In an analysis of 102 interventions included in an overall review of positive behavioral interventions and supports (Carr et al., 1999a), about one-half were associated with the use of extinction (removing or preventing the occurrence of whatever has been found to reinforce and increase the problem behavior) and one-half with the use of seven different punishment procedures: verbal reprimand, forced compliance, response cost, overcorrection, timeout, brief restraint (physically interrupting the response and preventing its recurrence), and water mist (one case, considered highly intrusive and aversive). Although research indicates that reinforcement-based procedures are often not as effective in eliminating severe problem behaviors as quickly as are punishment-based procedures (Iwata et al., 1982), punishment-based procedures can also cause undesirable side effects, such as the child avoiding the punisher.
The increase in efficacy of positive interventions, when based on functional behavioral analysis, reduces the need for punishment-based procedures (Neef and Iwata, 1994). When a behavior is not maintained by social reinforcement, however, it may be difficult to treat effectively with reinforcement-based procedures only (Iwata et al., 1994). Suppression of competing problem behaviors may sometimes be needed before reinforcement of functional alternative behaviors can be effective (Pelios et al., 1999). In any case, there is agreement (New York State Department of Health, 1999) that physically intrusive measures (e.g., response interruption, holding, or physical redirection) should only be used after positive measures have failed and only as a temporary part of a broader intervention plan to teach appropriate behaviors. The use of physical aversives such as hitting, spanking, or slapping is not recommended.
Although a comprehensive review of medications and medical interventions is beyond the scope of this report, because of the widespread use of psychoactive medications, they are addressed briefly as they relate to problem behaviors in young children with autistic spectrum disorders. Psychoactive medications alter the chemical make-up of the central nervous system and affect mental functioning or behavior. Most were developed to treat a variety of psychiatric and neurological conditions other than autistic spectrum disorders; all may have benefits, side effects, and toxicity (Aman and Langworthy, 2000; Gordon, 2000; King, 2000; and McDougle et al., 2000). There are currently no medications that effectively treat the core symptoms of autism, but there are medications that can reduce problematic symptoms and some that play critical roles in severe, even life-threatening situations, such as self-injurious behavior.