An Example of the Effectiveness of Contingent Skin Shock with Problem Behaviors that Proved Refractory to Standard Positive-Only Techniques
Nathan A. Blenkush, Robert E. von Heyn, and Matthew L. Israel
There exists a population of individuals with developmental disabilities and/or mental
illness who exhibit problem behaviors that are refractory either to current positive-only
behavioral interventions based on behavior function or to pharmaceutical interventions.
These individuals are often warehoused in residential treatment facilities or psychiatric
hospitals, contained using near-constant mechanical restraint and movement limitation, or
prescribed large doses of psychotropic medications that largely suppress their ability to
acquire new skills or interact with their family. Contingent skin shock (CSS), however, in
combination with reinforcement procedures, has proven to be effective in treating the
self-injury, aggressive behaviors, and rumination behaviors of such individuals (e.g.
Duker & Seys, 1996; Foxx, McMorrow, Bittle & Bechtel, 1986; Linscheid &
Cunningham, 1977) and makes possible effective treatment without the use of
In this report we describe the treatment of problem behaviors exhibited by a 19-year-old
male (C.M.) with past diagnoses of Pervasive Developmental Disorder, Post-Traumatic
Stress Disorder, Attention Deficit Disorder, and Expressive/Receptive Language
From September 1997 to March 2002, C.M. attended a well-respected residential school
for special needs which treated him primarily with what most persons would characterize
as "positive-only" behavioral interventions. While C.M. attended this school, he engaged
in the following problematic behaviors: (a) aggressive behaviors, which consisted of
punching, kicking, biting, spitting and throwing feces at others; (b) health dangerous
behaviors, consisting of punching his eyes, hitting or banging his head against objects,
pulling his teeth out, biting himself, ingesting inedibles, and inserting objects into bodily
orifices; (c) property destruction, consisting of behaviors such as clothes ripping,
inappropriate urinating on objects and fecal smearing; (d) major disruptive behaviors,
consisting of tantrums, yelling, disrobing in public, inappropriate sexual behavior, and
Over the course of 4.5 years, the school in question systematically utilized positive
reinforcement procedures, antecedent interventions, and medications (Ritalin, Risperdal,
Tegretol, Buspar, Trazadone, and Benadryl) to address C.M.'s behaviors. Previous
medications that had been used with C.M. prior to attending that school included
Clonidine, Haldol, Mellaril, Depakote, Dexedrine, and Corgard.
At one point, after obtaining consultation from a nationally-known expert in behavioral
psychology, the school in question implemented a treatment plan that, contingent upon
good behavior, allowed C.M. to select who would work with him on an hourly basis,
choose from any preferred item or activity, and request breaks and conversations at any
time. In addition, surprise rewards were delivered on a variable-time schedule. Following
certain targeted maladaptive behaviors C.M. was punished by being given non-preferred
meals and denied any form of social attention until he exhibited eight consecutive hours
of appropriate behavior. None of these interventions were successful and C.M. continued
to be restrained at a frequency of from 1 to 10 times per day. Eventually his behaviors
became so problematic that he was expelled and was subsequently admitted to the Judge
Upon admission to JRC, C.M. continued to be treated with positive-only interventions
such as differential reinforcement (both DRO and DRA), extinction, privilege loss, and
response cost. These procedures were used for three months, at the end of which period it
became clear that the procedures had proven insufficiently effective. On June 3rd, 2002,
JRC supplemented C.M.'s treatment with a programmed CSS application after each
instance of a targeted problem behavior. Prior to starting this treatment these safeguard
procedures were followed: (a) informed consent was obtained from his parents; (b)
individualized approval for his treatment plan was granted by a Massachusetts Probate
Court; (c) a psychologist retained by the attorney that represented C.M. in the Probate
Court case approved the treatment plan; (d) a physician certified to the absence of
medical contraindications to the use of CSS; (e) a psychiatrist certified to the absence of
psychiatric contraindications; (f) a peer review committee approved the treatment plan;
and (g) a human rights committee approved the treatment plan.
At first, skin shocks were delivered with a remote controlled skin-shock device known as
the Graduated Electronic Decelerator (GED) which has an intensity of 15 mA when used
across a 4 kO resistor (average skin resistance for the GED) and lasts for a fixed period of
two seconds. After 9 weeks, C.M.'s clinician determined that, because of the insufficient
change the frequency and intensity of C.M.'s behaviors, a stronger stimulus was needed.
On August 14th, 2002 the GED-4 was substituted in place of the GED. The GED-4 has
an intensity of 41 mA when used across a 1.6 kO resistor (average skin resistance for the
Charts 1-5 show the monthly frequency of Aggressive, Health Dangerous, Destructive,
Major Disruptive, and Noncompliant behaviors. Chart 6 is a composite of the data
presented in Charts 1-5. The vertical intervention lines indicate the two months during
which the GED was added and during which the GED-4 was substituted for the GED.
Because each of those intervention changes did not take place on the first or last day of
the month, the monthly totals for those two months are based on data for some days prior
to the day on which the intervention was changed and on some days after the intervention
was changed. Finally, celeration lines (calculated using the least square method) describe
the frequency trend after the GED-4 was added.
These charts demonstrate that a more intense shock may be necessary to decelerate the
problem behaviors of some individuals. This finding is consistent with Williams,
Kirkpatrick-Sanchez, and Iwata (1993) who found that a mild shock (delivered from
SIBIS) was not sufficiently effective and a more intense shock was necessary to reach
clinically significant results. In addition, our data show that the frequency of each
category of problem behavior decelerated over the course of almost 5 years. This finding
is consistent with Linshcheid and Reichenbach (2002) who demonstrated the long-term
effectiveness of CSS over a 5 year time period.
Duker, P.C. & Seys, D.M. (2000). A quasi-experimental study on the effect of electrical aversion treatment on imposed mechanical restraint for severe self-injurious behavior. Research in Developmental disabilities, 21, 235-242.
Foxx, R. M., McMorrow, 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.
Linscheid, T.R. & Reichenbach, H. (2002). Multiple factors in the long-term effectiveness of contingent electric shock treatment for self-injurious behavior: a case example. Research in Developmental Disabilities, 23, 161-177.
Linscheid, T.R. & Cunningham, C.E. (1977). A controlled demonstration of the effectiveness of electric shock in the elimination of chronic infant rumination. Journal of Applied Behavior Analysis, 10, 500.
Williams, D. E., Kirkpatrick-Sanchez, S., & Iwata, B. A. (1993). A comparison of shock intensity in the treatment of longstanding and severe self-injurious behavior. Research in Developmental Disabilities, 14, 207-219.
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