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A Comparison of the Long-Term Decelerative Effectiveness of
Two Intensities of Contingent Electric Shock on Aggressive and
Health Dangerous Behavior with Individuals with Severe Behavioral Disorders

Robert E. von Heyn, Matthew L. Israel, Robert W. Worsham

The Judge Rotenberg Center

JRC pub. no 93-2

The present paper reports on the extensive use of two remotely controlled contingent shock devices for decelerating aggressive and health dangerous behaviors in over 50 individuals with developmental disabilities. Data are presented on the effects of the Self-Injurious Behavior Inhibiting System (SIBIS) and the subsequent use of the Graduated Electronic Decelerator (GED). Results indicated that with SIBIS, behaviors that initially decelerated began to accelerate after 6 to 12 months. The GED was developed to be similar to SIBIS but with adjustable features such as duration and intensity. Data collected over the past 2.5 years show that the GED produced a greater initial jump- down, a sharper deceleration and, to date, a longer-lasting deceleration. These changes in turn have led to more time spent learning academic, self-care and habilitative skills. These students now spend more time in the community and at home with their families.

Electrical stimulation as a decelerative procedure has often been described in the literature (see Cataldo, 1989 for a review). Although viewed as intrusive, this procedure has been recognized as the most effective treatment for reducing life-threatening, self-injurious and aggressive behaviors for a small group of developmentally disabled individuals who do not respond to procedures using positive reinforcement only. In 1987, The Association for Advancement of Behavior Therapy concluded that "...shock for self- injury may... be necessary.' (Favell, et al., 1987). Similarly, in 1987 the Council on Scientific Affairs published its report in the Journal of the American Medical Association stating, "... the Task Force concluded that increasingly aversive techniques, up to electric shock for the most severe [behaviors] are appropriate." In 1988, the Association for Behavior Analysis Task Force on the Right to Effective Treatment report stated that it would be inappropriate to use a nonrestrictive intervention if analysis revealed that another procedure would be more effective. 

The 1989 National Institutes of Health (NIH) Consensus Development Conference also concluded that behavior reduction procedures might be necessary when other, less intrusive procedures have failed. The NIH Consensus report contained reviews of the punishment literature (Cataldo, 1989) and the reinforcement and stimulus-based (i.e. "nonaversive") literature (Carr, E. G., Robinson, F., Taylor, J., & Carlson, J., 1990). Cataldo (1989) found that shock and other contingent stimuli were effective in producing a 90% reduction in 86% of cases involving self-injury, and a 60% of cases involving aggression. This compares with the Carr et al. (1989) findings that reinforcement and stimulus- based treatments were effective in only 37% of cases of self-injury and in 36% of cases involving aggressive behavior, using the same 90% reduction criterion. Table 1 presents this data.

Table 1. Comparison of Effectiveness of Aversive and Nonaversive Treatments

Most recent studies of electric skin-shock devices have used only a single device with each individual reported. For example, Linscheid, lwata, Ricketts, Williams and Griffin (1990) found Human Technology's Self-Injurious Behavior Inhibiting Systems (SIBIS), with a current of 3.5 mA (value reported by the manufacturers), to be an effective stimulus to decelerate health dangerous behavior in 5 mentally retarded individuals. Foxx, McMorrow, Bittle and Bechtel (1986) reported that the Savage Company's Hot Shot Power Mite, with a current of 18.5 mA (value reported by the manufacturer), to be successful in decelerating aggressive behavior in a dually diagnosed deaf man.

Only a few studies have compared decelerative effectiveness of more than one intensity or device within the same individual. Trudel, Beaupre and Maurice (1981) compared three intensities of contingent electrical stimulation on the self-abuse of 5 mentally retarded individuals. They reported that only the "high" intensity stimulation, which they described only as 3.5mA," was effective in suppressing the self-injurious behaviors.

Recently Williams, Kirkpatrick-Sanchez and lwata (1993) compared SIBIS to the Power Mite. Because both devices had previously been reported to be effective in treating maladaptive behavior, yet differed greatly in power output, Williams et al. compared the effectiveness of the two devices within the same individual. They reported that SIBIS produced minimal reductions in the self-abusive behavior of a blind, profoundly retarded woman, while the Power Mite produced immediate and large reductions in self-abusive behavior of this same individual. William's et al. reported long-term maintenance at low levels for 6 months.

In 1989 Behavior Research Institute (BRI) decided to request contingent electrical stimulation as a decelerative procedure as part of court authorized treatment plans for several students. At that time there were only two commercially-available shock devices designed for use with humans, SIBIS and WhistleStop.

BRI selected the SIBIS device because it was designed by the John Hopkins Applied Physics Laboratory in consultation with Linscheid and lwata (Linscheid et al., 1990), it was remotely activated by a coded radio signal, and it was registered with the Food and Drug Administration as a medical device. WhistleStop was not selected due, in part, to the fact that its uncoded remote activation did not allow for more than one unit to be used at a time. However, after extensive experience with SIBIS it was noted that many students' behaviors, which had initially decelerative began to accelerate. A review of the literature indicated that SIBIS was relatively weak in terms of voltage and current in comparison to other devices that had shown long term effectiveness in decelerating health dangerous (HDR) and aggressive (AGG) behaviors (Foxx et al., 1986; Williams et al., 1993). These results are similar to those found in the basic experimental literature on punishment. Azrin (1960a) and Appel and Peterson (1965) demonstrated recovery of responding when using mild and moderate shock punishment in both pigeons and rats. When a stronger shock stimulus was used, however, response suppression was nearly complete and no recovery was seen. 

Given the lack of any other commercially-available device that could deliver a stronger stimulation, BRI decided to develop a remote-control device that would be stronger than SIBIS. The device was termed the Graduated Electronic Decelerator (GED) and its features have been described in detail elsewhere (Israel, von Heyn, Connolly & Marsh, 1992).

Method 

Students. Students were referred to BRI because of the severity of their maladaptive behaviors. All students who received contingent electrical stimulation exhibited aggressive and/or health dangerous behavior. An indication of the severity of these behaviors, and of the fact that their behaviors were very likely "case- hardened," is when in the fact dm the median student had been expelled from 5 prior programs (range = 0 to 17) and rejected from 5 (range = 0 to 37). No psychotropic medications were used with these students while at BRI. 

SIBIS. Twenty-five students at BRI were treated with SIBIS. The median age at the start of treatment was 22.0 (range 12.7 to 27.7) and the median length of treatment with SIBIS was 1. 1 years (range 0.2 to 1.7). 

GED. A total of 56 students at BRI were treated with GED. The median age at the start of treatment was 20.8 (range 14.0 to 32.1) and the median length of treatment with GED was 1.5 years (range 0.2 to 2.5) as of 3/l/93. Most of the 25 students who had used SIBIS were shifted to GED after some period of time on SIBIS, and consequently became part of the 56 students who used GED.

Apparatus. Thirteen SIBIS units were purchased from Human Technologies between 11/88 and 1/90.

The units consisted of a receiver/stimulator and a remote activator that sent a coded radio signal. Each device could be given a code so that a given remote would activate only one receiver/stimulator which has been given the exact same code. According to Human Technologies, SIBIS delivered an 84 volt electrical stimulation at 24K Ohms skin impedance with a current of 3.5 mA. 'The stimulation was delivered in 16 pulses of 5 ms duration, evenly spaced across 0.2 s. Measurements on 10 BRI staff volunteers showed a median current of 4.4 mA rms (range 4.0 to 5.0 mA nns) at 76 V rms (range 54 to 95 V rms). Median skin impedance was calculated as 17AK Ohms (range 13.4 to 20.9K Ohms).

BRI manufactured 100 GED units between 12/90 and 3/93. Similar to SIBIS, the GED consisted of a receiver/stimulator and a remote activator. One difference from SIBIS was that GED's electrode was attached with a wire to the receiver/stimulator; SIBIS's electrode was externally mounted on the housing of the receiver/stimulator. As a result, the GED's electrode was more easily attached to the student and could be placed in a larger number of areas. When operated through a 24K Ohm resistor, GED produced 130 V n-ns and a current of 5.2 mA rms. The stimulation was delivered in 160 pulses, each of 3.1 ms duration, evenly spaced across 2.0 s. When tested on 10 staff volunteers, GED produced a median of 61 volts rms (range 50 to 90 V rms) and a current of 15.3 mA rms (range 6.5 to 20.0 mA rms). 

Procedure. The overall procedure was the same for implementing and using both S IBIS and GED. Once the clinical team decided to use contingent electrical stimulation for a particular student's behaviors, permission was first obtained from his or her parent or guardian and then from the Probate Court, using the substituted judgment process. In addition, before contingent electrical stimulation was used, approval was obtained from a Peer Review and a Human Rights Committee, as well from the student's physician who determined that there were, no medical contradictions for its use.

The skin-shocks were administered within an extremely rich, state-of-the-art positive program that, by itself, constituted a powerful nonaversive treatment program. This consisted of a high frequency of rewards administered: (1) for teaming new skills and executing already-teamed skills; (2) for learning and executing behaviors that were alternatives to the problem behaviors; and (3) for failing to engage in the targeted problem behaviors. In addition, functional analyses were performed to ascertain the function of the problem behaviors, and a functional communication token system was in place to provide each student with acceptable means for communicating his or her needs and wants. 

Treatment was conducted twenty-four hours a day, seven days a week. Each topography within a class of behaviors was operationally defined by the clinical terms and written on a daily recording sheet. The recording sheet accompanied the student each day and night. This helped to eliminate any ambiguity staff may have had regarding targeted behaviors. Hourly behavior frequencies were recorded When a targeted behavior was exhibited, the therapist activated the remote transmitter as soon as he or she detected the occurrence of the behavior and said, "(Students name) there's no (description of behavior)." For example, the therapist would say, "Terry, there's no hitting your head!"

Results 

1. Comparison of SIBIS and GED for II Students Treated first with Non-Shock Aversives, then with SIBIS, and finally with the GED 

There were 11 students who were treated with SIBIS for at least 12 months, who were then switched to GED, and for whom we have 12 months of data while on GED. In some cases, the change from SIBIS to GED was made because the student had shown signs of adapting to SIBIS. In other cases, the change was part of an agency-wide changeover from SIBIS to GED that was made in order to take advantage of the improved features of the GED. 

Figure 1, Figure 2,  and Figure 3 show sample monthly Standard Behavior Charts4 for three of the eleven students. On these charts, each dot represents the total frequency of the behavior being treated during one month across the treatment conditions, which were Non-shock Aversives, SIBIS, and GED, in that order.

Figure 1 shows a case in which SIBIS was initially successful, but where the behavior "leveled out" after II months of SIBIS use. During C.B.'s first 12 months of SIBIS use, her health dangerous behavior (primarily banging her head against hard objects) decelerated from approximately 5,000 a month to approximately 100 per month. However, under SIBIS the decrease stalled at that level after 12 months, and went no lower during the next 8 months. The introduction of GED, however, further decelerated the behavior to as low as 12 per month. 

Figure 2 shows monthly data for J.K., a case in which SIBIS caused an increase, rather than the hoped- for decrease, in health dangerous behavior. It also shows a dramatic deceleration that followed the introduction of GED. 

Figure 3 are data for D.P., and show some initial success of SIBIS in decelerating D.P's health dangerous behavior, followed by his apparent adaptation to that stimulus after approximately 10 months. Adaptation was so severe that the behavior regressed to a point higher than it ever was under Non-Shock Aversives. Under GED treatment, which began in December 1990, there was a steady deceleration of D.P's health dangerous behavior during the next 28 months. 

In each of these three cases, the substitution of the GED in place of SIBIS resulted in a major improvement in control over the behavior being treated. 

Figures 4 and 5 summarize the data for all students in which data had been collected for 12 full months each of Non-shock aversives, SIBIS and GED. Figure 4 summarizes data for II students' aggressive or health dangerous behavior (whichever was most problematic) during their last 12 months on Non-Shock aversives and their first 12 months of SIBIS. Figure 5 summarizes the data for the same behaviors for the last 12 months of SIBIS and the first 12 months of GED. 

In Figures 4 and 5, each student is represented by a three-part curve. The student's initials appear at the right end of the right-hand component of the curve. The three components of the curve represent the following:

(1) Before-celeration (left hand segment-solid line). This component shows the approximate frequency (indicated by height of the curve) and celeration (indicated by the slope of the curve) of the behavior during the 12 months before the intervention change. 

(2) Jump-up or jump-down (middle segment- dashed line). The jump-up or jump-down is the immediate change in frequency caused by the introduction of the new consequence, and is indicated by the dashed line that connects each celeration-before line (left-hand curve component) to its corresponding celeration-after line (right-hand curve component). Each dashed line is "stretched" over 6 months of the chart to enable the eye to see which jump goes with which celeration-before, and which celeration-after. The actual jump took place immediately, but the line is stretched over 6 months to aid the viewer. 

(3) Celeration-after (right-hand segment-solid line). This component shows the approximate frequency (indicated by height of the curve) and celeration (slope of the curve) of the behavior during the 12 months immediately after the jump-up or jump-down. 

Table 2 shows median values for the celerations- before, jumps, celerations-after, and turns for the II students. Turn 6 refers to the amount of change from the celeration-before to the celeration-after. When the rate of celeration-after increases the turn is termed a multiply and when the celeration-after decreases the turn is termed a divide. For example, if the celeration-before was X2.0, and the celeration-after was +2.0, the celeration turn is +4.0. The turn, as a measure, has the advantage that it takes into account not only the celeration of the behavior after the intervention, but also the baseline celeration that was going when the intervention was applied. The larger the celeration turn that an intervention is able to cause, the greater its decelerative power. Note that the student who had the median value of the celerations-before was not necessarily the same student who had the median value of the jump or of the turns. 

The data in Table 2 suggest did the GED was more effective as a decelerator than SIBIS, in terms of all three measures- immediate effect on frequency (the jumps), the trends that took place after the jumps (the celerations-after), and the ability to "bend downward" a celeration-before (the celeration turns):

(1) The median of the jumps after GED was introduced was twice as large as the median of the jumps that occurred after SIBIS was introduced (+8.0 for GED versus +4.0 for SIBIS).

 (2) The median of the celerations-after that followed the introduction of GED was +2.0. By contrast, the median of the celerations-after that followed the introduction of SIBIS was an acceleration of x1.5. This reflects the fact that in several cases, after SIBIS produced an initial jump-down, there was a subsequent turn-up of the celeration, presumably reflecting adaptation. 

(3) The median of the celeration turns caused by GED was a turn-down of -t-2.2-twice as large as the median of the turn-downs caused by SIBIS, which was +1.1.

2. Comparison of the effects of SIBIS vs. GED on Health Dangerous and Aggressive Behaviors, Across All Students. 

Figures 4 and 5 summarized individual data for 11 students who had been treated first by Non-Shock Aversives, then by SIBIS, and then by GED, for 12 months each. A second analysis was conducted that examined the median monthly total of aggressive and health dangerous behaviors across all students for which we had 12 consecutive months of data before the introduction of SIBIS or GED and 12 months under that treatment. These analyses are described below. 

(1) We examined the data for each student who had been treated with SIBIS, and calculated the monthly total of the health dangerous (Figure 6) behaviors being treated during the first 12 consecutive months of SIBIS treatment. Then, for each month, we find the median student for that month and plotted that student's total for the month in question. The student whose monthly total was the median for any one month was not necessarily the same student whose monthly total was the median for any other month. These 12 data points may be seen on the right side of Figures 6. Each dot is the median of the monthly totals for the nine students whose health dangerous behaviors were treated with SIBIS. The first month's data point has been placed on the January line, the second on February, etc... but these do not indicate the actual dates on which the behavior occurred. The actual date for each student was different.

Table 2. Comparison of 12 Months Before and After SIBIS and GED

(2) For these same 9 students we also determined the medians of the monthly lows of these same behaviors, during the 12 months immediately preceding the introduction of SIBIS. In the case of these 9 students the aversive that was used during the preceding 12 months were Non-Shock Aversives. These 12 data points are plotted on the left side of Figure 6.

(3) A similar analysis was done for the aggressive behavior of those students who were treated with SIBIS. There were only 3 such students and their chart is shown in Figure 7. To review, Figure 6 summarizes the effects SIBIS produced on the health dangerous behaviors of 9 students during the 12 months before and after the introduction of SIBIS. Figure 7 summarizes the data for the use of SIBIS on the aggressive behaviors of 3 students. 

(4) We undertook a similar analysis for the effects of GED on health dangerous behaviors (Figure 8) and on aggressive behaviors (Figure 9). Notice that the left sides of these graphs are labeled "SIBIS and Other Aversives." This is because during the 12 months prior to the use of GED, some students received Non-Shock Aversives (usually one of the following: hand spank, spatula spank, ammonia, pinch, or muscle squeeze), other students received SIBIS, and still others received Non-shock Aversives during part of the year and SIBIS during the remaining part By grouping the data in this way, we were able to base Figure 8 on data from 36 students and Figure 9 on 30 students.

For each of the data plots in Figures 6-9 the chart shows the celeration, and the jumps. The values for these measures are shown in Table 3. 

For the treatment of health dangerous behaviors, a visual comparison of the curves in Figures 6 and 8, and an examination of Table 3 shows that GED was more effective than SIBIS. The GED-caused jump-down was greater (+5.0 vs. +2.0). GED's celeration turn-down of +2.4 was also greater than SIBIS's, which actually showed a turn-up of x1.7. For the treatment of aggressive behaviors, as shown in Figures 7 and 9, GED's superiority is even more evident. The jump-down after GED was +20, as compared with a jump-up of x20 after SIBIS. The GED-caused celeration turn-down was +3.3, compared with a celeration turn-up of x2.5.

Discussion 

These data are consistent with the findings of Azrin (1960a) and Appel and Peterson (1965), who demonstrated that low level punishment only temporarily suppressed responding; Trudel et al. (198 1), who found that only a 'high" intensity was effective in suppressing self-injurious behaviors; and Williams et al. (1993), who reported that SIBIS did not effectively reduce self-injurious behavior. With the students at BRI, SIBIS was only temporarily effective in decelerating health dangerous and aggressive behaviors. In comparison, GED produced a greater and longer lasting deceleration of these behaviors.

These results are, however, in contrast to Linscheid et al. (1990) who reported success with SIBIS. Student age and treatment history may have made SIBIS less successful at BRI as compared with its use with the subjects in the Linscheid et al. study. 'Me fact that the Linscheid et al. subjects were younger (their median age was 16) and may not have previously experienced punishment contingencies may explain the different results. BRI students treated with SIBIS had a median age of 22.0 yrs. and had attended BRI for a median of 6.0 years prior to the start of SIBIS. A wide variety of procedures had been used before and during that time to decelerate their problem behaviors and this may have desensitized them to relatively weak punishers. The BRI students' extensive pre-GED treatment history make it possible that their health dangerous and aggressive behaviors were more severe and more "case-hardened" than those of the subjects in Linscheid et al. The median BRI student had been expelled from 5 prior programs (range = 0 to 17) and rejected from 5 (range 0 to 37).

Table 3. Effects of SIBIS and GED on Health Dangerous Behaviors and on Aggressive Behaviors

In conclusion, data collected from our clinical use of SIBIS and GED demonstrated that the GED was more effective as a decelerative procedure as compared to SIBIS. The GED device produced a greater initial jump- down, a sharper deceleration and, to date, a longer- lasting deceleration. These changes in turn have led to more time spent learning academic, self-care and habilitative skills. These students now spend more time in the community and at home with their families. Overall their entire quality of life is much improved.

References 

Appel, J. B. & Peterson, N. J. (1965) Punishment: Effects of shock intensity on response suppression. Psychological Reports, 16, 721-730. 

Azrin, N. H. (1960a). Effects of punishment intensity during variable interval reinforcement. Journal of the Experimental Analysis of Behavior, 3, 123- 142. 

Carr, E. G., Robinson, F., Taylor, J., & Carlson, J. (1990). Positive approaches to the treatment of sever behavior problems in persons with developmental disabilities: A review and analysis of reinforcement and stimulus based procedures. Monograph of the Association for Persons with Severe Handicaps, 4. 

Cataldo, M. F. (1989) Punishment and behavior reducing procedures on the destructive behavior of persons with developmental disabilities. In: the National Institutes of Mental Health Consensus Development Conference. (NIH Publication No. 91-2410), 231-341. 

Favell, J. E., Azrin, N. H., Baumeister, A. A., Carr, E. G., Dorsey, M. F., Foxx, R. M., Lovaas, 0. I., Rincovor, A., Risley, T. R.,-Romanczyk, R. G., Russo, D. C., Schroeder, S. R. & Solnick, J. V.(1982). The treatment of self-injurious behavior. Behavior Therapy, 13, 529-554. 

Foxx, R. N4., McN4orrow, M. J., Bittle, R. G. Bechtel, D. R. (1986). The successful treatment of a dually-diagnosed deaf man's aggression with a program that included contingent electric shock. Behavior Therapy, 17, 170-186.

 Israel, M. L., von Heyn, R. E., Connolly, D. A. & Marsh, D. (1992). A remote-controlled electric shock device for behavior modification. (Available from [Matthew Israel, Behavior Research Institute, 240 Laban St., Providence, RI. 0290 

Lindsley, 0. R. (1992). Precision teaching: Discoveries and effects. Journal of the Applied Behavior Analysis, 25, 51-57. 

Linscheid, T. R., lwata, B. A., Ricketts, R. W., Williams, D. E. & Griffin, J. C. (1990). Clinical evaluation of the self-injurious behavior inhibiting system (SIBIS). Journal of the Applied Analysis of Behavior, 23, 53-78.

Pennypacker, H. S., Koenig, C. H., & Lindsley, 0. R. (1972). Handbook of the Standard Behavior Chart. (Distributed by: Precision Media (Kansas City, Kansas) 

Van Houten, R., Axelrod, S., Bailey, J. S., Favell, J. E., Foxx, R. M., lwata, B. A. & Lovaas, 0. 1. (1988). The right to effective behavioral treatment. Journal of the Applied Analysis of Behavior, 21, 381-384. 

Williams, D. E., Kirkpatrick-Sanchez, S., & lwata, B. A. (1993). A comparison of shock intensity in the treatment of and severe self-injurious behavior. Research in Developmental Disabilities, 14, 207- 221.

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