet these programs have high success rates (Hagopian et al., 2023). Thus, it brings into question why this is even an intervention at the JRC. It is stated that the JRC only uses CESS for treatment-resistant behaviors. However, they do not provide evidence that they have implemented best-practice procedures for treating challenging behavior prior to implementing CESS.

Best-practices and the Ethics Code of Behavior Analysts (Behavior Analysis Certification Board, 2020) state that treatments should be based on a functional analysis. It is our understanding and also reported in the Task Force’s report that functional analyses are rarely completed at the JRC but instead they identify function through observation and indirect measures of behavior. In addition, other leading centers often try numerous iterations of reinforcement-based approaches using different quality, magnitude, and schedules of reinforcement prior to initiating any punishment-based procedures even when those punishment procedures are far less controversial than CESS. The description of reinforcement-based procedures used at the JRC is vague and it appears the level of individualization that is commonly necessary for success for severe challenging behavior is not present. Finally, we have a concern with how consent and assent would be defined and evaluated. They are not synonymous and although the task force described interviews with individuals that indicated “if asked” they would not have assented to the use of CESS, this is not part of their standard of care. Unfortunately, individuals with legal guardians do not have the power to choose their treatment given current guardianship laws in the United States. In other countries, there is specific legislation governing decision making for those unable to make decisions for themselves, including decisions about psychological and medical treatment, and following these legal requirements, the use of aversive methods such as electric shock would not be allowed without specific consent from the legal guardian. Such legislation intentionally safeguards the rights of those who are unable to make decisions for themselves to protect them from harm. It is important that as ABAI is an international organization, review of the ethical and legal statutes in countries outside of the United States must be considered (as well as other states besides Massachusetts). But legal arguments aside, this is perhaps more of a moral and an ethical issue: moral in the sense that it is not considered the right thing to do, and ethical because it is not the best thing to do given that there are so many alternative empirically supported interventions. Academic journals, professional groups and many behavior analysts have explicitly spoken out against the use of CESS. These actions are a moral response, but they also reflect the ethical perspective that the use of CESS is unacceptable and does not reflect our standard of care for autistic and disabled individuals.

Data Availability

Data sharing not applicable in this article as no datasets were generated or analyzed during the current study.

Compliance with Ethical Standards

Conflict of Interest

The first author works for a nonprofit agency in MA that provides similar services as the Judge Rotenberg Center, and thus could be considered a “competing” agency for staff and clients. No other conflicts exist or competing interests. The first, second, third, and fifth authors have leadership roles with the International Association for Scientific Study of Intellectual and Developmental Disabilities as well as the organizations/universities noted.