Extinction Bursts

In psychiatric and behavioral health care, one of the more puzzling phenomena that parents often struggle with in caring for children who have psychiatric disorders is the extinction burst. This happens when a maladaptive behavior temporarily increases in frequency, intensity, and/or duration after the removal of its reinforcement, just before the behavior declines. Though this behavioral issue may seem alarming, this response is not a sign of treatment failing, which any parents assume at first. In fact, it is more often than not a predictable step toward a meaningful behavior change.

An extinction burst can be defined as a temporary increase in behavior following the discontinuation of reinforcement (Lipshultz & Wilder, 2017). It is a core concept applied in behavioral analysis (ABA) and relevant across psychiatric disciplines, especially when working with patients exhibiting maladaptive behaviors reinforced  over time, including tantrums, aggression, or attention-seeking behaviors.

For instance, when a child is no longer given access to a tablet after yelling, they may initially yell more loudly or for longer periods of time. In this context, the behavior worsens not because the treatment is ineffective, but because the behavioral consistency has changed. The individual is testing whether the old behavior will yield the same outcome.

How common are extinction bursts?

Extinction bursts are not guaranteed, but are common. In a review of over 40 studies, extinction bursts occurred in approximately 24 to 36% of cases, particularly when the behavior had a history of being reinforced on a dense or continuous basis. This is consistent with more recent research that found that the presence of extinction bursts was especially likely when extinction was used alone, without reinforcement of alternative, appropriate behaviors. Additionally, a clinical review emphasized that extinction bursts are most problematic in settings where there is a lack of appropriate reinforcement procedures. Athey argue that incorporating functional replacement behaviors through techniques such as Differential Reinforcement of Alternative behavior (DRA) can substantially reduce both the frequency and severity of bursts.

Clinical implications

In psychiatric settings, extinction procedures are used in behavior therapy and often intersect with pharmacologic strategies. This is often used for obsessive-compulsive behaviors, substance-seeking, or externalizing disorders. For example, a patient with Borderline Personality Disorder may escalate self-harming behaviors when a previously accommodating response like hospitalization is replaced with supportive but firm limits. A second example is a child with Autism Spectrum Disorder may show an increase in aggression when reinforcement for a problem behavior is removed, before acquiring a functional communication skill as a replacement. Fuhrman, Fisher, and Greer (2022) highlight that extinction bursts can be particularly aversive for caregivers and therapists. Without proper psychoeducation and support, clinicians risk misinterpreting the escalation as a treatment failure, rather than a predictable phase of behavior change. This misunderstanding can lead to premature abandonment of effective interventions.

Preventing and Managing Extinction Bursts
1. Prepare caregivers and patients: Clearly explain that behavior may initially worsen and that this is a known, expected response (Lerman et al., 1995; Fuhrman et al., 2022).
2. Use extinction with reinforcement: Research shows that combining extinction with reinforcement for alternative behaviors reduces both the likelihood and severity of bursts (Lipshultz & Wilder, 2017).
3. Monitor for dangerous escalation: While most extinction bursts are mild, Iwata et al. (1994) noted that in some clinical populations, particularly those with self-injurious behavior, the intensity can increase significantly. Safety planning and clinical supervision are critical.
4. Fade reinforcement schedules gradually: Extinction bursts are more likely after a behavior has been consistently reinforced. By thinning the reinforcement schedule gradually before implementing extinction, clinicians may reduce the abruptness of the change (Lerman et al., 1995).

Understanding extinction bursts is essential in psychiatric and behavioral treatment. When viewed through a clinical and empirical lens, these short-term increases in behavior are not obstacles. Instead, they are signposts of change. With the right support, education, and intervention planning, patients and families can be guided through this transitional phase toward more adaptive, sustainable behavior.

References:
1. Lerman, D. C., Iwata, B. A., & Wallace, M. D. (1995). Side effects of extinction:
Prevalence of bursting and aggression during the treatment of self-injurious behavior.
Journal of Applied Behavior Analysis, 28(2), 93–94.
https://doi.org/10.1901/jaba.1995.28-93
2. Lipshultz, J., & Wilder, D. A. (2017). The effects of extinction with and without a
differential reinforcement procedure on problem behavior. Journal of Applied Behavior
Analysis, 50(1), 163–175. https://doi.org/10.1002/jaba.954
3. Kranak, M. P., & Falls, A. (2022). Practical and ethical considerations in the use of
extinction procedures. Behavior Analysis in Practice, 15, 1092–1101.
https://doi.org/10.1007/s40614-022-00340-3
4. Fuhrman, A. M., Fisher, W. W., & Greer, B. D. (2020). What are the necessary and
sufficient conditions for an extinction burst? Journal of the Experimental Analysis of
Behavior, 114(3), 449–466. https://doi.org/10.1002/jeab.642

reviewed by Nicolas Sikaczowski, DO Board Certified Adult & Child Psychiatrist