JOURNAL OF APPLIED BEHAVIOR ANALYSIS

JOURNAL OF APPLIED BEHAVIOR ANALYSIS

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JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2002, 35, 431–464 NUMBER 4 (WINTER 2002)

ON THE STATUS OF KNOWLEDGE FOR USING PUNISHMENT:

IMPLICATIONS FOR TREATING BEHAVIOR DISORDERS

DOROTHEA C. LERMAN AND CHRISTINA M. VORNDRAN LOUISIANA STATE UNIVERSITY AND

THE LOUISIANA CENTER FOR EXCELLENCE IN AUTISM

In this paper, we review basic and applied findings on punishment and discuss the im- portance of conducting further research in this area. The characteristics of responding during punishment and numerous factors that interact with basic processes are delineated in conjunction with implications for the treatment of behavior disorders in clinical pop- ulations. We conclude 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 treat- ment.

DESCRIPTORS: behavior disorders, functional analysis, punishment, treatment

Punishment is generally defined as an en- vironmental change contingent on behavior that produces a decrease in responding over time (Michael, 1993). Numerous procedural variations of punishment have been devel- oped for clinical use. Results of research con- ducted over the past four decades have shown that punishment is effective in reduc- ing problem behavior in clinical popula- tions, and in some cases, may be an essential component of treatment (see Kazdin, 2001, and O’Brien, 1989, for reviews of this lit- erature). However, more knowledge is need- ed about factors that may influence the ef- fects of punishment on problem behavior. Few strategies have been identified for en- hancing the effectiveness of less intrusive punishment procedures, for attenuating un- desirable aspects of punishment, or for suc- cessfully fading treatment with punishment.

The direct and indirect effects of punish-

We thank Don Baer, Alan Baron, Linda LeBlanc, Tony Nevin, and the anonymous reviewers for their comments on earlier versions of this paper.

Reprints may be obtained by contacting Dorothea C. Lerman, 236 Audubon Hall, Louisiana State Uni- versity, Baton Rouge, Louisiana 70803 (e-mail: dlerman@lsu.edu).

ment have been studied extensively in the laboratory. Nevertheless, basic research on punishment has been declining rapidly de- spite substantial gaps in knowledge (Baron, 1991; Crosbie, 1998). The generality of basic findings to clinical populations and problems also is questionable (Hayes & McCurry, 1990). Most studies evaluated the effects of intense, unconditioned punishers (e.g., elec- tric shock), and a number of important re- lations have not yet been replicated with hu- mans or clinically relevant punishers.

The purpose of this paper is to review ba- sic and applied research findings on punish- ment, identify gaps in the literature, and dis- cuss the implications of these findings for the use of punishment in clinical settings. Basic findings that contradict common assump- tions about punishment effects found in text- books and review papers and that help elu- cidate inconsistent results on punishment in the applied literature are highlighted. The main premise of this paper is that further un- derstanding of punishment processes may lead to an improved technology of behavior change. We extend the most recent review papers on punishment (Matson & Di- Lorenzo, 1984; Van Houten, 1983) by (a)

432 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

providing a broader overview of the direct and indirect effects of punishment and fac- tors that influence basic processes (e.g., his- tory), (b) identifying areas in need of further research from both basic and applied litera- tures, and (c) discussing recent research find- ings on punishment within the context of ad- vances in the functional analysis of behavior.1

Some authors have suggested that addi- tional applied research on punishment is un- necessary in light of refinements to the func- tional analysis methodology and treatment with reinforcement (Donnellan & LaVigna, 1990; Guess, Helmstetter, Turnbull, & Knowlton, 1987). Results of numerous stud- ies conducted over the past 15 years have shown that the function of problem behav- ior often can be determined and that this information can be used to develop treat- ments based on extinction, reinforcement, and other processes such as establishing op- erations (e.g., Iwata, Pace, Dorsey, et al., 1994). Nevertheless, punishment may be critical to treatment success when the vari- ables maintaining problem behavior cannot be identified or controlled (for further dis- cussion, see Axelrod, 1990; Iwata, Vollmer, & Zarcone, 1990; Vollmer & Iwata, 1993). Punishment also may be preferable to rein- forcement-based treatments when problem behavior must be suppressed rapidly to pre- vent serious physical harm (Dura, 1991; see also Iwata et al.; Vollmer & Iwata). More important, results of several studies indicate that treatments derived from functional analyses (e.g., differential reinforcement of alternative behavior [DRA]) may not always reduce behavior to clinically acceptable levels without a punishment component (e.g., Grace, Kahng, & Fisher, 1994; Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998; Wacker et al., 1990).

1 Much of the applied research on functional anal- ysis and treatment of behavior disorders has been con- ducted with individuals diagnosed with developmental disabilities. Thus, this review reflects this emphasis.

Knowledge about punishment also is im- portant because common treatments that are associated with other processes may in fact reduce problem behavior through the mech- anism of punishment. For example, proce- dures such as response blocking, guided compliance, and the application of protec- tive equipment are often presumed to reduce problem behavior by terminating the rein- forcement contingency that maintains the response (i.e., through extinction; e.g., Reid, Parsons, Phillips, & Green, 1993; Rincover, 1978). Research findings suggest that these procedural variations of extinction may function as punishment instead of, or in combination with, extinction (e.g., Lerman & Iwata, 1996b; Mazaleski, Iwata, Rodgers, Vollmer, & Zarcone, 1994). Some authors also have suggested that the contingent loss of reinforcement associated with differential reinforcement procedures (e.g., differential reinforcement of other behavior [DRO]) may constitute a form of punishment (e.g., Rolider & Van Houten, 1990). Thus, the process of punishment may underlie a num- ber of popular function-based treatments.

Functional analysis methodology now permits more precise investigations of im- portant environment–behavior relations in the area of punishment. Basic findings in- dicate that various parameters of reinforce- ment influence the direct and indirect effects of punishment and interact with nearly ev- ery other factor that has been found to in- fluence responding during punishment (e.g., punishment schedule and magnitude). Such interactions have important clinical impli- cations because punishment is more likely to be used when the response–reinforcer rela- tion cannot be terminated completely. In ap- plied studies, important reinforcement vari- ables identified via functional analysis could be manipulated prior to and during punish- ment, even when the behavior is maintained by nonsocial consequences (i.e., the behavior is maintained in the absence of socially me-

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diated reinforcers, such as attention, tangible items, and escape from instructions; see, e.g., Lerman & Iwata, 1996b).

Important issues related to the ethics and acceptability of using punishment to treat problem behavior in individuals with devel- opmental disabilities have been the subject of numerous articles over the past 30 years. An overview of these issues is beyond the scope of this paper but can be found in a variety of sources (see Donnellan & LaVigna, 1990; Emerson, 1992; Guess et al., 1987; Jacob- Timm, 1996; Sidman, 1989; Van Houten et al., 1988). Suggestions for further applied studies on punishment are made throughout this paper, with the assumption that pertinent guidelines and cautions about the application of punishment will accompany published re- search findings (see Alberto & Troutman, 1999; Lovaas & Favell, 1987; Matson & DiLorenzo, 1984).

Ultimately, the consumers of behavioral technologies (e.g., clinicians, caregivers) will determine which treatments are used with individuals with developmental disabilities (see Iwata, 1988, for a cogent discussion of this issue). These decisions are at least partly guided by information generated by the sci- entific community. Safe, acceptable, and highly effective technologies of behavior change should be available to consumers who request them, including procedures that are based on punishment.

Basic and applied research findings on clinically relevant factors that influence the direct effects of punishment will be discussed in the first half of the paper. Other charac- teristics of punished responding, including maintenance, generalization, and side effects, will be discussed in the second half.

FACTORS THAT INFLUENCE THE DIRECT EFFECTS

OF PUNISHMENT Much of the basic research on the direct

effects of punishment was conducted more

than 30 years ago with nonhumans (see Azrin & Holz, 1966, for a review of this literature). Procedural variations of punish- ment examined in the laboratory have in- cluded the delivery of stimuli, often called positive punishment, and the removal of stim- uli, often called negative punishment (i.e., re- sponse cost, time-out from positive rein- forcement).2 The majority of studies, how- ever, employed contingent electric shock. In the earliest basic studies, the effects of pun- ishment were evaluated while the punished response was undergoing extinction (e.g., Estes, 1944; Skinner, 1938; Thorndike, 1932). However, in most subsequent studies, punishment contingencies were introduced with no change in the prevailing reinforce- ment schedule. This latter arrangement as- sured a certain level of responding by which to examine the effects of punishment inde- pendently of those produced by extinction (Azrin & Holz, 1966). Complex interactions between reinforcement and punishment pro- cesses also could be evaluated. A number of authors suggested that this laboratory ar- rangement may be more pertinent to appli- cation because punishment is most likely to be used when the reinforcer that maintains problem behavior cannot be identified or controlled (Azrin & Holz, 1966; Dinsmoor, 1952).

In fact, the function of problem behavior was not determined prior to treatment in most clinical studies on punishment. Pun- ishment thus was superimposed on an un- known schedule of reinforcement that likely took the form of extinction when the be- havior was maintained by social consequenc-

2 Consistent with previous articles and chapters on punishment, few distinctions will be drawn between positive and negative punishment in this review. Cur- rent research findings suggest that the procedures are associated with similar direct and indirect effects on responding. Nevertheless, the literature on positive punishment far exceeds that on negative punishment. Basic processes may differ in important ways under these two forms of punishment.

434 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

es (Iwata, Pace, Cowdery, & Miltenberger, 1994). That is, social consequences that may have maintained responding during baseline (e.g., verbal reprimands, escape from in- structions) often were removed with the in- troduction of punishment. A substantial portion of applied findings thus may have little generality to contemporary treatment approaches because punishment is most like- ly to be used when problem behavior con- tinues to produce reinforcement. Basic find- ings suggest that reinforcement parameters can influence the effects of punishment in important ways.

THE DIRECT EFFECTS OF PUNISHMENT

Basic research findings have shown that response-contingent shock, noise, blasts of air, response cost, and time-out can produce a rapid decrease in the frequency of behavior and, in some cases, may lead to complete response suppression in rats, pigeons, mon- keys, and humans (e.g., college students, psychiatric patients; Azrin, 1960; Crosbie, Williams, Lattal, Anderson, & Brown, 1997). Several studies with humans and nonhumans also found that the initial re- ductive effects of punishment with shock or point loss occurred more rapidly, or to a greater extent, than those produced by ex- tinction, satiation, and differential reinforce- ment (e.g., Holz & Azrin, 1963; Johnson, McGlynn, & Topping, 1973; Rawson & Leitenberg, 1973).

The potential benefit of using punish- ment to treat intractable behavior problems led to the development of numerous punish- ment procedures for clinical use. Results of research have shown that treatment with a wide variety of punishers (e.g., verbal repri- mands, restraint, water mist, lemon juice, shock, removal of reinforcing activities or conditioned reinforcers) can produce an im- mediate, substantial suppression in problem behavior (see Kazdin, 2001, and Matson &

DiLorenzo, 1984, for reviews of this litera- ture). Applied findings also indicate that the effects of punishment are superior to those obtained with less intrusive procedures alone, such as differential reinforcement (e.g., Barrett, Matson, Shapiro, & Ollen- dick, 1981; Favell et al., 1982; Scotti, Evans, Meyer, & Walker, 1991). Although results of such comparisons are consistent with those obtained in the laboratory, the findings are difficult to interpret because numerous parameters likely influence the effects of these behavior-reduction procedures. For ex- ample, a dense schedule of differential rein- forcement may reduce behavior more effec- tively than a mild punisher.

More important, the relative efficacy of treatment with reinforcement versus punish- ment likely depends on a variety of factors (e.g., history; use of extinction; type, amount, and schedule of the consequence). These complex interactions need to be eval- uated to generate more definitive findings about the suppressive effects of punishment relative to other procedures. Further research on strategies to improve the efficacy of pun- ishment would be more pragmatic over the long run than additional, complex compar- ative studies of reinforcement versus punish- ment.

Several authors have suggested that treat- ment with punishment is so effective be- cause punishment usually can compete suc- cessfully with reinforcement contingencies that maintain problem behavior (e.g., Van Houten, 1983). Although punishment often was confounded inadvertently with extinc- tion in applied research, recent studies have demonstrated that common punishment procedures (e.g., time-out, brief manual re- straint) can be effective in the absence of extinction (Fisher, Piazza, Bowman, Hago- pian, & Langdon, 1994; Lerman, Iwata, Shore, & DeLeon, 1997; Thompson, Iwata, Conners, & Roscoe, 1999). Reductions in behavior were obtained even after unsuc-

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cessful attempts to treat the behavior with less intrusive procedures (e.g., Fisher et al., 1993; Lindberg, Iwata, & Kahng, 1999).

Nevertheless, the generality of these find- ings may be limited because data on effective treatments are more likely to be published than those that show unsuccessful outcomes. Potentially important reinforcement param- eters also were unspecified in these studies. Results of pretreatment functional analyses indicated that the behavior was maintained independent of social consequences but did not isolate the precise reinforcer. Methods to identify the type of nonsocial reinforcement (often called automatic reinforcement) that is functionally related to problem behavior have been examined in a number of studies (e.g., Goh et al., 1995; Kennedy & Souza, 1995; Patel, Carr, Kim, Robles, & Eastridge, 2000; Piazza, Adelinis, Hanley, Goh, & De- lia, 2000). Although further methodological refinements are needed, these strategies may be useful for identifying and manipulating various reinforcement parameters (e.g., re- inforcer schedule and magnitude) while treating automatically reinforced problem behavior with punishment (e.g., Lerman & Iwata, 1996b). As described in more detail below, results of studies employing these types of manipulations with behavior main- tained by either social or nonsocial conse- quences could lead to a greater understand- ing of punishment processes and improved treatments.

As discussed in the following sections, a number of factors directly relevant to the de- velopment of an applied technology have been found to influence the direct effects of punishment. These factors include historical variables (e.g., prior experience with the punishing stimulus or intermittent reinforce- ment); the use of conditioned punishers; re- inforcement variables (e.g., schedule, avail- ability of alternative sources of reinforce- ment); and punishment variables (e.g., mag- nitude, immediacy, schedule). However,

much of the research on these factors has been conducted in the basic laboratory, and our knowledge of some important complex relations is relatively incomplete (Baron, 1991).

History

Basic findings indicate that previous ex- posure to certain factors can alter responding during punishment, a phenomenon that is especially relevant to the application of pun- ishment because clinical populations typical- ly have diverse learning histories. Results of numerous basic studies have shown that pri- or experience with the punishing stimulus either contingently or noncontingently can decrease a behavior’s sensitivity to punish- ment (e.g., Capaldi, Sheffer, Viveiros, Da- vidson, & Campbell, 1985; Halevy, Feldon, & Weiner, 1987). For example, research findings with rats indicate that exposure to intermittent punishment with shock decreas- es the efficacy of continuous punishment with shock, even when several days or weeks lapse between intermittent and continuous punishment (Banks, 1967; Halevy et al.; Shemer & Feldon, 1984). Deur and Parke (1970) replicated this effect with normally developing children and a loud buzzer as the punishing stimulus.

Although adaptation to the punishing stimulus may account for these findings (Ca- paldi et al., 1985), a similar relation has been obtained with intermittent reinforce- ment. That is, rats and college students with a history of intermittent reinforcement also showed less response suppression under ei- ther continuous or intermittent punishment with shock than participants with a history of continuous reinforcement (e.g., Brown & Wagner, 1964; Estes, 1944; Halevy et al., 1987; Vogel-Sprott, 1967). Moreover, Eisen- berger, Weier, Masterson, and Theis (1989) found that resistance to shock punishment increased for one response (lever pressing) in rats even after a topographically different be-

436 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

havior (running) was exposed to intermittent reinforcement.

In clinical settings, an individual is likely to experience common punishers (e.g., ver- bal reprimands, time-out) before these con- sequences are specifically arranged to treat a particular inappropriate behavior. Further- more, exposure to intermittent schedules of reinforcement and punishment is typical in the natural environment. Consequences of- ten are delivered on intermittent schedules because it is difficult for parents and teachers to reinforce or punish every occurrence of behavior. When initial attempts to treat a behavior with intermittent punishment fail, caregivers may switch to a continuous sched- ule of punishment in an attempt to improve the efficacy of the treatment. Basic findings indicate that a history with intermittent punishment may complicate treatment suc- cess in these cases, such that more intense punishers will be required to suppress be- havior effectively (Halevy et al., 1987; Shemer & Feldon, 1984). However, the rel- evance of these findings to the types of pun- ishers that are more commonly used in clin- ical settings is unknown because nearly all basic studies in this area evaluated the effects of shock, and no applied studies have repli- cated and extended these findings to prob- lem behavior.

Nevertheless, basic findings in this area suggest some important guidelines for clin- ical research and practice. First, it may be beneficial for caregivers to identify novel punishers when designing treatments and to avoid using common consequences, such as verbal reprimands and time-out, in unsys- tematic or unplanned ways. Second, inter- mittent schedules of punishment should not be implemented prior to continuous sched- ules. Third, if adaptation to the punishing stimulus accounts for the decreased sensitiv- ity of behavior (Capaldi et al., 1985), brief hiatus from punishment may be useful, as described in more detail below (Rachlin,

1966). Alternating among several effective punishment procedures in lieu of using a single procedure is another potentially useful strategy for minimizing exposure to any sin- gle punisher (e.g., Charlop, Burgio, Iwata, & Ivancic, 1988).

Conditioned Stimuli

Neutral stimuli that are paired with pun- ishing stimuli eventually may acquire prop- erties of the punishing stimuli. Results of ba- sic studies indicate that these conditioned stimuli can function as punishers when de- livered contingent on behavior in the ab- sence of the primary, or unconditioned, stimulus (e.g., Hake & Azrin, 1965). Con- ditioned punishers may be useful for increas- ing both the efficacy and acceptability of punishment in clinical settings. Suppose that a relatively nonintrusive but ineffective con- sequence (e.g., a brief verbal cue) was estab- lished and maintained as a potent condi- tioned punisher via intermittent pairings with a more restrictive, time-consuming in- tervention (e.g., overcorrection, time-out). Application of the conditioned punisher would reduce the individual’s exposure to the intrusive intervention and the degree of effort required by caregivers to implement treatment, factors that might circumvent problems with program inconsistency, habit- uation to the unconditioned punisher, and ethical issues associated with the use of re- strictive procedures.

Various stimuli have been established as conditioned punishers in the basic labora- tory, including tones, lights, and low-voltage shock (e.g., Crowell, 1974; Davidson, 1970; Hake & Azrin, 1965). With a few excep- tions (e.g., Trenholme & Baron, 1975), the unconditioned stimulus was electric shock and the subjects were rats or pigeons. Con- ditioned punishers were established via one of two primary methods. Under one meth- od, the neutral stimulus was presented be- fore the onset of an inescapable stimulus

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(e.g., shock delivered independent of re- sponding) and then was either removed with the onset of the unconditioned stimulus (e.g., Hake & Azrin, 1965; Mowrer & Sol- omon, 1954) or remained in the environ- ment while the unconditioned stimulus was delivered periodically (e.g., Orme-Johnson & Yarczower, 1974). Results of several stud- ies on this method indicated that more con- ditioning occurred if the neutral stimulus was presented prior to the onset of the un- conditioned stimulus rather than simulta- neously with or after its onset (e.g., Evans, 1962; Mowrer & Aiken, 1954).

Under the other method, the neutral stimulus was established as a discriminative stimulus for punishment. That is, the pres- ence of the neutral stimulus was correlated with delivery of the unconditioned stimulus contingent on responding (e.g., Davidson, 1970). Although the discriminative stimulus then was shown to suppress responding when delivered contingent on behavior, re- sults of Orme-Johnson and Yarczower (1974) indicated that stimuli established as discriminative stimuli were much less effec- tive as conditioned punishers than stimuli established via the former method. Regard- less of the conditioning method, research findings have shown that the effects of con- ditioned punishers on behavior are tempo- rary unless the conditioned stimulus and the unconditioned punisher continue to be paired in some manner (Davidson, 1970; Hake & Azrin, 1965).

A few basic studies have evaluated factors that appear to influence the conditioning process, such as the magnitude of the un- conditioned stimulus (Mowrer & Solomon, 1954) and the duration of the conditioned stimulus (Hake & Azrin, 1965). However, other clinically relevant parameters of con- ditioning, such as the number of pairings between the conditioned and unconditioned stimuli, the type of unconditioned punisher used, and characteristics of the neutral stim-

ulus (e.g., intensity or saliency), should be examined in further research. In addition, conditioned stimuli typically were estab- lished and maintained independent of re- sponding, a method that likely would invoke ethical concerns if extended to clinical pop- ulations. Although it may be more accept- able to pair conditioned and unconditioned stimuli contingent on problem behavior, op- portunities to condition the stimulus would be severely restricted if the unconditioned punisher suppressed problem behavior to low levels.

The use of conditioned punishers in treat- ing problem behavior has been reported in surprisingly few applied studies. More im- portant, no applied studies have focused ex- clusively on methods to develop and main- tain stimuli as conditioned punishers in clin- ical settings. Lovaas and Simmons (1969) paired the word ‘‘no’’ with shock contingent on severe self-injury with 1 participant. The brief verbal reprimand then was presented for self-injury in the absence of shock during a limited number of sessions, and results suggested that the stimulus had acquired the suppressive properties of the original punish- er. In a more thorough evaluation, Dorsey, Iwata, Ong, and McSween (1980) paired the word ‘‘no’’ with contingent water mist for 2 participants who engaged in self-injury. Re- sults showed that contingent presentation of the verbal stimulus maintained low levels of self-injury when water mist was withdrawn from the original treatment setting. Further- more, the suppressive effects of the verbal reprimand generalized to a setting that had not been previously associated with the wa- ter mist procedure, as well as to other ther- apists who had never delivered the water mist. Finally, Dixon, Helsel, Rojahn, Cipol- lone, and Lubetsky (1989) paired a mild, less effective punisher (visual screen) with a more effective punisher (the odor of am- monia) while treating aggression and disrup- tion exhibited by a young boy with devel-

438 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

opmental disabilities. Problem behavior re- mained suppressed for a short time when the visual screen was used alone.

Although results of these three studies in- dicated that conditioned punishers were es- tablished successfully for a clinical problem, the efficacy of treatment was evaluated across a limited number of brief sessions. Basic findings have shown that the effects of con- ditioned punishers on behavior are tempo- rary unless the conditioned stimulus and the unconditioned punisher continue to be paired in some manner (Davidson, 1970; Hake & Azrin, 1965). In addition, details necessary to replicate the conditioning pro- cedure (e.g., method of pairing, total num- ber of pairings, rules for determining when to test the conditioned effect) were not de- lineated. The generality of these findings and those obtained in the basic laboratory also may be limited by the use of relatively intrusive unconditioned punishers (i.e., shock, water mist, ammonia).

Thus, current knowledge about condi- tioned punishment is fairly incomplete, and prescriptions for the application of condi- tioned punishers should await further re- search. The efficacy of pairing various types of auditory, tactile, and visual stimuli should be evaluated with more common and so- cially acceptable forms of punishment (e.g., time-out). The number of pairings necessary to produce conditioning and factors that might alter the outcome of conditioning (e.g., intensity of the conditioned stimulus) could be evaluated by periodically testing the suppressive effects of the paired stimulus in the absence of the unconditioned punisher. The durability of conditioning could be de- termined by presenting the conditioned stimulus without the unconditioned punish- er until the effects on responding dissipate. This strategy also may be useful when de- veloping a schedule for pairing the condi- tioned and unconditioned stimuli to main- tain conditioning over time. For example,

clinicians could determine the maximum number of times that the conditioned stim- ulus could be presented before the condi- tioning effect begins to be extinguished. The conditioned and unconditioned stimulus then could be paired prior to that number on a regular basis.

Reinforcement Schedule

Basic findings indicate that the character- istics of responding during punishment may depend on the reinforcement schedule that maintains the behavior, a factor that is es- pecially relevant to application because prob- lem behavior is likely to be maintained by some form of reinforcement during treat- ment. Behavior may be concurrently ex- posed to schedules of reinforcement and punishment when caregivers do not com- pletely withhold social consequences during treatment or when the behavior is main- tained by automatic reinforcement. Results of basic studies generally showed that the amount of response suppression under pun- ishment was negatively related to the density of the reinforcement schedule, with extinc- tion producing the greatest decrease in re- sponding (Azrin & Holz, 1966). Various pa- rameters of punishment (e.g., schedule, in- tensity) also appear to interact with the re- lation between response suppression and reinforcement density (Bouzas, 1978; Brad- shaw, Szabadi, & Bevan, 1977, 1978). For example, Bradshaw and his colleagues found that the negative relation between reinforce- ment density and responding was much more pronounced when human subjects were exposed to a variable-ratio (VR) pun- ishment schedule of monetary loss than to a variable-interval (VI) punishment schedule.

Intermittent reinforcement schedules ex- amined in the laboratory have included fixed-interval (FI), fixed-ratio (FR), VI, and VR schedules. Although these reinforcement schedules have been found to interact dif- ferentially with the effects of punishment,

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this interaction has not been well studied and likely depends on various factors, such as the reinforcement density, punishment schedule, and amount of reinforcement lost due to a reduction in responding (e.g., Pow- ell, 1970; Scobie & Kaufman, 1969; see also Baron, 1991, for further discussion). The various ways in which these schedules influ- ence punishment effects are relevant to an applied technology because social contingen- cies for problem behavior often approximate these laboratory arrangements in the natural environment (e.g., Lalli & Goh, 1993; Voll- mer, Borrero, Wright, Van Camp, & Lalli, 2001). Such complex interactions between reinforcement and punishment schedules also are likely responsible for some inconsis- tent findings reported in both the basic and applied literatures on punishment (see fur- ther discussion below). Additional basic re- search in this area is needed to clarify these relations.

Knowledge about basic processes and pre- scriptions for best practices when using pun- ishment in clinical settings will be incom- plete without further evaluation of potential interactions between reinforcement sched- ules and parameters of punishment. Never- theless, no applied studies have examined the effects of reinforcement schedule or den- sity on the outcome of treatment with pun- ishment. Further research should determine if reducing the density of the reinforcement schedule operating in the natural environ- ment would substantially enhance the effi- cacy of commonly used punishment proce- dures. If so, strategies are needed to thin the schedule of reinforcement for problem be- havior during treatment with punishment. The parameters under which reinforcement schedule is and is not an important factor when treating problem behavior with pun- ishment also should be evaluated. Potentially relevant parameters include the schedule, type, and intensity of the punisher.

Although nonsocial sources of reinforce-

ment may be difficult to modify (but see Lerman & Iwata, 1996b, for one approach), results of this research may lead to useful guidelines for designing effective yet practi- cal treatments when caregivers will be un- likely or unable to withhold social reinforce- ment for problem behavior. Current knowl- edge indicates that reinforcement for prob- lem behavior should be withheld or diminished if possible. Thus, for example, when caregivers cannot withhold reinforce- ment completely during punishment (e.g., ignore all instances of self-injury), the den- sity and magnitude of reinforcement for problem behavior should be reduced and punishment should be delivered on a con- tinuous schedule (see further discussion be- low).

Availability of Alternative Reinforcement

Most textbooks and literature reviews on application highlight the benefits of combin- ing punishment with some type of reinforce- ment procedure, such as DRA (e.g., Cooper, Heron, & Heward, 1987; Matson & Di- Lorenzo, 1984). Basic studies with rats, pi- geons, and psychiatric patients have shown that the suppressive effects of contingent shock, noise, or time-out were enhanced when reinforcement could be obtained in some manner other than, or in addition to, engaging in the punished response (e.g., Boe, 1964; Herman & Azrin, 1964; Holz, Azrin, & Ayllon, 1963; Rawson & Leiten- berg, 1973). Although these findings suggest that increasing the density of alternative re- inforcement might enhance the efficacy of mild punishers in clinical settings, few basic studies have evaluated clinically relevant punishers or the parameters under which re- inforcement may provide optimal benefits during punishment.

In a study with pigeons reported by Azrin and Holz (1966), for example, an FR 25 schedule of alternative reinforcement did not increase sensitivity to punishment when a re-

440 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

sponse maintained by the same reinforce- ment schedule was punished with low-volt- age shock (less than 50 V). It is possible, however, that a denser schedule of alterna- tive reinforcement would have enhanced the efficacy of this mild punisher. Results of a study by Fantino (1973) indicated that the beneficial effects of alternative reinforcement were compromised when the reinforcement rate provided by a concurrent VI schedule prior to punishment could not be obtained via exclusive responding on the unpunished alternative. Punishment parameters such as schedule and delay and various reinforce- ment parameters also likely modify the ef- fects of alternative reinforcement. Thus, ba- sic findings suggest that various factors (e.g., type or intensity of the punisher, density of available reinforcement prior to punish- ment) must be considered when combining reinforcement with punishment in clinical settings.

However, other commonly used reinforce- ment arrangements, such as noncontingent reinforcement (NCR) and differential rein- forcement of low response rates (DRL), have not been evaluated in the context of a con- current punishment contingency in the lab- oratory. More important, basic findings on alternative reinforcement may have limited generality to application because clinically relevant factors (e.g., response topography; reinforcement quality, schedule, delay, and magnitude) usually were held constant across available response options. Treatment with punishment and differential reinforce- ment typically will incorporate different re- sponse, reinforcement, and punishment pa- rameters across the targeted behaviors, es- pecially when problem behavior is main- tained by unknown or uncontrolled sources of reinforcement. In such cases, alternative reinforcement may neither suppress the pun- ished response nor increase adaptive behav- ior. Results of basic studies in which sched- ules of reinforcement and punishment were

arranged for both response options also sug- gest that the amount of suppression pro- duced by punishment for a given behavior can be influenced by contingencies that op- erate on other behavior, including the rela- tive schedule, delay, and magnitude of re- inforcement and punishment (e.g., Deluty, 1976, 1978; Farley, 1980).

Despite obvious clinical implications, only one applied study has evaluated the re- lation between punishment effects and the availability of alternative reinforcement. Thompson et al. (1999) examined the sep- arate and combined effects of punishment and reinforcement on self-injury after results of a functional analysis indicated that the behavior was maintained by automatic re- inforcement. Reinforcement was arranged for an alternative behavior (toy manipula- tion) by giving the participants access to pre- ferred toys (thereby establishing automati- cally reinforced toy play) or by delivering food contingent on toy manipulation. Re- sults for the 4 participants indicated that al- ternative reinforcement enhanced the effi- cacy of relatively mild punishers (e.g., brief manual restraint). Furthermore, reinforce- ment alone was fairly ineffective for all par- ticipants, and punishment alone was ineffec- tive for 1 participant. As noted by the au- thors, however, the combined treatment was differentially confounded with an additional contingency (i.e., time-out from positive re- inforcement—access to programmed rein- forcement was withheld during punishment delivery) that may constrain the generality of the findings.

Further research is needed on clinical strategies to enhance the efficacy of mild punishers through the use of DRA, DRO, DRL, and NCR procedures. Thus far, basic findings in this area suggest a number of ten- tative prescriptions for application. Natural- istic reinforcement schedules for targeted problem and alternative behavior should be considered first when developing treatments

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that combine reinforcement and punish- ment. The type, schedule, and magnitude of reinforcement maintaining problem behav- ior should be identified, so that a larger amount of the same reinforcer could be pro- vided independent of undesirable respond- ing or contingent on alternative behavior (Fantino, 1973). When the functional rein- forcer cannot be identified or delivered by others, selecting reinforcers that compete with or substitute for maintaining reinforc- ers may be critical to effective treatment (e.g., Shore, Iwata, DeLeon, Kahng, & Smith, 1997).

As many of the available sources of rein- forcement as possible also should be deter- mined prior to treatment, so that steps can be taken to ensure that the total amount of obtainable reinforcement can be sustained or exceeded despite a reduction in the punished behavior. To this end, differential reinforce- ment procedures should target simple free- operant responses or adaptive behavior that is already in the individual’s repertoire. Pro- cedures such as NCR, DRO, and DRL, which do not require an alternative response for reinforcement delivery, may be preferable during the initial stages of treatment with punishment to insure a sufficient density of available reinforcement. In fact, multiple re- sponses, reinforcers, and reinforcement con- tingencies (e.g., DRO plus NCR) should be incorporated into treatment such that pun- ishment for a restricted number of responses is implemented within the context of a rich- ly reinforcing environment.

Punishment Magnitude

The relation between the effects of pun- ishment and the magnitude or amount of punishment delivered for responding is es- pecially germane to the efficacy and accept- ability of punishment in clinical settings. From an ethical and practical standpoint, the least amount of punishment that is ef- fective (i.e., lowest intensity, shortest dura-

tion) should be used to treat behavior prob- lems, and strategies that increase the effec- tiveness of mild punishers should be incor- porated into treatment. Basic studies on magnitude have shown that response sup- pression is positively related to the intensity and duration of shock with rats, pigeons, monkeys, and college students (Church, 1969; Deluty, 1978; Scobie & Kaufman, 1969), the duration of time-out with normal humans (Kaufman & Baron, 1968; N. B. Miller & Zimmerman, 1966), and the num- ber of points lost as part of response cost with normal humans (Weiner, 1964). In fact, recovery during punishment and fol- lowing the termination of the punishment contingency was most likely to occur with mild punishers, such as a bar slap (Skinner, 1938) and low-voltage shock (Hake, Azrin, & Oxford, 1967). Furthermore, punishment with high-intensity shock or forceful air blasts was found to be ineffective with rats if the intensity of the punisher was initially low and then gradually increased over time (Cohen, 1968; N. E. Miller, 1960; Terris & Barnes, 1969).

On the basis of these findings, numerous authors have recommended using moderate or high-intensity punishers to treat problem behavior and cautioned against increasing the intensity of punishment gradually over time (e.g., Cooper et al., 1987; Martin & Pear, 1996; O’Brien, 1989). These guide- lines may be difficult to reconcile with eth- ical mandates to identify the least restrictive procedure that is effective. Moreover, close examination of basic findings in this area in- dicates that the relation between responding and punishment magnitude is more complex than frequently assumed. As a result, strat- egies that are based on recommendations de- lineated in applied textbooks (e.g., Cooper et al.; Martin & Pear) and literature reviews may not influence behavior as expected.

As previously noted, the basic relation be- tween response suppression and punishment

442 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

magnitude may be influenced by the avail- ability of alternative reinforcement (e.g., Holz et al., 1963) and the type of reinforce- ment schedule that maintains behavior (e.g., Powell, 1970; Scobie & Kaufman, 1969). Other variables (e.g., immediacy; Cohen, 1968) also may alter the relation between punishment magnitude and responding. Such complex interactions may be respon- sible for some contradictory findings on punishment magnitude that have been re- ported in the applied literature. The extent to which basic findings are directly compa- rable to applied findings also is limited be- cause most basic studies examined the mag- nitude of shock, whereas applied studies in this area have focused on more clinically ac- ceptable forms of punishment (e.g., overcor- rection, time-out).

In one of the few applied studies to eval- uate the magnitude of electric shock, D. E. Williams, Kirkpatrick-Sanchez, and Iwata (1993) compared the efficacy of treatment for self-injury under two shock-intensity lev- els (3.5 mA vs. 18.5 mA). Results were con- sistent with those obtained in basic studies. The high-intensity shock produced larger, more immediate decreases in behavior than the low-intensity shock. The generality of this finding, however, is somewhat limited because punishment was combined with ex- tinction. In addition, sequence effects could have influenced the outcome because the participant was exposed to the lower inten- sity shock prior to the higher intensity, and a reversal to the low-intensity condition was not implemented.

Results of studies examining the relation between punishment magnitude and treat- ment efficacy using other types of punishers (e.g., physical restraint, unpleasant smells, time-out) have been inconsistent and often appeared to be confounded with other var- iables (e.g., Altman, Haavik, & Cook, 1978; Cole, Montgomery, Wilson, & Milan, 2000; Marholin & Townsend, 1978; Singh, Daw-

son, & Manning, 1981). For example, Cole et al. found that treatment with overcorrec- tion produced similar decreases in stereotyp- ic behavior, regardless of whether the inter- vention lasted 30 s, 2 min, or 8 min. The effects of overcorrection, however, may have been confounded with those of extinction and verbal reprimands. Results of studies on the duration of time-out have shown a pos- itive relation (e.g., Burchard & Barrera, 1972; Hobbs, Forehand, & Murray, 1978), a negative relation (e.g., Kendall, Nay, & Jef- fers, 1975), and no relation (e.g., White, Nielsen, & Johnson, 1972) between dura- tion length and treatment effects. These findings are difficult to interpret because the function of problem behavior was not iden- tified (thus, time-out may have been contra- indicated for some participants), and se- quence effects may have confounded the re- sults (Matson & DiLorenzo, 1984).

Further research on the relation between punishment magnitude and response to treatment, as well as on factors that can alter this relation (e.g., reinforcement schedule, punishment delay), may be useful for rec- onciling inconsistent findings in the litera- ture and for developing more comprehensive prescriptions for application. The common assumption that a larger magnitude of a giv- en punisher will be more effective than a smaller magnitude is not strongly supported in the current literature, with the exception of findings on contingent shock. Magnitude should be manipulated with a variety of punishers and in a variety of ways that have not been examined in basic research. For ex- ample, the amount of reinforcement avail- able during ‘‘time-in’’ is another potentially important dimension of magnitude when treatment with time-out is implemented (e.g., Solnick, Rincover, & Peterson, 1977).

Strategies to enhance response suppression and maintenance under less effective values of punishment magnitude also should be ex- plored. Basic findings indicate that smaller

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magnitudes of punishment may be more ef- fective if the punisher is delivered immedi- ately following the behavior (e.g., Cohen, 1968) and if reinforcement is available for an alternative response (e.g., Holz et al., 1963). Basic studies with shock also indicate that a less intense punisher may be effective, at least temporarily, if a high intensity level is decreased gradually over time (e.g., Azrin, 1960; Cohen, 1968; Hake et al., 1967). An approach that involves periodically inter- spersing less intense punishers with more in- tense punishers may be useful for maintain- ing treatment effects while the magnitude of punishment is gradually reduced. As dis- cussed above, further research on condi- tioned punishers and treatments combining reinforcement with punishment also may lead to methods for increasing the effective- ness of mild punishers.

Finally, further studies should evaluate methods for identifying the most appropri- ate magnitude of a given punishment pro- cedure prior to treatment implementation in the natural environment. The typical trial- and-error approach to punishment selection is inefficient and may be counterproductive if an individual receives prolonged exposure to ineffective procedures (e.g., N. E. Miller, 1960; Terris & Barnes, 1969). Efficient strategies for identifying the least restrictive, effective treatment are surprisingly absent from the applied literature. In two studies conducted by Fisher and colleagues (Fisher, Piazza, Bowman, Hagopian, & Langdon, 1994; Fisher, Piazza, Bowman, Kurtz, et al., 1994), the potential suppressive effects of various procedures (e.g., time-out, facial screen, contingent demands) were rapidly as- sessed by exposing participants to the puta- tive punishers while negative vocalizations (e.g., yelling, crying) and avoidance or es- cape responses (e.g., dropping to the floor) were measured. Each punishment procedure was delivered noncontingently across five different durations, ranging from 15 s to

180 s. Results of subsequent treatment anal- yses indicated that the procedure associated with the highest levels of negative vocaliza- tions, avoidance, or escape responses was the most effective punisher for problem behav- ior. However, results of the initial assessment did not differentiate among the various du- ration lengths for any participant, possibly because the procedures were alternated rap- idly across a limited number of trials. The utility of such assessments should be evalu- ated in further studies. For example, a sep- arate assessment of punishment magnitude, similar in design to that conducted by Fisher et al., might be useful after an initial assess- ment has identified a potent punisher.

Until further applied research on magni- tude is conducted, practitioners should select magnitudes that have been shown to be safe and effective in clinical studies, as long as the magnitude is considered acceptable and practical by those who will be implementing treatment. Punishment should be combined with some type of reinforcement procedure, and the punisher should be delivered as im- mediately as possible following occurrences of problem behavior (see further discussion below). If the punisher fails to suppress be- havior over time, alternative procedures probably should be considered instead of in- creasing the magnitude of the punisher un- der the presumption that this strategy will improve the efficacy of treatment.

Immediacy of the Punisher

Consequences for problem behavior are frequently delayed in the natural environ- ment. Caregivers and teachers often are un- able to monitor behavior closely or to deliver lengthy punishers (e.g., 15-min contingent work) immediately following instances of problem behavior (Azrin & Powers, 1975). Punishment also may be delayed when the individual actively resists application of the programmed consequences by struggling with the punishing agent or running away.

444 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

In some cases, problem behavior occurs pri- marily in the absence of the punishing agent, necessarily delaying programmed conse- quences until the behavior is detected (Grace, Thompson, & Fisher, 1996; Van Houten & Rolider, 1988).

For these reasons, research on delayed punishment is especially pertinent. Labora- tory findings with rats indicate that the lengthier the delay between the occurrence of the response and delivery of contingent shock, the smaller the amount of response suppression under punishment (e.g., Baron, Kaufman, & Fazzini, 1969; Camp, Ray- mond, & Church, 1967). Even brief delays of 10 s or 20 s have been found to seriously compromise the effects of contingent shock with rats and college students (e.g., Banks & Vogel-Sprott, 1965; Goodall, 1984) and of reinforcement loss with college students (Trenholme & Baron, 1975).

Stimuli that might bridge the interval be- tween a response and its consequence have been notably absent from laboratory ar- rangements involving delayed punishment. Results of at least one study suggest that fac- tors such as the presence of a conditioned punisher and delivery of instructions can al- ter the efficacy of delayed punishment. In Trenholme and Baron (1975), delays of 10 s, 20 s, and 40 s were equally effective with college students when a brief noise that was paired with reinforcement loss also occurred immediately following the behavior. A sub- sequent experiment showed that delayed punishment was just as effective as imme- diate punishment when the participants re- ceived instructions about the delay. The gen- erality of these findings to clinical popula- tions, such as individuals with developmen- tal disabilities, has not been determined. In addition, no basic studies have evaluated the effects of numerous other potentially impor- tant factors on delayed punishment (e.g., history, reinforcement schedule, availability of alternative reinforcement).

Surprisingly few applied studies have eval- uated the efficacy of delayed punishment or strategies to improve treatment effects when consequences do not occur contiguous to the behavior. In one of the few studies to compare immediate and delayed punish- ment, Abramowitz and O’Leary (1990) found that immediate verbal reprimands were much more effective in decreasing off- task behavior in school children than were reprimands that were delayed by 2 min. These results are somewhat difficult to in- terpret, however, because delayed repri- mands were delivered only if off-task behav- ior had occurred continuously for 2 min, during which time the students had varied opportunities to interact with other students and non-task-related objects. Thus, the ef- fects of punishment delay were not separated from those of reinforcement schedule and punishment schedule.

Results of just two studies have delineated conditions under which delayed punishment may produce effective outcomes. Rolider and Van Houten (1985) and Van Houten and Rolider (1988) demonstrated the effi- cacy of delayed punishment using various mediated consequences with children with emotional and developmental disabilities. One form of mediation involved playing au- diotape recordings of the child’s disruptive behavior that were collected earlier in the day. The punishing consequence (physical restraint, verbal reprimands) then was deliv- ered. In some cases, the tape recorder was clearly visible to the child while the record- ings were being collected, and a verbal ex- planation of its role in the delivery of de- layed punishment was provided. These fac- tors may have served to bridge the temporal gap between inappropriate behavior and its consequence (e.g., by functioning as dis- criminative stimuli for punishment; Tren- holme & Baron, 1975). However, for 1 par- ticipant, neither instructions about delayed punishment nor an immediate consequence

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designed to signal that punishment was forthcoming (a mark placed on the child’s hand) was as effective as the audiotape pro- cedure.

In Van Houten and Rolider (1988), care- givers physically guided 2 participants to en- gage in the problem behavior (aggression or theft) after occurrences of the behavior were detected or reported. Caregivers then deliv- ered the punishing consequence (physical re- straint) immediately following the guided re- sponse. Although treatment was effective, the efficacy of delayed punishment without the guided response component was not ex- amined. The length of the delay and care- givers’ immediate response to the problem behavior also were not specified.

Current knowledge indicates that the mild punishers typically used in clinical set- tings will be ineffective unless the conse- quence immediately follows problem behav- ior. Thus, further research is needed on fac- tors that might enhance treatment effects under delayed punishment, especially pro- cedures or stimuli that would bridge the temporal gap between a response and its consequence. Research on the utility of de- livering conditioned punishers, instructions, and other types of stimuli associated with delayed consequences is needed with clinical populations.

Until further applied research is conduct- ed, teachers and caregivers should be con- cerned with selecting punishers that can be readily delivered as soon as the behavior oc- curs. Consequences that do not require the close proximity of the caregiver (i.e., stimuli that can be delivered or removed from a dis- tance) and technology to increase the prac- ticality of immediate punishment may be es- pecially useful in this regard. Electronic de- vices that detect occurrences of problem be- havior and either alert caregivers or deliver consequences automatically might circum- vent the problems of delayed punishment

(e.g., Linscheid, Iwata, Ricketts, Williams, & Griffin, 1990).

However, the timing of punishment in re- lation to reinforcement delivery also should be considered, because some basic studies have found that immediate punishment was less effective than delayed punishment if the immediate punisher preceded reinforcement delivery but the delayed punisher followed it (e.g., Epstein, 1984; Rodriguez & Logan, 1980). It is conceivable that diligent caregiv- ers may respond to problem behavior by first delivering the prescribed punisher (e.g., con- tingent work, time-out), followed (inadver- tently) by the maintaining social reinforcer (e.g., access to materials). In a similar man- ner, automated punishment may be deliv- ered immediately prior to social or nonsocial consequences for problem behavior. Results of other basic studies, in which the avail- ability of reinforcement for one response was perfectly correlated with the delivery of mild punishment for an immediately preceding response, indicated that pairing punishment and reinforcement in this manner estab- lished the mild punisher as a conditioned positive reinforcer (e.g., Murray & Nevin, 1967; D. R. Williams & Barry, 1966). Thus, the timing of punishment and reinforcement in the natural environment should be eval- uated carefully as part of treatment.

Schedule of Punishment

The effects of punishment schedules on responding have important implications for the efficacy and acceptability of treatment with punishment. Intermittently delivered consequences that successfully reduce prob- lem behavior are easier to use, less time con- suming, and less intrusive than consequences that must follow each occurrence of behav- ior. Results of basic research with pigeons and rats suggest that punishment with shock or time-out will not produce acceptable re- sults unless the punisher follows nearly every occurrence of the behavior in situations in

446 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

which no alternative is available or when the density of reinforcement is not reduced (Ap- pel, 1968; Azrin, Holz, & Hake, 1963; De- luty, 1976; Farley, 1980; Thomas, 1968).

Although a number of applied studies have examined the efficacy of intermittent punishment for treating problem behavior, results have been inconsistent, and the con- ditions under which intermittent punish- ment might be effective remain unclear. In some studies, for example, intermittent pun- ishment schedules were associated with a so- cially significant reduction in behavior, par- ticularly if responding was already sup- pressed to low levels via continuous punish- ment (e.g., Clark, Rowbury, Baer, & Baer, 1973; Rollings & Baumeister, 1981; Ro- manczyk, 1977). Conversely, even dense in- termittent punishment schedules were inef- fective for some individuals in other studies (e.g., Calhoun & Matherne, 1975; Lerman et al., 1997). Basic findings on factors that interact with the effects of punishment schedules (e.g., reinforcement schedule) may explain why clinical applications have pro- duced inconsistent results.

First, punishment appeared to be con- founded with extinction and other potential punishers (e.g., verbal reprimands) in ap- plied studies that showed significant treat- ment effects under thin punishment sched- ules (e.g., Barton, Brulle, & Repp, 1987; Clark et al., 1973; Romanczyk, 1977). Sec- ond, important parameters of punishment (i.e., type, intensity, and schedule) varied considerably among these studies. Basic findings indicate that these variables alter the relation between intermittent punishment and response suppression. Increasing the in- tensity of a punisher, for example, can either enhance or degrade the efficacy of intermit- tent schedules, depending on other factors (e.g., Appel, 1968; Lande, 1981). Certain punishment schedules (e.g., VI) also have been associated with greater decreases in re- sponding than other schedules (e.g., FR or

FI; Azrin, 1956; Camp, Raymond, & Church, 1966), although the nature of this relation is complex (e.g., Arbuckle & Lattal, 1992) and appears to be influenced by the schedule of reinforcement that maintains the behavior (e.g., Bradshaw et al., 1977, 1978; Powell, 1970; Scobie & Kaufman, 1969).

In the only applied study that examined the interaction between type or intensity of punishment and intermittent punishment schedules, Cipani, Brendlinger, McDowell, and Usher (1991) found that a VR 4 sched- ule of punishment with contingent applica- tion of lemon juice was just as effective as a continuous schedule in reducing a child’s stereotypic behavior. A ‘‘manual guidance overcorrection’’ procedure (i.e., physically guiding the child’s arms over the head and to the sides 10 times) also was effective when the procedure was delivered under a contin- uous schedule. Unlike the lemon juice, how- ever, a VR 4 schedule with the overcorrec- tion procedure did not produce clinically significant reductions in behavior.

Finally, interactions between schedules of reinforcement and punishment may account for the idiosyncratic effects of intermittent punishment on problem behavior. For ex- ample, Lerman et al. (1997) treated 5 par- ticipants’ self-injurious behavior (SIB) with a continuous schedule of punishment after results of a functional analysis indicated that the behavior was maintained by automatic reinforcement. Initial application of inter- mittent punishment (FI 2 min or FI 5 min) was ineffective for 4 of the 5 participants. The continuous punishment schedule then was successfully thinned to FI 5 min for 2 of these participants. In contrast, continuous punishment was necessary to suppress SIB for the other 2 participants, despite repeated attempts to thin the schedule. Although the function of SIB had been identified prior to treatment, important parameters of the maintaining reinforcers were unknown (e.g., schedule, density, magnitude). These param-

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eters, which likely varied across participants, may have been responsible for the inconsis- tent success of the schedule-thinning proce- dure.

Further research on interactions between punishment schedule (e.g., VR vs. VI) and other potentially important parameters of punishment and reinforcement is needed to clarify the conditions under which intermit- tent punishment would and would not be effective. Few studies have directly evaluated strategies to systematically thin punishment schedules or to utilize highly variable (and thus unpredictable) schedules. Combining a thin schedule of punishment with a rich schedule of conditioned punishment is an- other potential approach for increasing the efficacy of intermittent punishment. De- pending on the nature of the conditioned and unconditioned punishers, this arrange- ment may be more practical than using a rich schedule of unconditioned punishment alone. A dense schedule of alternative rein- forcement also may promote the efficacy of intermittent punishment.

Other types of punishment schedules ex- amined in the basic laboratory, such as the differential punishment of high (DPH) or low (DPL) response rates, also may be useful in clinical settings. These schedules do not specify a direct contingency between the de- livery of the punisher and the occurrence of a response. For example, under DPH or DPL, punishment is delivered contingent on the pause length that immediately preceded a response (i.e., the selective punishment of certain lengths of interresponse times). Re- sults of basic studies on DPH and DPL schedules showed that overall responding in- creased when relatively long interresponse times (DPL) were punished and decreased when short interresponse times (DPH) were punished (e.g., Galbicka & Branch, 1981; Laurence, Hineline, & Bersh, 1994). DPH schedules may be more beneficial than con- tinuous punishment when treating behavior

that is considered problematic only because it occurs at high rates or in bursts. Further understanding of these schedules also is im- portant because they may commonly operate in the natural environment. For example, caregivers may be more likely to deliver pun- ishment when problem behavior occurs in- frequently (i.e., is characterized by long in- terresponse times) than when behavior oc- curs at high rates (see Arbuckle & Lattal, 1992, for a discussion of this issue). Such an arrangement could compromise the efficacy of treatment by increasing the frequency of short interresponse times.

Current knowledge about punishment schedules suggests that parents and teachers should punish each occurrence of problem behavior unless the behavior is simulta- neously exposed to extinction. Until further research is conducted, clinicians should be extremely cautious when attempting to thin the punishment schedule, utilize DRH schedules, or evaluate other strategies for im- proving the effects of intermittent punish- ment (e.g., employing variable schedules or conditioned punishers). A continuous sched- ule of punishment always should be imple- mented initially, and intermittent schedules should be considered only if the continuous schedule remains effective in suppressing problem behavior to low levels over a con- siderable amount of time.

FACTORS RELATED TO MAINTENANCE, GENERALIZATION,

AND INDIRECT EFFECTS

A much smaller proportion of basic and applied studies on punishment have evalu- ated the long-term maintenance, generaliza- tion, and side effects of punishment relative to those on direct effects. The extent to which punishment effects are maintained over time, transfer across settings and con- texts, and produce changes in other behavior

448 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

has significant implications for treatments involving punishment.

Maintenance

The durability of treatment with punish- ment is one of the most important consider- ations for practitioners, teachers, and caregiv- ers of individuals with behavior disorders. A number of authors, however, have suggested that the clinical effects of punishment are rel- atively short-lived, even when the treatment remains unchanged over time (e.g., Parsons, Hinson, & Sardo-Brown, 2001; Walker & Shea, 1999). In basic studies with both hu- mans and nonhumans, various punishers have been associated with continued response sup- pression under punishment, including relative- ly intense levels of electric shock with pigeons and rats (Azrin, 1960; Crosbie et al., 1997), point or monetary loss with normal humans (Crosbie et al.; Weiner, 1962), and time-out from positive reinforcement with squirrel monkeys (McMillan, 1967). Response recov- ery, however, has been associated with less in- tense punishers, such as low-voltage shock with pigeons (Rachlin, 1966), a bar slap with rats (Skinner, 1938), and noise with pigeons (Holz & Azrin, 1962). Basic findings on the maintenance of response suppression follow- ing the termination of the punishment con- tingency also generally showed that response rates immediately returned to prepunishment levels—sometimes even temporarily exceeding baseline—unless intense punishers were used (e.g., high-voltage shock; Azrin, 1960).

These results suggest that sufficiently in- tense punishers, including some commonly used clinical procedures (e.g., time-out), may produce lasting reductions in problem behavior as long as the punishment contin- gency remains in effect. Nevertheless, basic findings may not be applicable to treatment outcomes in clinical settings because the time periods evaluated in the laboratory (e.g., 30-min to 60-min punishment sessions across 10 to 20 days) may have little relation

to the numerous months (and sometimes years) over which problem behavior requires treatment. Moreover, few studies have ex- amined factors that may influence the du- rability of punishment effects.

Although brief treatment evaluations are predominant in the applied literature on punishment, an increasing number of stud- ies have examined the long-term efficacy of punishment over the past 10 years. Treat- ment effects have been examined for 1 to 60 months after punishment was initiated and continued with minor changes to the pro- cedure (Duker & Seys, 1996; Ricketts, Goza, & Matese, 1993; D. E. Williams, Kirkpatrick-Sanchez, & Crocker, 1994), and after the original punishment component was withdrawn (Arntzen & Werner, 1999; Foxx, Bittle, & Faw, 1989; Rolider, Wil- liams, Cummings, & Van Houten, 1991). Results have shown varying success in main- taining the reduction in behavior, yet poten- tial reasons for the inconsistent outcomes have not yet been identified.

For example, D. E. Williams et al. (1993) observed a relapse in treatment with contin- gent electric shock 6 months after punish- ment was initiated. Conversely, Linscheid, Hartel, and Cooley (1993) found that con- tingent electric shock continued to suppress 2 individuals’ self-injurious behavior for 5 years. Duker and Seys (1996) examined the long-term efficacy of contingent shock with 12 individuals by obtaining information on the degree of physical restraint each required from 2 to 47 months after the initiation of punishment. Results at follow-up suggested that treatment remained effective for 7 par- ticipants, including 1 individual who was evaluated at 36 months and another who was evaluated at 47 months.

Conclusions about applied findings on maintenance are difficult to draw for a num- ber of reasons. First, the majority of studies examined the long-term effectiveness of con- tingent electric shock, so results may not be

449PUNISHMENT

applicable to other (or more mild) punishers (Azrin & Holz, 1966). Second, the reinforc- ing consequences of problem behavior were not identified prior to treatment in most cas- es. Long-term maintenance may have been more likely to occur if the maintaining re- inforcer was withheld contingent on prob- lem behavior or readily available for engag- ing in more appropriate behavior (Estes, 1944). Third, other factors potentially re- sponsible for both successful and unsuccess- ful cases of treatment maintenance may have varied widely across the studies (e.g., pun- ishment schedule, availability of reinforcers that competed with or substituted for the maintaining reinforcer). In fact, components of the original intervention were modified over time in some studies (e.g., additional behavioral procedures or drugs were intro- duced; Duker & Seys, 1996), and it is dif- ficult to determine which, if any, treatment modifications may have been responsible for the outcomes. Furthermore, the lengthy time period required to conduct these stud- ies increased the likelihood that unplanned changes or other uncontrolled factors inter- acted with the efficacy of the original treat- ment in either desirable or undesirable ways. Finally, the number of treatment relapse cas- es reported in the literature may not accu- rately reflect the prevalence of this problem in applied settings because such cases are less likely to be submitted or accepted for pub- lication than successful cases of treatment maintenance.

Identifying factors or processes associated with long-term maintenance is key to the design of a systematic technology for pre- venting and remediating treatment relapse. Several authors have suggested that adapta- tion, or habituation, to the punishing stim- ulus accounts for instances of recovery (i.e., repeated exposure decreases the aversiveness of the punisher; Goodall, 1984). Moreover, adaptation is more likely to occur with mild punishers, which are typically employed in

clinical settings. One strategy that may de- crease the likelihood of habituation is the use of hiatus from punishment. In several basic studies with pigeons, response suppression under shock punishment was enhanced fol- lowing brief time periods during which the subject was removed from the punishing sit- uation or exposed to reinforcement only (e.g., Rachlin, 1966). Further research is needed, however, because the beneficial ef- fect of this procedure was found to wane across repeated punishment–hiatus cycles (e.g., Orme-Johnson, 1967). Other strate- gies that may prevent or attenuate habitua- tion, such as using intermittent, varied, or brief punishers (e.g., Charlop et al., 1988), should be evaluated in further studies.

Research also is needed on strategies to maintain punishment effects while the inter- vention is systematically faded. Basic find- ings with pigeons and monkeys have shown that responding will remain suppressed un- der low-intensity shock if an initially intense shock is reduced very gradually (e.g., Hake et al., 1967). Further applied research is needed to determine if treatment effects will be maintained while the intensity or dura- tion of a punishment procedure is altered very gradually or less intrusive procedures are simultaneously introduced. For example, it may be possible to reduce a 5-min time- out to a 1-min time-out over time. The use of conditioned punishers may enhance the likelihood of fading certain dimensions of intrusive punishers while treatment effects are maintained over the long run. Moreover, basic studies have found that response re- covery is more gradual following the with- drawal of intermittent shock punishment than following the removal of other punish- ment schedules (e.g., Azrin et al., 1963; Camp et al., 1966). Thus, strategies to in- crease the utility of conditioned punishers and intermittent punishment for routine clinical practice also may promote the long- term efficacy of punishment.

450 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

Several authors have suggested that com- bining punishment with differential rein- forcement may increase the likelihood that punishment can be faded successfully (e.g., Kazdin, 2001). Although this clinical strategy has not been evaluated directly, one study found that differential reinforcement was more effective in reducing problem behavior after a participant had been exposed to a pe- riod of punishment (contingent work) than when differential reinforcement preceded punishment (Fisher et al., 1993). Research findings on the indirect effects of punishment suggest that punishment may increase res- ponsivity to reinforcement (see below for fur- ther discussion). Thus, punishment may en- hance the efficacy of reinforcement for estab- lishing appropriate behavior that competes with or replaces inappropriate behavior, an outcome that in turn may increase the like- lihood that punishment can be withdrawn.

Until additional research on long-term maintenance is conducted, practitioners and caregivers should not assume that punish- ment will remain effective over the long run. Strategies for increasing the likelihood of maintenance should be employed from the outset of treatment. Although basic findings suggest that relatively intense punishers may be associated with successful long-term out- comes, the use of analogous procedures to treat problem behavior probably would raise ethical concerns for all but the most serious cases. Caregivers instead should focus on the use of reinforcement to insure that alterna- tive behavior is at high strength in the rep- ertoire of individuals who are exposed to punishment. Systematic reinforcer assess- ments and functional analyses of problem behavior always should precede treatment implementation (Fisher et al., 1992). The ef- fects of punishment may last longer if ap- propriate behavior is maintained by the same reinforcers that maintain problem behavior or by reinforcers that are effective substitutes for maintaining reinforcers. The reinforcing

consequences of problem behavior also should be minimized or withheld if possible.

Potential problems with habituation may be curtailed by limiting exposure to the pun- isher in various ways. For example, caregivers could schedule brief vacations from punish- ment on a regular basis (Rachlin, 1966) or restrict the use of specific procedures to one or two problem behaviors (e.g., those of greatest concern) instead of applying the same treatment for a variety of responses. Comprehensive punisher assessments also should be employed to identify clinically ac- ceptable procedures that produce the great- est reduction in behavior and, hence, would lead to the least amount of exposure to the punisher (see Fisher, Piazza, Bowman, Ha- gopian, & Langdon, 1994). If the assess- ment identifies more than one effective form of punishment, caregivers could alternate among several procedures to minimize ex- posure to any single punisher.

Finally, practitioners and caregivers should have a plan for dealing with treatment re- lapse when it occurs during punishment or following the removal of punishment. The first step is to identify and rectify other fac- tors that may be responsible for treatment failure. Many instances of relapse likely are attributable to problems with treatment in- tegrity (D. E. Williams et al., 1993), espe- cially when the punishment procedure is complex or time consuming (e.g., Foxx & Livesay, 1984). The next step is to reassess a wide range of stimuli and activities that may function as potent reinforcers for appropri- ate behavior and to target additional, mul- tiple responses that might compete with the punished behavior. Alternative forms of punishment should be considered only after determining that the current punisher is in- effective within the context of a richly rein- forcing environment. At this point, another comprehensive punisher assessment should be conducted to identify other effective pun- ishers. Increasing the intensity or magnitude

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of the ineffective punisher is not recom- mended, as discussed above (see Reinforce- ment Magnitude).

Stimulus Generalization

The transfer of treatment effects across dif- ferent settings and contexts (i.e., stimulus generalization) is another critically important outcome for individuals with behavior dis- orders. (Response generalization under pun- ishment, or a concomitant reduction in un- punished behavior when a punished response decreases, will be discussed under the heading Indirect Effects of Punishment.) Integration into the community may be restricted even when problem behavior is responsive to treat- ment if the procedure cannot be implement- ed everywhere the behavior occurs (e.g., dur- ing transitions at school or in public places such as stores and buses). Basic findings on stimulus generalization, however, suggest that the effects of punishment on problem behav- ior may transfer to untreated settings and contexts. Results of several basic studies with pigeons showed that the suppression in re- sponding produced by shock punishment oc- curred in the presence of antecedent stimuli that were not used in the training situation, even though punishment was withheld dur- ing tests for generalization (e.g, Hoffman & Fleshler, 1965; Honig & Slivka, 1964). The amount of response suppression (i.e., level of stimulus control) was a function of the phys- ical similarity between the generalization stimuli and the stimuli present during train- ing with punishment, a finding that is anal- ogous to basic findings on stimulus general- ization and reinforcement effects (Guttman & Kalish, 1956).

Research findings with pigeons and shock punishment, however, may not be directly applicable to humans in clinical settings. In the only two studies to examine stimulus generalization with humans in the labora- tory, generalization was relatively difficult to obtain with college students and a more

clinically relevant form of punishment (point loss; O’Donnell & Crosbie, 1998; O’Donnell, Crosbie, Williams, & Saunders, 2000). Further basic research is needed with both humans and nonhumans to identify factors that influence the degree and dura- bility of stimulus generalization during pun- ishment. Such factors may include parame- ters of punishment or reinforcement (e.g., intensity, amount, schedule) and features of the generalization stimuli (e.g., saliency).

In fact, results of numerous applied stud- ies indicate that punishment effects rarely transfer to settings or contexts that are un- associated with punishment delivery (e.g., Corte, Wolf, & Locke, 1971; Doke & Ep- stein, 1975; Marholin & Townsend, 1978; Rollings, Baumeister, & Baumeister, 1977). Surprisingly few studies have evaluated strat- egies to promote generalization since Matson and Taras (1989) lamented this gap in a 20- year review of the applied literature on pun- ishment. In early studies, factors such as the presence of the therapist (Risley, 1968) and proximity of the individual to the therapist or treatment setting (Lovaas & Simmons, 1969; Rollings et al.) were found to influ- ence generalization. These findings are con- sistent with those of basic studies showing a positive relation between amount of re- sponse suppression and the degree of simi- larity between punishment and generaliza- tion contexts. This relation may in fact ex- plain why generalization has rarely been ob- served in applied studies. In most cases, the phenomenon was tested via abrupt alteration of both the stimulus context and the pun- ishment contingency. Participants who con- tinued to exhibit at least some instances of the target behavior would readily detect the transition from a continuous schedule of punishment to the removal of punishment (Azrin & Holz, 1966). In basic studies, re- sponding eventually recovered when the generalization stimuli were repeatedly pre- sented in the absence of punishment.

452 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

Thus, it is not surprising that punishment effects typically failed to generalize in the ab- sence of procedures designed to promote transfer (Stokes & Baer, 1977). Several au- thors have suggested that techniques found to enhance generalization under reinforce- ment may be similarly effective under pun- ishment (e.g., Matson & DiLorenzo, 1984; Miltenberger, 2001). A few applied studies on punishment have evaluated generalization strategies analogous to those used to promote reinforcement effects. For example, common stimuli were introduced into treatment and generalization settings (e.g., a discriminative stimulus for punishment was presented in the generalization setting; Birnbrauer, 1968), stimuli that might acquire discriminative control over the behavior were removed from the treatment setting (e.g., the therapist was hidden from view; Corte et al., 1971; Tate & Baroff, 1966), and training was conducted with multiple stimulus exemplars (e.g., sev- eral different therapists delivered shock; Lo- vaas & Simmons, 1969). In nearly all cases, however, these strategies were ineffective un- less punishment was delivered in the gener- alization context.

Other potential tactics drawn from the lit- erature on reinforcement include pairing the punisher with naturalistic consequences (e.g., verbal reprimands), varying the stim- ulus conditions during initial treatment with punishment, providing instruction on self- management, and using delayed or intermit- tent punishment (i.e., indiscriminable con- tingencies; Stokes & Baer, 1977; see also O’Donnell & Crosbie, 1998, Experiments 3 and 4). Generalization also may be achieved by implementing a modified form of the treatment in generalization contexts (e.g., delivering a smaller amount of the punisher or a single component of a multicomponent treatment procedure).

Current knowledge about punishment, however, is insufficient to guide the appli- cation of such strategies. For example, many

factors that are useful for promoting gener- alization under reinforcement, such as de- layed or intermittent contingencies, have been found to undermine the efficacy of punishment (Azrin et al., 1963; Goodall, 1984; Trenholme & Baron, 1975). The sup- pressive effects of naturalistic consequences and component derivatives of complex in- terventions likely depend on the process of conditioned punishment, an area that re- quires further study. Finally, the develop- ment of stimulus control under punishment has been evaluated in few basic or applied studies (see Rollings & Baumeister, 1981, for a notable exception). Successful general- ization may hinge on the presence of stimuli that have acquired tight control over re- sponding, such that few responses occur in the absence of the punishment contingency. Relative to reinforced responding, it may be difficult to establish control over punished responding with stimuli that are not per- fectly correlated with the delivery of punish- ment. Thus, further research in the areas of conditioned punishment, stimulus control, and intermittent or delayed punishment ap- pears to be critical for developing a technol- ogy of generalization.

The current literature indicates that pun- ishment must be delivered consistently in all relevant contexts. Nevertheless, various gen- eralization strategies described by Stokes and Baer (1977) may be useful for promoting treatment generality when the procedure is extended beyond the initial treatment set- ting. For example, a variety of stimulus con- ditions could be arranged in the initial treat- ment setting (e.g., different caregivers and peers could be present, diverse activities could be scheduled, physical features of the environment could vary). Stimuli common to other settings and contexts in which pun- ishment will be applied could be introduced in the initial treatment setting before the in- tervention is widely implemented. Treat- ment generality also may be enhanced by en-

453PUNISHMENT

suring that reinforcement is implemented consistently across settings, incorporating certain aspects of self-management into treatment (e.g., self-monitoring), and estab- lishing salient discriminative stimuli for pun- ishment in all settings and contexts (see Stokes & Baer for further discussion of gen- eralization procedures).

Indirect Effects of Punishment

The effects of punishment on responses that can occur concurrently with the pun- ished behavior or in a different context as the punished behavior also have been studied in basic and applied research. Among these side effects, collateral increases in aggression, es- cape behavior, and emotional reactions are most commonly described in basic textbooks and literature reviews (e.g., Azrin & Holz, 1966; Mazur, 1998) and by authors who rec- ommend against using punishment in clinical settings (e.g., LaVigna & Donnellan, 1986; McGee, Menolascino, Hobbs, & Menousek, 1987; Parsons et al., 2001).

Aggression (i.e., attacking nearby subjects, biting inanimate objects) in rats, pigeons, and monkeys has been associated with non- contingent delivery of unavoidable stimuli, including shock and intense heat (e.g., Hutchinson, 1977; Ulrich & Azrin, 1962). Although this phenomenon is often called punishment-elicited aggression, few studies have examined this side effect of punish- ment. Basic findings on the effects of ines- capable, intense punishers probably have limited generality to the application of pun- ishment (see Linscheid & Meinhold, 1990, for further discussion). Furthermore, elicited aggression in monkeys and rats has been ob- served to decrease when the subject could exhibit a response (e.g., lever press) to escape from the situation in which the stimulus was delivered (e.g., Azrin, Hutchinson, & Hake, 1966). This finding suggests that elicited ag- gression may be less problematic during punishment than is commonly assumed be-

cause the contingency itself provides an es- cape response (i.e., delivery of the punisher can be avoided by refraining from the pun- ished behavior). In fact, results of several studies with rats showed that emotional re- sponses in the form of crouching and defe- cation were more pronounced and persistent when subjects were exposed to unavoidable shock than to response-contingent stimula- tion (Hearst, 1965; Hunt & Brady, 1955).

On the other hand, numerous basic stud- ies indicate that other forms of unpunished behavior, including responses that occur in the absence of programmed consequences (e.g., species-specific behavior) and those that are maintained by experimenter-deliv- ered reinforcement, may increase, decrease, or remain unchanged during punishment. Factors that determine whether unpunished behavior will increase or decrease (called con- trast and induction, respectively) have not been thoroughly studied. The function of the behavior, schedule and intensity of the punisher, and prior exposure to the punisher may be important (see Crosbie et al., 1997, for a discussion).

In a series of studies, Dunham and col- leagues examined the effects of punishment on multiple responses in gerbils by deliver- ing shock contingent on one response (e.g., eating) while changes in alternative responses (e.g., digging, grooming, running) were measured. Results indicated that the most probable of the unpunished responses in- creased during punishment, whereas re- sponses that tended to follow the punished response decreased (Dunham, 1977, 1978; Dunham & Grantmyre, 1982). A subse- quent study suggested that the function of the unpunished behavior also may determine these side effects. Baker, Woods, Tait, and Gardiner (1986) found that when eating in gerbils was punished by shock or noise, dig- ging increased even though running was the most probable response during baseline. The authors suggested that digging was a species-

454 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

specific response to food deprivation (i.e., digging was in the same response class as eating). Results of studies on behavior that is maintained in the absence of experiment- er-arranged reinforcement may have some relevance to problem behavior that produces its own reinforcing consequences (e.g., sen- sory stimulation).

In other basic studies with humans and pi- geons, the same reinforcer was used to estab- lish and maintain two or more functionally equivalent responses (e.g., key pecking, lever pulling) under concurrent or multiple sched- ules. Punishment in the form of shock, time- out, and point or monetary loss was then de- livered for one member of the response class while the effects on the other responses were observed. The most common finding for both humans and nonhumans was an increase in unpunished behavior (i.e., contrast; Bennett & Cherek, 1990; Bradshaw, Szabadi, & Bev- an, 1979; Brethower & Reynolds, 1962; Cros- bie, 1991; Powell, 1971; Thomas, 1968). However, results were inconsistent both with- in and across subjects, and the effects often were short-lived. The main findings of Dun- ham and colleagues (i.e., an increase in the most probable behavior and a decrease in be- havior that often followed the punished be- havior; Dunham, 1977, 1978; Dunham & Grantmyre, 1982) were not replicated with college students when up to 10 responses were reinforced simultaneously and one response was exposed to contingent point loss (Crosbie, 1990, 1991).

From a clinical standpoint, collateral in- creases in appropriate behavior and collateral decreases in unpunished inappropriate behav- ior would be desirable. In fact, applied re- search findings suggest that a variety of de- sirable and undesirable side effects can occur within and across individuals. Punishment of problem behavior has been associated with increases in appropriate behavior, such as compliance and toy play (e.g., Koegel, Fire- stone, Kramme, & Dunlap, 1974; Rolider,

Cummings, & Van Houten, 1991) and with decreases in unpunished inappropriate behav- ior, including aggression and crying (e.g., Bit- good, Crowe, Suarez, & Peters, 1980; Lovaas & Simmons, 1969; Linscheid et al., 1990; Ricketts et al., 1993; Singh, Watson, & Win- ton, 1986). On the other hand, decreases in appropriate behavior (e.g., toy play, speaking) and increases in unpunished problem behav- ior (e.g., aggression, emotional reactions, ste- reotypic behavior) also have been reported (e.g., Bitgood et al., 1980; Duker & Seys, 1996; Foxx & Azrin, 1973; Harris & Wol- chick, 1979; Pendergrass, 1971; Singh, Man- ning, & Angell, 1982; Thompson et al., 1999). A number of authors have suggested that desirable side effects are more likely to occur than undesirable side effects during treatment with punishment (see Lundervold & Bourland, 1988, and Matson & Taras, 1989, for reviews). The prevalence of these side effects is unknown, however, because rel- atively few studies have directly examined the effects of punishment on unpunished behav- ior in clinical settings. More important, data collection often was limited to one or two collateral behaviors (see Sisson, Hersen, & Van Hasselt, 1993, for a notable exception). Positive side effects also may be reported more frequently than undesirable side effects in clinical studies on punishment, regardless of the actual prevalence.

Although relatively incomplete, basic findings in this area suggest some possible explanations for the inconsistent outcomes obtained in applied studies. Punishment- elicited aggression and emotional reactions are less probable when exposure to the pun- ishing stimulus can be reduced or avoided (e.g., Azrin et al., 1966; Hunt & Brady, 1955). Thus, these undesirable side effects may have been less likely to occur in clinical studies when a relatively brief punisher sup- pressed behavior to low levels or when an alternative source of reinforcement was high- ly effective in strengthening an incompatible

455PUNISHMENT

response. Conversely, aggression and other inappropriate behavior may have increased in some applied studies because the respons- es were in the same response class as the punished behavior (Baker et al., 1984). Re- sults of several basic studies with rats and pigeons also indicate that the likelihood of contrast is positively related to the density of the punishment schedule (e.g., Deluty, 1976; Thomas, 1968). Thus, increases in unpunished behavior may have been more probable when the punishment procedure was implemented with a high degree of in- tegrity (i.e., consistently followed each oc- currence of the response).

Some basic findings suggest that context may be an important factor in determining which responses increase or decrease during punishment. Bolles, Holtz, Dunn, and Hill (1980) found that induction in rats was more likely to occur when the unpunished response was performed under the same stimulus condition as the punished response (e.g., pushing vs. lifting the same lever) than under different stimulus conditions (e.g., manipulating separate levers). Crosbie et al. (1997) found that induction in both hu- mans and nonhumans was more likely to oc- cur under mixed schedules during the initial exposure to punishment, whereas contrast was more likely to occur under multiple schedules. Together, these findings suggest that functionally equivalent unpunished re- sponses may have been likely to decrease in applied studies if the behavior tended to be exhibited in the same context as the pun- ished behavior.

Further research on factors that determine whether a particular unpunished behavior will increase, decrease, or remain unchanged during punishment is needed so that the di- rection and nature of side effects can be pre- dicted and controlled. Further research also is needed to determine if these side effects are specific to punishment because similar results have been obtained when a response

was suppressed via satiation or response blocking (e.g., Dunham & Grantmyre, 1982), indicating that such effects may be associated with response suppression per se. In fact, several undesirable side effects of punishment (e.g., increases in aggression, es- cape, and emotional reactions) have been as- sociated with extinction procedures (Lerman & Iwata, 1996a) that often were confounded with punishment in applied research.

Nevertheless, basic findings suggest a number of potentially useful clinical strate- gies. Punishment-elicited aggression or emo- tional responses (e.g., crying) may be atten- uated by implementing procedures that min- imize exposure to the punishing stimulus (e.g., using brief stimuli that produce near- complete suppression of the behavior; strengthening competing responses by deliv- ering potent reinforcers on rich schedules). Comprehensive descriptive or functional analyses of appropriate and inappropriate behavior in an individual’s repertoire may be useful for predicting the likelihood of un- desirable collateral effects and for arranging conditions to increase desirable effects. In- suring that caregivers withhold reinforce- ment for unpunished problem behavior might prevent collateral increases in behavior that is in the same response class as the pun- ished behavior. Alternative strategies for managing undesirable contrast effects (e.g., arranging punishment for other inappropri- ate responses) may be necessary if extinction cannot be used.

Identifying and punishing precursors to dangerous behavior (e.g., mild forms of self- injury that consistently precede more severe forms) may lead to collateral reductions in the severe behavior, augmenting the safety and efficacy of treatment (e.g., Dunham, 1977, 1978). Collateral reductions in func- tionally equivalent appropriate behavior might be avoided by arranging reinforce- ment for the behavior under stimulus con- ditions that are distinctly different from

456 DOROTHEA C. LERMAN and CHRISTINA M. VORNDRAN

those present when the punished behavior occurs (e.g., by modifying features of the en- vironment or introducing reinforcement in a new setting). To this end, caregivers should ensure that alternative reinforcement is avail- able for multiple responses across a variety of contexts and settings.

Finally, the potential for undesirable side effects that involve caregiver behavior (e.g., overusing punishment, dehumanizing the punished individual) should be given more attention in the applied literature. Although these effects are frequently described in text- books and reviews (e.g., Cooper et al., 1987; Guess et al., 1987; Kazdin, 2001), few stud- ies have directly evaluated changes in the punishing agent’s behavior. Research findings that are relevant to this phenomenon have not supported the hypothesis that using pun- ishment negatively affects caregiver behavior or attitudes toward the punished individual (e.g., Bihm, Sigelman, & Westbrook, 1997; Goza, Ricketts, & Perkins, 1993; Harris, Handleman, Gill, & Fong, 1991; Propst & Nagle, 1981). Bihm et al., for example, found that college students’ attitudes toward a fic- titious client (i.e., ratings of client compe- tence, adjustment, and learning potential) were related to treatment success rather than to the type of intervention used (i.e., rein- forcement vs. mild or intense punishment).

CONCLUSIONS

The use of punishment to treat problem behavior in clinical populations has re- mained controversial for many years (see Iwata, 1988; Johnston, 1991). Results of ba- sic and applied research indicate that current treatment approaches based on punishment have advantages (e.g., they are highly effec- tive) and disadvantages (e.g., there are un- predictable side effects). Nevertheless, pun- ishment is still sometimes needed to reduce destructive behavior to acceptable levels (e.g., Grace et al., 1994; Hagopian et al.,

1998; Wacker et al., 1990); punishment may underlie the effects of certain common func- tion-based treatments (e.g., Lerman & Iwa- ta, 1996b; Mazaleski et al., 1994); and care- givers continue to use punishment to reduce problem behavior in the natural environ- ment (e.g., Peterson & Martens, 1995).

Further understanding of punishment processes is needed to develop a systematic, effective technology of behavior change. A review of the applied literature indicates that a wide range of punishment procedures can successfully treat severe behavior disorders in clinical populations. Variables that contrib- ute to the findings reported in this research, however, have not been delineated. The ma- jority of studies focused on procedural vari- ations of punishment rather than on factors that may influence the direct and indirect effects of punishment. A review of labora- tory research on punishment suggests that numerous variables alter basic processes in complex ways. Factors such as history, rein- forcement schedule, various punishment pa- rameters, and alternative sources of reinforce- ment may influence the immediate effects of punishment and other clinically relevant out- comes, such as long-term maintenance, gen- eralization, and the emergence of side ef- fects. Basic findings also contradict some commonly held assumptions about punish- ment effects and provide possible explana- tions for the inconsistent findings that have been reported in applied studies.

Nevertheless, current knowledge about basic processes is insufficient for translation to application. The basic literature on some important relations remains incomplete (Baron, 1991; Crosbie, 1998). More impor- tant, the extent to which findings with non- humans and response-contingent electric shock can be extrapolated to the treatment of behavior disorders in clinical populations may be substantially restricted. Although some basic studies have been conducted with human participants, the typical punisher

457PUNISHMENT

(point or monetary loss) and population (normal adults) may limit the relevance of the findings for individuals with restricted verbal skills (see Hayes & McCurry, 1990, for further discussion).

Research on punishment only tentatively supports most prescriptions for application discussed in previous articles on punishment and in this updated review of the literature. Basic findings also suggest that the process of punishment may be more complex than frequently assumed. As such, clinicians, par- ents, and teachers should be cautioned about the need for further research on potential strategies for increasing the effectiveness of mild punishers, for attenuating undesirable aspects of punishment, and for successfully fading treatment with punishment.

The basic literature suggests a number of avenues for further research. In particular, knowledge about conditioned, intermittent, and delayed punishment and the interactive effects of reinforcement and punishment may lead to technological advances that increase the effectiveness and acceptability of punish- ment in clinical settings. Concurrent sched- ules of reinforcement and punishment are es- pecially germane to application because mul- tiple contingencies typically operate in the natural environment. Treatment also may have a greater likelihood of immediate, long- term, and generalized success when multiple sources of alternative reinforcement are ar- ranged within the context of punishment.

The refinement of functional analysis methodologies has led to greater understand- ing of variables that can maintain problem behavior and an emphasis on function-based intervention. Yet, potentially important links between function and treatments based on punishment often may be overlooked. The utility of functional analysis for guiding de- cisions about potential treatments that in- clude a punishment component should be emphasized in further research. Results of functional analyses may indicate whether

treatment with reinforcement alone (e.g., differential reinforcement) or with common punishment procedures (e.g., time-out, ver- bal reprimands) will be successful. For ex- ample, time-out is more likely to be effective than contingent verbal reprimands if prob- lem behavior is sensitive to attention (Iwata, Pace, Dorsey, et al., 1994). Problem behav- ior that occurs at high levels across a wide variety of conditions may be less responsive to treatment with reinforcement than behav- ior that is differentially low under certain conditions (e.g., the play or control condi- tion of the functional analysis; see Paisey, Whitney, & Hislop, 1990). Functional anal- ysis methodology also may be useful for identifying potent reinforcers to arrange as part of treatment (e.g., for use in differential reinforcement or noncontingent reinforce- ment procedures) and for identifying func- tionally equivalent appropriate behavior to strengthen as part of treatment.

Finally, a greater willingness to publish studies showing treatment failures and other undesirable outcomes during punishment may be helpful. For example, unsuccessful at- tempts to attenuate side effects, to increase the efficacy of delayed punishment, or to pro- mote long-term maintenance and generaliza- tion may guide further research for delineat- ing variables that are and are not relevant to clinical application. This knowledge ultimate- ly may lead to more effective, empirically sound recommendations for treatment.

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Received September 1, 2001 Final acceptance August 12, 2002 Action Editor, Joseph Spradlin

 
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