The Alaska Association for Behavior Analysis (AKABA) believes that contingent electric skin shock (CESS) is a needless and demonstrably harmful tactic with possible long-term negative physical, psychological, and emotional effects. Contingent electric skin shock, which is used by one program in the United States, is inconsistent with the ethics rules of Applied Behavior Analysis.
AKABA does not support electric shock in treating individuals with disabilities and considers its use immoral, inhumane, and unethical.
Ethics of Behavior Analysis:
Applied Behavior Analysis’s largest accrediting body, the Behavior Analyst Certification Board (BACB®), published ethical guidelines in 2001, revised them as a set of enforceable rules in 2016 (Rosenberg & Schwartz, 2018), and revised them further for 2022. The changes in the ethical guidelines and codes have shaped practice principles for the field. It is the view of AKABA that the application of CESS and/or oversight of treatment involving its use is not consistent with the BACB® ethics code.
Licensed Behavior Analysts in Alaska must hold certification from the BACB and are therefore bound by the Ethics Code for Behavior Analysts (BACB ®, 2020). Portions of the code that directly apply to this issue are as follows:
Core Principle #1 - Behavior analysts work to maximize benefits and do no harm.
Core Principle #2 - Behavior analysts behave toward others with compassion, dignity, and respect.
2.01 - Behavior analysts prioritize clients’ rights and needs in service delivery.
2.11 - [Behavior Analysts] are responsible for obtaining assent from clients.
2.15 - Behavior analysts must continually evaluate and document the effectiveness of restrictive or punishment-based procedures and modify or discontinue the behavior-change intervention in a timely manner if it is ineffective.
It is our consensus that these guiding principles are in direct opposition to the use of CESS. Furthermore, the consideration of individual assent was introduced to the latest revision of the ethics code, which is indicative of progress in our field to incorporate client feedback into treatment planning, building trust between client and practitioner. Additionally, because many individuals who engage in severe behavior may have limited communication and other skills, they are at risk of being subjected to interventions that they may not understand fully and for which they may not be able to give assent (Ethics Code Standards 2.09 and 2.11).
Behavior analysts understand that behavior is communication or provides a way to meet a personal need. Our role is to learn more about the need and teach our clients safe, functional and effective ways to meet that need. If behavior reduction is a goal, there are many other evidence-based practices available without severe ethical implications. Strategies including antecedent-based interventions, augmentative and alternative communication, behavioral momentum, differential reinforcement, functional behavior assessment, functional communication training, and reinforcement have been determined to meet evidence-based practice criteria (Hume et al., 2021). Practitioners have a wealth of options to treat severe challenging behaviors while also showing compassion, upholding their client’s dignity, and supporting client health and wellbeing
We direct the reader to the excellent rationales and resources provided by MassABA in their position statement (2021).
AKABA further notes that:
1. The U.S. Food and Drug Administration (FDA) has determined that it has regulatory authority over the use of medical devices that administer an electric shock, and that such devices are medical devices;
2. The application of CESS is a medical intervention which has been reported as inherently dangerous in both the long and short term to the client;
3. Many treatments such as the use of medication as part of chemotherapy and electroconvulsive shock therapy are used in medical settings;
4. The BACB® Task List, 5th Ed. (BACB®, 2017) does not specify training content for behavior analysts in the administration or use of CESS using or any FDA approved medical devices;
5. The Association for Behavior Analysis, International (ABAI)® accreditation standards (ABAI®, 2021) do not specify training content for behavior analysts in the administration or use of CESS using or FDA approved medical devices;
6. These treatments are generally considered painful to those undergoing such treatment, and data suggest that they can cause longer term deleterious effects (Zarcone, J. R., Mullane, M. P., Langdon, P. E., & Brown, I., 2020);
7. Such treatments are appropriately conducted in medical settings when sanctioned by appropriate medical authorities. These treatments, however, are used only under strict conditions and with strong levels of informed consent by those being treated;
8. The risks inherent to such interventions to the individual, in our view, mandate that should such treatment occur, it only occurs in a medical setting with significant medical oversight and be administered only by medical professionals.
In March 2020, the U.S. Food and Drug Administration (FDA) issued a ban on the use of CESS in the treatment of severely harmful behavior in individuals with disabilities, including autistic children and adults (Banned Devices, 2020).
The FDA’s ban was subsequently overturned by the Washington D.C. Circuit Court of Appeals in July 2021. The ruling was not based on whether the practice is inhumane but rather on the grounds that the FDA does not have the authority to ban specific uses of a medical device, which was declared the responsibility of each state (Judge Rotenberg Educational Center v. FDA, 2021).
In October 2021, Massachusetts Association for Applied Behavior Analysis (MassABA), a regional chapter of ABA professionals practicing in the same state as the only agency using CESS, condemned the use of CESS in ABA due to ethical and scope-of-practice concerns.
In November 2021, the Association for Behavior Analysis International, the largest professional membership group in behavior analysis, announced a task force to investigate the use of CESS in ABA-based practice and to issue a formal statement. As of this date, the task force’s work is underway, but a formal statement has not yet been published.
We believe in a compassionate science, one that employs evidence based practices to help individuals reach their full potential. By advocating for the discontinuation of CESS, we hope to support the continued evolution of an ethical and compassionate behavior analysis.
ABAI Accreditation Board Accreditation Handbook (ver. 2/2021)
Behavior Analyst Certification Board. (2017). BCBA/BCaBA task list (5th ed.). Littleton, CO: Author
Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. Littleton, CO: Author.
Federal Register (2020). 21 CFR Parts 882 and 895: 85 FR 13312: Banned Devices; Electrical Stimulation Devices for Self-Injurious or Aggressive Behavior (2020): A Rule by the Food and Drug Administration, Docket No. FDA-2016-N-1111, 2020-04328, 85 (45), 13312-13354.
Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S.W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan,S., & Savage, M. N. (2021). Evidence-based practices for children,youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders, 51(11), 4013-4032.https://doi.org/10.1007/s10803-020-04844-2
Judge Rotenberg Educational Center v. FDA, No. 20-1087 (D.C. Cir. 2021). https://www.govinfo.gov/content/pkg/USCOURTS-caDC-20- 01087/pdf/USCOURTS-caDC-20-01087-0.pdf
Massachusetts Association for Applied Behavior Analysis. (2021). Massachusetts Association for Applied Behavior Analysis (MassABA) position statement on the use of electric shock as an intervention in the treatment of individuals with disabilities. https://www.massaba.net/wp-content/uploads/Position- Statement_Electric-Shock_2021.pdf
Méndez, J. E. (2013). Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment (A/HRC/22/53/Add.4). Human Rights Council. https://digitallibrary.un.org/record/745883?ln=en pages 83-84
National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. https://nationalautismcenter.org/national-standards-project/phase-2/
Rosenberg, N. E., & Schwartz, I. S. (2018). Guidance or Compliance: What Makes an Ethical Behavior Analyst? Behavior analysis in practice, 12(2), 473-482.
Zarcone, J. R., Mullane, M. P., Langdon, P. E., & Brown, I. (2020). Contingent Electric Shock as a Treatment for Challenging Behavior for People with Intellectual and Developmental Disabilities: Support for the IASSIDD Policy Statement Opposing Its Use [https://doi.org/10.1111/jppi.12342]. Journal of Policy and Practice in Intellectual Disabilities,17(4), 291-296. https://doi.org/https://doi.org/10.1111/jppi.12342