The majority of empirically based behavioral interventions are rooted in the principles of applied behavioral analysis (ABA) (Johnson et al. 2007). There is a wide range of research supporting the use of focused ABA strategies for enhancing social and functional communication skills and treating behavior problems in children with ASD (National Research Council 2001; Schreibman and Ingersoll 2005). Although much of this research is based on single subject design (Johnson et al. 2007), there are at least some randomized controlled studies completed to date (for review see Tonge et al. 2006). These interventions have reflected a shift from consequence driven approaches to more preventive antecedent approaches (Horner et al. 2002). Positive behavior support (PBS) underlies the most current treatment approach and has been supported by extensive research (e.g., Dunlap et al. 1999, 2008; Fox et al. 2002; Koegel and Keogel 2006). PBS focuses on modifying situations and environmental context that precipitate problem behavior, thus creating a prosthetic environment in which the child with ASD is more likely to function well and benefit from experience. Concomitantly, there is also a focus on teaching adaptive and appropriate behaviors with the goal of reducing impairment and helping children experience greater success. PBS has been shown to be effective in reducing a range of negative behaviors in children and adults with autism (Koegel et al. 1996, Van Bourgondien et al. 2003).

These behavioral approaches have also evolved in that rather than focusing on reductions in very specific targeted behavior change they take a more global view attempting to impact motivation and communication providing the child with a greater chance of generalizing learned skills. This pattern of pivotal response training (Koegel et al. 1996) attempts to use intrinsic motivation within the child to teach functional social skills and communication. This pattern of child initiated learning in children with ASD has demonstrated positive outcomes that may be more generalizable across settings (Koegel et al. 1996).

There has also been an equal shift away from treatment within highly controlled clinical settings to more natural contexts with caregivers and teachers acting as agents of change. This has allowed for collaborative treatment and opportunities to teach skills within the context of children’s daily routines (Smith et al. 2010). This approach, known as family centered intervention, has also been demonstrated to lead to positive outcomes for ASD (Smith et al. 2010). Intensive community based interventions based on PBS and positive support strategies have yielded positive outcomes with respect to enhanced language and communication as well as reductions in problem behavior (Perry et al. 2008; Smith et al. 2010).

Concomitantly, there is an increased interest in functional behavioral analysis (Gresham et al. 2001), for example, this model has become the central part of assessment within the schools for all children with developmental challenges. Problem behaviors associated with ASD are often complex, difficult to operationalize, and guided by multiple variables. Functional behavioral analysis involves direct and indirect clinical observation and data collection to determine the function, purpose, or outcome of such behaviors. This information is then utilized to develop efficient and effective treatment plans. There has been an increased focus on attempting to collect specific, quantified data concerning symptoms and impairments as part of the assessment process to guide treatment planning (Goldstein and Naglieri 2009b).

Numerous single case studies have demonstrated the positive effects of parent training and parent directed interventions for reducing problem behaviors in children with ASD’s (Aman et al. 2009). Parents are taught behavioral principles and strategies for defining and shaping positive behaviors. Many of the current comprehensive training programs for children with ASD include parent components, including TEACCH (Mesibov et al. 2005), SCERTS (Prizant et al. 2003), and Star Denver (Arick et al. 2005). In 2007, the RUPP Autism Network developed a manualized training program for parents of children 4–16 years of age with ASD and severe behavior problems. A multisite, randomized controlled treatment study was developed as an adjunct to medication treatment. Primary treatment goals included improving child compliance and adaptive functioning and decreasing disruptive behaviors. Sessions included empirically based behavioral techniques such as direct instruction, modeling, role play, homework, and activity sheets for behavior tracking as well as a review of video vignettes. Autism specific strategies were employed. The feasibility of this parent training program was carefully evaluated. Rates of parental attendance and adherence as well as satisfaction with the program were high as was treatment integrity. Parents reported reduced rates of child noncompliance and irritability as well as enhanced child daily living skills and reductions in parenting stress (RUPP Autism Network 2007). In 2009, Aman et al. completed a randomized controlled trial examining the effects of this program combined with medication in children with ASD and serious behavioral problems. They demonstrated significant improvements in hyperactivity/noncompliance, stereotypic behavior, and irritability symptoms beyond the medication only effect.

The effectiveness of medications particularly focused on hyperactivity and impulsivity has been being well demonstrated (Aman et al. 2009). Although medications have been demonstrated to be helpful in managing severe disruptive behaviors in ASD, these medicines offer symptom relief but do not target core symptoms of the disorder. Typically challenging behaviors associated with ASD reemerge when medications are missed or discontinued (Aman et al. 2009). The pharmacotherapy of particularly disruptive and to some extent nondisruptive behavioral problems associated with ASD has primarily focused on associated impairments and not necessarily attempted to directly treat autistic symptoms. Particularly, physical aggression and self-injurious behaviors have been of greatest concern to treating physicians. As such, targeted behaviors involving irritability, aggression, and self-injurious behavior that are thought to be beyond capacity for efficient behavioral management and shaping are often treated with a variety of atypical antipsychotic agents. Further, problems of hyperactivity, impulsiveness, and inattention are found to be highly associated with ASD if not a part of the diagnostic condition (Goldstein and Naglieri 2009b). Pharmacotherapy has become increasingly a part of the treatment regime for children with autism spectrum disorders. Some community surveys have suggested a prevalence of medication use in this population of at least 40–80 % (Aman et al. 2005; Oswald and Sonenkler 2007; Witwer and Lacavalier 2005). Most common medications include the selective serotonin reuptake inhibitors, antipsychotics Alpha 2 adronergic agonists, psychostimulants, and anticonvulsants. Empirical support for the use of medications in children with ASD varies widely. Multiple researchers have demonstrated that the antipsychotic Risperidone can reduce serious behavioral problems in children with ASD including tantrums, aggression, and self-injury. The Food and Drug Administration has approved Risperidone as a treatment for children with autism accompanied by irritability such as tantrums, aggression, and self-injury. However, this medication clearly does not improve the core symptoms of the condition. Stimulants have also been widely used in children with ASD, particularly in light of their common attention, impulse, and hyperactive behaviors (Research Units on Pediatric Psychopharmacology Autism Network 2002; Shay et al. 2004).