discrete trial training

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.{{cite book |vauthors=Waltz M |title=Autism: A Social and Medical History |publisher=Palgrave Macmillan |year=2013 |isbn=978-1-349-35819-9}}{{rp|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/self-regulatory ("stimming") behavior, teach listener responding, eye contact, and rapid fine and gross motor imitation, as well as to establish playing with toys in their correct 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, basic social rules, 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.{{update after|2020|9|3|reason=1987 study, this should be updated to a newer source, do we know this is still true?}}{{cite journal |vauthors=Lovaas OI |title=Behavioral treatment and normal educational and intellectual functioning in young autistic children |journal=J Consult Clin Psychol |volume=55 |issue=1 |pages=3–9 |date=February 1987 |pmid=3571656 |doi=10.1037/0022-006x.55.1.3 }}{{primary source inline|This is a 2007 primary source, should be replaced with a secondary source or review|date=September 2020}}

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.{{update after|2020|9|3|reason=1998 study, this should be updated to a newer source}}{{cite journal |vauthors=Jacobson JW, Mulick JA, Green G | year = 1998 | title = Cost-benefit estimates for early intensive behavioral intervention for young children with autism: General model and single state case | journal = Behavioral Interventions | volume = 13 | issue = 4| pages = 201–226 | doi=10.1002/(sici)1099-078x(199811)13:4<201::aid-bin17>3.0.co;2-r| citeseerx = 10.1.1.522.9130 }} 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"{{clarify|date=June 2024}} 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.{{cite journal |vauthors=McEachin JJ, Smith T, Lovaas OI |title=Long-term outcome for children with autism who received early intensive behavioral treatment |journal=Am J Ment Retard |volume=97 |issue=4 |pages=359–72; discussion 373–91 |date=January 1993 |pmid=8427693 }}{{primary source inline|This is a 2007 primary source, should be replaced with a secondary source or review|date=September 2020}}

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 autistic individuals.{{primary source inline|This is a 2007 primary source, should be replaced with a secondary source or review|date=September 2020}}{{cite journal |vauthors=Howlin P, Gordon RK, Pasco G, Wade A, Charman T |title=The effectiveness of picture exchange communication system training for those who teach children with autism: a pragmatic, group randomised controlled trial |journal=J Child Psychol Psychiatry |volume=48 |issue=5 |pages=473–81 |date=May 2007 |pmid= 17501728 |doi=10.1111/j.1469-7610.2006.01707.x }} As many as 25% of autistic individuals have no functional speech.{{cite journal |vauthors=Volkmar FR, Lord C, Bailey A, Schultz RT, Klin A |title=Autism and pervasive developmental disorders |journal=J Child Psychol Psychiatry |volume=45 |issue=1 |pages=135–70 |date=January 2004 |pmid=14959806 |doi=10.1046/j.0021-9630.2003.00317.x }} The program teaches spontaneous social communication through symbols or pictures by relying on ABA techniques.{{page needed|date=September 2020}}{{cite book | vauthors = Frost LA, Bondy AS |year= 2002 |title= The picture exchange communication system training manual |edition= Second |location= Newark, DE |publisher= Pyramid Educational Products Inc }} 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.

Limited research shows DTT to be effective in enhancing spoken language,{{cite journal|author=Kasari C, Shire S, Shih W, Landa R, Levato L, Smith T|title=Spoken language outcomes in limited language preschoolers with autism and global developmental delay: RCT of early intervention approaches|journal=Autism Research|date=June 2023|volume=16|issue=6|pages=1236–1246|doi=10.1002/aur.2932|pmc=10460274|pmid=37070270}}{{cite journal|author=Brignell A, Chenausky KV, Song H, Zhu J, Suo C, Morgan AT|title=Communication interventions for autism spectrum disorder in minimally verbal children|journal=Cochrane Database of Systematic Reviews|date=November 2018|volume=2018|issue=11|pages=CD01234PMC|doi=10.1002/14651858.CD012324.pub2|pmc=6516977|pmid=30395694}}{{cite journal|author=Paul R, Campbell D, Gilbert K, Tsiouri I|title=Comparing spoken language treatments for minimally verbal preschoolers with autism spectrum disorders|journal=Journal of Autism and Developmental Disorders|date=February 2013|volume=43|issue=11|pages=418–431|pmid=22733301|doi=10.1007/s10803-012-1583-z|s2cid=263518387 |url=https://pubmed.ncbi.nlm.nih.gov/22733301/}} academic and adaptive skills,{{cite journal | vauthors = Rogers SJ, Vismara LA | title = Evidence-based comprehensive treatments for early autism | journal = Journal of Clinical Child and Adolescent Psychology | volume = 37 | issue = 1 | pages = 8–38 | date = January 2008 | pmid = 18444052 | pmc = 2943764 | doi = 10.1080/15374410701817808 }}{{cite journal |vauthors=Smith T, Iadarola S |date=2 November 2015 |title=Evidence Base Update for Autism Spectrum Disorder |journal=Journal of Clinical Child and Adolescent Psychology |publisher=Taylor & Francis |issn=1537-4416 |volume=44 |issue=6 |pages=897–922 |doi=10.1080/15374416.2015.1077448 |pmid=26430947 |doi-access=free}}{{cite journal | vauthors = Myers SM, Johnson CP | title = Management of children with autism spectrum disorders | journal = Pediatrics | volume = 120 | issue = 5 | pages = 1162–1182 | date = November 2007 | pmid = 17967921 | doi = 10.1542/peds.2007-2362 | url = https://pediatrics.aappublications.org/content/120/5/1162 | doi-access = | s2cid = 1656920 | url-access = subscription }}{{cite journal | vauthors = Eikeseth S | title = Outcome of comprehensive psycho-educational interventions for young children with autism | journal = Research in Developmental Disabilities | volume = 30 | issue = 1 | pages = 158–178 | year = 2009 | pmid = 18385012 | doi = 10.1016/j.ridd.2008.02.003 | citeseerx = 10.1.1.615.3336}} as many studies are of low quality research design and there needs to be more larger sample sizes.{{cite journal |vauthors=Ospina MB, Krebs Seida J, Clark B, Karkhaneh M, Hartling L, Tjosvold L, Vandermeer B, Smith V |title=Behavioural and developmental interventions for autism spectrum disorder: a clinical systematic review |journal=PLOS ONE |volume=3 |issue=11 |pages=e3755 |date=2008 |pmid=19015734 |pmc=2582449 |doi=10.1371/journal.pone.0003755|bibcode=2008PLoSO...3.3755O |doi-access=free }}{{cite journal | vauthors = Reichow B, Hume K, Barton EE, Boyd BA | title = Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD) | journal = The Cochrane Database of Systematic Reviews | volume = 5 | pages = CD009260 | date = May 2018 | issue = 10 | pmid = 29742275 | pmc = 6494600 | doi = 10.1002/14651858.CD009260.pub3 }}

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.

In April 2002 treatment cost in the U.S. was about US$4,200 per month ($50,000 annually) per child.{{update after|2020|9|14}}{{cite journal | last = Elder | first = Jennifer Harrison | name-list-style = vanc | year = 2002 | journal = Journal of Neuroscience Nursing | url = http://goliath.ecnext.com/coms2/gi_0199-1827603/Current-treatments-in-autism-examining.html | title = Current treatments in autisms: Examining scientific evidence and clinical implications | volume = 34 | issue = 2 | pages = 67–73 | access-date = 2007-07-23 | doi = 10.1097/01376517-200204000-00005| s2cid = 145106552 | url-access = subscription }} The 20–40 hours per week intensity of the program, often conducted at home, may place additional stress on already challenged families.{{cite journal |author1=Lovaas O.I. |author2=Wright Scott | year = 2006 | title = A reply to recent public critiques… | journal = JEIBI | volume = 3 | issue = 2| pages = 221–229 }}

Discrete trial training is rooted in the hypothesis of Charles Ferster who theorized 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.{{cite book |chapter=Chapter 10: Behavioral treatments for children with ASDs |vauthors=Spreat S |title=The Autism Spectrum: Scientific Foundations and Treatment |veditors=Reber M |publisher=Cambridge University Press |year=2012 |doi=10.1017/CBO9780511978616.011 |pages=239–257 |isbn=9780511978616}} {{subscription required}}

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".{{cite journal |vauthors=Gresham FM, MacMillan DL |title=Early Intervention Project: can its claims be substantiated and its effects replicated? |journal=J Autism Dev Disord |volume=28 |issue=1 |pages=5–13 |year=1998 |pmid=9546297 |doi=10.1023/a:1026002717402 |s2cid=7219819 |type=Review}}

Lovaas's original technique used aversives such as striking, shouting, and electrical shocks to punish undesired behaviors.{{cite journal|url=https://pediatrics.aappublications.org/content/133/3/364|vauthors=Bowman RA, Baker JP|title=Screams, slaps, and love: The strange birth of applied behavior analysis|journal=Pediatrics|volume=133|issue=3|pages=364–66|date=March 2014|doi=10.1542/peds.2013-2583|pmid=24534411|s2cid=28137037|url-access=subscription}} 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.{{cite book |vauthors=Silverman C |publisher=Princeton University Press |title=Understanding Autism: Parents, Doctors, and the History of a Disorder |year=2011 |page=90 |isbn=978-0-691-15968-3}}

• Professional practice of behavior analysis

{{Reflist}}

• [http://www.lovaas.com/ Lovaas Institute for Early Intervention]
• [https://riseupforautism.com/ Autism Therapy Center]

{{Pervasive developmental disorders}}

{{Autism resources}}

Category:Treatment of autism

Category:Behaviorism

Category:Behavior modification