Association for Behavior Analysis International

Positive punishment procedures are controversial, misunderstood, and misrepresented inside and outside behavior analysis. We provide a contemporary review of the efficiency, efficacy, and side effects of contingent skin shock to treat the severe problem behaviors of individuals with various diagnoses. Contrary to popular belief, contingent skin shock by way of an electrical stimulation device often results in an increased quality of life by allowing the individual to contact new contingencies of reinforcement.

Any BCBA interested in positive punishment and/or electrical stimulation devices.

Electrical stimulation devices have been used to treat severe and treatment refractory problem behavior across a variety of topographies and diagnoses. In 2020, the Food and Drug Administration banned electrical stimulation devices used to treat aggressive and self-injurious behaviors. Treatment has been successfully used for individuals with diagnoses of autism spectrum disorder, conduct disorders, intellectual disability, and mood disorders who exhibit aggressive and self-injurious behaviors of sufficient intensity to cause serious damage to themselves and others. These behaviors include, but are not limited to blows to the head, rectal digging, rumination, eye gouging, body hits to the environment, and violent acts towards others. In addition, in the literature, the treatment of other idiosyncratic topographies that cause harm has been described. It is important to note that these behaviors are repeated overtime and produce bleeding and permanent tissue damage. Findings support the use of contingent skin shock in conjunction with other behavior analytic procedures for severe treatment refractory behaviors. Typically, the treatment is extremely effective in reducing the frequency of targeted behaviors. Types of electrical stimulation devices, client characteristics, and treated topographies will be discussed.

The use of electrical stimulation devices to treat severe, dangerous, and potentially life threatening problem behaviors is a controversial topic in the field of behavior analysis. The potential of negative effects such as learned helplessness, aggression, anxiety, among other side effects are often cited as sequelae associated with the use of electrical stimulation devices. However, many of these effects are derived from basic research with animals that do not necessarily comport with the clinical application of electrical stimulation devices. In many cases, specific experimental preparations are required to produce certain effects that are inconsistent with clinical applications. Here, the negative side effects described in the applied and experimental literature are reviewed. Literature regarding the use of electrical stimulation devices in a clinical setting to treat severe problem behaviors reflect relatively infrequent and less prevalent negative side effects than those noted in laboratory studies. This discussion will examine the negative side effects of both non-contingent and contingent skin shock, while clarifying common misconceptions associated with the treatment.

Clinically significant decelerations are observed across a variety of topographies of severe, treatment refractory problem behaviors after contingent skin shock treatment. As these once refractory problem behaviors decrease, multiple positive side effects emerge. Some such side effects include reductions in the use of chemical, mechanical, and physical restraint, health related supports, and level of supervision required to maintain safety. Substantial increases in pivotal behaviors are commonly observed as maladaptive behaviors decelerate and availability of reinforcement increases. For example, the elimination of mechanical restraint sets the occasion for increased ambulation, which may act as a pivotal behavior that enables social initiation and access to leisure activities. An increased repertoire of pivotal behaviors often results in the development of behavioral cusps, or behavior change that exposes the individual to novel environments, reinforcers, and contingencies. Individuals who receive the treatment demonstrate improvements in quality of life as measured by increased access to the community, home visits, and employment, social behaviors, academic progress, and independence. This discussion will review positive side effects associated with contingent skin shock, to include both reduced use of restrictive interventions and increased adaptive behavioral repertoires.