Thursday, March 5, 2020
Banning a Potentially Harmful Treatment for Children
According to an article in the Washington Post (https://www.washingtonpost.com/2020/03/05/electric-shock-fda-ban), the U.S. Food and Drug Administration has after at least six years of consideration decided to ban a device that delivers electric shocks to children and adolescents. The shock is given with the intention of stopping dangerous or undesirable behavior and helping children learn not to do the unwanted things. Although the use of electric shocks as aversive treatments was not uncommon several decades ago, such methods have been used less and less as they have been shown to have potential dangers like skin burns and in addition to create so much distress that little learning may take place.
In fact, there is only one place in the United States that has continued to use aversive shocks regularly for behavior management. That is the Judge Rotenberg Center in Massachusetts, which will be uniquely affected by the FDA ban and plans to appeal the ruling in court. Judge Rotenberg staff claim that aversive shock use is lifesaving for some children.
There are a few circumstances where aversives, if effective, can prevent even worse outcomes than they risk. For example, some genetic syndromes drive their victims to mutilate themselves, even gouging out their own eyes and pulling out teeth. A skin burn seems a small price to pay for keeping one’s eyes in place.
Unfortunately, the effective use of aversives is not a simple matter. Ideally, a shock or other aversive should begin as the patient starts a concerning behavior. The longer the time that passes between the behavior and the aversive, the less effective the aversive will be—but adverse side effects like burns or general fearfulness will still be present. Staff must be carefully trained and supervised to make sure that aversives are used correctly if used at all.
Staff problems are exactly how FDA attention was drawn to Judge Rotenberg. Not only did staff members fail to use aversive shock correctly some years ago, but they were reported to have used it in a totally arbitrary and even sadistic way. One staff member telephoned in the night to a colleague on duty, pretended to be an administrator, and told the colleague to wake up a boy and to give him a large number of shocks. The on-duty staff member did as he was told, against every principle on which use of aversives is normally founded. There was no unwanted behavior to try to stop or prevent, as the boy was sleeping, and the number of shocks was far beyond the usual practice. That the off-duty staff member thought this trick was clever or funny and ignored the impact on the patient is almost unbelievable, but that’s what seems to have happened. I have to question whether any level of training could correct this attitude, or the readiness of the on-duty staff to comply, but surely careful supervision could have prevented this incident from occurring.
It is far from clear what is currently happening at Judge Rotenberg with respect to the use of aversive shocks. It appears that the center wants to continue use as in the past. The FDA gives the center 180 days to retool and transition from the use of the shock device to other methods. A possible change might be to the use of unpleasant sounds as aversives, a method that is safe and has been reported to be as effective as shocks. Even if this were accomplished, however, abolishing shock use may be only one step toward safe and effective use of aversives, which if applied capriciously can create anxiety that interferes with good functioning. (What if you were awakened from a sound sleep by repeated loud, unpleasant sounds that you could not escape or avoid?) Training and supervision are keys to appropriate use of aversives, and I hope this point will be thoroughly discussed as the Judge Rotenberg Center challenges the FDA decision.