Discrete trial training

Discrete trial training (DTT; also called discrete trial instruction or DTI) 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 is a practitioner-led, structured instructional procedure that breaks tasks down into simple subunits to shape new skills. Often employed up to 6–7 hours per day for children with autism, the technique relies on the use of prompts, modeling, and positive reinforcement strategies to facilitate the child's learning. It is also noted for its previous use of aversives to punish unwanted behaviors. Discrete trial training (DTT; also called discrete trial instruction or DTI) 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 is a practitioner-led, structured instructional procedure that breaks tasks down into simple subunits to shape new skills. Often employed up to 6–7 hours per day for children with autism, the technique relies on the use of prompts, modeling, and positive reinforcement strategies to facilitate the child's learning. It is also noted for its previous use of aversives to punish unwanted behaviors. Lovaas spent most of his career conducting groundbreaking research on the use of this methodology to teach autistic children. As of 2005, two studies have shown that most children with autism under the age of 5 who received structured early intensive behavioral intervention (EIBI), or 35–40 hours per week of DTT, had gained significant language, intellectual, and adaptive skills. The first, a seminal study by Lovaas (1987) reported that 47% of such children acquired typical language and academic skills, and were placed into mainstream classrooms at age 7. Follow-up measures in 1993 showed that nearly each 'were indistinguishable from average children on tests of , intelligence, and adaptive behavior.' The study, later, received praise in a mental health report by the US Surgeon General in 1999. Since 2009, the American Academy of Pediatrics identified EIBI and the early start denver model (ESDM)—a comprehensive early intervention that consists of both developmental, play therapy and naturalistic ABA—as the only evidence-based clinical interventions for the population. While EIBI is 'well-established,' the ESDM is 'emerging.' The Lovaas approach is a highly structured comprehensive program that relies heavily on discrete trial training (DTT) methods. Within Lovaas therapy, DTT is used to reduce stereotypical autistic behaviours through extinction and the provision of socially acceptable alternatives to self-stimulatory behaviors. Intervention can start when a child is as young as three and can last from two to six years. Progression through goals of the program are determined on an individual basis and are not determined by which year the client has been in the program. The first year seeks to reduce self-stimulating ('stimming') behavior, teaches imitation, establishes playing with toys in their intended manner, and integration of the family into the treatment protocol. The second year teaches early expressive and abstract linguistic skills, peer interaction, basic socializing skills, and strives to include the individual's community in the treatment to optimize mainstreaming while eliminating any possible sources of stigmatization. The third year focuses on 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. The Lovaas method is ideally performed five to seven days a week with each session lasting from five to seven hours, totaling an average of 35–40 hours per week. Each session is divided into trials with intermittent breaks. The trials do not have a specified time limit to allow for a natural conclusion when the communicator feels the child is losing focus. Each trial is composed of a series of prompts (verbal, gestural, physical, etc.) that are issued by the 'communicator' who is positioned directly across the table from the individual receiving treatment.These prompts can range from 'put in',' put on',' show me',' give to me' and so on, in reference to an object, color, simple imitative gesture, etc. The concept is centered on shaping the child to correctly respond to the prompts, increasing the attentive ability of the individual, and mainstreaming the child for academic success. Should the child fail to respond to a prompt, a 'prompter,' seated behind the child, uses either a partial-, a simple nudge or touch on the hand or arm or a full-, hand over hand assistance until the prompt has been completed, physical guide to correct the individual's mistake or non-compliance. Each correct response is reinforced with verbal praise, an edible, time with a preferred toy, or any combination thereof. DTT 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 mainstream individuals with autism. As many as 25% of individuals with autism have no functional speech, the remainder typically display pronounced phonological and grammatical deficits in addition to a limited vocabulary. The program teaches spontaneous social communication through symbols and/or pictures by relying on ABA techniques. 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. More than 500 articles have been published showing the effectiveness of the Lovaas technique for children with autism. Questions concerning the effectiveness of the method involve reports of recovery from autism, based on the intervention. The Lovaas technique was developed based on research performed by Ivar Lovaas and his assistants. This research reported that 47% of those children who had received the Lovaas treatment protocol of an average of 40 hours of intensive therapy, were mainstreamed into regular classrooms, and were classified as 'indistinguishable' from their peers in follow-up studies. Although subsequent studies have shown that intensive behavioral therapy clearly benefited children with autism, it has been claimed that Lovaas's original claims of effectiveness were overstated. A 2005 California study found that early intensive behavioral intervention (EIBI), the Lovaas technique used for very young children, was substantially more effective for preschool children with autism than the mixture of methods provided in many programs. However, this study did not use random assignment or a uniform assessment protocol, and provided limited information about the intervention, making it difficult to replicate. Smith et al. (2002) performed a preliminary study of nine high-functioning children with autism, all of whom were previous recipients of early intensive behavioral intervention (EIBI), of ages five to seven in free play settings. The purpose was to assess the effects of EIBI on solitary activities, ritualistic behaviors, and social activity when exposed to the two experimental groups. Each child participated in four one-hour sessions consisting of 15 minute periods of play with either a typically developing peer or a lower functioning child with autism who had major deficits in pragmatic communication, social interaction and self-care. The children had never met prior to these experimental sessions. The period of play began with 15 minutes of play with either the typically developed (TD) peer or the developmentally disabled (DD) peer, and alternated accordingly in one of two variations: TD-DD-TD-DD or DD-TD-DD-TD. Observers rated play on five criteria: i. interactive toy play, ii. interactive speech, iii. solitary toy play, iv. solitary speech, and v. self-stimulation. Data showed the high-functioning children displayed significantly more instances of interactive play and interactive speech when paired with the typically developed peer. The Lovaas technique is best generalized when paired with natural settings, and the implementation is clearly structured. A good sense of direction is needed when planning for intervention. Although this is one approach, many children on the autism spectrum learn differently and this needs to be taken into account to ensure the Lovaas approach is effective for all. It has been shown that, for some children with autism, typical peer interaction can increase the chance of leading a normal life. Lovaas techniques are cost effective for administrators.