Association for Behavior Analysis International

The Association for Behavior Analysis International® (ABAI) is a nonprofit membership organization with the mission to contribute to the well-being of society by developing, enhancing, and supporting the growth and vitality of the science of behavior analysis through research, education, and practice.


47th Annual Convention; Online; 2021

All times listed are Eastern time (GMT-4 at the time of the convention in May).

Event Details

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Symposium #376
CE Offered: BACB — 
Positive Punishment: Efficacy, Efficiency, and Side Effects of Electrical Stimulation Devices
Monday, May 31, 2021
9:00 AM–10:50 AM
Area: DDA/PCH; Domain: Translational
Chair: Elizabeth A. Fitter (Judge Rotenberg Educational Center)
Discussant: Nathan Blenkush (Judge Rotenberg Educational Center)
CE Instructor: Elizabeth A. Fitter, Ph.D.

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.

Instruction Level: Basic
Keyword(s): electrical stimulation, positive punishment, problem behavior, skin shock
Target Audience:

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

Learning Objectives: At the conclusion of the presentation, participants will be able to: (1) identify the behavioral dimensions associated with electrical stimulation device treatment; (2) identify the efficiency and efficacy of electrical stimulation device treatment; (3) identify negative side-effects associated with electrical stimulation device treatment; and (4) identify positive side-effects associated with electrical stimulation device treatment.

Sample Characteristics and Topographies Treated With Electrical Stimulation Devices

(Applied Research)
ELIZABETH A. FITTER (Judge Rotenberg Educational Center), Nathan Blenkush (Judge Rotenberg Educational Center)

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.

Efficiency and Efficacy of Electrical Stimulation Devices
(Applied Research)
JOHN O'NEILL (Judge Rotenberg Educational Center), Nathan Blenkush (Judge Rotenberg Educational Center)
Abstract: In 1965, Lovaas described the first clinical application of an electrical stimulation device for severe problem behaviors. Since then, the effect has been replicated hundreds of times using various single-subject designs by numerous researchers. Here, we review and summarize the efficacy of electrical stimulation devices described in the literature. Across 117 behaviors or groups of behaviors, eighty-three of 117 were reduced by 100%; 110 of 117 by at least 90%; 112 of 117 by 50% or more; and 5 of 117 continued at the same rate or increase. This data is supplemented by recent analyses of contingent skin-shock (i.e., positive punishment) in the treatment of severe problem behaviors in 173 individual cases between 2001 and 2019. Overall, a 97% reduction in the frequency of severe aggressive and health dangerous (e.g., self-injurious) behaviors was observed in the first full month of treatment across participants. Findings provide support for the supplemental use of contingent skin-shock in conjunction with differential reinforcement and other behavioral procedures for severe treatment refractory behaviors. We present findings from the largest clinical sample in the skin-shock literature (describing approximately 350 treatment years), planned versus unplanned fading of treatment, reversal of treatment effects, and follow-up data spanning 15 years. The evidence provides support for the assertion that contingent skin-shock is the least intrusive, most effective, and efficient treatment available for the severe problem behaviors of some individuals.

Negative Side Effects of Electrical Stimulation Devices

(Applied Research)
JESSICA LINDSAY (Judge Rotenberg Educational Center)

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.


Positive Side Effects of Electrical Stimulation Devices

(Applied Research)
LYNDE KAYSER (Judge Rotenberg Educational Center)

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.




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