Observations and Findings of Out-of-State Program Visitation 
Judge Rotenberg Educational Center

Review Team: Rusty Kindlon, Regional Associate; Susan Bandini, Regional Associate; Christopher Suriano, Regional Associate; Paula Tyner-Doyle, RD; Dr. Caroline Magyar, Consultant; Dr. Daniel Crimmins, Consultant; Dr. David Roll, Consultant

Background Information

The Judge Rotenberg Educational Center (JRC) (formerly known as the Behavior Research Institute) is a private residential school located in Canton, Massachusetts. JRC is currently approved by the New York State Education Department (NYSED) under Chapter 853 of the Laws of 1976 as a residential school serving students with autism, mental retardation, emotional disturbance and multiple disabilities. JRC serves students who exhibit serious behaviors that interfere with learning and provides an intensive behavioral treatment program to students 24 hours a day, seven days a week.

Recent Activity

Based on documentation provided by the program subsequent to a previous site visit which raised concern about JRC's use of aversive interventions, as well as recent questions from legislators, the Board of Regents and others, NYSED conducted a review of JRC's program on April 25 and 26, and on May 16,17, and 18, 2006. The review was conducted by NYSED staff and three behavioral psychologists in the role of independent consultants. The April 25-26 review was an announced visit. The May 16- 18 review was an unannounced visit.

The purpose of these visits was to conduct a review of the behavioral intervention program at JRC to gain an understanding of the scope of the behavior intervention plans; to identify any health and safety issues relating to JRC's use of aversive interventions; to identify the general standard for implementing and monitoring students’ behavior plans; to determine if the interventions are commensurate with the level of behavioral difficulties the students’ are exhibiting; and to determine if students are receiving behavior interventions consistent with their individualized education programs (IEPs).

Methods used for the site review in April and May included the review of school policies, student records, observations of school and education programs, and staff and student interviews. A sample of 12 NYS students were selected for review from the 71 NYS students receiving aversive interventions that included electric skin shock, food contingent programs and/or manual or mechanical restraints (Level III Behavioral Interventions). The students were randomly selected based on age and disability category. The school district of residence of the student was also considered to ensure that the sample included students from districts other than New York City (NYC), where most NYS students served at JRC reside. In addition, the Registered Dietician (RD) reviewed records of four students on the Contingent Food Program, one student on the Specialized Food Program and one student that was reported to be at nutritional risk.

The site team reviewed the following information:

Summary of Findings

Following is a summary of the findings of concern primarily relating to the behavioral interventions and related instructional practices used at JRC. The findings represent the collective professional opinion of the site review team members based on data obtained from a review of written information, direct observations and interviews obtained during and related to the April and May 2006 site reviews. These findings include the specific observations and/or information obtained during the review process that support the conclusions of the team.

Information Regarding NYS Students Attending JRC

At the time of the site visit on April 25 and 26, 148 NYS school aged students were enrolled at JRC. Eighty-two percent of NYS students were placed at JRC by the New York City Department of Education. The additional NYS students represent school district placements from 22 other NYS school districts. Most of these students have the disability classification “Emotional Disturbance” with IQ scores that fall in the low average to average range of intelligence. There are also a number of students with the classification of Autism with cognitive abilities falling in the range of mild to profound mental retardation. Many of the students from NYS have diagnoses of posttraumatic stress disorder (PTSD), schizophrenia, attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and bipolar disorder. A number of students also have histories of abuse and abandonment. JRC has a ‘near zero’ rejection policy and accepts students with psychiatric, developmental, and dually diagnosed disorders.

In March 2006, NYSED requested that JRC submit the IEPs of all NYS students. NYSED received a total of 146 IEPs. Seventy-one out of the 146 IEPs indicated students were receiving Level III behavioral interventions2, which constitutes a range of punishment techniques designed to reduce or eliminate target behavior(s). The IEPs identified ten additional NYS students for whom court ordered substituted judgment was being sought in order to include Level III aversive procedures in their behavior intervention programs. Of the 71 students’ IEPs, 49 indicate NYC as the district of residence (69 percent). A total of 33 of the 71 students receiving aversive behavioral interventions have the educational classification of Emotional Disturbance (46 percent), 21 are classified with Autism (30 percent), one student is classified as Other Health Impaired (one percent), five are classified with Mental Retardation (7 percent), and 11 have Multiple Disabilities (15 percent).

JRC Program Model and Operations

The behavioral program model at JRC is based on a Skinnerian (behavioral) approach and does not differentiate between the treatment of students with psychiatric or developmentally related childhood disorders. Instead childhood disorders are viewed as learned behavior disorders, which can be corrected through behavior modification techniques. Psychotropic medication is discouraged at JRC and currently only a small number of students with severe psychiatric diagnoses are receiving medication for symptoms associated with their psychiatric conditions.

Referral and admission practices

A review of student records revealed that in a number of instances the family of the student became aware of JRC’s program as a result of their child’s psychiatric hospitalization. 2 Level III behavioral interventions are explained beginning on page 6 of this summary.

Determination of the need for aversive interventions

JRC may decide prior to a student’s acceptance into the program that he/she requires aversive procedures based on historical and current behavioral information provided by parents, the CSE and other records/reports. The school districts and the parent are informed that JRC will seek a Court Order through the substituted judgment process to use aversive procedures that include the use of skin shock, manual and mechanical restraints, helmets, and contingent food or specialized food programs (Level III). Parents are asked to sign an informed consent for JRC to use the aversive procedures and for JRC to seek the Court Order to use the aversives. The school district and parents are informed that the use of aversive procedures may be a condition of the student’s acceptance and continued enrollment in the program.

Upon enrollment, a student may be initially placed in an educational setting designated by JRC as an “alternative learning center (ALC)” or a "small conference room" and a residence that is identified by JRC as one of the most restrictive settings characterized by a high staff-to-student ratio. The stated purpose for student placement in these restrictive settings is to control students who present with current behavioral difficulties which require physical intervention at a high rate, and for whom substituted judgments have not yet been obtained. The majority of staff in the ALC and “small conference rooms” are Mental Health Aides (MHA’s). (JRC employs a total of 386 MHAs and 254 Mental Health Relief Aides in the school and residences. Most of these individuals, 468 of the total 640 MHAs and Mental Health Relief Aides, have completed only a high school education.)

Level III Aversive Procedures Used by JRC Staff

Upon receipt of parental consent, JRC applies to a Massachusetts Probate Court through a substituted judgment petition to use Level III aversives in the student’s behavioral program. Level III aversives constitute a broad spectrum of punishment techniques that include movement limitation (i.e. mechanical and physical restraint), contingent food, helmet, and electric skin shock. The use of Behavior Rehearsal Lesson ("BRL" -  BRL is described later in the report) and combined use of aversive techniques are also Level III interventions.

Substituted judgment process

Pursuant to a settlement agreement between JRC and the Massachusetts Office for Children, Level III aversive procedures are permitted for use at JRC only when authorized as part of a court-ordered “substituted judgment” treatment plan for each individual student. The settlement agreement states that in any substituted judgment proceeding the court appoints a monitor who will report to the court as to the effectiveness of the treatment plan, adherence to orders by JRC and any proposed modifications to the treatment plan. The settlement agreement also required ongoing training and supervision of staff by a doctoral level psychologist, and treatment approaches as a method of minimizing the use of restrictive procedures including passive behavior management, functional communication, analysis of stimulus control and analysis of consequence control.

Electric skin shock

The most common Level III aversive procedure used at JRC is skin shock in which one or more electrical stimulations are administered to a student after he or she engages in a targeted behavior. Skin shocks are delivered through a graduated electronic deceleration (GED) device that consists of a transmitter operated by JRC  staff and a receiver worn by the JRC student. The receiver delivers an electrical current to the student’s skin upon command from the transmitter. Electrodes are worn by the student on various parts of the body, notably the arms, legs and stomach area, and can range in number and placement dependent upon the students’ behavior program guidelines.

Students wear the GED device for the majority of their sleeping and waking hours, and some students are required to wear it during shower/bath time. The GED receivers range in size and are placed in either “fanny” packs or knapsacks. Staff carry the GED transmitters in a plastic box. Students may have multiple GED devices (electrodes) on their bodies. For example, one NYS student’s behavior program states, “C will wear two GED devices. C will wear 3 spread, GED electrodes at all times and take a GED shower for her full self care.”

The GED is manufactured by the JRC. While JRC has information posted on their website and in written articles which represents the GED device as "approved", it has not been approved by the Food and Drug Administration (FDA). FDA has cleared the device for marketing as “substantially equivalent to devices marketed or classified as “aversive conditioning devices.” FDA's clearance prohibits JRC from representing the device as FDA approved. JRC’s GED was modified from other similar devices on the market by doubling the intensity (amperage and voltage) and increasing the duration by 10 times (from .2 to 2 seconds) of the shock administered and by expanding the positions on the body where the electrodes could be placed. JRC also uses a device called the GED-4, which applies an even greater intensity shock to the student when the student fails to respond to the lower level shock.

FDA recommended warnings on the GED device include statements that the device is to be used only by or under the direct supervision of an appropriately licensed professional as part of an overall therapy program; the GED should not be allowed to become wet or submerged in water; the electrode must be properly located and secured to the skin and never placed on the chest or breasts, genitals, head, top of hand, top of foot, the lower quadrant of the buttocks, or on any area of skin that the patient is known to be unusually sensitive or subject to allergic reaction to contact with stainless steel; the instructions must be thoroughly reviewed and fully understood by the operator/therapist and the supervising professional whenever the GED is in use with a patient; a regular program of training and review for anyone operating the GED is necessary; a review of the GED manual by each operator no less frequently than once a month is strongly recommended.”

The site review team was informed by JRC staff that most students have behavior programs that require two-person verification of a behavior that will result in a GED skin shock. There are students with 1:1 staff for whom the two-person verification is not required.

Use of automated electronic devices – “automatic negative reinforcement”

At JRC, an additional form of electrical circuitry is used to automatically administer a series of aversives (e.g., skin shocks) as soon as a behavior is initiated. Shocks are administered at regular intervals (e.g., one every three seconds). The automatic negative reinforcement shocks terminate as soon as the behavior stops occurring. This device is not operated by JRC staff. For example, some students are made to sit on a GED cushion seat that will automatically administer a skin shock for the targeted behavior of “standing up”, while others wear waist holsters that will administer a skin shock if the student pulls his/her hands out of the holster. NYSED could not find evidence, nor did JRC provide the evidence as requested, that this automated electric shock device has been cleared for marketing by FDA or approved by FDA. FDA regulations prohibit the use of an aversive conditioning device that has not been approved or cleared by FDA.

Movement limitation

Movement limitation is another commonly used Level III intervention that may be applied manually or mechanically. When applied manually, staff members physically hold the student. With mechanical movement limitation the student is strapped into/onto some form of physical apparatus. For example, a four-point platform board designed specifically for this purpose; or a helmet with thick padding and narrow facial grid that reduces sensory stimuli to the ears and eyes. Another form of mechanical restraint occurs when the student is in a five-point restraint in a chair. Students may be restrained for extensive periods of time (e.g., hours or intermittently for days) when restraint is used as a punishing consequence. Many students are required to carry their own “restraint bag” in which the restraint straps are contained.

Under the terms of the Court Order, JRC must notify the Court Monitor if a student requires more than eight continuous hours of movement limitation procedures in a 24-hour period. In addition, the Court must also be notified if the student spends five or more days in movement limitation in a seven-day period. The school nurse stated that she is responsible to monitor any skin burns caused by the GED and abrasions due to restraints. She also advises staff on the positioning of restraints and potential complications for each student. Based upon the nurse’s recommendation, a student may be restrained in a prone, seated, or upright position.

Combined restraint/shock interventions

A combination of mechanical restraint and GED skin shock is also used to administer a consequence to students that attempt to remove the GED from their bodies. In instances where this combined aversive approach is used, the student, over a period of time specified on his or her behavior program, is mechanically restrained on a platform and GED shocks are applied at varying intervals.

GED skin shock and restraint are also used together when the Behavior Rehearsal Lesson (BRL) is practiced on a student. The BRL is used when a student exhibits a high risk, low frequency behavior. As described by a JRC staff person, during a BRL, the student is restrained and GED administered as the student is forcibly challenged to do what the procedure seeks to eliminate. If the student attempts to pull away he receives a GED skin shock; if the student attempts to follow through with the high-risk behavior he receives multiple GED skin shocks at closer intervals. Contingent and Specialized Food Programs

JRC is approved by the Massachusetts Department of Education (MDOE) to receive federal funding for participating in the National School Lunch and School Breakfast Program. For the 2005-06 school year, MDOE has approved JRC to serve students the “Traditional Meal Pattern.” JRC’s current food program promotes a diet that is largely based on whole plant foods and actively restricts consumption of meat and dairy products. The chef, nutritionist, food service staff and school and residential staff have an adequate system in place to ensure that each student is allocated his or her prescribed diet. The facility’s food handling practices are adequate and all food leaves the kitchen at temperatures that meet industry standards. The nurse, nutritionist and case manager meet weekly to review a sample of students’ weights. Weights are recorded on a daily weight chart that is maintained in the classroom with the student. The school physician contacts nursing daily and examines each student at least once per month or as needed.

The Contingent Food Program is also widely applied and designed to use hunger to motivate students to be compliant. This intervention requires that a student “earn” a portion of his or her daily prescribed calories by not engaging in identified target behaviors (as per his/her behavior contract). If the student passes each of the behavioral contracts that are set for him/her, he/she will earn 100 percent of the planned calories for each meal served. If the student fails to pass one or more of his/her contracts, the student is not given the food portion(s) that is (are) the potential reward(s) for that contract. Food portions not earned are discarded by the staff and/or student. If the student does not earn the minimum daily total of calories by 7:00 PM, then the balance necessary to bring the total calories eaten to the student’s targeted calories is dispensed to him in the form of nonpreferred staple food (e.g., consisting of mashed food sprinkled with liver powder). The Court Monitor must be informed when a student has been required to consume the full calories in the form of nonpreferred food for a period of two weeks.

The Specialized Food Program is more restrictive. For students on the Specialized Food Program, JRC does not offer make-up food to compensate for food that the student missed by failing to pass his or her contracts unless the student has eaten 20 - 25 percent or less of his normal daily caloric target. If the student has eaten 20 - 25 percent or less, he/she is offered make-up food to bring him up to the 20 - 25 percent level. The Court Monitor is informed whenever the student receives no more that 20 – 25 percent of the daily caloric goal for two consecutive weeks. Daily weights are maintained and ketone levels are measured when the prior day’s intake is less than 80 percent of the recommended daily caloric intake.

Following is a summary of the identified findings, primarily relating to the behavioral interventions and related instructional practices used at JRC, followed by supporting observations, facts and information learned. The findings are based on a review of written information, direct observations and interviews obtained during and related to the April and May 2006 site reviews. Each statement of findings reported below are followed by observations or information that served as the basis for the findings.
Findings: The integrity of the behavioral programming at JRC is not sufficiently monitored by appropriate professionals at the school and in many cases the level of background and preparation of staff is not sufficient to oversee the intensive treatment of children with challenging emotional and behavioral problems.
Findings: JRC employs a general use of Level III aversive behavioral interventions to students with a broad range of disabilities, many without a clear history of self-injurious behaviors.
Findings: JRC employs a general use of Level III aversive behavioral interventions to students for behaviors that are not aggressive, health dangerous or destructive, such as nagging, swearing and failing to maintain a neat appearance.
Findings: The use of electric skin shock conditioning devices as used at JRC raises health and safety concerns.
Findings: The Contingent Food Program and Specialized Food Program may impose unnecessary risks affecting the normal growth and development and overall nutritional/health status of students subjected to this aversive behavioral intervention.
Findings: The education program is organized around the elimination of problem behaviors largely through punishment, including the use of delayed punishment practices.
Findings: Some students at JRC are forced to exhibit target behaviors so aversive behavioral interventions can be used.
Findings: There is limited evidence of comprehensive functional behavioral assessments (FBAs), in accordance with the Individuals with Disabilities Education Act (IDEA), being conducted at JRC.
Findings: Students are provided insufficient academic and special education instruction, including insufficient related services
Findings: JRC does not support the implementation of IEP recommended related services and/or promote the transition of students to less restrictive environments.
Findings: Behavioral Intervention Plans (BIPs) are developed to support the use of aversive behavioral interventions with very limited evidence of students “being faded” from the GED device
Findings: JRC promotes a setting that discourages social interaction between staff and students and among students
Findings: The privacy and dignity of students is compromised in the course of JRC’s program implementation.
Findings: The collateral effects (e.g., increased fear, anxiety or aggression) on students of JRC's punishment model are not adequately assessed, monitored or addressed.