TRIAD’s response to ABAI’s Draft Report/Recommendations on CESS

TRIAD’s response to ABAI’s Draft Report/Recommendations on CESS

TRIAD’s Response to Association for Behavior Analysis International Draft Report and Recommendations on Contingent Electric Skin Shock


TRIAD, the autism institute at the Vanderbilt Kennedy Center, is calling on the Association for Behavior Analysis International (ABAI) to fully condemn the use of contingent electric skin shock (CESS) by behavior analysts and related providers.

In response to mounting public criticism, ABAI assembled a task force to investigate the use of CESS in applied behavior analytic services. On September 28, 2022, ABAI released the findings of their task force report as well as a draft of recommendations informed by the report. This draft document, entitled, "Report of the ABAI Task Force on Contingent Electric Skin Shock," was distributed to ABAI members for feedback. Upon studying and discussing the report and the associated recommendations, we concluded it is deeply flawed through inconsistent, confusing, and contradictory conceptualization and reasoning. This draft report did not provide a clear justification for CESS; rather, it provided components for a clear scientific and humanistic case against CESS which would make ABAI’s lack of a full condemnation of CESS within a final report perplexing and troubling.

See below for a PDF of the published “Report of the ABAI Task Force on Contingent Electric Skin Shock.”

Below is the text of our statement to ABAI, which we submitted on October 17, 2022, meeting ABAI’s deadline for feedback. TRIAD implores ABAI to fully condemn the use of CESS by behavior analysts and related providers.




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

We are writing in response to the call for feedback from the Association of Behavior Analysis International’s (ABAI) membership regarding the task force report on the use of Contingent Electric Skin Shock (CESS) and their draft of recommendations that was ostensibly informed by the report. This response represents the collective opinions of staff and faculty employed at Vanderbilt Kennedy Center’s Treatment and Research Institute for Autism Spectrum Disorders (TRIAD) at Vanderbilt University Medical Center. Our team includes 28 BCBAs and BCBA-Ds, nine of whom are current members of ABAI.

We appreciate the effort and consideration given by the task force to investigate and organize the report and are especially appreciative that the committee is seeking input from ABAI’s membership. We understand the purpose of the task force is to (a) take seriously the criticisms put forth by the larger applied behavior analysis (ABA) community about the continued apparent endorsement by ABAI of the CESS program at the Judge Rotenberg Center (JRC) and (b) investigate the nature and scope of the CESS program’s implementation to take an informed stance, on an organizational level, about the present and future relationship between Behavior Analysis and CESS. Upon studying the report and reflecting on our own training, professional and scholarly experiences, and collective values, we conclude the recommendations presented by the task force are egregiously out of alignment with the findings of their own report. For this reason, we cannot support the publication of these recommendations.

In what follows, we outline our concerns with the draft of recommendations put forth by the task force, highlighting fundamental issues as well as pointing out concerns that could be modified with revision:

  1. ABAI’s assembly of the task force was myopic at its inception, as it failed to adequately represent the organization’s constituency. The criteria ABAI laid out in attempting to identify a “small group of established and respected scholars, scientist-practitioners, and leaders in the field with professional credentials'' resulted in the notable inclusion of some task force members who seemingly do not engage in applied research, much less applied practice, as well as the conspicuous omission of individuals from underrepresented racial and ethnic minority groups, neurodivergent individuals, and individuals with lived experience having received ABA and/or CESS. There are BCBAs and potentially ABAI members who were the previous recipients of ABA services; these individuals’ perspectives are exceptionally important and their omission from the task force may have contributed the draft of recommendations containing several aspects out of touch and out of alignment with broader contemporary perspectives (some of which we elaborate below).
  2. The draft of recommendations does not sufficiently condemn the use of CESS in the name of ABA. A stronger statement of condemnation is warranted considering the report’s findings. The draft opens with the statement, “…we strongly oppose the inappropriate or unnecessary use of [CESS].” The modifiers “inappropriate” and “unnecessary” in referring to what is problematic about CESS are too ambiguous and invite anyone, including JRC, to deem their use of CESS as appropriate and necessary without repercussion. As we will elaborate below, we do not believe that the report contained any information regarding the use of CESS at JRC to justify its continued application relative to myriad other behavior-analytic approaches to addressing dangerous and complex behavior. Additionally, in our assessment of the report, we do not believe the task force found use of CESS at JRC to be appropriate or necessary based on poor and insufficient evidence of the effectiveness, social validity, and capacity to fade the intrusiveness of CESS, as well as wholly insufficient evidence that all possible alternative strategies have been exhausted.
  3. On a similar note, the draft of recommendations leaves too much room for “professional clinical discretion” to be the arbiter of whether CESS should be used or not. Based on our read, the task force has crafted recommendations that could all too easily result in future abuse and marginalization of vulnerable individuals. Relying on the independent approval of one BCBA-D, for example, gives one human being (who may be influenced by their own biases or other social contingencies) the power to impose CESS on others. In fact, this report clarifies CESS is a practice not established as an evidence-based or even emerging practice for our field. As such, substantive oversight should be an absolute bare minimum, but given the potential and probability of physical and emotional harm within such an intervention, even that bare minimum is likely not enough.
  4. The statement included in Principle #1, “controversy surrounding a therapeutic procedure does not, in itself, disqualify its use,” is dismissive of the criticisms made about the pernicious association between CESS and ABA. In our interpretation, it reads as though the harms experienced by autistic or otherwise neurodivergent individuals in the name of ABA are not so much “valid” criticisms as they are merely “controversy.” Greater and more compassionate consideration should be given to these perspectives from our discipline’s flagship professional organization. Per their own report, task force members reported that 75% of interviewed clients (and 100% of clients with disabilities) found CESS to be unacceptable and unhelpful, and the task force members themselves found the GED to be painful; however, these reports did not appear to meaningfully influence the recommendations made. We ask that the task force center the perspectives of people who are currently or have previously received CESS in designing their recommendations. To be certain, we believe the task force members when they say the GED was painful; we kindly ask the task force to extend that courtesy to individuals who have experienced CESS and their allies and for this courtesy to be carefully and clearly reflected in their statement.
  5. Given JRC is the only facility in the USA that incorporates CESS, and the report appears to be a broadly directed public statement, it is not clearly specified how ABAI intends to act upon their own recommendations with respect to their relationship with the only facility using CESS (JRC). This is especially notable given the myriad ways in which JRC’s current practices (per the task force’s report) are out of compliance with the draft of recommendations. In the absence of contingency-specifying statements regarding how ABAI would act if violations were committed, this list appears to be nothing more than lip service to placate the growing masses who expressed valid criticisms regarding the very real harms suffered by individuals in the name of behavior analysis and JRC. Some examples of misalignment between current JRC practices and the recommendations include, but may not be limited to, the following:
    1. The draft of recommendations begins with the recognition that “some individuals may choose a program that incorporates CESS for themselves or those in their care.” Although informed consent appears to be collected from caregivers, no mention is made in the “practices at the JRC” report that client choice is factored into any admission or assessment process. The only information included in the report pertaining to client preferences came from the four clients who were interviewed, three of whom vocally indicated in strong terms that they neither preferred CESS nor found it helpful. This is a grave concern as clients did not choose and were not able to choose to be electrically shocked by professionals.
    2. Principle 3 suggests irresponsible use of a procedure should not disqualify responsible use. However, the report on JRC practices does not explicitly or implicitly suggest responsible use of CESS.
      1. One notable example involves the delayed delivery of CESS as a punishment procedure, which JRC is said to do for up to 2 min following an instance of target behavior. Furthermore, as per the CESS task force report, “some clients are approved for up to a 30-min delay to CESS if results of standard cognitive/intelligence tests indicate that they are able to connect the behavior to the consequence” (p. 8). Lerman and Vorndran (2002; p. 444) made a compelling argument that “even brief delays of 10 s or 20 s have been found to seriously compromise the effects of contingent shock…” To extend the delay to 30 min based upon results of a standard intelligence test seems a strategy not grounded in behavior analysis, let alone one that behavior analytic research has supported with evidence.
      2. Furthermore, the literature review included in the report, which examined the use of CESS in behavior analysis (both non-JRC and JRC papers), revealed that it has almost exclusively been studied in relation to dangerous self-injurious behavior; however, JRC electrically shocks clients for engaging in non-life-threatening behavior such as yelling, verbal threats, stealing, noncompliance, and attempts to remove the GED. There does not appear to be any peer-reviewed evidence in support of the efficacy of CESS to meaningfully address dangerous and complex behavior by targeting non-dangerous topographies (see related counterpoint 5.d.ii below).
      3. Considering this, it seems that JRC’s verification and delay of the punishment procedure, as well as their application of CESS to non-dangerous behaviors, do not represent recommendations from research, may not be behavior analytic in nature, and can be construed as irresponsible and/or non-evidenced use of the CESS procedures.
    3. The recommendations in Restriction #4 note that diligent efforts should be made to evaluate the individual’s assent to the treatment program to the extent possible. Morris et al. (2021) found limited research on obtaining assent from recipients of behavioral services and identified no examples in the literature of clear signs of assent withdrawal. Despite this paucity of research, it seems evident an individual attempting to remove their GED device would be an indication of their assent withdrawal; however, the report suggests that JRC personnel may electrically shock individuals for engaging in such a response.
    4. Restriction #1 specifies “Most instances of severe problem behavior are successfully treated without CESS when the treatments are based on the results of a functional analysis. Therefore, CESS may be considered only after competently implemented, state-of-the-art, reinforcement-based programs without CESS have been proven unsuccessful.” However, the report makes very clear functional analyses are rarely if ever implemented at JRC, citing three outdated barriers to the contemporary conduct of functional analysis. Moreover, the very brief description of reinforcement-based behavioral interventions, employed for at least one year prior to authorizing CESS, does not appear to be informed by contemporary behavior analytic research and practice. We would be remiss to not mention multiple lines of research that have emerged and proliferated since the time of the last published investigation of CESS.
      1. Functional analyses have indeed been demonstrated to lead to more effective and socially valid interventions compared to their absence in the assessment process (Hayvaert et al., 2014). Multiple variations of functional analysis have been developed and refined in the past two decades to explicitly address previously documented barriers such as low-rate or high-risk dangerous behavior. Trial-based (Lloyd et al., 2015), Latency-based (Thomason-Sassi et al., 2011), and Interview-informed synthesized contingency analyses (Hanley et al., 2014) are all contemporary options with large and growing literatures that limit exposure to evocative contexts, thereby limiting the risk of danger in functional analyses.
      2. Perhaps the most notable advancement in safety with respect to functional analysis technology (that can be incorporated into all abovementioned analysis formats) has been our increased understanding of the extent to which precursor or co-occuring less dangerous response topographies share response-class membership with more dangerous forms. Over a dozen studies have confirmed that if less dangerous topographies are reported to precede or co-occur with more dangerous forms, they are highly likely to be maintained by the same consequences (see Heath & Smith [2019] and Warner et al. [2020] for compelling summaries). Furthermore, Jessel et al. (2022) provided a direct comparison of analyses that reinforced only dangerous behavior compared to those that reinforced all possible response topographies and found the latter to be safer while still yielding an interpretable functional relation. The important implication of the phenomenon of shared response-class membership is it has enabled the functional analysis of dangerous behavior while only evoking, observing, and reinforcing less dangerous responses. However, perhaps more important to the current discussion is the practical takeaway that providing all suspected reinforcers (rather than punishers; e.g., CESS) contingent upon these precursors is a reliable way to mitigate escalation to dangerous behavior (Rajaraman et al., 2022). JRC currently reports implementing CESS upon non-dangerous precursor responding to prevent such escalation; it is much less clear if the alternative strategy of reinforcing those responses has been exhausted.
      3. Additionally, we note the conspicuous omission of practical functional assessment and skill-based treatment procedures (initially reported by Hanley et al. [2014] and subsequently replicated in over a dozen studies) in any discussion surrounding (a) reinforcement-based programs to address dangerous behavior, (b) designing behavior-change intervention with a focus on minimizing risk and harm to the client, and (c) attempting less intrusive interventions prior to implementing shock. Professional disagreements about various functional analysis approaches notwithstanding, there is unassailable evidence that skill-based treatment procedures informed by a practical functional assessment have a high probability of producing effective, socially validated outcomes with respect to dangerous behavior without ever resorting to punishment tactics. Of particular mention are the findings from Jessel et al. (2018) who achieved elimination of dangerous behavior and social validation of outcomes in 25 out of 25 consecutive cases with skill-based treatment. In their discussion, Jessel et al. (2018) compared the outcomes of their consecutive-controlled case series (CCCS; a design tactic used to minimize publication bias and increase confidence in actuarial conclusions) to the findings from three other influential large-N behavior-analytic CCCS studies examining function-based procedures for addressing dangerous behavior (Greer et al., 2016; Hagopian et al., 1998; Rooker et al., 2013). In short, function-based procedures have needed to rely less and less on any punishment procedures, with the skill-based treatment package relying 0% on punishment procedures. In all other studies, punishment and supplemental procedures were incorporated into the treatment package at least some of the time. Again, professional biases notwithstanding, it seems to us a grave omission that the task force did not mention or report on the efficacy of these procedures, let alone recommend they at least be attempted prior to CESS at institutions like JRC.
    5. In sum, there are multiple ways in which the current practices at JRC, per the task force report, do not align with the recommendations regarding current and future use of CESS. Clear language regarding if and how ABAI would address these, and other grievances should be explicitly included in the final statement.
  6. A previous ABAI statement pertaining to conversion therapy stated the following: “Conversion therapy practices are scientifically discredited, violate fundamental human rights, and are known to directly harm individuals who are subjected to them.” Based upon the findings of the task force report, it could be argued that CESS (a) is scientifically discredited due in part to an insufficient and outdated evidence-base, (b) violates fundamental human rights, and (c) is known to directly harm individuals.

We thank the task force for providing this opportunity to weigh in on this sensitive and contentious matter. Our TRIAD team strives to represent the principles of applied behavior analysis with an emphasis on compassion, social validity, and equity. As such, the 28 BCBA’s at TRIAD and the nine of us who are current members of ABAI cannot endorse these recommendations. In fact, we found them to be as disconcerting as they were biased and contradictory to the task force’s own findings. We call upon the task force to write a position statement that condemns the use of CESS given the only remaining institution using CESS does not make a clear and sufficient case for its necessity and based on the information in the report, are misusing the electronic and behavioral technology.


References

Greer, B. D., Fisher, W. W., Saini, V., Owen, T. M., & Jones, J. K. (2016). Functional communication training during reinforcement schedule thinning: An analysis of 25 applications. Journal of Applied Behavior Analysis49(1), 105-121.

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 analysis31(2), 211-235.

Hanley, G. P., Jin, C. S., Vanselow, N. R., & Hanratty, L. A. (2014). Producing meaningful improvements in problem behavior of children with autism via synthesized analyses and treatments. Journal of Applied Behavior Analysis47(1), 16-36.

Heyvaert, M., Saenen, L., Campbell, J. M., Maes, B., & Onghena, P. (2014). Efficacy of behavioral interventions for reducing problem behavior in persons with autism: An updated quantitative synthesis of single-subject research. Research in Developmental Disabilities35(10), 2463-2476.

Heath Jr, H., & Smith, R. G. (2019). Precursor behavior and functional analysis: A brief review. Journal of Applied Behavior Analysis52(3), 804-810.

Jessel, J., Ingvarsson, E. T., Metras, R., Kirk, H., & Whipple, R. (2018). Achieving socially significant reductions in problem behavior following the interview-informed synthesized contingency analysis: A summary of 25 outpatient applications. Journal of Applied Behavior Analysis51(1), 130-157.

Jessel, J., Rosenthal, D., Hanley, G. P., Rymill, L., Boucher, M. B., Howard, M., ... & Lemos, F. M. (2022). On the occurrence of dangerous problem behavior during functional analysis: An evaluation of 30 applications. Behavior Modification46(4), 834-862.

Lerman, D. C., & Vorndran, C. M. (2002). On the status of knowledge for using punishment: Implications for treating behavior disorders. Journal of applied behavior analysis35(4), 431-464.

Lloyd, B. P., Wehby, J. H., Weaver, E. S., Goldman, S. E., Harvey, M. N., & Sherlock, D. R. (2015). Implementation and validation of trial-based functional analyses in public elementary school settings. Journal of Behavioral Education24(2), 167-195.

Morris, C., Detrick, J. J., & Peterson, S. M. (2021). Participant assent in behavior analytic research: Considerations for participants with autism and developmental disabilities. Journal of Applied Behavior Analysis54(4), 1300-1316.

Rajaraman, A., Austin, J. L., Gover, H. C., Cammilleri, A. P., Donnelly, D. R., & Hanley, G. P. (2022). Toward trauma-informed applications of behavior analysis. Journal of Applied Behavior Analysis55(1), 40-61.

Rooker, G. W., Jessel, J., Kurtz, P. F., & Hagopian, L. P. (2013). Functional communication training with and without alternative reinforcement and punishment: An analysis of 58 applications. Journal of Applied Behavior Analysis46(4), 708-722.

Thomason-Sassi, J. L., Iwata, B. A., Neidert, P. L., & Roscoe, E. M. (2011). Response latency as an index of response strength during functional analyses of problem behavior. Journal of Applied Behavior Analysis44(1), 51-67.

Warner, C. A., Hanley, G. P., Landa, R. K., Ruppel, K. W., Rajaraman, A., Ghaemmaghami, M., ... & Gover, H. C. (2020). Toward accurate inferences of response class membership. Journal of Applied Behavior Analysis53(1), 331-354.



Last Updated: 10/19/2022 7:44:41 AM

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