A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions
Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication
Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative paly or in making friends; to absence of interest in peers
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text)
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases)
Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day)
Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest)
Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)
C. Symptoms must be present in the early developmental period (but may not become fully manifested until social demands exceed limited capacities, or may be masked by learned strategies in later life)
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level
The DSM-V language describes ASD as a neurodevelopmental disorder that “must be present from infancy or early childhood, but may not be detected until later because of minimal social demands and support from parents or caregivers in early years.” In actuality, neuronal structure or function is irrelevant to the diagnosis of the disorder, which is based purely on the basis of behavioral characteristics, and such structural or functional deficits are rarely if ever detected in diagnosed individuals, either early in life or subsequently. Instead, they are simply inferred, which is reasonable but not especially informative. Moreover, specifying that evidence of neurodevelopmental impairment at one point in life is evidence that such impairment was present earlier in life makes the requirement that ASD “must be present from infancy or early childhood” practically meaningless and of no diagnostic value.
Behaviors characteristic of autism appear to be normally distributed throughout the population (Constantino and Todd 2003; Hoekstra et al. 2007), meaning that most people display a few of the behaviors (i.e., the center of the distribution), a few people display none of them (i.e., one tail of the distribution), and a few people display all of the them (i.e., the other tail of the distribution). Put differently, autism represents one end of the spectrum of typically occurring behavior. From this perspective, essence of diagnosis is determining where the line separating “autistic” from “not autistic” should be drawn. Currently, the line is situated in such a way that about 1.1 % of the population falls on the “autistic” side of the line (Center for Disease Control and Prevention 2012). In a normal distribution, this point is about 2.3 standard deviations from the mean.
The ethical implications of moving the cutoff line in either direction are important and should be considered carefully before decisions about changes in diagnostic criteria are made. Members of advocacy groups, such as Autism Speaks, appear to be in favor of moving the cutoff line closer to the mean, but others argue that autism is diagnosed too liberally and that the line should be moved away from the mean. It should be noted that any discussion of “overdiagnosis” is irrelevant in the context of a socially defined disorder such as autism, but concerns about applying the label too frequently may be justified on other grounds. As noted previously, there is no “gold standard” for identifying autism and it is meaningless to talk about the sensitivity or specificity of particular diagnostic techniques. It is, however, highly meaningful to talk about the practical implications of applying those techniques.
When a child is diagnosed with autism, the world from the child’s perspective can change dramatically. She or he might be immediately placed in an early intervention program or begin working with a therapist in the home. It is hard to imagine how these changes would be detrimental, even if the child is “misdiagnosed.” Indeed, a compelling argument could be made that any child would benefit from appropriate early interventions building on her or his behavioral strengths and remedying any weaknesses. Early intensive behavioral interventions (EIBIs) for children with autism are often characterized by intensive, individualized instruction, with a high instructor to student ratio. Such conditions are apt to maximize the full potential of anyone exposed to them.
If a child is old enough to attend school when the diagnosis of autism occurs, he or she will most often be placed in a special education classroom, sometimes one specifically geared toward children diagnosed with autism (White et al. 2007). One potential disadvantage of children being exposed to such alternative education is that special education comes at the cost of typical education (Dunn 1968). That is, children receiving early intensive educational services are not exposed to the same environment as their typically developing peers experience and may become “atypical” as a result of the atypical educational environment. “Atypical” in this sense is not necessarily bad, but it is imperative that children educated under special circumstances have the opportunity to develop appropriate social skills and adaptive behaviors and to ensure that desired responses developed through early atypical interventions generalize to other situations.
Another issue that is particularly relevant to individuals who are, or will become, verbal (in the traditional sense of the word), is the effect of the label, “autism,” on the individual. Although the reasons are not entirely understood, labels appear to have a strong influence on human behavior. A child who is told that she has dyscalculia may never attempt to improve her math skills and may indeed appear to have a disability, even if there were no grounds for the diagnosis. None of us was born with the ability to solve complex math equations, just as none of us was born with a repertoire of culturally defined social graces. Clearly, many individuals who have been diagnosed with autism are not able to learn social skills as readily as their typically developing peers, and some cannot reach a comparable skill level regardless of the amount of time invested. The diagnosis of autism is invaluable if it affords access to services that increase the likelihood of skill development, but the label itself may also affect social behavior. As Orsini (2009) observed:
Calling a quark a quark makes no difference to the quark [Hacking 2000, p. 105]. Such is not the case with autism. Autistic labels, characterizations, or classifications have a ‘looping effect’ on autistic people, on non-autistics, and on the ways in which we understand the autistic descriptor. (p. 126)
The influence of the label on people deeply concerned with the child who has been diagnosed as “autistic” is especially important. When parents first hear the diagnosis, “autism,” a wide variety of reactions can ensue. Some feel as if they have lost the child, and others feel relieved that they have found the reason for their difficulties in raising the child. Regardless of the specific reaction, it is unlikely that the parents will ever treat their child the same as they did before the diagnosis or the same as his or her siblings. Some likely changes in parenting behavior are appropriate and generally advisable, such as enrolling the child in early intervention programs and focusing on communication skills. But it is possible that the parent may use the label to explain and in a sense excuse inappropriate behaviors as stemming from autism, rather than recognizing that the inappropriate behaviors are the reason for the diagnosis of autism and can be changed in desirable ways. Changes in the behavior of siblings, educators, and peers who have learned of the diagnosis can also have a major impact on the child diagnosed with autism. It is almost as if the act of diagnosing a child with autism places her or him in an entirely different world. Determining whether that world is better or worse for the child is the crux of ethical diagnosis and treatment.
Increased Prevalence of Autism
In the USA and many other affluent countries, the number of people diagnosed with autism has increased rapidly in recent years. This accelerating trend, although alarming, may not be due to an actual increase in the number of people who exhibit behaviors characteristic of autism, but rather to changes in diagnostic practices and other social influences, and studies suggest that changes in diagnostic criteria, average age of diagnosis, accuracy of diagnosis, cultural practices, and awareness of autism account for much of the increase (King and Bearman 2009; Matson and Kozlowski 2011). It is unclear how much, if any, of the upward trend is due to an actual increase in the prevalence of the behaviors that define autism. Therefore, practitioners should be wary of any claims that the “autism epidemic” is anything other than a shift in social and diagnostic practices until there is evidence to support such claims.
Interestingly, recent studies have found that children born in areas associated with high rates of autism have a higher probability of being diagnosed with autism than children born in otherwise similar areas (Liu et al. 2010; Mazumdar et al. 2010). These studies examined the possibility that the effect is due to factors such as viral transmission or environmental toxicity, but the data suggest that the effect is due instead to social factors. For example, Liu et al. (2010) found that “when two children displayed the same level of autism symptoms, the one who lived closer to a child with autism was more likely to be subsequently diagnosed with autism, while the other was more likely to be diagnosed with sole [mental retardation]” (p. 8).
Children who are diagnosed with autism may receive services that differ substantially from the services provided for children diagnosed with mental retardation. If local cultural norms have a major influence on diagnostic decisions and, as a consequence, the services to which children with special needs have access, labels such as “autism” and “mental retardation” may be less effective at grouping children with similar behavioral characteristics and ensuring that they have access to interventions with a high likelihood of benefiting them. With diagnoses of autism on the rise, this is an issue of increasing concern. The best course of action may be to focus on each individual’s needs and skill deficits rather than making treatment decisions based on the child’s diagnostic label.
Such an approach to service provision is often termed “non-categorical,” or “needs-based.” With this approach, the services that a child receives do not depend on her or his receiving a specific diagnosis, but rather on exhibiting general categories of behavioral impairment and specific difficulties within those areas which are targeted for treatment with appropriate evidence-based treatments (Stein and Jessop 1989). For example, if a child is not acquiring language at a normal pace, rather than attempting to attach a nebulous label to the child, such as autism, and base treatment options on that label, specific language acquisition difficulties would be targeted for change with the best available intervention. This approach avoids the ambiguity associated with all socially defined conditions, it does not involve labeling people, and it focuses attention on the specific needs of individuals. It requires, however, a reconceptualization of developmental disabilities and raises vexing issues regarding which children qualify for services beyond the ordinary in education and elsewhere. As with traditional diagnosis, one important issue regards where the cutoff separating children with “special” needs from those with “ordinary” needs is drawn. A second important issue regards how best to match individuals with special needs with interventions likely to be effective in meeting those needs. In all of the helping professions, matching individuals to appropriate treatments is the crux of ethical conduct. Traditional psychiatric diagnosis falls short in this regard, but it is unclear whether alternative approaches would fare substantially better.
Autism and Comorbid Conditions
Although relevant data are not extensive, it is generally recognized that many people with autism exhibit signs and symptoms that appropriately call for assignment to other psychiatric (or educational) diagnoses (e.g., Leyfer et al. 2006; LoVullo and Matson 2010; Simonoff et al. 2008; Yeargin-Allsopp et al. 2003). For example, Yeargin-Allsopp et al. (2003) reported that 68 % of their sample of 987 children with autism for whom relevant data were available had cognitive impairment, and Simonoff et al. (2008) found that, in a sample of 112 children with autism “70 % of participants had at least one comorbid disorder and 41 % had two or more” (p. 921). Like autism, common comorbid conditions often can be detected early in life (Matson et al. 2011a). It is important that this occur, because if untreated these conditions can adversely affect the child early in life and thereafter. Phobias , for instance, are more common in children diagnosed with autism than in children without this diagnosis (Matson and Love 1990). If these phobias are not detected and treated effectively early on, they may be inadvertently strengthened and become both debilitating and difficult to eliminate when treatment is eventually implemented.
Given the high prevalence of other distressing conditions in people with autism and the potential value of early interventions for treating these conditions, it is important that screening devices used for the early detection of autism make provision to detect significant comorbidities. Matson et al. (2011b) make this point clearly in a review of instruments for the early detection of autism:
[I]nstruments should go well beyond measuring core symptoms of autism. The available research shows a marked overlap between core symptoms of autism, challenging behaviors , and some specific types of psychopathology (e.g., ADHD and anxiety disorders). Tests that cover this broader set of symptoms should be paired with an established measure of developmental milestones. We believe this approach to be best practice for early identification and diagnosis of autism, at this point, given current knowledge in the field. (p. 1323)
We agree. Best practices in a given discipline are ethical practices and the general strategy recommended by Matson and his colleagues has much to recommend it. They suggest that the age range of 17–24 months is appropriate for initially screening for autism, because doing so at an earlier age does not yield reliable results, and also argue that it is inappropriate for all children to be screened for autism. Because parents of children subsequently diagnosed with autism recognize that something is amiss early in the children’s lives and pediatricians can also detect marked deficits in early developmental milestones, Matson et al. argue that only children who “evince red-flag variables, or who evince other at-risk variables” (p. 1323) require such specific screening. Taking this tack saves valuable resources and spares parents the agony of contemplating a disability that their child almost certainly does not have.
Autism, Money, and Insurance Coverage
Providing early interventions for children with autism is expensive. For example, early intensive behavioral intervention (EIBI) is extremely costly to implement, and it could be argued that financial resources, which are limited in every society, would be better allocated elsewhere. Given the generally positive findings of most reviews of EIBI (Reichow and Wolery 2009; Sallows and Graupner 2005; Rogers and Vismara 2008; Smith 1999; Warren et al. 2011), however, it can also be argued that providing EIBI to a certain percentage of the population is a sound economic decision in that some children respond well to the treatment, no longer require special services, and in the long run become productive members of society, that is, people who produce more than they consume (Chasson et al. 2007; Jacobson et al. 1998). In such cases, EIBI more than pays for itself .
Moreover, to base treatment decisions purely on financial considerations would strike most of us as unethical. There is within the USA growing acceptance that people with autism deserve to receive effective early (and subsequent) interventions and that the provision of such services should be covered by medical insurance. At the time this is written, 34 states and the District of Columbia have passed statutes requiring insurance coverage of autism (National Conference of State Legislatures 2012). Providing insurance coverage for people with autism raises interesting issues regarding who is to be covered and what kinds of services and service providers are eligible for reimbursement.
It is likely and understandable that parents of young children with special needs will press for those children to be diagnosed with autism, and for caregivers to apply the diagnosis liberally, if a diagnosis of autism provides access to insurance payments affording access to needed services. That is, providing insurance coverage for people with autism may move the cutoff for diagnosis closer to the mean, even if formal diagnostic criteria do not change. In our opinion, this is fine. Many people, including us, believe that it is appropriate for all children to receive the best possible services and that it is especially important that children who are at risk for developing significant behavioral deficiencies in any domain receive specialized early interventions designed to meet their needs. As noted, however, meeting these needs is costly and insurance companies will undoubtedly resist the “overdiagnosis” of autism.
Moreover, as the new DSM-5 rules of classifying people with autism spectrum disorder by level of severity becomes commonplace, one can anticipate that insurance providers will attempt to limit services according to severity. That is, put crudely, more money will be available to provide services for a child with level 3 ASD, the most severe level, than for a child with level 1, the least severe. If this practice becomes widespread, one can anticipate protracted legal battles between insurance companies and representatives of children with special needs over whether those children are properly diagnosed with ASD or another, uncovered condition and, if autism spectrum disorder is the proper diagnosis, whether the level of severity is 1, 2, or 3. The outcome of these battles will establish legal precedent and affect the quality of life of many children with special needs and those who love them.
Advocacy Around the World
Even in wealthy countries, there frequently is resistance to supporting expensive educational (or other) programs designed to benefit a relatively small number of children. An advantage of traditional diagnostic schemes is that they help to unify parents and other caregivers as they advocate for appropriate treatment for their children. Autism advocacy groups, such as Autism Speaks, The Autism Advocacy Network, Autism One, Moms on a Mission for Autism, and Unlocking Autism, have been highly effective in calling attention to autism and in lobbying politicians to provide financial support for autism research and treatment. Although estimates vary widely (see Sharpe and Baker 2009), the USA and other developed countries currently spend enormous sums on providing services for people with autism. Whether sufficient funds are spent on early intervention is open to debate—we would argue probably not—it is clear that much less would be spent if there were no effective advocacy groups. Such groups are essentially nonexistent in resource-poor countries, where autism is rarely diagnosed and seldom treated (Samadi and McConkey 2011).
As Samadi and McConkey (2011) point out, there is very little information about autism in resource-poor countries, and this lack of information has led some writers (e.g., Sanua 1984; Zhang et al. 2006) to the unwarranted assumption that autism is rare in non-Western cultures. What is lacking in such countries is not children with the characteristics that lead to a diagnosis of autism in wealthy countries, but rather sufficient resources to look for, find, and treat those children. As Samadi and McConkey wisely emphasized:
For those families in low- and middle-income countries who have a child with ASD [an autism spectrum disorder], access to professional support services will be limited. But even so there is a growing recognition of the need for cultural sensitivity in importing knowledge and practices from one culture—such as European nations—into societies with very different cultural backgrounds [Blacher and Mink 2004]. For example, different cultures can have different opinions about appropriate intervention and treatment of children with disabilities [Bailey and Powell 2005]. Hence indigenous research is needed to identify the particular needs of families in nonwestern countries and how information and supports can be better tailored to meet their needs and be respectful of their cultures. (p. 1)
Formation of the World Autism Organization (www.worldautism.org) should help to focus worldwide attention on autism in resource-poor countries. Important ethical issues concern the extent to which citizens of wealthy countries should provide financial support for autism diagnosis and treatment in developing countries and the extent to which early intervention specialists should share their skills and knowledge with professionals and laypeople in those countries. Technology, such as teleconferencing, now makes it possible to provide services at a distance, so that, for example, behavior analysts can help to arrange EIBI for children with autism whom they never contact directly. If those children live in resource-poor countries, it is likely that such services would have to be arranged on a pro bono basis. No ethical code requires behavior analysts to work for free, but the possibility of doing so occasionally certainly merits consideration by anyone truly devoted to making the world a better place.
As noted in DSM-IV (American Psychiatric Association 2000), the naming of categories based on criteria sets with defining features is “the traditional way of organizing and transmitting information in everyday life and has been the fundamental approach used in all systems of medical diagnosis” (p. xxii). “Autism” is a broad, heterogeneous, even amorphous, diagnostic category. Although widely recognized and useful for focusing attention on the diverse needs of many children, “autism” leaves much to be desired as a diagnostic category. According to the DSM-IV, “A categorical approach to classification works best when all members of a diagnostic class are homogeneous, when there are clear boundaries between classes, and when the different classes are mutually exclusive” (p. xxii). None of this is true of autism.
Moreover, as noted previously, from an ethical perspective diagnostic categories are justifiable to the extent that they allow care providers to match patients to effective interventions. Consider, for example, a child who is very thirsty (a symptom) and urinates copiously (a sign). If that child is accurately diagnosed with Type I diabetes, insulin injections are likely to be an effective treatment. If, however, kidney failure is the appropriate diagnosis, then insulin is of no value. From a practical perspective, “autism” is a useful diagnostic category if (a) children who receive this diagnosis are especially likely to benefit from specific interventions that would not benefit children who behave similarly but are not diagnosed with autism and (b) receiving the diagnosis of “autism” affords relevant children access to needed interventions. With respect to behavior-analytic interventions, at least, it appears that the general procedures used to change behavior are similar regardless of the diagnostic labels assigned to clients. There are no “magic bullets” for treating autism, and anyone who makes assertions to the contrary is going well beyond the facts.
We have devoted a good amount of space to issues relevant to diagnosis, an area that may not appear at first glance to be directly relevant to ethics . Our goal has been twofold: First, we want to help parents and practitioners avoid common misunderstandings about the nature of autism and the precision with which the condition can be diagnosed. Second, we want to emphasize the impact that a diagnosis of autism can have on an individual, his or her family, and society in general. The label should be viewed as a rough guide, a sticky note placed above a group of people with some similar behavioral characteristics to emphasize these behaviors, but certainly not as the cause of these characteristics. To be clear, the behavioral differences between most people diagnosed with autism and their typically developing peers are very real, as those who live with autism can attest, but we do people with autism no favor by treating the label as anything more than a label.
Treatment Goals, Risk of Harm, and Ethical Conduct
Poling (1994) argued that ethical interventions are intended to benefit the people who are exposed to them, regardless of the nature of the interventions or the characteristics of the people exposed to them. We agree that this is certainly the case with early interventions for children with autism. Good intentions—that is, focusing first and foremost on the well-being of the child when considering the interventions, if any, to which she will be exposed early in life—is a quintessential part of ethical conduct by the adults who care for and provide services to that child. Interventions intended to serve other purposes merit careful scrutiny, although they are not necessarily unethical.
It is, of course, widely accepted that ethical interventions are intended not just to maximize benefit for those treated, but also to minimize harm. The so-called Hippocratic injunction, to first do no harm (in Latin, primum non nocere), has long been an axiom central to the education of medical and graduate students in the helping professions (Smith 2005) and it is clear that behavior analysts and other professionals who offer early intervention services have a fundamental responsibility to not harm their clients or to allow harm to occur under their watch (Bailey and Burch 2011). Occasionally, however, some degree of harm must be tolerated in the short term to reduce overall harm and maximize benefit over the long run. This is the case, for example, when a child is exposed to a painful and debilitating surgical procedure that corrects a cleft palate or a heart defect. As discussed elsewhere (Poling et al. in press; Weeden et al. 2010b), functional analysis (FA) of self-injurious behavior is similar in that participants are allowed to injure themselves under controlled conditions so that the variables responsible for self-injury can be isolated and subsequently manipulated to reduce, or ideally eliminate, such behavior in the participant’s everyday environment.
In the seminal study of FA of self-injury, Iwata et al. (1982/1994) took great care to ensure that protections were in place to minimize the risk of harm to participants. Iwata and his colleagues indicated that procedures were approved by a human subjects committee (i.e., an institutional review board), individuals who were at risk of severe physical harm were excluded from participation, and all potential participants received a complete medical exam, with neurological, audiological, and visual evaluations as appropriate “to assess current physical status and to rule out organic factors that might be associated with or exacerbated by self-injury” (p. 199). Criteria for terminating sessions were established through consultation with a physician. The physician or a nurse observed sessions intermittently to assess whether or not termination criteria needed to be adjusted. If termination criteria were met, participants were immediately removed from the therapy room and evaluated by a physician or nurse, who determined whether or not the sessions would continue. After every fourth session, each participant was examined by a nurse. Finally, each case was reviewed at least weekly in both departmental case conferences and in interdisciplinary rounds. Using safeguards such as those arranged by Iwata et al. and limiting the number and length of sessions to the minimum required to provide useful information minimizes harm to participants during FA.
Despite the possibility that harmful behavior will be temporarily reinforced (and thus increased) during FA sessions, it is important to point out that a properly conducted FA does not increase the risk of harm to participants relative to that they encounter in their everyday environment, a point made by Iwata et al. (1982/1994). If it is ethically acceptable for a target behavior to occur outside FA sessions, then the same should be true within such sessions, although safeguards to prevent serious harm might be required. Interestingly, published studies rarely mention such safeguards. Of 116 articles describing the FA of self-injurious behavior recently reviewed by Weeden et al. (2010), nine (7.7 %) described session termination criteria and 23 (19.8 %) described other procedural safeguards for reducing risk to participants.
As Weeden et al. pointed out, it is possible, even probable, that appropriate safeguards to prevent harm to participants were in place in the other studies but were not described. Nevertheless, it is important for those implementing FA procedures to consider the potential importance of having in place structured termination criteria and safeguards to protect individuals engaged in FA. Regardless of the procedure involved, before a young person with autism is exposed to the procedure, ethical researchers and care providers should carefully consider the potential adverse effects of that procedure and take appropriate steps to minimize the likelihood and severity of such effects.
Although punishment, in the technical sense of operant behavior being weakened by its consequences, is ubiquitous in the everyday world, it is noteworthy that prominent behavior analysts, including Skinner (1953) and Sidman (1989), have been critical of the use of punishment to reduce behavior and the use of punishment procedures in education and therapeutic settings is strongly restricted. It is the case, however, that behavior analysts differ widely in their opinions regarding the effectiveness of punishment procedures and the ethicality of using them to reduce problem behaviors. For example, a national survey of the efficacy and ethics of punishment mailed to 500 members of the Association for Behavior Analysis in 2004 (DiGennaro Reed and Lovett 2008) produced results revealing that “the range of opinion among respondents was very large, suggesting that any statements in both the popular media and professional publications claiming that ‘professionals’ think punishment to be ineffective or unethical (or, for that matter, effective or ethical) are not credible” (p. 65). Nonetheless, respondents generally agreed that punishment should be used only to reduce dangerous behaviors, punishment procedures have more negative side effects and are less effective than reinforcement procedures, and obtaining informed consent and administrative approval are not sufficient ethical safeguards when punishment is used.
Although it is often ignored, as when people content that punishment inevitably has serious side effects, there is a substantial literature dealing with the effects of punishment and alternative methods to treat problem behaviors in developmentally delayed persons, although most of the research appeared more than 20 years ago. For example, Matson and Taras (1989) reviewed 382 relevant studies published from 1967 to 1987 and found that punishment procedures were often effective and no more likely to produce negative side effects than alternative response-deceleration procedures. Despite such findings, in a recent review of punishment as it pertains to therapeutic applications of behavior analysis, Lerman and Vorndran (2002) contend that “further understanding of punishment processes is needed to develop a highly systematic, effective technology of behavior change, including strategies for improving the efficacy of less intrusive procedures and for successfully fading treatment” (p. 431).
It is perhaps worth noting as an aside that punishment procedures and procedures involving negative reinforcement are often grouped together as “aversive” or as “aversive control” operations. There is little to recommend this grouping. Although exposure to punishers and to stimuli that generate escape or avoidance responding (i.e., negative reinforcers) is often, but not inevitably, unpleasant, environmental events that serve as punishers may or may not serve as negative reinforcers and vice versa, and under some circumstances people will avoid or escape from procedures involving positive reinforcement (i.e., positive reinforcement can be “aversive”). Grouping together all punishment and negative reinforcement procedures and considering them as “aversive” is misleading and in our view unfortunate, especially in view of the strongly negative position regarding aversive procedures taken by advocacy groups. For instance:
The Arc [For People with Intellectual and Developmental Disabilities] and AAIDD [American Association on Intellectual and Developmental Disabilities] are opposed to all aversive procedures [italics ours], such as electric shock, deprivation, seclusion and isolation. Interventions must not withhold essential food or drink, cause physical and/or psychological pain or result in humiliation or discomfort. (The Arc 2012)
Depending on how “discomfort” is defined, many early intervention strategies might produce it. For example, it is highly probable that at least some children with autism would indicate that they do not like to attend school or participate in discrete-trial training and they would not do so without inducement. Therefore, these activities, which are clearly intended to benefit the children, are aversive (i.e., the children would escape or avoid them if possible) and produce “discomfort” (because they maintain escape and avoidance responding and are labeled as “unliked,” “unpleasant,” or “uncomfortable”). Most people, including members of Arc and AAIDD, probably would not consider it to be unethical to require a child with autism to go to school or attend a well-designed training session at home, but this example illustrates the difficulties associated with blanket pronouncements regarding what is and is not proper, that is, ethical, treatment of children with autism or other developmental disabilities. Saying “please don’t hit your sister” to a boy who strikes his sibling is punishment if the future probability of hitting is reduced, and so is using a cattle prod to produce the same outcome. That, however, is their sole commonality.