The use of skin-shock as a behavior modification punishment procedure is the most widely researched and scientifically supported punishment procedure in the psychological literature. This web site contains an extensive bibliography of research articles documenting the effectiveness of skin shock as a punishment procedure.

Skin shock is not generally used in treatment programs today. This is due to an unfortunate current cultural bias against aversive treatment procedures as well as a general lack of information among the public concerning skin shock’s remarkable effectiveness, its total lack of negative side effects, its safety, and the fact that students often choose it over alternative treatments.

The Judge Rotenberg Center (JRC) first began using skin shock in 1989 in order to provide life-saving treatment to individuals who otherwise would have been unable to be successfully treated. Because this treatment was so effective, JRC has employed skin-shock with many of its students during the past 13 years with constantly increasing success. At this point JRC has accumulated the most extensive experience with the use of skin shock of any organization. The purpose of this paper is to make the most important aspects of this information available to others.

The JRC Population

JRC is a residential school/treatment center that currently (July, 2002) serves 145 individuals. Exhibit 1 summarizes their characteristics. Seventy-two percent are of school age, with a median age of 17 and a range from 6 to 21. Twenty-eight percent are adults with a median age of 31, and a range from 22 to 42. The students have a wide variety of diagnoses. Fifty-nine percent have behavior/psychiatric disorders. The remaining 41% are developmentally disabled and/or autistic-like. At any given time JRC's population includes up to four individuals who are part of a short-term respite program that JRC operates for the Massachusetts Department of Mental Retardation.

All of the individuals served by JRC live in JRC-operated residences and attend the JRC day school. JRC does not currently serve any day students but anticipates admitting day students in the fall of 2002.

Basic JRC Policies

JRC's key policies are these (Exhibit 2):

• Near-zero rejection/expulsion policy. JRC accepts the really difficult-to-treat students that may have failed in other placements. Provided the parent/guardian grants JRC permissions for needed treatment procedures, JRC has a policy of not rejecting or expelling a student solely because of the behavioral difficulties the student presents.
  
  Because of this policy, JRC has come to serve one of the most difficult-to-treat population of students in the country. Students often come to JRC after having failed at, or been rejected by, other schools and programs. The average JRC student has been rejected or expelled by several programs prior to coming to JRC. Two judges have made court findings that JRC serves one of the most difficult-to-treat groups of students in the country.
  
  
• Highly consistent behavioral program. JRC provides a highly structured, highly consistent behavior modification program that operates 24 hours a day, 7 days per week, 365 days per year. The individualized treatment program at the school building is the exact same program that is in effect at the student's residence, on the bus or van, and on field trips. The same systems, staff and supervisors work in both the residences and the school building, and everything is done to carry out the treatment systems as consistently as humanly possible.
   
• Minimal or no use of psychotropic medication. We seek to minimize the use of psychotropic medication and to remove it entirely, under the supervision of a psychiatrist, when it is not necessary within a highly structured behavioral program. See www.judgerc.org for further information about this policy.
   
• Use of full range of professionally-supported behavioral treatment procedures. JRC has always supported a parent's right to choose the most effective, professionally supported treatment that is available for his or her child. As a result, JRC is able to offer a wide variety of effective treatment options, many of which are not available in any other facility.

JRC's Facilities

JRC's facilities (Exhibit 3) include two administration/school buildings (Exhibits 4 and 5) on an 8 acre campus in Canton, Massachusetts, a suburb of Boston, and 23 residences in nearby communities. JRC's residences are located in Canton, Stoughton, Mansfield, Norton, Attleboro and Rehoboth, Massachusetts. All of JRC's residences are normal homes or apartments in suburban or semi-rural locations that blend in with the surrounding neighborhoods. Exhibits 6 through 20 show JRC's residences.

Exhibit 3	Exhibit 4
Exhibit 5	Exhibit 6
Exhibit 7	Exhibit 8
Exhibit 9	Exhibit 10
Exhibit 11	Exhibit 12
Exhibit 13	Exhibit 14
Exhibit 15	Exhibit 16
Exhibit 17	Exhibit 18
Exhibit 19	Exhibit 20

A Tour through the JRC school/administration building

The first room one sees, upon entering JRC, is a very colorful reception area (Exhibit 21) with some bright and cheery Mickey Mouse prints. As we pass the reception desk (Exhibit 22) we see two life-like mannequin sculptures of policemen (Exhibit 23) who provide building security and a mannequin sculpture pianist (Exhibit 24) in formal dress tickling the ivories of a player piano. Turning the corner to enter the main hallway we are greeted by big Mickey and Minnie (Exhibit 25). Looking down the main hallway we see three of our secretaries busy at work (Exhibit 26). Behind them is a collection of 25 music-and-movement clocks (Exhibit 27). and some sculptures of candies (Exhibit 28). (The one on the left is real the one on the right is a sculpture.) On the right side of the corridor is a wall of framed portraits of current and former students (Exhibit 29). At the end of the hall is a mannequin sculpture of a seated Freudian psychologist with a pipe (Exhibit 30) here accompanied by two of our real clinicians. At the end of the hall is the office of our executive director (Exhibit 31) whose office features some modern acrylic sculptures and a large bowl of M&M's (Exhibit 32).

Exhibit 21	Exhibit 22
Exhibit 23	Exhibit 24
Exhibit 25	Exhibit 26
Exhibit 27	Exhibit 28
Exhibit 29	Exhibit 30
Exhibit 31	Exhibit 32

As we turn the corner we pass walls containing Mickey Mouse prints from many decades and artists (Exhibits 33 through 35) and offices that are also decorated with colorful prints (Exhibit 36). Next is a section with neon prints (Exhibit 37). These are just outside the Big Reward Store (Exhibits 38 and 39) which is a focus of the JRC reward system.

As we continue, we pass the exercise room (Exhibit 40), we pass by a few classrooms for some of our highest functioning students (Exhibits 41 and 42) and the Library (Exhibit 43). After turning another corner we pass the monitoring room (Exhibit 44) where staff monitor all areas of the building throughout the day and the nursing office (Exhibit 45) Then we come to the contract store (Exhibit 46) where students can choose items that they can earn by showing desired behaviors over specified periods of time.

Exhibit 46

The Mickey Room (Exhibit 47) is where many new parents have their first meeting with members of JRC's admission department. Another mannequin sculpture (Exhibit 48) of a proctologist (here shown with our real nurse) stands in front of the entrance to the computer department (Exhibit 49) which oversees a network of 185 staff computers and one of 125 student computers. Our Andy Warhol foyer features beautiful Warhol prints (Exhibit 50), funky furniture (Exhibit 51), and a little mannequin sculpture of a little old lady gardener (Exhibit 52).

A classroom for some of our youngest students comes next (Exhibit 53). Then comes our Chagall Conference room (Exhibits 54 and 55) which features prints by the famous French painter of that name. Across from it is a collection of fun antique miniature cars beneath prints of Monaco racing posters (Exhibit 56).

The stairwell to the lower level (Exhibit 57) has a Coca Cola theme with nostalgic Coke ads, sparkling rope lights and two metal dog sculptures (Exhibit 58) at the bottom. The foyer of the lower level features modern aluminum furniture (Exhibit 59), a wall of artistic clocks (Exhibit 60), a waterfall (Exhibit 61) with fantastic animal sculptures (Exhibit 62) and a bubbling tree with a sculpture dog known as the Golden Reliever (Exhibit 63).

Exhibit 57	Exhibit 58
Exhibit 59	Exhibit 60
Exhibit 61	Exhibit 62

Exhibit 63

The lower level contains most of our classrooms. We start by passing walls of colorful prints by the contemporary Brazilian artist Britto (Exhibit 64), and then walls with prints by Lichtenstein (Exhibit 65). Off of this corridor are the classrooms for our newest students (Exhibits 66 and 67) and several classrooms for our autistic students (Exhibits 68 and 69). Then we pass through a corridor of Tarkay prints (Exhibit 70) leading to our multi-purpose room (Exhibit 71) that serves as our lunch room. It is decorated with Coca Cola ads from many decades and has a player piano (Exhibit 72) and CD jukebox (Exhibit 73). A mannequin sculpture chef (Exhibit 74) stands outside the lunch room and just down the corridor is a mannequin sculpture cleaning lady (Exhibit 75) here shown with our own real cleaning lady on the left. We walk down a corridor lined with Bukovnik prints (Exhibit 76) on one side and with impressionist prints by Dufy (Exhibit 77) on the other and enter our work activities training room (Exhibit 78) and our work activities center (Exhibit 79). After turning the corner, we come to two corridors which feature Warhol prints (Exhibits 80 and 81) and which contain several more classrooms (Exhibits 82 and 83).

Exhibit 64	Exhibit 65
Exhibit 66	Exhibit 67
Exhibit 68	Exhibit 69
Exhibit 70	Exhibit 71
Exhibit 72	Exhibit 73
Exhibit 74	Exhibit 75
Exhibit 76	Exhibit 77
Exhibit 78	Exhibit 79
Exhibit 80	Exhibit 81
Exhibit 82	Exhibit 83

It should be evident from these photographs that we have gone to extraordinary lengths to create a warm, happy, colorful décor in our buildings. A walk through our building is a uniquely interesting experience in itself--something like a cross between a beautiful museum, miniature theme park, interesting store and lovely home. We deliberately made our school so attractive an environment that our students would actually like to come to school!

A Tour through one of the JRC residences

We pay equal attention to the choice of, and decoration of our residences. Here are some views from one of our residences called Old Maple: a living room (Exhibits 84 and 85), kitchen (Exhibit 86) den (Exhibit 87), dining room (Exhibit 88), bathroom (Exhibit 89), playroom (Exhibit 90) and, from another one of our residences, an outdoor swimming pool (Exhibit 91).

Exhibit 84	Exhibit 85
Exhibit 86	Exhibit 87
Exhibit 88	Exhibit 89
Exhibit 90	Exhibit 91

Exhibit 92 shows a bedroom in the Old Maple house. The students decorate their own bedrooms. We provide cable TV, stereo, a CD/DVD player and Sony Playstations in each bedroom (Exhibit 93). The students must earn the time to enjoy these through their behavioral contracts and points. In the bedrooms of many of our higher-functioning students a computer is provided that the student can use when doing his or her homework (Exhibit 94). In houses for lower functioning students there is at least one computer for the house.

All of our homes are carefully and tastefully designed with the aid of a highly skilled decorator-consultant. We furnish each common area with beautiful, non-institutional furnishings and colorful prints. A staff of special monitors visits all of our residences on a frequent basis to make sure that they remain in the same clean, well-furnished condition that they were in when originally furnished.

Photographs of each interior space of each of our residences may be seen on our web site, www.judgerc.org.

When students first arrive at JRC, they live in one of our larger and highly staffed residences that specialize in handling new admissions. Each of these "Intake Residences" serves 8-12 students. While students are living in one of these Intake Residences, they come to the school building 7 days a week and their school day extends to 8:00 pm each evening.

As the students' behaviors improve, however, they advance to smaller homes and apartments that have fewer staff members and students (some have as few as four students), more privileges and a more normal schedule for attendance at the school. There are five categories of residences which are shown in Exhibit 95. Just as a student can advance from one residence to another by showing desired behaviors, undesired behaviors may cause the student to move back to a lower step on the residences ladder until his or her behavior improves.

More detailed information concerning this residence ladder is available in Exhibit 96.

The JRC Educational Program

Educational Program for Higher Functioning Students

JRC is certified as a special needs school by the Massachusetts Department of Education. JRC makes as much use of behavioral technologies in the classroom as is possible. For example, we make extensive use of computers that present individualized self-instructional programs. To accomplish this, JRC's own staff has developed a variety of self-teaching software in key areas such as phonics, reading, math, spelling, and vocabulary.

We use precision teaching to measure and advance student progress. In precision teaching, rates correct and incorrect, rather than percent correct, are used to evaluate student progress. The teacher or the student plots daily data for each academic skill on standard behavior charts. These enable the teacher, as well as the teacher's supervisors, to monitor the student's progress daily and to act quickly to remedy any lack of progress.

Exhibit 97 shows a classroom for some of our higher functioning students. Notice that there is a dress code in which both students and staff wear shirts and ties when in school. Each student has a pedestal desk. Almost all of our higher functioning students are provided with their own personal computer.

Exhibit 98 is another classroom for higher functioning students in which each student is working at his or her own computer. If the total number of computers at each JRC residence is added to the total number in the classrooms, the ratio of computers to students is 1:1. The student computers are networked and database software allows both the teachers and the educational administrators to keep track of each student's progress on their own desktop computers. This network also allows students to view their own behavior charts to see their progress and to send email messages to staff members.

A "token economy" point system is used to motivate the students to learn. A separate point sheet (Exhibit 99) is used to keep track of the points each student has earned during the day. Students must earn points or tokens in order to purchase various rewards that the school makes available. A certain percentage of these points must be earned through the student's academic performance and a certain percentage must be earned by meeting treatment objectives. These percentages are individually determined for each student and are changed as needed.

Because commercially available educational material is generally not designed in accordance with principles of behavioral psychology, JRC has designed much of its own educational software. Each higher functioning student has his/her own computer and uses this software both at the school and at his/her residence (Exhibit 100). Exhibits 101-104 show screen shots of custom computer programs that JRC's software development staff have designed for use with JRC's higher functioning students in key areas such as phonics, reading, writing, spelling, vocabulary and math. These sample screen shots are taken from our programs to teach math facts (Exhibit 101), Spelling (Exhibit 102), Phonics (Exhibit 103) and science (Exhibit 104).

The important features of this software are listed shown in Exhibits 105, 106, and 107 and are as follows: 

1. Self-paced instruction. The student studies and learns at his/her own pace 
2. Immediate feedback on each learning trial. The student learns immediately if he/she is right or wrong and can study the correct answer immediately; 
3. Behaviorally designed sequencing of component skills. All competencies are analyzed and broken down into a carefully sequenced series of skills, each of which builds upon the skills learned up to that point. 
4. Prompting to minimize errors. 
5. Student-paced testing of competency on each chapter. 
6. Mastery measured by rates correct/incorrect instead of percent correct. 
7. Automatic reward for chapter mastery with computer games. 
8. Built-in Review of previously mastered skills. 
9. Graphical display of goals and achievement. 
10. Mastery of each skill required before advancement. The student is required to master each skill at a certain target level (at or above a pre-designated rate correct and at or below a pre-designated rate incorrect) before he or she is allowed to advance to the next skill in the series.
11. Integration with behavioral treatment program. The overall behavior modification program, with its various reward and correction procedures is employed to motivate the student to learn and make progress on his/her software.

An important by-product of JRC's heavy reliance on computers and software is that all of our students become computer literate. Students use the computers to record their own self-management behavior data and to display it in graphical form. They also use them the practice writing business letters and to send email messages. Each student is taught to type using typing software and most achieve a level of skill in typing that can be a valuable office skill to help secure a job.

Exhibit 108 shows another form in which some of JRC's educational material is presented-flash cards. The math facts curriculum and the phonics curriculum are made available both through our custom-designed computer software as well on flash cards. Flash cards make it easy for the student to set aside the problems he/she has learned and concentrate on those that need further study. The student times himself with a timer, and when his rate correct and rate incorrect have reached the target levels, the student asks the teacher for a timing test. If the student passes the timing test, he or she is advanced to the next chapter or skill.

In addition to the self-paced learning using computers and flash cards, JRC also provides group instruction so that students will be able to handle more traditional means of instruction when they return to public school (Exhibit 109).

Exhibit 110 illustrates another aspect of JRC's program-teaching students the responsibility that is involved in having a child. This is called the "Baby Think it Over" program. Each of our higher functioning students is required to spend a week taking care of a simulated, computerized "baby" that cries at unexpected times throughout the day and night, must be "fed" regularly (by inserting a key into slot), etc. Once a student spends a week or two taking care of the computerized baby, he or she is likely to think more responsibly about creating a baby and is less likely to think of it as a lark.

JRC prepares students for the high school competency examinations required by their home state such as Massachusetts' MCAS exams and the New York State Regents Exams. Some students have earned their local high school diploma through their academic work at JRC. Other students may earn an IEP diploma, a Certificate of Completion, or a Certificate of Attendance from their home school district that is awarded at JRC Culmination/Graduation ceremonies (Exhibit 111). For more details about JRC's educational program please see Exhibit 112.

Educational Program for Lower-Functioning Students

Exhibits 113, 114 and 115 show a few of the classrooms for our lower functioning students. Notice that each of these classrooms has a reward area within the classroom, access to which must be earned by appropriate behaviors. In it the students may sit on a couch or armchair and watch TV, listen to music, play a game or just relax with peers. Exhibits 116, 117, 118, 119, and 120 show a closer view of these classroom reward stores.

Exhibit 113	Exhibit 114
Exhibit 115	Exhibit 116
Exhibit 117	Exhibit 118
Exhibit 119	Exhibit 120

JRC's lower functioning students also use computers and JRC-designed custom software for much of their instruction (Exhibit 121). Responses are usually entered by means of a touchscreen. The software is basically designed for self-instruction, but requires occasional participation by a teacher or aide to administer rewards. The software teaches students how to point, how to match shapes, letters and numerals, and how to point to the appropriate picture of an item when its name is given by the computer. Most important, the software teaches the student how to use his or her pointing skills to choose a reward and how to ask for something by saying the name of the item.

Exhibits 122-128 are some screen shots taken from this software. Exhibit 122 is from a program to teach the student to touch a form wherever it appears on the screen. Exhibit 123 is from one that teaches matching forms. This leads to matching letters (Exhibit 124), matching numbers (Exhibit 125) and then selecting a letter or number after hearing its name (Exhibit 126). Exhibit 127 is from a program to teach receptive vocabulary in which the student hears the name of an item and then must point to the correct item. Other programs teach the student how to use a computer mouse (Exhibit 128).

Exhibit 122	Exhibit 123
Exhibit 124	Exhibit 125
Exhibit 126	Exhibit 127

Exhibit 128

There are two types of reward systems used with this software. For some students we use an automatic reward dispenser (Exhibit 129) that dispenses a small food reward to the student automatically after he or she has completed a certain number of problems. For most students, when the student has completed a certain number of problems on the computer a special screen comes up on the student's computer (Exhibit 130). This screen flashes once per second and also emits a periodic beeping noise. Its function is to signal the teacher to come over to the student and to reward him/her for having completed a certain number of problems. When the teacher comes over to the student, the teacher presses a certain key combination that brings up a pictorial reward screen on the student's computer (Exhibit 131). The student now points to the picture of what he/she wants for a reward (Exhibit 132) and vocalizes the name of the item. (The teacher provides a prompt for this vocalization if needed.) The computer screen then displays a larger picture of the reward that the student has chosen (Exhibit 133) and the teacher now delivers the reward that the student has asked for (Exhibit 134).

Exhibit 129	Exhibit 130
Exhibit 131	Exhibit 132
Exhibit 133	Exhibit 134

Pre-vocational and vocational training

The JRC behavior modification treatment program automatically teaches a number of important job skills. Most important is, of course, how to follow directions of one's supervisor, how to be courteous and polite and how to dress appropriately for the job. All JRC students also learn certain specific skills that are useful today's work environment, including typing and computer use.

For students who are unable to work in competitive environments, JRC operates a Work Activities Center (Exhibit 135) where students work on various assembly jobs that JRC contracts to do for local businesses.

JRC purchases training slots for several of its at the Blue Hills Regional Vocational School, a public vocational training high school located near JRC. Our students have taken courses in culinary arts (Exhibit 136), small engine repair, and graphic communications and in the future will be taking courses in woodworking and carpentry. This school also helps its students obtain entry-level jobs in the vocational areas in which they have been trained.

Whenever possible, JRC provides part-time paid jobs within JRC (Exhibit 137) which students at all levels can do. Students who develop the necessary behaviors and skills are also able to graduate to do competitive jobs, without support from JRC staff, at local businesses (Exhibit 138).

The JRC Treatment Program

Exhibits 139 and 140 present the key steps in JRC's behavior modification treatment program. Each is explained in greater detail below.

1. Identify the behaviors to be changed (Exhibit 141).

At JRC we analyze the student's problems in terms of sets of behaviors that need to be increased or decreased in frequency. By the term "behaviors" we include externally-observed behaviors such as overt actions as well as internal behaviors that are more difficult to observe, such as thoughts feelings, emotions and urges.

We have found it convenient to categorize problematic behaviors as belonging to one of seven broad categories, which are these: 

1. Health Dangerous (includes self-abusive actions such as hitting self) 
2. Aggressive 
3. Destroying 
4. Noncompliance 
5. Major disruptive behaviors 
6. Educationally and Socially-Interfering behaviors 
7. Inappropriate Verbal Behaviors

If a particular student needs more than these seven standard categories, additional categories are created. And if a clinician wishes to divide one of these categories into smaller sub-categories, he/she may do this.

Most of the target behaviors we initially seek to change are external, observable behaviors. However, as the external behaviors improve, internal behaviors, such as the student's thoughts, feelings, urges and emotions, tend to show an automatic improvement. For example, as the student begins to pass behavioral contracts, succeed in his/her academic work, etc., he/she feels better and his/her self-concept, self-esteem and confidence improves.

2. Record and chart the frequencies of the behaviors (Exhibit 142).

At JRC we record the daily frequencies of each of these major behavior categories. This recording is done around the clock, 24 hours each day, seven days a week. To accomplish this, a "Daily Recording Sheet" (see Exhibit 143) is prepared for each student. It has a separate row for each of the major categories of problem behaviors. The name, or abbreviation, of each category is listed at the left end of its row in capital letters, and to the right is a listing of the specific behaviors that will be recorded as part of this category.

Each of the columns is for one hour of the day. If the student exhibits a certain targeted behavior, the staff member makes a mark in the cell that is at the intersection of the row for the behavior, and the column for the time when it occurred. The number of marks at the end of the day shows the number of times that the behavior occurred on that day. That data is then entered in a database by a member of the charting staff at JRC and software converts the data in the database to daily, weekly, monthly and yearly charts.

Exhibit 144 shows a typical daily behavior chart that we use. The vertical scale is logarithmic. This enables us to use one standard chart that can accommodate a very wide range of behavior frequencies-anywhere from 1/day to 100,000/day. When an important change is made in the treatment procedures-e.g., the introduction of the skin-shock procedure-a vertical "intervention" line is drawn to indicate when this change was made and to help the reader of the chart interpret whether the intervention appears to be associated with any subsequent changes in the behavior's frequency.

The software automatically plots the same behavior data on weekly (Exhibit 145), monthly (Exhibit 146) or yearly (Exhibit 147) charts so that trends over longer periods of time can be detected.

Our system of charting makes use of the principles and procedures known as Precision Teaching or Standard Celeration Charting, which was developed by Dr. Ogden Lindsley and his students.

The same type of charting system is used to measure positive behaviors that the students are taught in their educational program. In some cases, the software we use has a built-in charting system.

3. Establish a powerful set of rewards that the student will want to earn (Exhibit 148).

At the heart of any successful behavior modification system is a set of rewards that the student will want to earn. Some of the most prominent at JRC are these (the list is only partial): 

1. Classroom Reward store (Exhibit 149)
2. Classroom Reward box (Exhibit 150)
3. Big reward store (Exhibits 151)
4. Contract store (Exhibit 152)
5. Thursday Barbecue/Field Day Afternoon (Exhibit 153)
6. Field trips (Exhibit 154)
7. Dances (Exhibit 155)
8. Internet usage (Exhibit 156) 
9. Money (Exhibit 157)
10. Reward areas in the students' residences (Exhibits 158)

Exhibit 149	Exhibit 150
Exhibit 151	Exhibit 152
Exhibit 153	Exhibit 154
Exhibit 155	Exhibit 156
Exhibit 157	Exhibit 158

4. Set up point or token reward systems (Exhibit 159).

These are systems in which points can be earned by the display of target behaviors and the points can be spent to purchase rewards. For some lower functioning students, pennies may be used instead of points. Each student who earns and spends points has a "point sheet" (see Exhibit 160) that specifies what behaviors earn points, how much various rewards cost in points and what the maximum number of points are that the student is allowed to earn in one day.

5. Arranging a system of behavioral contracts (Exhibit 161).

Contracts are arrangements in which if the student goes for a specified period of time without displaying certain specified problem behaviors, he or she earns a specified reward at the end of the contract period. If, however, the student exhibits the specified problem behavior(s), the contract is "broken," a new contract is set up and the student tries again. There are many types of contracts that are used at JRC. Normally several will be used at the same time for a given student.

1. Brief period. These last for a few minutes-currently it is two minutes-and the duration is not changed. At the end of the two minutes, if the student has not shown certain behaviors he/she earns some points or pennies.
2. Less-than-a-day. Each student has one of these in his/her program. The duration lasts from 1 minute up to 8 hours. If the student is successful in making a certain duration, the duration is gradually extended, on an individual basis, to require more and more from the student. This practice of gradually extending the length of the contract is also followed for each of the other contract types listed below. 
3. One day. 
4. Overnight
5. Transportation
6. Multi-day. This type of contract might last for 1 to 7 days and would entail a major reward. 
7. Multi-week
8. Multi-month
9. Special. Special contracts might be made for other special behavior issues, such as task completion, behavior on field trips, etc.

Sometimes the student must pass a certain contract in order to gain access to a place where the student's points or pennies can be spent. For example, the student might have a contract which, if it is passed successfully, allows him/her to go to the Big Reward Store. Once there, however, the student must have earned some points in order to purchase the items that are available in the Reward Store.

See Exhibit 162 for a more complete description of various contracts that JRC uses with a typical student.

6. Establish a "Loss-of-Privileges" (LOP) procedure (Exhibit 163).

If the student displays certain major inappropriate behaviors, all opportunities to earn contract rewards or to spend points are suspended. At JRC we call this a "Loss of Privileges" period. The duration of the LOP can vary from minutes to several weeks. Sometimes an LOP status may be combined with shifting the student's residence or classroom to place him in a more highly staffed and less desirable residence or classroom.

7. Teach self-management procedure (Exhibit 164).

Each of the higher functioning students are taught to select at least one "outer" problem behavior (such as being aggressive) and one "inner" behavior (such as having urges to be aggressive), to count and chart those behaviors, and to select and arrange their own rewards or penalties to change the frequency of the behaviors. Exhibit 165 shows the chart of a student who is counting his urges to hurt himself. The students meet each week (Exhibit 166) with other students and with a supervising clinician or other staff member to share the data, display their behavior data and discuss their behavior management techniques.

8. Minimize or eliminate the use of psychotropic medication (Exhibit 167)

If a student is on medication when he or she enrolls at JRC, the medication may be removed under the guidance of a psychiatrist. Psychotropic medication is employed only if the charted behavior data support the need to use it as an adjunct to JRC's behavioral treatment program. More information about JRC's policies in this area may be found at www.judgerc.org

9. Insure that all counseling is behaviorally oriented. (Exhibit 168)

It is important that all aspects of the treatment program, including any counseling (Exhibit 169) that is provided to the student, be fully coordinated with the rest of the JRC program and that the counseling be conducted and offered in a behavioral manner. See www.judgerc.org for further details on JRC's policies on behavioral counseling.

10. (Exhibit 170) Teach the student to cope successfully with events that normally trigger problem behaviors ("Programmed Opportunities").

It is important to important to identify those stimuli and events that normally trigger the occurrence of the student's problem behaviors. These should be presented to the student on planned occasions; the student should be taught how to cope with these successfully; and he/she should be rewarded when he does so.

11. Set up Safety Procedures to Handle Aggressive Behaviors Safely. (Exhibit 171)

If a student displays violent behaviors that are a danger to him/herself or others, JRC employs emergency manual restraint in a safe and carefully supervised manner.

12. Changing the components of the treatment system until the charts show the desired changes in behaviors (Exhibit 172).

At JRC a behaviorally-trained doctoral psychologist or clinician, assisted by the student's case manager, and with consultation from others such as the nurse, psychiatrist, and classroom teacher, oversees the progress of each student. The clinician is responsible for reviewing the charts on a regular basis, meeting with the student from time to time, entering progress notes and writing progress reports, and making changes in all interventions until the treatment program is working with sufficient effectiveness.

At JRC the philosophy is that the student is never "wrong." If the student is not behaving the way we want him or her to behave what is wrong is simply the current set of interventions-they need to be changed until they work more effectively. The clinician who supervises the treatment team is held responsible for making the needed changes.

Each week one of the clinicians presents the charts of his or her students at a "data sharing" session (Exhibit 173) attended by all of the other clinicians, case managers, other administrators and the executive director. JRC's charting software makes it possible to display all of the important charts of each student on one screen at the same time in "thumbnail" views, as shown in Exhibit 174. This type of display enables all behaviors being treated to be reviewed quickly and to enables relationships among them to be seen easily.. The group makes suggestions for improving the treatment and becomes immediately aware of any case where a student is not progressing satisfactorily. In effect, through these sessions the group holds the clinician responsible for producing progress in all of the students under his or her care.

Exhibit 172

Exhibit 173

Exhibit 174

Use of Supplementary Aversives at JRC

Many of the students placed at JRC have been exposed to positive-only, non-aversive procedures in their past placements, but these were not affective. It is likely, however, that none of the students have previously been exposed to as rich, consistent and as highly structured a positive behavioral program as JRC offers. For many of JRC's students, therefore, JRC's positive only, treatment systems prove to be sufficiently effective, by themselves, to produce satisfactory treatment progress. For example, of JRC's current students, this has proven to be the case for approximately 43% of those students (see Exhibit 175). In such cases, JRC is able to accomplish effective treatment with its positive programming systems alone, and does not need to consider the possibility of adding supplementary aversive procedures to the treatment package.

For the remaining 57%, however, positive treatment procedures alone may not be sufficiently effective. For these students who prove to be resistant to positive-only treatment, JRC is able to supplement its positive-only treatment systems with aversives, providing JRC has prior parental consent and court approval. The aversives employed at JRC are safe, effective and professionally approved and are used only with prior parental and court authorization (Exhibit 176). If JRC seeks and obtains court authorization to employ supplementary aversives, this authorization also permits, in the typical case, the use of both mechanical and manual restraints to be applied as supplementary aversives. JRC's use of aversives is discussed in the remainder of this paper. A videotape illustrating the aversive procedures JRC uses, together with case history material from students who have used them, is available from JRC upon request.

The supplementary aversive employed at JRC in most cases is a brief, harmless remote-controlled skin-shock described in more detail below. For many individuals, this skin-shock treatment is required only during the first few months of treatment, and is no longer necessary or is necessary to a far lesser and diminishing degree, after that period.

Safeguards

JRC's use of aversives is carried out carefully, openly and with a maximum number of safeguards. The safeguards are listed in Exhibits 177 through 179.

Exhibit 177	Exhibit 178

Exhibit 179

1. Professionally Approved Procedure (Exhibit 180). Skin Shock was recognized as a professionally accepted treatment for destructive behaviors by the 1987 Consensus Conference on Destructive Behaviors sponsored by the National Institutes of Health. In addition, it is the most widely researched decelerative procedure in the field of applied behavior analysis. Both the Consensus Conference Report, as well as an extensive bibliography on the use of skin-shock may be found at www.effectivetreatment.org (Exhibit 181).

Exhibit 180	Exhibit 181

2. Acceptance by the FDA. JRC submitted its skin shock device to the FDA for review and the device was accepted in 1991. (Exhibit 182)

3. Prior approval by parents or guardians. No aversive is employed without prior written, informed consent by the parent or guardian. The parent or guardian may also revoke this approval at any time. (Exhibit 183)

4. Inclusion in the student's Individual Education Program (IEP) and Individual Service Plan (ISP) (Exhibit 184). When a school system or other agency places a child for treatment at JRC, JRC informs the agency that supplementary aversives may be required at some time during the individual's treatment and the placement is made with that knowledge.

5. Individualized authorization by a Massachusetts Probate Court (Exhibit 185). No aversive is employed at JRC unless authorized by a Probate Court through a "substituted judgment" petition. This process has two components. First, the court decides if the individual is competent to make his or her own medical or treatment judgments. Second, the court decides whether the individual would have chosen aversives if he or she had been competent to decide.

The process begins when JRC submits a proposed treatment plan to the court. The plan is a detailed account of the behaviors JRC proposes to treat and the supplementary aversives that JRC requests authorization to use. The court appoints an attorney to represent the rights of the student (as distinct from the rights of the parent or of the school). This attorney may retain expert psychologists to evaluate the treatment plan that JRC proposes. The court ultimately decides how much of JRC's proposed treatment plan will be allowed. A review of the case is held every year to insure that the treatment is working and that it should be allowed to continue.

6. JRC Human Rights Committee Review (Exhibit 186). JRC has a human rights committee that is composed of parents of students at JRC and other outside lay and professional persons such as a nurse, an attorney, a psychologist, etc. This committee reviews each proposed treatment plan that involves the use of supplementary aversives, and must grant its approval to the treatment that is proposed.

7. JRC Peer Review Committee Review (Exhibit 187). A peer review committee made up of JRC staff members, and including clinicians other than the one in charge of the student's program, must also approve of each treatment plan that involves intrusive treatment procedures.

8. Medical contraindications sign-off (Exhibit 188). A physician examines each student whose treatment plan includes supplementary aversives. These procedures are employed only if the physician certifies, after the physical examination and a review of the student's records, that there are no medical contraindications to their use with that particular student.

9. Psychiatric contraindications sign-off (Exhibit 189). A psychiatrist must also examine the student and find no contraindications to the use of supplementary aversives before they can be used with that student.

10. Oversight by JRC nursing staff. (Exhibit 190) JRC has a nursing staff that consists of 4 RNs and 3 LPNs. One of their duties is to make sure that any supplementary aversives employed have no harmful effects.

11. Pre-service training (Exhibit 191). Each staff member undergoes 2 weeks of pre-service training and additional in-service training thereafter.

12. Careful supervision and frequent evaluation of a full-time, direct care staff (Exhibit 192). JRC does not hire temporary workers from employment agencies. All JRC direct care staff members are full or part time employees of JRC and are trained by JRC's training department. They are supervised and monitored by a staff of nine quality control supervisors and seven videotape monitors.
    
    Direct care staff members are evaluated on their performance every two weeks. If a staff member is not performing his or her duties correctly, JRC takes immediate disciplinary or other appropriate remedial action to promote proper performance at all times.

13. Live video monitoring throughout the school day (Exhibit 193). All activities in all school rooms and other areas are monitored throughout the day by our monitoring department. This video monitoring system enables supervisors and also visiting parents to observe what goes on in all areas of the school without having to enter the room and make obvious the fact that they are observing. To our knowledge, this monitoring capability is unique to JRC.

14. Live video monitoring of staff in certain residences (Exhibit 194). In certain residences, one staff member monitors the performance of other staff members through a live video monitoring system within the residence. Video cameras connected to this system are located in all rooms of the home (Exhibit 195). This monitoring goes on throughout the evening hours when students are active in the residence, as well as throughout the overnight hours while students are sleeping.

Exhibit 194	Exhibit 195

15. (Exhibit 196) Review of staff performance by videotape or digital video recorded on CDs. Everything that goes on at every residence at all times is video recorded on videotape or on CDs. These videotapes and CDs are spot-checked by a special "tape monitoring" staff (Exhibit 197) that checks to see whether or not staff are carrying out their duties correctly. Staff are rewarded for desired performance and receive disciplinary actions for performances that do not meet JRC's standards.

Exhibit 196	Exhibit 197

1971-1989: Use of Non-shock Supplementary Aversives

From 1971, when JRC was founded, through 1989, the supplementary aversives JRC employed were ones that did not involve the use of skin shock. The procedures that JRC employed as aversives during that period are listed in Exhibit 198: 1. Water squirt (from water mist plant spray bottle); 2. Vapor spray (a mi