Behavioral treatment of aggression with contingent skin shock (CSS) has been investigated in relatively few studies and never with cognitively typical individuals. We evaluated CSS during a 3-year period with 60 participants, half to two-thirds of whom functioned at normal or near-normal cognitive levels. Sixty individual charts, arranged in a multiple baseline across participants display, reveal clearly the effectiveness of the treatment. When end-of-baseline data were compared with end-of-treatment data, CSS, as a supplement to positive programming, showed effectiveness (defined as a 90% or greater reduction from baseline) with 100% of the participants. This compares favorably with positive behavior support procedures, which, according to the 1999 treatment outcome review by Carr at al., achieved that effectiveness standard with only 55.5% of the cases (Carr et al., 1999). Higher functioning participants showed from 2 to 6 times more reduction than did lower functioning participants. Psychotropic medications were reduced by 98%, emergency takedown restraints were reduced by 100%, and aggression-caused staff injuries were reduced by 96%. As a result of the treatment, 38% of participants no longer required CSS and some returned to a normal living pattern.

In the debate over aversives a little-known but significant fact is often overlooked: programs that restrict themselves to positive-only treatment procedures sometimes expel individuals with severe behaviors when their behaviors become too difficult to handle. We review seven such cases of individuals with severe behavior problems who were exp elled from state-of-the-art, positive-only programs and describe what happened to them when they were enrolled in a program that was able to supplement its positive-only procedures with contingent skin-shock when necessary.

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A small proportion of patients with intellectual disabilities (IDs) and/or autism spectrum disorder (ASD) exhibit extraordinarily dangerous self-injurious and assaultive behaviours that persist despite long-term multidisciplinary interventions. These uncontrolled behaviours result in physical and emotional trauma to the patients, care providers and family members. A graduated electronic decelerator (GED) is an aversive therapy device that has been shown to reduce the frequency of severe problem behaviours by 97%. Within a cohort of 173 patients, we have identified the four most common patterns of response: (1) on removal of GED, behaviours immediately return, and GED is reinstated; (2) GED is removed for periods of time (faded) and reinstated if and when behaviours return; (3) a low frequency of GED applications maintains very low rates of problem behaviours; and (4) GED is removed permanently after cessation of problem behaviours. GED is intended as a therapeutic option only for violent, treatment-resistant patients with ID and ASD.

Lovaas, Schaeffer, and Simmons [18] described using skin shock as part of negative reinforcement and punishment procedures, to treat selfstimulatory and tantrum behaviors of children with autism spectrum disorder. Subsequently, skin shock has been used to treat behaviors such as dangerous climbing and aggression [19]; head hitting [20]; stomach tensions and vomiting [21]; hand to face, face slapping, eye/ tongue poking, hitting face on floor, pulling out strands of hair, skin picking, hand biting, eating inedible objects [22]; seizure induction [23]; hair pulling, attempted hair pulling, property destruction [24],