Discrete trial training (DTT) is a technique used by practitioners of applied behavior analysis (ABA) that was developed by Ivar Lovaas at the University of California, Los Angeles (UCLA). DTT uses direct instruction and reinforcers to create clear contingencies that shape new skills. Often employed as an early intensive behavioral intervention (EIBI) for up to 30–40 hours per week for children with autism, the technique relies on the use of prompts, modeling, and positive reinforcement strategies to facilitate the child's learning. It previously used aversives to punish unwanted behaviors. DTT has also been referred to as the "Lovaas/UCLA model",[1] "rapid motor imitation antecedent",[2] "listener responding",[3][4][5] errorless learning", and "mass trials".[6]

Technique

Discrete trial training (DTT) is a process whereby an activity is divided into smaller distinct sub-tasks and each of these is repeated continuously until a person is proficient. The trainer rewards successful completion and uses errorless correction procedures if there is unsuccessful completion by the subject to condition them into mastering the process. When proficiency is gained in each sub-task, they are re-combined into the whole activity: in this way proficiency at complex activities can be taught.[7]: 93 

DTT is carried out in a one-on-one therapist to student ratio at the table. Intervention can start when a child is as young as two years old and can last from two to six years. Progression through goals of the program are determined individually and are not determined by which year the client has been in the program. The first year seeks to reduce self-stimulating ("stimming") behavior, teach listener responding, eye contact, and fine and gross motor imitation, as well as to establish playing with toys in their intended manner, and integrate the family into the treatment protocol. The second year teaches early expressive language and abstract linguistic skills. The third year strives to include the individual's community in the treatment to optimize "mainstreaming" by focusing on peer interaction, basic socializing skills, emotional expression and variation, in addition to observational learning and pre-academic skills, such as reading, writing, and arithmetic. Rarely is the technique implemented for the first time with adults.[8]

DTT is typically performed five to seven days a week with each session lasting from five to eight hours, totaling an average of 30–40 hours per week.[9] Sessions are divided into trials with intermittent breaks, and the therapist is positioned directly across the table from the student receiving treatment. Each trial is composed of the therapist giving an instruction (i.e., "Look at me", "Do this", "Point to", etc.), in reference to an object, color, simple imitative gesture, etc., which is followed by a prompt (verbal, gestural, physical, etc.). The concept is centered on shaping the child to respond correctly to the instructions throughout the trials. Should the child fail to respond to an instruction, the therapist uses either a "partial prompt" (a simple nudge or touch on the hand or arm) or a "full prompt" to facilitate the child to successfully complete the task. Correct responses are reinforced with a reward, and the prompts are discontinued as the child begins to master each skill.[8][10]

The intervention is often used in conjunction with the Picture Exchange Communication System (PECS) as it primes the child for an easy transition between treatment types. The PECS program serves as another common intervention technique used to conform individuals with autism.[11] As many as 25% of autistic individuals have no functional speech.[12] The program teaches spontaneous social communication through symbols or pictures by relying on ABA techniques.[13] PECS operates on a similar premise to DTT in that it uses systematic chaining to teach the individual to pair the concept of expressive speech with an object. It is structured in a similar fashion to DTT, in that each session begins with a preferred reinforcer survey to ascertain what would most motivate the child and effectively facilitate learning.[13]

Effectiveness

Limited research shows DTT to be effective in enhancing communication, academic and adaptive skills,[6][14][15] as many studies are of low quality research design and there needs to be more larger sample sizes.[16][17]

Society and culture

In media

A 1965 article in Life magazine entitled Screams, Slaps and Love has a lasting impact on public attitudes towards Lovaas's therapy. Giving little thought to how their work might be portrayed, Lovaas and parent advocate Bernie Rimland, M.D., were surprised when the magazine article appeared, since it focussed on text and selected images showing the use of aversives, including a close up of a child being slapped. Even after the use of aversives had been largely discontinued, the article continued to have an effect, galvanizing public concerns about behavior modification techniques.[18][19]

United States cost

In April 2002 treatment cost in the U.S. was about US$4,200 per month ($50,000 annually) per child.[20] The 20–40 hours per week intensity of the program, often conducted at home, may place additional stress on already challenged families.[21]

Public opposition

Organizations including the Autism National Committee (AutCom) have publicly stated their opposition to discrete trial training (DTT) and similar programs.[22]

History

Discrete trial training is rooted in the hypothesis of Charles Ferster that autism was caused in part by a person's inability to react appropriately to "social reinforcers", such as praise or criticism. Lovaas's early work concentrated on showing that it was possible to strengthen autistic people's responses to these social reinforcers, but he found these improvements were not associated with any general improvement in overall behavior.[1]

In a 1987 paper, psychologists Frank Gresham and Donald MacMillan described a number of weaknesses in Lovass's research and judged that it would be better to call the evidence for his interventions "promising" rather than "compelling".[23]

Lovaas's original technique used aversives such as striking, shouting, and electrical shocks to punish undesired behaviors.[19] By 1979, Lovaas had abandoned the use of aversives, and in 2012 the use of electric shocks was described as being inconsistent with contemporary practice.[1][18] In 1985, Massachusetts medical authorities intervened after a case of fatal starvation at the Judge Rotenberg Center in which a 19-year-old woman was denied food by staff as a punishment.[7]: 97 

See also

References

  1. 1 2 3 Spreat S (2012). "Chapter 10: Behavioral treatments for children with ASDs". In Reber M (ed.). The Autism Spectrum: Scientific Foundations and Treatment. Cambridge University Press. pp. 239–257. doi:10.1017/CBO9780511978616.011. ISBN 9780511978616. (subscription required)
  2. ↑ Tsuroi I, Simmons ES, Paul R (2012). "Enhancing the application and evaluation of a discrete trial intervention package for eliciting first words in preverbal preschoolers with ASD". Journal of Autism and Developmental Disorders. 42 (7): 1281–1293. doi:10.1007/s10803-011-1358-y. PMID 21918912. S2CID 7164416.
  3. ↑ Causin KG, Albert KM, Carbone VJ, Sweeney-Kerwin EJ (September 2013). "The role of join control in teaching listener responding to children with autism and other developmental disabilities". Research in Autism Spectrum Disorders. 7 (9): 997–1011. doi:10.1016/j.rasd.2013.04.011.
  4. ↑ Grow L, LeBlanc L (2013). "Teaching receptive language". Behavior Analysis in Practice. 6 (1): 56–75. doi:10.1007/BF03391791. PMC 3680153. PMID 25729507.
  5. ↑ Geiger KB, Carr JE, LeBlanc LA, Hanney NM, Polick AS, Heinicke MR (2012). "Teaching receptive discriminations to children with autism: A comparison of traditional and embedded discrete trial teaching". Behavior Analysis in Practice. 5 (2): 49–59. doi:10.1007/BF03391823. PMC 3592489. PMID 23730466.
  6. 1 2 Rogers SJ, Vismara LA (January 2008). "Evidence-based comprehensive treatments for early autism". Journal of Clinical Child and Adolescent Psychology. 37 (1): 8–38. doi:10.1080/15374410701817808. PMC 2943764. PMID 18444052.
  7. 1 2 Waltz M (2013). Autism: A Social and Medical History. Palgrave Macmillan. ISBN 978-1-349-35819-9.
  8. 1 2 Lovaas OI (February 1987). "Behavioral treatment and normal educational and intellectual functioning in young autistic children". J Consult Clin Psychol. 55 (1): 3–9. doi:10.1037/0022-006x.55.1.3. PMID 3571656.
  9. ↑ Jacobson JW, Mulick JA, Green G (1998). "Cost-benefit estimates for early intensive behavioral intervention for young children with autism: General model and single state case". Behavioral Interventions. 13 (4): 201–226. CiteSeerX 10.1.1.522.9130. doi:10.1002/(sici)1099-078x(199811)13:4<201::aid-bin17>3.0.co;2-r.
  10. ↑ McEachin JJ, Smith T, Lovaas OI (January 1993). "Long-term outcome for children with autism who received early intensive behavioral treatment". Am J Ment Retard. 97 (4): 359–72, discussion 373–91. PMID 8427693.
  11. ↑ Howlin P, Gordon RK, Pasco G, Wade A, Charman T (May 2007). "The effectiveness of picture exchange communication system training for those who teach children with autism: a pragmatic, group randomised controlled trial". J Child Psychol Psychiatry. 48 (5): 473–81. doi:10.1111/j.1469-7610.2006.01707.x. PMID 17501728.
  12. ↑ Volkmar FR, Lord C, Bailey A, Schultz RT, Klin A (January 2004). "Autism and pervasive developmental disorders". J Child Psychol Psychiatry. 45 (1): 135–70. doi:10.1046/j.0021-9630.2003.00317.x. PMID 14959806.
  13. 1 2 Frost LA, Bondy AS (2002). The picture exchange communication system training manual (Second ed.). Newark, DE: Pyramid Educational Products Inc.
  14. ↑ Myers SM, Johnson CP (November 2007). "Management of children with autism spectrum disorders". Pediatrics. 120 (5): 1162–1182. doi:10.1542/peds.2007-2362. PMID 17967921.
  15. ↑ Eikeseth S (2009). "Outcome of comprehensive psycho-educational interventions for young children with autism". Research in Developmental Disabilities. 30 (1): 158–178. CiteSeerX 10.1.1.615.3336. doi:10.1016/j.ridd.2008.02.003. PMID 18385012.
  16. ↑ Ospina MB, Krebs Seida J, Clark B, Karkhaneh M, Hartling L, Tjosvold L, Vandermeer B, Smith V (2008). "Behavioural and developmental interventions for autism spectrum disorder: a clinical systematic review". PLOS ONE. 3 (11): e3755. Bibcode:2008PLoSO...3.3755O. doi:10.1371/journal.pone.0003755. PMC 2582449. PMID 19015734.
  17. ↑ Reichow B, Hume K, Barton EE, Boyd BA (May 2018). "Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD)". The Cochrane Database of Systematic Reviews. 5 (10): CD009260. doi:10.1002/14651858.CD009260.pub3. PMC 6494600. PMID 29742275.
  18. 1 2 Silverman C (2011). Understanding Autism: Parents, Doctors, and the History of a Disorder. Princeton University Press. p. 90. ISBN 978-0-691-15968-3.
  19. 1 2 Bowman RA, Baker JP (March 2014). "Screams, slaps, and love: The strange birth of applied behavior analysis". Pediatrics. 133 (3): 364–66. doi:10.1542/peds.2013-2583. PMID 24534411. S2CID 28137037.
  20. ↑ Elder JH (2002). "Current treatments in autisms: Examining scientific evidence and clinical implications". Journal of Neuroscience Nursing. 34 (2): 67–73. doi:10.1097/01376517-200204000-00005. S2CID 145106552. Retrieved 2007-07-23.
  21. ↑ Lovaas O.I.; Wright Scott (2006). "A reply to recent public critiques…". JEIBI. 3 (2): 221–229.
  22. ↑ "Treatment brings hope for children with autism". The Philadelphia Inquirer. May 16, 1999. Retrieved 2022-10-04 – via Newspapers.com.
  23. ↑ Gresham FM, MacMillan DL (1998). "Early Intervention Project: can its claims be substantiated and its effects replicated?". J Autism Dev Disord (Review). 28 (1): 5–13. doi:10.1023/a:1026002717402. PMID 9546297. S2CID 7219819.
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