The use of punishment to treat severe behavioral challenges in autistic children was first introduced nearly 60 years ago. Although most people in the autism community strongly disagree with using any form of punishment as a therapeutic approach, aversives continue to be a source of discussion and controversy. Recently, the Association for Behavior Analysis International, a renowned professional organization established in 1974, asked its members to vote on whether contingent electric shock should be entirely ruled out or be appropriate in some cases. Given the recent renewed interest in aversives, I thought it would be timely to share my thoughts on this topic.

Over the past 50+ years, much has been written about using aversive interventions to treat those on the autism spectrum. Aversives involve mild to severe degrees of discomfort or pain, from saying the word “no” or making a loud noise to more extreme forms such as forced ammonia inhalation, blindfolding, and electric shock [1-3].

Although aversives can be moderately effective in reducing challenging behaviors, such as self-injurious behavior (SIB) and aggression toward others, critics often use the words “cruel” and “torture” to describe extreme forms of aversives. However, some forms of aversives are currently accepted by the general professional community. For instance, aversives, including contingent electric shock (CES), are sometimes employed to treat addictions in the general population, including alcoholism, gambling, and smoking [4-6].

In this editorial, I will address CES given a legal decision rendered last year (July 2021) [7]. Basically, a judge allowed the utilization of CES for clients who engaged in severe challenging behaviors potentially leading to harm to others or to themselves. This ruling applies only to clients at the Judge Rotenberg Educational Center in Canton, Massachusetts. The ruling affects about one-fifth of the approximately 300 clients at the center. However, this decision can now be referred to in other legal cases involving similar situations.

CES should not be confused with electroconvulsive therapy (ECT). The former is applied immediately, usually within seconds, after a challenging behavior, such as self-harming behavior or aggression. The latter, ECT, involves administering electric current into the brain to induce a brief seizure. ECT has been given to some individuals on the spectrum to treat severe self-injurious behavior [8] and catatonia [9].

Research on CES started in the mid-1960s, soon after autism was recognized as a biological condition as opposed to a condition caused by emotional neglect by parents. Early studies typically involved single-subject controlled experiments. Over the years, few studies have been reported in the literature.

Today, CES is, for the most part, not considered a viable form of intervention within the autism community. In addition, the Food and Drug Administration banned CES in the United States [10], and the United Nations has stated that CES is dehumanizing and abusive [11].

The use of CES over the decades was never widespread; however, it was sometimes employed as a last resort since SIB can lead to severe self-inflicted harm, such as lacerations, bone fractures, and concussions. There are also reports of individuals blinding themselves in addition to biting off their fingers or part of their tongue. One rationale people have used when condoning CES is to avoid other “less desirable” options, including long-term sedation or restraint.

Several methods have been used to deliver CES, including (1) an electrical prod, (2) an electrical grid embedded in the floor, (3) a remote-controlled device activated by a therapist, and (4) an automated movement sensor. Regarding the latter, the Self-Injurious Behavior Inhibiting System (SIBIS) was created to control head-banging by placing a sensor on the child’s head that would deliver a signal to activate a shock to the arm or leg [12].

How should we approach the treatment of severe challenging behaviors?

Edward Carr, one of the leading experts in treating challenging behaviors, would often tell a heart-wrenching story about the time he attempted to treat a young man on the spectrum who engaged in severe SIB [13]. Dr. Carr’s team developed a behavioral strategy that involved giving CES immediately after the man engaged in head-hitting. The intervention was moderately successful in that the frequency of head-hitting decreased but was not entirely eliminated. Later, the team learned that the man suffered from migraine headaches. One could imagine how an individual would feel when experiencing both a severe head pain and electric shock.

In a recent interview in the Boston Globe, a father described his son who had blinded himself in one eye and exhibited numerous challenging behaviors (August 1, 2021) [14]. After receiving CES, he stopped poking his other eye. Other benefits seen in the child were also attributed to the CES, including improvements in communication and self-help skills.

However, it is important to mention that one research study demonstrated a dramatic reduction in eye-poking behavior in a group of autistic children after receiving liquid calcium [15]. This is because some-to-many individuals who exhibit this type of behavior suffer from hypocalcemia. One possible explanation for eye-poking is that low calcium levels are associated with dry eye syndrome, which may lead to inflammation on the surface of the eyes and/or the eyelids as well as cause a burning sensation [16, 17]. Thus, giving an individual a simple nutritional supplement may be beneficial when treating behavior directed toward the eyes. Unfortunately, this treatment is not well-known among clinicians.

The use of CES, as almost always argued, is considered after attempting all other possible options for intervention. Although this may sound convincing and commendable, the term “all” can be considered a misnomer because this really depends on the knowledge-base as well as the training of the members of the clinical team as well as outside consultants. Given the limited amount of research and the lack of widespread knowledge about the biology of challenging behaviors, one can easily question whether the decision to administer electric shock is truly reasonable and thorough.

There is mounting evidence indicating that internal discomfort or pain may be associated with SIB. Unfortunately, many individuals on the autism spectrum have impaired communication skills. As a result, they often cannot express their feelings of discomfort and pain. Comorbidities associated with SIB include gastrointestinal problems [18], immune system issues [19], metabolic problems [20], seizures [21], abnormal sensory processing [22], nutritional issues [23], anxiety [24], and sleep problems [25].

Obviously, it can be a daunting task to assess all possibilities when determining the underlying reasons for a severe behavior, but it is crucial that an all-out effort be made.

The Autism Research Institute recently launched a new webpage, www.Self-InjuriousBehavior.com, designed to assist professionals and parents in identifying treatments that may reduce or eliminate self-injurious behavior. After answering questions regarding the location of the injury as well as related factors, users are directed to a description of possible underlying causes for the behavior. In addition, online links are presented with respect to understanding and treating the behavior.

A large parent survey that collected data on almost 40,000 individuals with ASD indicated that 9% engaged in SIB, 19% engaged in aggression, and 19% engaged in both behaviors (data collected by the Autism Research Institute between 1964 and 2006). Given that nearly half of individuals on the spectrum exhibit one or both of these challenging behaviors, we urge the autism community to work collaboratively to establish a consensus report on treating challenging behaviors. The goal of such an effort would be to recommend a number of behavioral, sensory, medical, and biomedical approaches that could help to identify the underlying reasons for the behaviors of interest, pointing to the most appropriate treatments. We hope that the autism community will welcome such a challenge and support such an endeavor.

References are available at www.ARRIReferences.org.

This editorial originally appeared in Autism Research Review International, Vol. 36, No. 4, 2022

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