I first heard about the Judge Rotenberg Center several months ago. They've been in the news recently for some controversy regarding their use of electric shock as an aversive for behavioral therapy. I'm by no means the first to write about this place and its methods. I know I can't state my opinion with much authority, as I've never worked with anyone with severe/damaging behavioral issues, but I'm still wary. As usual, I can kind of see both sides.
JRC accepts a lot of cases that were rejected everywhere else. That fact alone might be justification for use of extreme measures. But....
The JRC website's FAQ makes a somewhat convincing argument for the ineffectiveness of positive-only programming for severe aggressive/self-injurious behaviors. One wants to give them the benefit of the doubt. But....
But, there are a few programs and methods of theirs I definitely, strongly disagree with (in no particular order):
1. Using food as a reward/punishment.
Yes, primary reinforcers are powerful tools. But I don't think that justifies this:
When JRC employs mealtime food to motivate the students to change their behaviors, the food is used under either of two alternative treatment programs--the Contingent Food Program (in which all food missed through contracts is made up at the end of the day) or the Specialized Food Program (in which the make up procedure is more restrictive). Neither of these programs can be used unless JRC obtains prior informed consent by the parent, prior approval from a physician and prior authorization by the Probate Court as part of an individualized substituted judgment authorization.
Isn't it common knowledge that behavior/mood is affected by energy and therefore nutrition/blood sugar levels? If the kid is already having behavioral problems, giving him chronic low blood sugar isn't gonna help....
Even if the caloric intake is "made up" at the end of the day, they're still running on inadequate fuel for the majority of the day.
At the end of the day, we offer to students who are on the Contingent Food Program a make-up meal that is composed of chicken and mashed potatoes with liver powder sprinkled on top and that will make up all the calories that the student will have missed by not passing one or more of his contracts earlier in the day. This make-up food is deliberately intended to be an unattractive option, however, because we want the student to be motivated to earn the portions of real mealtime food that can be earned by passing the behavioral contracts.
That's bad enough. But just wait....
For students on the Specialized Food Program (currently it is being used with only 3 out of our 245 students) we do not offer make-up food to compensate for food that the student missed by failing to pass his contracts unless he has eaten 25% or less of his normal daily caloric target. If he has eaten 25% or less, he is offered make-up food to bring him up to the 25% level.
They do all kinds of tests on the Specialized Food Program kids to make sure they're healthy on paper, but still....
I don't even know what else to say about that. It defies logic.
2. "Behavior rehearsal" scenarios.
There are certain behaviors that are so dangerous to the student or to others that one wants to prevent them from occurring even one more time, if one can.
In such situations behavior rehearsal lessons are applied as follows. One prompts the student to engage in the first phase of the behavior. For example one prompts a student to pick up a knife and begin to direct it toward his arm as though to cut it with the knife. Then one arranges an aversive stimulus, for example one administers a GED skin shock. This is called a behavior rehearsal lesson. The student is prompted (against his will if necessary) to begin the undesired behavior (i.e., to move the knife in the direction of the arm) and is then receives an aversive stimulus while engaging in that beginning phase of the behavior.
I can see what they're trying to do, but....
I honestly don't know what alternative treatments there could be for such behavior, yet I still don't think this is the best solution.
First, they're casting one of their staff members in a horrible role. The patient will learn to distrust and fear whoever prompts/forces them to behave in ways that get them punished. That distrust/fear might very well generalize to the rest of the staff or even the entire environment.
They also don't mention -- in this context -- any attempt to find possible triggers of the problem behavior. That's a basic strategy of positive behavior programming (aka Functional Assessment, addressed -- insufficiently, in my opinion -- by JRC here). If you can find out what might cause the problem behavior, you can a) begin to teach/encourage acceptable alternative behaviors, and b) possibly use said triggers to set up more naturalistic, less damaging "behavioral rehearsal lessons." And avoid forcing the patients, against their will, to engage in a behavior you don't want them to continue.
(I have more to say about JRC's use of Functional Assessment, but that will have to wait until later.)
3. Eliminating most psychiatric medications.
It's true that "chemical restraints" are sometimes over-used. I'd also agree that, at least in some cases, use of aversives such as skin shock is preferable to drugs and better preserves the individual's dignity and free will.
However, there are some conditions that, I believe, simply aren't effectively addressed by behavioral methods. Sometimes the problem stems from brain chemistry gone awry and can only be remedied by adjusting said chemistry. Expecting someone to modify a behavior that is chemically or neurologically mandated may be too much to ask, and learned helplessness is the probable result.
4. Their brand of speech/language therapy."
All they work on, according to this description, is requesting behavior. Yes, that's a good first step for communication, but it's not enough. I really, really hope their program is a bit more extensive than this.
Also:
Step 2. Good sitting.
The student learns to sit still for 30-60 seconds, with good posture, feet together, knees together, hands folded in lap and making eye contact with the teacher’s eyes. The teacher is sitting directly in front of the student.
If they treat people with autism like they say they do, that's got to be one of the stupidest things I've ever heard.
Their visual cortex works differently than yours! There's a reason they avoid direct eye contact. Forcing them to pretend to act "normal" won't help them.
5. Behavioral counseling (JRC's only version of "therapy") as an earned reward.
So now you might have to earn the right to discuss your own behavior with a (quasi?)professional ("The counseling is provided by the student’s clinician, by a social worker, by the student’s case manager, by his or her teacher, by a monitor or supervisor, by a member of the treatment office, or by all of these persons")?
They admit that, for some cases, this may be asking too much. But they still don't eliminate the need to "earn" counseling entirely. They just lower the standards for earning.
6. Use of delayed aversives.
Because JRC has a near-zero expulsion policy, and because we see our mission to treat individuals with severe behavior behaviors and not simply to throw the student into the criminal justice system (which will no doubt make the student worse) we use a stronger consequence than the normal one application of the GED. Typically that consequence involves a period (e.g. a half-hour) during which several GED stimulations are applied at unpredictable intervals during the time period. The safest way to do this is to use mechanical restraint to contain the student, in a prone position, on a flexible plastic restraint platform that has been specially designed for the purpose. JRC currently uses this procedure with eight of its students. In each case the procedure was used with the student less than 1.4 times on average and in each case resulted in dramatic improvement for the student.
I seem to remember a key point of behavioral psychology being that reinforcement must be applied immediately after the target behavior. Not over a subsequent period "during which several [reinforcements] are applied at unpredictable intervals."
-----
I'm not precisely sure where I stand on the general skin-shock-as-aversive issue, because I can see that it could be the most humane, respectful way to deal with truly dangerous behavior that had truly resisted all other treatment methods. But I'm not sure I agree with precisely how they use it. I'll save that mess for a later (possibly never-to-be-written) post.
Also, the authors of the JRC website accuse anti-aversive and positive-only advocates of using misleading and euphemistic language.
Well, the anti-aversive advocates aren't alone:
In such cases we may either use multiple applications of the GED, or we may shift, with court authorization, to the use of the GED-4, which delivers a stimulation that is judged to be two or three times more aversive.
"More aversive" instead of "more painful." Even "more uncomfortable" would've been a step in the right direction if still a bit euphemistic. And they brag about the fact that they're honest and above-the-board about their methods.
Also also, JRC has a Human Rights Committee that they claim is not controlled by JRC itself. Check this out:
JRC Procedures Followed by JRC's Human Rights Committee
13. REMOVAL FROM THE COMMITTEE. JRC may remove a member from the Committee for just cause or for violation of any of the terms of this policy. [Also from the FAQ.]
Now, I'm not a lawyer or even a law student. But doesn't "just cause" basically mean they can kick off anybody as long as they have a reason (any reason -- it doesn't necessarily have to be good or even true, they just have to be able to argue it in court)?
Oy. There'll probably be more on this later.
JRC accepts a lot of cases that were rejected everywhere else. That fact alone might be justification for use of extreme measures. But....
The JRC website's FAQ makes a somewhat convincing argument for the ineffectiveness of positive-only programming for severe aggressive/self-injurious behaviors. One wants to give them the benefit of the doubt. But....
But, there are a few programs and methods of theirs I definitely, strongly disagree with (in no particular order):
1. Using food as a reward/punishment.
Yes, primary reinforcers are powerful tools. But I don't think that justifies this:
When JRC employs mealtime food to motivate the students to change their behaviors, the food is used under either of two alternative treatment programs--the Contingent Food Program (in which all food missed through contracts is made up at the end of the day) or the Specialized Food Program (in which the make up procedure is more restrictive). Neither of these programs can be used unless JRC obtains prior informed consent by the parent, prior approval from a physician and prior authorization by the Probate Court as part of an individualized substituted judgment authorization.
Isn't it common knowledge that behavior/mood is affected by energy and therefore nutrition/blood sugar levels? If the kid is already having behavioral problems, giving him chronic low blood sugar isn't gonna help....
Even if the caloric intake is "made up" at the end of the day, they're still running on inadequate fuel for the majority of the day.
At the end of the day, we offer to students who are on the Contingent Food Program a make-up meal that is composed of chicken and mashed potatoes with liver powder sprinkled on top and that will make up all the calories that the student will have missed by not passing one or more of his contracts earlier in the day. This make-up food is deliberately intended to be an unattractive option, however, because we want the student to be motivated to earn the portions of real mealtime food that can be earned by passing the behavioral contracts.
That's bad enough. But just wait....
For students on the Specialized Food Program (currently it is being used with only 3 out of our 245 students) we do not offer make-up food to compensate for food that the student missed by failing to pass his contracts unless he has eaten 25% or less of his normal daily caloric target. If he has eaten 25% or less, he is offered make-up food to bring him up to the 25% level.
They do all kinds of tests on the Specialized Food Program kids to make sure they're healthy on paper, but still....
I don't even know what else to say about that. It defies logic.
2. "Behavior rehearsal" scenarios.
There are certain behaviors that are so dangerous to the student or to others that one wants to prevent them from occurring even one more time, if one can.
In such situations behavior rehearsal lessons are applied as follows. One prompts the student to engage in the first phase of the behavior. For example one prompts a student to pick up a knife and begin to direct it toward his arm as though to cut it with the knife. Then one arranges an aversive stimulus, for example one administers a GED skin shock. This is called a behavior rehearsal lesson. The student is prompted (against his will if necessary) to begin the undesired behavior (i.e., to move the knife in the direction of the arm) and is then receives an aversive stimulus while engaging in that beginning phase of the behavior.
I can see what they're trying to do, but....
I honestly don't know what alternative treatments there could be for such behavior, yet I still don't think this is the best solution.
First, they're casting one of their staff members in a horrible role. The patient will learn to distrust and fear whoever prompts/forces them to behave in ways that get them punished. That distrust/fear might very well generalize to the rest of the staff or even the entire environment.
They also don't mention -- in this context -- any attempt to find possible triggers of the problem behavior. That's a basic strategy of positive behavior programming (aka Functional Assessment, addressed -- insufficiently, in my opinion -- by JRC here). If you can find out what might cause the problem behavior, you can a) begin to teach/encourage acceptable alternative behaviors, and b) possibly use said triggers to set up more naturalistic, less damaging "behavioral rehearsal lessons." And avoid forcing the patients, against their will, to engage in a behavior you don't want them to continue.
(I have more to say about JRC's use of Functional Assessment, but that will have to wait until later.)
3. Eliminating most psychiatric medications.
It's true that "chemical restraints" are sometimes over-used. I'd also agree that, at least in some cases, use of aversives such as skin shock is preferable to drugs and better preserves the individual's dignity and free will.
However, there are some conditions that, I believe, simply aren't effectively addressed by behavioral methods. Sometimes the problem stems from brain chemistry gone awry and can only be remedied by adjusting said chemistry. Expecting someone to modify a behavior that is chemically or neurologically mandated may be too much to ask, and learned helplessness is the probable result.
4. Their brand of speech/language therapy."
All they work on, according to this description, is requesting behavior. Yes, that's a good first step for communication, but it's not enough. I really, really hope their program is a bit more extensive than this.
Also:
Step 2. Good sitting.
The student learns to sit still for 30-60 seconds, with good posture, feet together, knees together, hands folded in lap and making eye contact with the teacher’s eyes. The teacher is sitting directly in front of the student.
If they treat people with autism like they say they do, that's got to be one of the stupidest things I've ever heard.
Their visual cortex works differently than yours! There's a reason they avoid direct eye contact. Forcing them to pretend to act "normal" won't help them.
5. Behavioral counseling (JRC's only version of "therapy") as an earned reward.
So now you might have to earn the right to discuss your own behavior with a (quasi?)professional ("The counseling is provided by the student’s clinician, by a social worker, by the student’s case manager, by his or her teacher, by a monitor or supervisor, by a member of the treatment office, or by all of these persons")?
They admit that, for some cases, this may be asking too much. But they still don't eliminate the need to "earn" counseling entirely. They just lower the standards for earning.
6. Use of delayed aversives.
Because JRC has a near-zero expulsion policy, and because we see our mission to treat individuals with severe behavior behaviors and not simply to throw the student into the criminal justice system (which will no doubt make the student worse) we use a stronger consequence than the normal one application of the GED. Typically that consequence involves a period (e.g. a half-hour) during which several GED stimulations are applied at unpredictable intervals during the time period. The safest way to do this is to use mechanical restraint to contain the student, in a prone position, on a flexible plastic restraint platform that has been specially designed for the purpose. JRC currently uses this procedure with eight of its students. In each case the procedure was used with the student less than 1.4 times on average and in each case resulted in dramatic improvement for the student.
I seem to remember a key point of behavioral psychology being that reinforcement must be applied immediately after the target behavior. Not over a subsequent period "during which several [reinforcements] are applied at unpredictable intervals."
-----
I'm not precisely sure where I stand on the general skin-shock-as-aversive issue, because I can see that it could be the most humane, respectful way to deal with truly dangerous behavior that had truly resisted all other treatment methods. But I'm not sure I agree with precisely how they use it. I'll save that mess for a later (possibly never-to-be-written) post.
Also, the authors of the JRC website accuse anti-aversive and positive-only advocates of using misleading and euphemistic language.
Well, the anti-aversive advocates aren't alone:
In such cases we may either use multiple applications of the GED, or we may shift, with court authorization, to the use of the GED-4, which delivers a stimulation that is judged to be two or three times more aversive.
"More aversive" instead of "more painful." Even "more uncomfortable" would've been a step in the right direction if still a bit euphemistic. And they brag about the fact that they're honest and above-the-board about their methods.
Also also, JRC has a Human Rights Committee that they claim is not controlled by JRC itself. Check this out:
JRC Procedures Followed by JRC's Human Rights Committee
13. REMOVAL FROM THE COMMITTEE. JRC may remove a member from the Committee for just cause or for violation of any of the terms of this policy. [Also from the FAQ.]
Now, I'm not a lawyer or even a law student. But doesn't "just cause" basically mean they can kick off anybody as long as they have a reason (any reason -- it doesn't necessarily have to be good or even true, they just have to be able to argue it in court)?
Oy. There'll probably be more on this later.
Labels: autism, disability, fundamentalism, language
