What Procedures Are Used?What Procedures Are Used?
The types of aversive procedures reported in the literature as used on persons with disabilities include, but are not limited to:
Electric shock applied to the body (e.g. arm, leg, or hand) for the purpose of discouraging the specific behavior it follows by causing pain [not to be confused with electroconvulsive therapy (ECT) used to treat severe depression]Extremely loud white noise or other auditory stimuli Forced exerciseShaving cream to the mouthLemon juice, vinegar, or jalapeno pepper to the mouthWater spray to the facePlacement in a tub of cold water or cold showersSlapping or pinching with hand or implementPulling the hairAmmonia capsule to the noseBlindfolding or other forms of visual blockingPlacement in a dark isolated box or other methods of prolonged physical isolationIce to the cheeks or chinTeeth brushed or face washed with caustic solutionsProlonged restraint through manual or mechanical techniques (e.g. face-down four- or five-point restraint using mechanical tie-downs or several staff applying physical pressure)Withholding of multiple meals/denial of adequate nutritionNo solid evidence exists which would tell us how widely aversive procedures are used, but studies reporting the use of such procedures continue to be published. The published research is probably not representative of the range and intensity of the aversive procedures being used. It is known, for example, that some of the facilities most notorious for their use of these techniques do not publish their findings. Although it is generally believed that aversive procedures are most frequently used in institutional and private educational settings, there continues to be widespread use of these techniques in public education and community based settings throughout the country.
Aversive procedures are not used universally. In fact, some states and countries have outlawed their use. Some federal and state regulations attempt to limit the use of aversive procedures, often by requiring that non-aversive techniques be tried before aversive techniques are used. This approach to protecting the rights of individuals with disabilities is insufficient. Often a poorly designed or overly simplified non-aversive approach is tried for a few days before it is dismissed and aversive techniques substituted.
When aversive techniques are available as an option it can be predicted that less effort will be expended in trying to understand the functions of the behaviors and in addressing problems proactively. Good behavioral programming focuses on assisting the individual to avoid the need for demonstration of the behavior rather than focusing on the response after the behavior occurs.
Electric shock in a variety of forms is being used with increasing frequency as technological advances allow for quicker and more convenient response. The use of electric shock most often entails the presentation of an electrical charge immediately following the behavior through two electrodes placed on the individual's fingers, forearms, legs, or feet. A second means of delivering contingent shock is by way of a hand held shock stick. This hand held device is described as a stick with "two protruding electrodes at its end. The shock stick (more commonly known as a cattle prod) delivers a peak shock of 1400 volts at .4 milliamperes".
A more recent invention, an automatic shock helmet known as SIBIS (Self-Injurious Behavior Inhibiting System) has caused considerable controversy. The helmet is designed to sense when the wearer bangs or hits his/her head and to deliver an electric shock to the individual's arm or leg. As described in one of the introductory examples, it can also be triggered remotely and is being approved and used for non-dangerous behaviors such as rapid eye blinking, jiggling one's leg or getting out of one's seat.
Approving the use of such devices opens a Pandora's box. Recently a "working group" was convened by a residential school in response to a state court's concerns regarding the use of electric shock to control behavior at that school. This group, convened by the courts to investigate limiting the use of shock, instead recommended that a new device be developed that would be similar to the SIBIS helmet but that would increase the average milliamperage of the shock that is delivered from its standard level of 1.5mA. to levels as high as 47.5mA. This group then contracted with an electrical engineer to develop such a device. It was also recommended by the working group that the placement of electrodes on areas of the body other than the arms and legs be explored.
Often, two or more aversive techniques are used in combination. At one residential school a student's behavior plan read as follows:
When Roy becomes person or object aggressive he is to be placed in arm restraints and seated. Staff are to ask, "Roy, your behavior is irresponsible. Are you ready to accept responsibility for your behavior?" If Roy responds "yes," he is to be forced to inhale ammonia for three seconds, sprayed with water for thirty seconds, and again forced to inhale ammonia for three seconds. Roy is then to thank staff for their help. If Roy responds negatively and does not accept responsibility for his behavior, staff are to repeat the ammonia, water spray, ammonia sequence. If, asked again to accept responsibility for his behavior, he again refuses, the aversive sequence is to be repeated twice in succession.
At another residential school children and young adults who are "non-compliant" (don't do as they are told) are forced to wear a visual screening helmet. The helmet blocks any light and emits loud white noise. In addition, a pressurized water hose attached to the front of the helmet sprays water in the wearer's face. The children wearing this helmet are either strapped face down on a board or are forced into a kneeling position with their legs strapped down behind them and their arms strapped to a low bench in front of them. They are left wearing the helmet, and physically restrained for a minimum of fifteen minutes and up to a half hour if the individual continues to struggle or to make noise. In July, 1985 a twenty-two year old student died while wearing the visual screening helmet.
At this facility, children, most of whom have autism, arrive at school in the early morning and do not return to their living units (group homes) until 8 or 9 p.m. While at the school they sit in work carrels sorting objects, putting small objects into containers, or performing other "practice work". If the children stop working, make any noises or utterances other than speech, get out of their seats, take their eyes off their work, or fail to follow directions, they will receive an aversive procedure selected at random (water spray, visual screening helmet, time out in restraints, ammonia to the nose, pinching, spanking, or taste aversives).
A bizarre twist at this school is the use of "behavioral-rehearsal lessons". To provide adequate opportunities for the receipt of a punisher, staff urge the child to display the negative behavior. Several years ago, a team from the New York Office of Mental Retardation and Developmental Disabilities visited this school and found these instructions taped to a student's work station, "Kathy is to receive one stealing opportunity per hour. She should be prompted to steal a juice squirter and a spank is to be administered. If Kathy does actually steal the juice she is to receive the helmet and white noise for fifteen minutes". The instructions for another student who was being trained to "accept disappointment" read as follows: "Three times during the hour, when Eric earns juice or food for task completion or good working -- do not give the reward. Say, 'No reward this time, go back to work please.' Wait a few minutes and if Eric accepts the disappointment, reward him with a sip of juice. If Eric does not accept it, consequate the behavior displayed". The evaluation team from New York did not refer to this practice as "behavioral-rehearsal lessons". They called it "entrapment".
The following quotations about this school (and its sister facility in California) also are from the article by Ric Kahn that appeared in the Boston Phoenix.:
George Nazareth, former chairman of the Rhode Island Protection and Advocacy System spoke with former employees of BRI who told him that "they were under extreme pressure to put an end to each bizarre behavior in their students within two weeks. If a student hadn't responded as the deadline approached, the workers claimed they 'started pinching harder and harder to meet their goal'. Nazareth says the workers told him 'they were turning into monsters'". p.7.
Kathy Corwin, a former treatment worker at BRI, says that she saw Israel finger-pinching the bottoms of 12 year old Christopher Hirsh's feet. Israel was administering a behavioral-rehearsal lesson to get Hirsh to stop defecating on rugs and in the shower. Corwin said she heard the boy cry and scream in pain. The next morning a BRI worker named Nancy Thibeault got sick to her stomach when she saw Hirsh's feet. "There were open blisters and a reddish substance oozing from them," she testified. BRI workers continued to pinch the boy's feet. Corwin returned to work after two days off. She was horrified at what she found. "the insteps of both of Christopher's feet had a considerable amount of blisters and a considerable amount of open bloody patches where the skin had been entirely removed," she said. Soon after Christopher had received his "lessons" the boy's father took him to a doctor. It took three adults to hold him down. "He was absolutely terrified," a friend of the family who was there recalled, "There was no part of this skinny boy's body that didn't have a bruise. Then they took off his shoes. It was horrible". Christopher's father said the insteps of his son's feet "were covered with strange wounds that can only be described as holes. It looked as if the skin or flesh had been removed and that it was healing or growing back to the level of the skin". p.13.
The North Los Angeles County Regional Center, reviewed services at BRI in California. They said that "The real BRI is never seen by any outsider. Two weeks before official state or parent visits, aversives that caused bruises or marks were halted. p.13.
The California Attorney General's office filed accusations against BRI in administrative proceedings before an administrative law judge. The following are excerpts from that report:
On one occasion during the period September 3, to December 15, 1980 Matthew Israel, consultant for respondent (BRI of California) instructed Nicolas DeCila, a staff member, to grow his fingernails longer so he could give an effective pinch. Such pinches were administered with the fingernails and caused excessive and unnecessary cuts and bruises. p.17.
On or about March 1, 1981, Richard L. was restrained in a large black chair by himself in the kitchen. Richard's hands were tied to the chair, his feet were tied to the bottom of the chair, and a huge box covered his head and torso. He was kept in this position for at least one hour. p.17.
In or about February 1980, it was confirmed that Willie R. is a deaf child, and his parents so notified respondent. Respondent failed to modify Willie's program, and continued to inflict water squirts and corporal punishment upon Willie in contexts where it was unlikely if not impossible that Willie could understand the behavior he was required to exhibit to avoid punishment. For example, Willie received water squirts for not responding to verbal commands to keep his eyes closed while in bed. p.17.
On April 24, 1980 Willie R. was administered 77 spanks for hitting himself, 33 spanks for crying and 64 spanks for other behavior. In addition, Willie received 100 water squirts. p.17.
During the period September through December 1980 and for an unknown period of time before and after these months, respondent threatened to fire employees for not leaning hard enough on residents who were bent over to be spanked or for not giving an effective spank or pinch. p.17-21.
On occasion during the period from September through December 1980 and for an unknown period of time before and after that month, Richard L. was placed by himself while in restraints. Respondent fed Richard L. when he was in the yard by placing a plate of food on the ground with no eating utensils. Ricky would have to eat with his arms restrained to his sides. p.21.
When Carl was placed in isolation, respondent would not allow anyone to speak to Carl for 24 hours. He would be restrained in the classroom behind the boxes until 11 p.m., then he would be tied to a piece of furniture in the living room in a kneeling position to sleep. On these occasions he would be deprived of a bed, pillow, and blanket. p.21.
On occasion during the period from September through December 1980 and on unknown occasions before and after that period, respondent instructed his employees to administer pinches and spanks to the buttocks, inner arm, inner thigh, and/or the soles of the feet, and to dress residents in long pants and long-sleeved shirts to prevent relatives and other visitors from seeing the bruises and abrasions resulting from pinches and spanks. p.21.
On the morning of July 17, 1981, Danny A. was restrained in bed by an arrangement which kept him flat on his stomach in bed. Danny A. died between 9:00 and 10 a.m. on this date while being so restrained. The county coroner ruled that 14-year-old Danny Aswad's death had been from natural causes: "Mental retardation" and "cerebral malformation" p.21.
Licensing investigator, Michael Avery spent 250 hours at BRI in Rhode Island. He experienced some of the aversives firsthand. He took his shoes off and climbed into the automatic vapor-spray (AVS) station. He stood barefoot on a ridged rubber mat. His ankles and wrists were cuffed. He skipped the usual bucket of water dumped on the head. He got a hit of ammonia two or three inches from his nose. Then he put on the remote vapor spray helmet -- no visibility, white noise, and air-and-water combo sprayed in his face. At first he was scared. The ammonia threw him, and then the helmet went on. He thought he was going to pass out. He was in the station for half an hour, but he says he became so disoriented that he felt it could have been five minutes or two hours. When he got out he needed a minute or two before he could put a whole sentence together. p.22.
During April, 1985 the OFC licensor reviewed student "G"'s behavior charts and learned that from March 9, 1985, to March 20, 1985, student "G" was placed in the Automatic Vapor Station (AVS) on a continuous non-stop basis except for time out of the A.V.S. for bathroom and water opportunities and sleep time. Student "G" was required to wear a white noise visual screen with the noise turned off while sleeping. p.26.
Avery found one student who had been spanked 133 times within two hours. He saw students in wet clothes, shaking two hours after having been doused with cold water. p.25.
On July 24, 1985 a 22-year-old student at BRI named Vincent Milletich died. He was going to be "consequated," reportedly for making inappropriate sounds. He became aggressive and started thrashing around. BRI workers pushed his head between a staff member's legs and handcuffed his hands behind his back. Then they threw on the helmet with the white noise and the blocked vision and put him down on the floor. Vincent went limp. He died at the Rhode Island Hospital. p.25.
On August 28 Avery went back to BRI with Bette McClure, Massachusetts Office for Children (OFC), Acting Director of group-care licensing. For the first time, Avery says, he saw all the aversive sign-off sheets together. There were 60 of them, he says. And a BRI doctor had approved all 20 aversives for each kid. "That absolutely caused concern," he says. "He (the doctor) had 1200 opportunities to say no, and there wasn't a comment". p.25.
On July 16, 1985, student "H" received 173 spanks to the thighs, 50 spanks to the buttocks, 98 muscle squeezes to the thighs, shoulders and triceps, 88 finger pinches to the buttocks, 47 finger pinches to the thighs, approximately 527 finger pinches to the feet, and 78 finger pinches to the hand between 6:00 a.m. and 9:30 p.m. for "aggressive acts and head to object". p.26.
On July 27, 1985, student "G" received 170 spanks to various areas of the body, 139 finger pinches to an unknown area of the body, 31 muscle squeezes to the triceps, and 139 water squirts to the face between approximately 9:00 a.m. and 5:00 p.m. for "aggressive acts". p.26.
At this school, even when the children return to their living units (operated by the same agency) late in the evening, there is no opportunity for relaxation or recreation. In fact, they report directly from the bus to work carrels that replicate those they just left at the school. They again begin "practicing work" until it is time to get ready for bed. When they complete all of the work in front of them; for example sorting a large plastic dish pan full of plastic tableware into a sectioned tableware tray, their attendant comes over, says "good work", pours the sorted tray back into the dish pan, and says "OK - start again". Again, any "inappropriate" movements or vocalizations will be swiftly punished. Even people with severe mental retardation can be expected to respond in anger and frustration to the requirement to perform meaningless tasks day-in-and-day-out, from waking to bedtime. Service providers create untenable environments and then punish individuals for their natural responses.
Visitors to this program were surprised to find that the children were not allowed to break for meals and that the program offered few, if any, opportunities to relax or socialize. In fact, the children attend "school" eleven to twelve hours per day, seven days a week, with only a rare change of routine for a major holiday or weather emergency. There are no periods during the day when children are free from the threat of swift and severe punishment. The living unit that was visited did not contain a dining table large enough to accommodate the eight individuals who lived there. It was explained that portions of meals could be earned during the day. Between the time students woke and 11 a.m., children could earn portions of their breakfast, delivered to them in their work carrels as a reward for good behavior. Portions of lunch could be earned from 11 a.m. to 4 p.m. and portions of dinner could be earned thereafter. Even mealtimes did not provide an opportunity to relax, let down one's defenses or converse informally with schoolmates or staff. Children who did not behave as required could have their needs for basic nutrition threatened.
Children at this school were observed to be quiet and cooperative but they also appeared sullen, frightened, and withdrawn. In the face of the application of these highly aversive procedures for even non-dangerous and non-disruptive behaviors, the young people who were students at this school appeared to have given up their spirit and their will. As one author states, "Nothing negates one's sense of what it means to be human more than the deliberate infliction of unnecessary pain and humiliation on a helpless victim". Most of the children at this school were unable to express their feelings about their treatment verbally, but one young man begged the visitors to help him escape this environment "Can you see what they're doing to us here?" he pleaded; "Please help me. There must be laws against this. Can you help me?"
In 1993, this author and a fellow journalist conducted interviews with current and former employees of this school. Some verbatim quotations follow:
I've seen kids so badly beaten we'd have to switch cheeks, then move to the thighs, then the calves, then the bottoms of their feet … nowhere where it would show.
I gave a sixteen year-old with no speech 112 or 113 shocks in one night. When I called to get approval (I was told) `call if it goes over 90 shocks'.
You can get shocked for swearing, for telling someone to go to hell or for crossing your legs.
It's against the policy to form relationships with the students. We use taste aversive sprays in the mouth, a special kind of finger pinches, ammonia pellets, spatula spanks. We make our own helmet so you can adjust the shock level. It's called the GED, the Graduated Electronic Device. It's stronger and the wires can go anywhere; the torso, fingers, hand, bottom of the foot, inner thigh. Not on the genitals or on the chest or on the spine. It might give them a heart attack or paralyze their spines.
We have a student on five GED's. He wears five! He's a seizure student; very non-compliant.
You have to put his head between your knees and pull his pants down and spank him.
(The director) was in such a rage treating one girl, a woman worker pulled the fire alarm so everyone would have to evacuate the building. She was afraid there'd be a death.
(The director) is a sadist. He decided on a new program to implement. He decided to use a spatula spank. He had one made that was huge which he used to hit the clients with. It is the most terrible bruises I had ever seen in my life on anybody. It was brutal. He used it hisself. Make you sick to see the bruises where the blood comes to the surface.
I don't think parents really realize what they're subjecting their kids to when they send them here. Parents would come. They wouldn't let the parents come to the classroom. I never saw it, that's for sure. You wouldn't go for it if you seen what was done for different behaviors. How could they live with themselves - how could they close their eyes at night and go to sleep knowing what was going on?
The taste aversives, the rolling pinches, spatula spanks … they had this one restraint, a canvas mat with PVC tubes and a helmet on. They had keys to lock on the helmets. I kept one of those keys. They used the keys for mechanical restraints too. It's a metal buckle with a lock … tortured … day in and day out.
One student was in bed for two or three days from spatula spanks (while she was) on a 4-point restraint. It can happen, like when you're striking at the breasts.
There were technicians who just fixed the torture devices. It's exactly what it is, torture.
There are parents who abuse their kids but it's not eight hours a day. It's day in, day out. A constant barrage.
In February, 1995, Massachusetts lawmakers heard testimony for and against this school's continued use of electric shock and other aversive procedures. Under questioning, Matthew Israel , the school's director conceded that one student had received 5,300 shocks from the Graduated Electronic Device (GED) in one day. In his testimony, Israel stated that over a 24-hour period, the student, a teenager who weighed only 52 pounds, was subjected to an average of one shock every 16 seconds. During some periods, the student was automatically shocked every second if he lifted his hand off a paddle, Israel said. Israel testified that the intent of the frequent electric shock was to "save the student's life". During the hearing Massachusetts State Representative James V. DiPaola attached the Graduated Electronic Device to his own forearm and delivered a shock to himself. Audience members observed him to leap out of his seat, cry out in pain, and claw at the arm on which the device was attached. "It was torture. It was very painful." said DiPaola, Vice Chairman of the committee investigating the use of electric shock.
A former BRI employee, testifying during the hearing, stated that the shock is more painful than described by school officials. Colleen Seevo said, "I got hit accidentally on my thumb and I had a tingling up to my elbow, on the inner part of my arm, I would say for four hours. I was saying, `I can't believe these kids can do this'. My hand was shaking. I wanted to go home; that's how bad it was." Gail Lavoie, another former employee said the device has side effects and that she had observed students whose skin was burned and blistered by the shocks. At least four students have died after being subjected to aversives at this school.
There is no question that painful procedures like these can result in at least a temporary reduction of difficult behaviors. It is also known however, that these procedures are not necessary to decrease behavior problems. Not only is their use unethical and immoral, but these techniques are not needed to effectively change behaviors. Their use should not be tolerated by a society that bases its system of beliefs on the fair and ethical treatment of all of its citizens.
There is simply no truth to the notion that because a behavior is serious it needs or deserves punishment as a response. Many practitioners who, for ethical reasons, began using behavioral techniques that do not require the use of aversive procedures, are now contributing to a "growing body of empirical data which demonstrates that non-aversive procedures are at least as effective and possibly more effective than intrusive interventions".