ABAI Had a Lot to Say.

TW: ableism, contingent electric skin shock (CESS) 

Well, it took the better part of a year, but ABAI finally released their – erm – “statement” regarding the use of Contingent Electric Skin Shock (CESS). It’s hard to call a 34-page document a “statement,” so I supposed the authors’ description of it as a “report” would be more accurate. The authors consist of the Task Force ABAI created to investigate the criticisms about the Judge Rotenberg Center (Read: Relent to the fact that planned ignoring was ineffective).

If you’d like to know more about who those Task Force members are, here you go.

If you’re new to ABA and don’t know what the Judge Rotenberg Center is, here you go. 

Before we begin, I feel it’s important to offer some examples of other ABA organizations’ statements on CESS.

“Contingent electric skin shock (CESS) is an unnecessary tactic with possible long term harmful physical and emotional effects (Zarcone, et al. 2020).”

Oregon Association of Behavior Analysis

“We, Autism Learning Partners, Center for Autism and Related Disorders, Centria Autism, Hopebridge, InBloom Autism Services, LEARN Behavioral, and Trumpet Behavioral Health, unequivocally condemn the use of painful aversive procedures, including the use of contingent electric skin shock (CESS), under the scope of practice of applied behavior analysis (ABA) based treatment for challenging behaviors. Our organizations do not and never will employ the use of CESS under any circumstance.”

Consensus Statement on the Use of CESS

Association for Behavior Analysis International

Sorry, that was a little biased. As scientists, bias is our enemy. So from this point on, here are all of the objective reasons this report is a problematic word salad. 

But you don’t have to take my word for it. Read it for yourself:

Cherry-Picking Supporting Sources

In stark dichotomy to the intense attention to detail, the report becomes notably vague when discussing their research into treating severe behavior without CESS. They interviewed the clinical directors or 9 unnamed agencies about a general list of topics, but didn’t provide the questions themselves. Thus, these practitioners’ statements are filtered through the authors’ summaries. As much as I’d love to see the actual questions and the specific responses, what would have been especially interesting would be to see these clinical directors’ views on CESS. Normally in a report like this, it might seem most logical to seek out neutral sources – clinical directors with no strong feelings one way or another about the use of CESS (if such people could be found on this polarizing topic). 

However, I argue that it would be worthwhile to dig into the methods used by practitioners who are vehemently opposed to it. Multiple practitioners on this side of the argument have been vocal about their success in treating severe behaviors without severe punishment (e.g. Hops, Hooves, and Humanity). As specific and deliberate as the authors were in addressing every single argument made against JRC and the use of CESS, these practitioners were conspicuously absent.

Also conspicuous by his absence was any mention of Dr. Greg Hanley’s work in treating severe behaviors. In all their multiple pages claiming that there is no convincing evidence that CESS could be deemed entirely unnecessary, there is not one mention of Dr. Hanley’s Interview-Informed Synthesized Contingency Analysis (IISCA), his Practical Functional Assessment (PFA), or his “My Way” protocol. Ironically, their only mention of Dr. Hanley is his 2005 study looking at learner treatment preferences, in which he found child participants chose treatment procedures that contained punishment over those that did not.

An important detail about that 2005 study is that the punishment involved was 1 learner’s arms at his sides for 30 seconds and a 30-second visual screen for the other learner. While the results are interesting indeed, there is a huge difference between a 30-second hold or visual screen and a 41mA shock.

Furthermore, Hanley’s work also discusses reinforcing less severe behavior in order to prevent more severe behaviors. Preventing escalation also prevents learning opportunities, such as the FCT responses required in “My Way.” This is a pretty significant hit against the claims JRC makes that shocking behavior that isn’t dangerous, such as noncompliance, is justified because they may precede dangerous behaviors.

Although the authors seemed to be hesitant to include supporting sources more recent than 2016, Hanley’s work on “my way” can be found as early as 2014. 

This is not to say I am a Hanley Hero Worshiper like some practitioners. I am not. He has good ideas, but my overall thoughts are for a different post on a different day. The point is that the authors were attempting to claim that severe behavior cannot always be properly treated without severe punishers, and Dr. Hanley’s work provides years of evidence to the contrary. To omit it is suspect and irresponsible to their own statement. 

The snarky remark about their old sources is relevant, too. Here are some numbers: There are 97 sources listed in their references. Of those, 85 are academic studies. Of those 85, 69 are 10 years old or older. In ABA, these older articles can still be relevant today for a variety of reasons, including reliability and our history of studying a topic. Indeed, meta-analysis can shine new light on a topic, and create opportunities for further study. That being said, the issue at hand is the place of CESS in modern ABA given our current technologies and updated information. 

With the vast majority of their supporting evidence being older than a decade, it suggests some serious biases on the part of the authors, not to mention the worrisome suspicion that they may be quite out of touch with modern practices and studies. Is this not why BCBAs are required to get continuing education? By all means, pull from the 69 earlier studies on topics such as punishment and FCT, but there should be a hell of a lot more from this decade if you are trying to defend the use of CESS in 2022. 

Non-JRC Sources

The report mentions that studies on CESS are limited, and even more so when attempting to find studies not from JRC. This is no fault of theirs: JRC is the only institution still using CESS, and they’re not permitted to release their proprietary shock-delivering systems to the public. Thus, the main research on CESS is going to come from JRC. In thinking critically about any study, it would be highly suspect if the research on a topic came from an institution that has spent years defending itself on said topic. Their existence revolves around defending the use of CESS at this point as it’s the only thing setting them apart from other residential ABA facilities. It’s their hill to die on, which throws red flags onto every study they do, but there aren’t many other options from which to source this research either. 

The authors do make it a point to describe confounds in the studies themselves: The small number of participants (common across most ABA studies), the inability to fade the device, and lack of follow-up in the few instances in which the device has been faded. They also discuss the measurements in a matter-of-fact way, such as Linscheid et al. 1990 and 1994, which measured collateral responses such as crying versus smiling. 

Immediately after stating these flaws, however, the authors make this confusing conclusion: “In summary, non-JRC research indicates that responding typically remains suppressed under CESS over the long run although instances of breakdown have been reported,” and “the few studies presenting data on the side effects of CESS have reported only positive collateral changes in responding.” 

Um… what? 

First of all, using overt behaviors to make assumptions about covert behaviors and private events is literally one of the biggest complaints BCBAs have about other fields, such as psychology. None of those studies measuring collateral changes measured internal states such as heart rate and release of stress hormones, which is definitely possible. Smiling, crying, placing one’s head down, none of these are consistent measurements for private events. All of these behaviors can be easily shaped in various circumstances and can mean different things for different individuals. 

Hell, I smile all the time, but unless I’m hissing, you might think I’m happy, but really it means that if you get any closer, you’re getting a nasty bite. I’ve heard humans have similar reactions: Many humans smile or even laugh when they are angry. It’s an evolutionary carryover from their primate cousins. Like us opossums, if a chimpanzee smiles at you, they are not amused, and you’re fucked. 

In defense of Ricketts et al. (1993), they did measure individualized responses based on staff who knew the participant best. Idiosyncratic vocalizations and expressions are usually our most reliable way of measuring these private events. The difference between Ricketts et al. and Linschield et al. is that Linschield et al. used generalized responses such as smiling that can too easily become conditioned masking responses based on the contingencies described in that study. Ricketts et al. made an attempt to find more specific reactions to the individual. 

I maintain that we, as ethical practitioners, do have to make assumptions about private events in order to prevent harm. At the same time, we need to be aware of how our own behavior may be affecting these overt responses. This is not something that can happen within the first month of meeting a client. It’s systematically attending to and being aware of what behaviors we’re shaping over the course of several months if not years. I am not convinced that any of the participants in Linschield et al.’s study had no negative effects from CESS. 

As for Ricketts et al., SIBIS was ineffective in reducing the targeted behavior (self-injury). Some of the rates of positive versus negative idiosyncratic behaviors do show large differences in favor of positive, however, the overall rates of these idiosyncratic behaviors are low (e.g. 18% of sampled observations sessions), and there were potential confounds described in the paper itself. While I can only commend Ricketts et al. and the Journal of Behavior Therapy and Experimental Psychiatry for publishing a study in which the intervention was ineffective for the participant, it hardly supports ABAI’s thesis. 

JRC Sources

As has been discussed by JRC’s critics, ABAI acknowledges that “CESS has not been successfully faded for the majority of the JRC’s clients.” Nathan Blenkush, the clinical director of JRC, stated that the CESS device has to be a permanent part of some client’s lives, describing it as a “prosthetic” as opposed to “curative” for most cases. Still, the task force draws the conclusion that “responding typically remains suppressed under CESS over the long run,” despite immediately following this with “strategies to fade CESS completely are not successful for a large portion of individuals.” 

It was here that I realized the code of ethics for BCBAs doesn’t say anything about fading procedures over time. So in this way, the authors are correct: There is nothing about being unable to fade a shock device that has to be worn 24/7 that directly violates our code of ethics. That’s not to say anything about where it stands in terms of social validity, ethics outside of ABA, or just general morality, just an objective statement, the implications of which are, once again, a different post. 

In their critique of Zarcone et al. (2020), the authors state that their conclusion that Linschield et al. (1994) and van Oorsouw et al. (2008) reported negative collateral effects was false, that these studies showed “only positive” side effects. Having read both of these articles, my only conclusion is that Zarcone et al. actually read these studies with a properly critical eye, while Perone et al. here seems to have simply read the discussion and taken the authors’ word for it. A running theme that comes up often in reports like this is “what are we really measuring?” Those who die upon the hill that is “CESS must continue” often quote these conclusions as evidence, yet they never seem to fully examine the studies they cite. Often the measurement is inherently flawed. I would argue that ABA alone is not equipped to fully examine the issue of side effects related to CESS and how JRC implements it. Clinical psychologists, especially those with experience working with autistic and other disabled populations, need to be consulted. 

Though it’s clear the task force would take great issue with that last line, but more on that later. 

Their final critique of Zarcone et al.’s conclusions states that they are “puzzled” by the criticism of AB designs. While it’s a fair statement that some treatments would be unethical to withdraw and thus, an AB design is appropriate, Zarcone et al. is still not incorrect in highlighting the flaws in AB studies. Is this not ABA Grad School 101? Designs become more valid the more ABs you add to it. Based on the task force’s previous statements though, it’s consistent that they would find this critique puzzling since they have at this point found no issue with the fact that there is no evidence that CESS can be reliably faded. 

For JRC’s critics, including presumably Zarcone et al., an ABA design would have been the more ethical approach because it would involve fading CESS. ABABA would be even more reliable, though ethically questionable as fading the device would imply that the dangerous behavior has indeed been suppressed. Despite the authors’ claims that such dangerous behaviors do remain suppressed, the inability to fade the treatment suggests otherwise (as do their own supporting studies if you actually read them). 

Anecdotal sources

The authors describe their visit to JRC in quite extensive detail. They discuss who they meet with and even include the demographics (to address past concerns of racial inequality among clients receiving CESS). They also make sure to mention interactions between clients and the clinical director, describing them as positive, unprompted, and that no crying or avoidance behavior was observed. It’s probably safe to assume these details are meant to further reinforce their conclusion that CESS does not have any negative side effects. There are a few flaws with that logic though.

Reactivity is a thing. You are a novel person present in a classroom and receiving a tour from someone who is likely perceived as an authority figure.

It’s also highly unlikely that the Clinical Director and Chief Executive Officer are the ones more often paired with punishing consequences. Anyone who’s ever supervised a session with BTs or RBTs could tell you that the one implementing the non-preferred consequence is far more likely to get the consequences of those decisions regardless of who wrote the programs.

RBTs and BTs probably have something to say about that too.

The authors also note that no instances of CESS were observed during their visit. Again, likely also considered a supporting point to the idea that shocks are not delivered often, but it would be fair to question these results when considering reactivity as well. Everyone cleans up their act when the boss is around, intentionally or not. It’s a natural behavior in reaction to being observed. It also means the task force did not at any point directly observe the CESS component of any treatment plan. 

The authors did observe “problem behaviors” from some clients who were not wearing GEDs though, and noted that the consequences were usually blocking, protective equipment, restraint, or time-out. So there’s that. 

From the horse’s mouth

I think it’s important to see the sections on the interviews as they are. Here’s the one in which they interviewed clients.

The indicated section perhaps best exemplifies the authors’ attitudes towards the disabled clients they frequently work with and study. It also exemplifies why ABAI continuously dismisses criticism from autistics. This paragraph places extensive emphasis on the single client who did not have an intellectual disability (of the 4 they interviewed out of 52 just currently receiving CESS). Half of the paragraph is his testimony alone. He is also the only one who had anything positive to say about CESS. 

Here, the authors demonstrate in no uncertain terms that social validity decreases with the presence of a disability and continues to decrease as support needs raise. While it’s important to acknowledge that many clients at JRC likely cannot consistently express themselves in ways we understand or respond to complex questions, 3 clients were asked a question and gave a clearly negative opinion. One even literally “asked the task force members to remove them from the JRC because they didn’t want CESS.” That is a cry for help, and they were ignored.

That client was not consenting or assenting to treatment, and was ignored. 

As a reader, I was left to wonder what would have changed if the client who did not have a disability had said this instead of one with a disability. Would the task force have been alarmed, or would they have discussed his clear history of mental illness? 

The next section of interviews with the parents of 4 clients with CESS in their treatment plans. 

Pausing objectivity:

Oh. My. God.

“Their children finally had personalities?” 

“Something they never realized their children had?” 

As awful as that is to hear from parents, it’s even more disturbing that it was included in the report. There is no good, objective reason to include that statement. Also, if you’re trying to argue that you are not ableist, that is not helping. 

Every human has a personality no matter how often they engage in dangerous behaviors. No person is engaging in dangerous behaviors at all times. Anyone unable to see that is not paying attention. This is not to invalidate the stress these behaviors place on caregivers, but to instead fault the professionals who are meant to support them for not only never helping them shift their perspective, but for also reinforcing this idea. 

Imagine your own parents thinking you don’t have a personality. Imagine hearing professionals agree with this. 

Cherry-Picking Ethics

I see your 

… and raise you 

The statement that psychotropic medications are not prescribed by behavior analysts just reminded me of the tendency in this field to assume that if a BCBA wasn’t involved, then the quality of care is diminished if not non-existent. 

Yes, psychiatrists, not behavior analysts, prescribe psychotropic medications. That would be because psychiatrists are trained in medicine, mental health, and how to adjust brain chemistry with … well… psychotropic medications. Behavior analysts are trained in the science of learning, conditioning, and the way organisms interact with their environment. 

Yet, the behavior analysts authoring this report have an awful lot to say about the horrors of psychotropic medication. They’re not alone of course. Their concerns are echoed by pretty much every study to ever come out of JRC or practitioners supporting their methods. There’s this pervasive idea that the absolute worst thing that can happen to an individual – worse even than painful electric shock to the skin – is psychotropic medication. 

This is not to say there isn’t a serious issue in the field of psychiatry and the way it treats people with cognitive disabilities. Working with adults, I would see lists of prescribed medications that spanned entire pages. As the article mentions, autistic individuals are more likely to be prescribed psychotropic medications, and risperdone, an antipsychotic, has had “autism” listed as one of its uses. 

It’s a problem – and potentially something to be discussed in another post. 

The thing is: Some people need psychotropic medications. Some people’s brains are not performing in a way that benefits them. And that is OK. 

JRC survivor, Jennifer Msumba, even expressed that she would take psychotropic medication, even with the side effects, over CESS. Of course Jennifer Msumba has a disability, and the authors have already expressed that this makes her accounts and opinions less worthy. 

Getting a little biased again but: I disagree. 

Spoiler alert: Jennifer Msumba is also conspicuous by her absence of any mention in this article. 

Doing more harm than good

By treating psychotropic medications this way, the task force, and thus, ABAI as a whole, perpetuates harmful stigmas against those who do need and benefit from these medications. This stigma often prevents people from getting the care they need from these meds. It also contributes to gaslighting and negligence from other medical professionals. Often legitimate medical issues are ignored because doctors see that their patients are taking psychotropic medications and immediately blame symptoms on their mental illness without any further investigation. 

But tell me again how it’s better to be shocked and have to wear a GED device 24 hours a day for the rest of your life than to take a pill. 

The authors also cite the BACB Code of Ethics’ requirement that practitioners obtain client assent to treatment whenever possible, yet they literally disregarded multiple accounts of clients not assenting to treatment with CESS or by JRC as a whole. They recommend diligent efforts be made to evaluate this and adjust accordingly, yet based on their own descriptions, I might demand a better operational definition than the one they describe. Their 6th recommendation states that “treatment programs involving CESS, including procedures related to consent and assent, must be approved and periodically reviewed by a peer review committee and a human rights committee, and the judgements of these committees must be documented.” A great idea for sure, but leaves some questions about how this relates to assent and consent. The implication seems to be that this committee has the ability to overrule withdrawal of consent or assent, and that is disturbing to say the least.

Also, there is nothing to describe who this committee should include. As with the task force, there’s a history here of filling a room with the most privileged of individuals, giving them the highest control over things, calling it a “committee,” and then patting themselves on the back for a job well done. Who is on a committee though matters, especially when dealing with marginalized and vulnerable populations. The committee should include trauma-informed experts and actual disabled people. Yes, they will need to break their rule that disabled opinions carry less weight. 

Object and Subjective Conclusions 

As noted before, there is a conflict of interest between ABAI and JRC, and this report is rife with bias. In looking at the Task Force itself, there were already serious concerns about their ability and willingness to really examine this issue objectively and it seems those concerns were founded. The report describes little to no effort to truly do a cost/benefit analysis on the use of CESS, and shows every effort to prove the need for its continued use. 

The authors’ dismissiveness for disabled voices is disturbing but not surprising. What is disappointing is their ability to contradict themselves and skim through research in order to support what was clearly already a set conclusion. For years, practitioners have been discussing the need for better training in scientific understanding or else risk decreasing the quality of services in the field (e.g. Moore et al. 2003, Johnston, 1996). This report could not have highlighted these concerns better – especially considering the authors of the report were primarily their contemporaries. 

At this point, it is our responsibility to be discussing these issues loudly and directly. ABAI has now officially promoted harmful treatments and blatantly ignored evidence contradicting its effectiveness. Their attempts to understand the use of CESS and form an empirically-based statement on the subject were disingenuous at best. The fact that they are restricting access to these reports to members only also says nothing good about their practices or values as practitioners. Shutting out dissenting voices pulls away from science and pushes towards cultishness. The points in this report could be read as a rant on YouTube by some guy sitting in his truck wearing Oaklies and it would fit right in. 

That’s another theme in ABAI’s behavior recently. From Carol Pilgrim referring to criticism about JRC as “histrionics” and “alternative facts” to Ron Leaf claiming that ABA is “under attack,” they are behaving more like a right-wing rally than a respectable organization promoting scientific efforts. I’ve said it before, and I’ll say it again: Politics do matter, and that is a problem.

ABAI’s status in the field needs to be diminished if we are to improve our practices and stop causing harm. 

References

(2021) Consensus Statement on the Use of Contingent Electric Skin Shock.

Association for Behavior Analysis International (2022). Report on the ABAI Task Force on Contingent Electric Skin Shock.

European Association for Behavior Analysis (2021). Statement on the Use of Contingent Electric Skin Shock.

Ghaemmaghami, M., Hanley, G.P., Jessel, J., & Landa, R. (2018). Shaping complex functional communication responses. Journal of Applied Behavior Analysis, 51(3), 502-520.

Hanley, G.P., Piazza, C. C., Ficher, W. W., & Maglieri, K. A. (2005). On the effectiveness of and preference for punishment and extinction components of function-based interventions. Journal of Applied Behavior Analysis, 38(1), 51-65.

Linscheid, T.R., Iwata, B., Ricketts, R., Williams, D., & Griffen, J. (1990). Clinical evaluation of the Self-Injurious Behavior Inhibiting System (SIBIS). Journal of Applied Behavior Analysis, 23, 53-78.

Oregon Association for Behavior Analysis (2021). Statement on Contingent Electric Skin Shock.

Rajaraman, A., Hanley, G.P., Gover, H.C., Staubitz, J.L., Staubitz, J.E., Simcoe, K.M., & Metras, R. (2022). Minimizing escalation by treating dangerous problem behavior within an enhanced choice model. Behavior Analysis in Practice, 15(1), 219-242.

Ricketts, R.W., Goza, A.B., & Matese M. (1993). A 4-year follow-up on treatment of self-injury. Journal of Behavior Therapy and Experimental Psychiatry, 24, 57-62.

Slaton, J. D., Hanley, G.P., & Raftery, K.J. (2017). Interview-Informed functional analyses: A comparison or synthesized and isolated components. Journal of Applied Behavior Analysis, 50(2), 252-277.

van Oorsouw, W.M.W.J., Israel, M.L., Von Heyn, R.E., & Duker, P.C. (2008). Side effects of contingent shock treatment. Research in Developmental Disabilities, 29, 513-523.

Zarcone, J.R., Mullane, M.P., Langdon, P.E., & Brown, I. (2020). Contingent electric shock as a treatment for challenging behavior for people with intellectual and developmental disabilities: Support for the IASSIDD policy statement opposing its use. Journal of Policy and Practice in Intellectual Disabilities, 17(4), 291-296.