In December of 2004, following a 4 week investigation of the abuse and neglect of Jonathan Carey at the Anderson School, along with a list of 14 violations and substantiations, OMRDD documented, “It is advised that Anderson School take immediate action to insure that no other student is subjected to comparable abuse, neglect and/or mistreatment.”

A report regarding Jonathan Carey was later completed by the New York State Inspector General’s Office, which hired two experts in the field of developmental disabilities. That report, which was obtained through FOIL, documented, “The Office of the State Inspector General of New York requested us to provide an impartial evaluation of the care and treatment of Jonathan Carey while he was a resident and student at the Anderson School in Staatsburg, New York. In compiling this report, we reviewed a considerable amount of documentation and records pertaining to Jonathan Carey’s care and treatment while in residence at the Anderson School from January 2003 until October 2004.”

 ***The following quotes are taken directly from their 21 page report.

“From the evidence provided, it appears that regular meals were withheld from Jonathan Carey for extended periods of time (ie. Several days) and, during this time, the evidence suggests that there was no alternative functional communication strategy being taught to assist him in communicating his needs. Most likely, Jonathan was using problem behaviors (e.g., bolting, aggression, incontinence, disrobing ) to communicate his needs and wants and/or to protest withholding meals or making meals contingent on “dressing.”

“Withholding regular meals for an individual who is nonverbal and/or an individual that does not have continuous access to food to consume whenever he or she is hungry is particularly unethical according to recommended practices in the field of developmental disabilities.”

“It was not until after an extended period of time when Jonathan was not provided regular meals that a nutritional consult was provided.”

“The behavioral intervention plan for Jonathan Carey implemented a highly aversive intervention strategy by making food contingent on “getting dressed;” thus it is highly negligent, irresponsible, and unacceptable for staff to not have closely monitored Jonathan’s ongoing consumption of food, caloric intake, and weight in a reliable and precise manner. The evidence reviewed on Jonathan’s food intake indicates that the staff at the Anderson School did not consistently document his food intake and appeared to only document it after the intervention had been employed for an extended period of time and negative side effects were occurring.”

“Changing bed sheets once, in the morning and not thereafter (i.e., allowing him to lie in his own urine)” “Clearly, remaining in one’s own urine for periods of time (as happened with Jonathan) is not acceptable now or as of 2003.”

“The documentation reviewed indicates as Jonathan Carey spent more time in his bedroom personal items were eventually removed.”

“Covering windows with frosted adhesive paper to prevent looking out.” “Documents reviewed indicate that maintenance was ordered to install adhesive paper on Jonathan’s windows.”

“Removal of all personal items in bedroom” “Finally, the removal of all reinforcers from his room, as well as the application of frosted adhesive paper to his window, would appear to be an attempt to create a time-out/seclusion room in his bedroom.”

“Documents reviewed suggest that Jonathan’s door handle was held to prevent him from leaving his room and/or the unit.”

“Documents reviewed indicated that Jonathan Carey’s was allowed to remain naked for extended periods of time.” “Additionally, as was suggested later, staff could have dressed Jonathan in clothing that would be difficult to remove.”

“When Jonathan did not comply with getting dressed, he was forced to remain in his room, which most likely resulted in an increase in many of his other problem behaviors (i.e., bolting, aggression, and urination).”

“There would appear to be no clinically appropriate reason for Jonathan Carey to miss multiple days of school, unless he was ill, to remain in his room.” (Note: Jonathan missed 8 days of school in October of 2004, while staff forced Jonathan to remain in his room much of this time.)

“No documents were reviewed that indicated a parental or rights committee approval for techniques used with Jonathan Carey;”

“Moreover, a Behavior Support Plan dated October 20, 2004 indicates that there would be a suspension of home visits for Jonathan, as well as visits from family to allow for “intense programming.” “Additionally, communication between Jonathan and his parents would be limited to two telephone conversations per week.” “This appears to be another coercive and inappropriate response to a behavioral situation that was spiraling out of control.”    

“Based on a review of the documentation, it appears that the Anderson School employed a number of aversive interventions with Jonathan Carey. The three most aversive interventions are: 1) making full meals contingent on being fully dressing, 2) using seclusionary timeout in a separate room for extended periods of time (this include removal of all personal items and covering the window from his bedroom) contingent on the display of severe problem behaviors, and 3) physical restraint following severe problem behavior. There is no indication from the review of documents that less restrictive alternative interventions were implemented prior to these more aversive interventions and that a concerted effort to teach Jonathan alternative, functional communication skills was conducted.”

“Finally, there is no indication that the aversive interventions were approved by a human rights or ethics review committee or approved by Jonathan’s parents.”

“In summary, based on the documentation and evidence provided, our professional opinion is that the care and treatment that Jonathan Carey received during his stay at the Anderson School was not based on research or recommended practices that were available in 2003-2004 and was provided by individuals  that lacked the competence and skills to implement the treatment strategies in a correct and acceptable manner.”

“Based on our professional expertise and evaluation, it appears that the Anderson School staff reacted to Jonathan’s behavior using aversive interventions to try to punish his behaviors, rather than providing a systemic behavioral intervention plan linked to a functional behavioral assessment. They often used crisis intervention strategies and did not appear to have a systematic plan for teaching functional replacement behaviors. When Jonathan’s behavior escalated, they continued to implement practices that would be considered punishment (e.g., seclusionary timeout, etc.). These strategies prevented Jonathan from obtaining adequate nourishment and opportunities to socially interact and learn from attending school and in our opinion violated Jonathan’s basic rights. As a result, Jonathan appeared to suffer physical and emotional harm, which is demonstrated by the bruises on his body and the anxiety he displayed through the increase of behaviors, such as bolting, aggression, and incontinence. Skinner (1989) suggested that “aversive consequences are responsible for many kinds of problems” and …”the side effects of punishment may be severe” (p. 78) “Unfortunately, this seems to have been the case with the care and treatment of Jonathan Carey.”

Kevin S. Sutherland, Ph.D.

Maureen A. Conroy, Ph.D.

To read the entire 21 page report completed by the two experts in the field of developmental disabilities, Kevin Sutherland Ph.D. and Maureen Conroy Ph.D., please click here.