Behavioral intervention for autism: a distinction between two behavior analytic approaches.
Key Words: autism, behavioral intervention, Discrete Trial Instruction, Applied Verbal Behavior.
Schreibman (1997) indicates that few professionals working with children and families affected by autism spectrum disorders (ASD) would deny that behavioral intervention is the treatment of choice. Behavioral treatment has been defined as synonymous with applied behavior analysis (ABA), and as the application of the principles of learning to human behavior for the resultant effect of improved socially significant behaviors (Schreibman, 1997). Despite some methodological criticisms of the research (Connor, 2003, Eikeseth, 2001, Gresham, Beebe-Frankenberger, & MacMillan, 1999, Gresham & MacMillan, 1997, Gresham & MacMillan, 1998), ABA-based early intervention is empirically supported in helping children with ASD to achieve significant gains (Herbert & Brandsman, 2002). Programs based on ABA methodology remain popular interventions for children diagnosed with ASD (Herbert & Brandsma, 2002, Lovaas, 1987, McEachin, Smith, & Lovass, 1993, Schreibman, 1997). Special-education litigation has increasingly involved requests that school districts provide or reimburse parents for a program characterized by ABA (Yell & Drasgow, 2000). For example, the New York State Guideline Technical Report for clinical practice of the assessment and treatment of ASD for children ages 0-3 years recommends the principles of ABA be included as an important programmatic element (NYDH, 1999). Given the increased demand for ABA methodology for preschool and school-aged children with ASD in school settings, it is necessary that teachers of special education and other school personnel understand the distinction between different types of programs that fall under the umbrella of ABA and what is implied when parents request discrete trial or applied verbal behavior programs.
In their selective review of treatments for children with autism, Gresham, Beebe-Frankenberger, and MacMillan (1999) evaluated several programs categorized as comprehensive behavioral and educational treatment programs. These include, among others, the UCLA Young Autism Project (YAP), based on the work by O. Ivar Lovaas (1987); Treatment and Education of Autistic and Related Communication Handicapped Children (Project TEACCH), based on the work of Schopler and Reichler (1971); and Learning Experiences Alternative Program (LEAP), based on the work of Strain and others (1977) (Gresham, Beebe-Frankenberger, & MacMillan, 1999). Since the publication of the Gresham, Beebe-Frankenberger, and MacMillan article in 1999, additional approaches considered behavior analytic in nature have come to the forefront. These include Pivotal Response Training (PRT) (Koegel, Koegel, & Carter, 1999) and Applied Verbal Behavior (AVB) (Sundberg & Michael, 2001).
For some educators, the distinction among ABA programs remains nebulous. The purpose of this paper is to distinguish between two popular approaches currently provided for early intervention and school-aged children in home- and school-based settings: Lovaas' Young Autism Project (YAP), more commonly referred to as Discrete Trial Instruction (DTI) or Discrete Trial Teaching (DTT), and B.F. Skinner's Analysis of Verbal Behavior, more commonly referred to as Applied Verbal Behavior (AVB or simply, VB).
First and foremost in grasping the distinction is keeping current with the abbreviations. Is it "ABA"?, "DTI"?, "DTT"?, "AVB"?, "VB"?, and what is implied by each? Whereas "ABA" typically refers to the science of Applied Behavior Analysis, it became synonymous with DTI or DTT around the time of Catherine Maurice's book, Let Me Hear Your Voice (1993) and with the rising popularity of this instructional format in home- and school-based settings. Maurice describes the learning successes her children experienced using behavioral interventions and has since been a powerful advocate for ABA technology and, in the face of multitudes of pseudo-treatments, reliance on science in the treatment of autism (Maurice, Green, & Luce, 1996).
Empirical validation for behavioral intervention stems from the research of O. Ivar Lovaas (1987), initiated in 1970 and then referred to using the acronym YAP. For purposes of continuity we will refer to it as DTI. In his research, Lovaas (1987) reported the results of a behavioral treatment program for two groups of participants diagnosed with autism. All participants had a chronological age of less than 40 months if non-verbal, and less than 46 months if presented with echolalia. The experimental group (n=19) received intensive one-to-one treatment for more than 40 hours per week for two years, whereas Control Group 1 (n=19) received minimal one-to-one treatment, characterized by 10 hours or less, also for two years. Participants were assigned to one of these two groups based on the number of available staff and the distance participants lived from UCLA. An additional control group (Control Group 2) was comprised of 21 participants selected from those participating in a previous study by Freeman, Ritvo, Needleman, & Yokota (1985). Data from this control group helped to control for biased participant selection. Participants were treated like Control Group 1 subjects but were not treated by the DTI team. The goal of this project was to maximize treatment gains by providing the intervention for most of the participants' waking hours. Results showed 47% of the participants in the experimental treatment group achieved normal intellectual functioning as defined by normal-range IQ scores and successful performance in first grade in a public school setting (Lovaas, 1987).
The original treatment protocol for this study is described in Lovaas's book, Teaching Developmentally Disabled Children: The Me Book (Lovaas, Ackerman, Alexander, Firestone, Perkins, Young, Carr, & Newsom, 1981) and has been updated to reflect the removal of aversive contingencies as were used in the original protocol (Lovaas, 2003). In addition, long-term follow-up research using the same participants was reported by McEachin, Smith, and Lovaas (1993).
Critics of the original Lovaas study and the UCLA Project have questioned its experimental validity (Gresham & MacMillan, 1997), criticized the researchers for their failure to use a randomly selected sample with random assignment to groups (Gresham et al., 1999), and accused the researchers of falsely promising a "cure" for autism (Herbert & Brandsma, 2002). Lovaas and colleagues have responded to these criticisms (Eikeseth, 2001), pointing out erroneous interpretations of the research by these authors, as well as defending decisions with regard to experimental design and other aspects of the study (Smith & Lovaas, 1997).
DTI, as implemented in the original Lovaas study (1987), is a specialized form of instruction that breaks down tasks into their component parts with instruction delivered in small units. It is comprised of a cue ([s.sup.d]), prompt, student response, and a consequence (i.e., reinforcement or feedback in the form of error correction). Gresham et al. (1999) define the core characteristics of DTI as a discriminative stimulus ([s.sup.d])-response-consequence type of instructional delivery that includes discrimination training and compliance with instructional commands (e.g., "Stand up" and "Touch your nose"). In addition, there exists an inter-trial interval (ITI) (brief pause before presentation of subsequent cue) (Smith, 2001). Although many proponents of DTI exist, educational competition has evolved from the AVB enthusiasts of the behavior analytic community. As with DTI, the procedures employed in an AVB model are empirically derived from years of behavior analytic research. For interested readers, advocates promoting the AVB approach have provided specific citations to original publications from which procedures are derived through workshop manuals and other training tools (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). Although the AVB approach is not promoted by professionals as an educational or treatment "package" or "method" (www.abatoolchest.com), in the experience of the first author it has been conceived of as such by the consumers of this approach.
The AVB approach to teaching children with autism incorporates discrete trial instruction; however, for language acquisition it relies on B.F. Skinner's classification of language with initial emphasis on teaching expressive language with manding (Carbone, 2003; Carbone, 2004; Sundberg & Partington, 1998). In his book, Verbal Behavior, Skinner (1957) applied the environmental principles of behavior, previously used to analyze nonverbal behavior, to an analysis of language. This approach emphasizes the formal and functional properties of language and distinguishes between several different types of functional control (Sundberg, 2003). Skinner defined the mand as a type of verbal relation whose response form is controlled by a motivational variable, termed establishing operation (EO) (i.e., satiation, deprivation, and aversive stimulation), or more recently termed, motivational operation (MO) (Laraway, Snycerski, Michael, & Poling, 2003). The mand is a type of verbal behavior where the speaker asks for what he or she wants, resulting in specific reinforcement (i.e., access to a desired item specific to the request) (Sundberg, 2003). Effective mand training is accomplished through manipulation of the EO/MO. The elementary verbal relations (mand, tact, echoic, intraverbal, textual, and transcriptive) are viewed as the elements of which more complex forms of verbal behavior are composed and as developing as a function of reinforcing contingencies (Sundberg & Michael, 2001).
In their 2001 article, The Benefits of Skinner's Analysis of Verbal Behavior for Children with Autism, Sundberg and Michael credit the work of Lovaas and colleagues for the advancement of the field of applied behavior analysis in autism treatment; however, they criticize the work of Lovaas and his colleagues and previous programs for failing to make use of the concepts and principles provided by Skinner in Verbal Behavior (1957). Most importantly, these include the failure to emphasize early mand training (Sundberg & Michael, 2001), as well as use stimulus control transfer procedures to teach across the classes of verbal operants. Both are believed to lead to or facilitate the development of conversational skills (Carbone, 2004).
The AVB approach to teaching children with autism is derived primarily from four lines of research that lead to differences in program structure or application. These lines of research include functional assessment / analysis, EOs or MOs, the matching law, and Skinner's analysis of verbal behavior (Carbone, 2003). In their application, several distinctions can be made between a traditional DTI program and an AVB program. For purposes of this paper, the distinctions will be made along the following dimensions: curriculum, reinforcement and motivation, delivery of instruction, prompting and error correction, language acquisition, augmentative communication, and data collection.
DTI programs have helped children diagnosed with autism acquire skills across a variety of skill domains (Smith, 2001). The curriculum scope and sequence for DTI programs is derived from resources such as Teaching Developmentally Disabled Children, The Me Book (Lovaas et al., 1981), Behavioral Intervention for Young Children with Autism (Maurice, Green, & Luce, 1996), A Work in Progress (Leaf & McEachin, 1999), and more recently, Teaching Individuals with Developmental Delays, Basic Intervention Techniques (Lovaas, 2003). Given that there is no standard assessment practice and a variety of curriculum resources, each child's program will vary with regard to the order in which new tasks are introduced. Generally skills are taught beginning with the simplest form, while moving gradually toward increased complexity. In addition, the plan for generalization of skills involves the student practicing the skills across instructors, materials, and settings, as well as programming for common stimuli and using multiple exemplars.
AVB programs rely on the Assessment of Basic Language and Learning Skills (ABLLS) (Partington & Sundberg, 1998) as a standard assessment tool and baseline. The completed ABLLS provides a visual display of the learner's strengths and weaknesses across 26 skill domains. Together the ABLLS and its complimentary guides for IEP writing and teaching skills (Sundberg & Partington, 1998) provide the scope and sequence for the curriculum. No other guides to curriculum or teaching targeting this approach are commercially available. Most teachers or therapists become skilled in this approach through attendance at professional workshops, commercially available training modules (www.abatoolchest.com), and / or by working with professionals trained in its application. The Verbal Behavior Network website offers programming guidance, sign language video models, and downloadable data collection forms (http://www.verbalbehaviornetwork.com/).
Reinforcement and Motivation
A DTI program typically employs a negative reinforcement paradigm for learner motivation (i.e., the student can work for earned breaks from task) (Harris & Weiss, 1998). Additionally, other components of an individualized motivational system such as token systems of reinforcement and choice boards comprised of photos of potential rewards are incorporated. Initially, continuous schedules of reinforcement are used and are subsequently faded to fixed- and variable-ratio schedules whenever possible.
In teaching children using the AVB approach, there is an initial emphasis on establishing the teacher as a conditioned reinforcer. This is accomplished through pairing the teacher with reinforcement and the use of a stimulus demand fading procedure (Carbone, 2003; Carbone 2004; www.abatoolchest.com). As opposed to the negative reinforcement paradigm mentioned in the DTI approach, the AVB approach relies on the use of competing positive reinforcement or motivation to increase on-task behavior (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). The teacher or therapist continually attempts to offset the value of escape during instructional times while viewing every opportunity as a learning opportunity to maximize responding. Schedules of reinforcement for initial mand training are continuous; however, variable schedules are implemented as quickly as possible during intensive teaching time (ITT) and faded as the learner is successful (Carbone, 2004). In a AVB program, there tends to be less reliance on token boards, choice boards, and other visual displays that are common to motivational programs in a DTI approach.
Delivery of Instruction
In a DTI program, instruction is typically delivered via a 1:1 or 1:2 teacher-to-student ratios (Harris & Weiss, 1998). The teacher and student are usually situated at a desk or table facing one another in a knee-to-knee physical arrangement. Instruction is introduced in an environment where distractions are minimized to include removable physical barriers such as room dividers and cubbies when necessary. Novel concepts are often introduced in isolation, or mass trials, with expectation of mastery before the interspersal of other concepts (expanded trials) (NYFAC video, 1999). During teaching, there is reliance on visual cues, such as picture schedules to prompt learners' behaviors throughout the day.
Although also delivered in a 1:1 or 1:2 teacher-to-student ratio, the initial phases of teaching in an AVB program take place in the natural environment as opposed to a traditional desk or table. Natural environment teaching (NET), commonly referred to as incidental or milieu teaching, relies on student interest for instruction (Goldstein, 2002) and has no defined location. Both pairing and initial mand training take place in "the NET". The teacher or therapist must become skilled at determining the ratio of time spent in NET and intensive teaching time (ITT) for learning other new skills (Kibbe & Twigg, 2004). The delivery of instruction during ITT mimics that of discrete trial instruction as defined previously as a specialized form of instruction that breaks down tasks into their component parts with instruction delivered in small discrete units (Lovaas, 1987).
Whereas the DTI approach allows for the introduction of tasks in isolation via mass trailing, the AVB approach is characterized by tasks that are mixed and varied from the onset (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). Both approaches would suggest a ratio of easy-to-hard tasks that is approximately 8:2 or 7:3. In addition, the AVB approach emphasizes teaching skills to fluency and a quick pace of instruction with shorter latencies for the learner to respond (0-2 seconds as opposed to a traditional DTI approach of 5-7 seconds) (Carbone, 2003; Carbone, 2004; www.abatoolchest.com).
The intensity of instruction across the two approaches should be comparable in terms of hours of service delivery (30-40 hours per week) (Harris & Weiss, 1998); however, it could be conceptualized that use of a negative reinforcement paradigm for motivation in DTI detracts from the intensity since this time is often viewed as an earned break from task and therefore instruction is not delivered. For some students, home program services that extend or reinforce concepts taught in school offered outside the school day would add to the intensity of instruction in either type of program.
Prompting and Error Correction
In a DTI program, initial reliance is on errorless teaching procedures such as a most-to-least prompting sequence, constant and progressive time delay, stimulus fading, positional cues, and blocked errors (Agnew & Kates-McElrath, 2004). As the learner acquires skills, the no-no-prompt error correction procedure is introduced. This procedure presumes the student can respond correctly to the instruction or self-correct following a "No" or no alternative ("Try again") from the teacher. This approach allows for two errors before prompting is provided (Pelios & Kates-McElrath, 2002).
Although both rely on errorless teaching methods as described above, the AVB approach does not employ the no-no-prompt model of error correction. In addition, it places added emphasis on transfer trials following errors of responding (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). That is, the instructor re-presents the discriminative stimulus ([S.sup.d]) following an error and a prompted response, permitting the student to respond correctly in the presence of the [S.sup.d]. For example, following the [S.sup.d], "Show me clapping", the learner stomps his feet (error). The instructor may interrupt the response and manually guide or model the correct response (hand clapping), before restating the [S.sup.d], "Show me clapping". This allows the learner another opportunity to respond correctly in the presence of the [S.sup.d].
As part of an errorless teaching model, previously acquired verbal behavior is used to prompt or cue novel repertoires (Drash, High, & Tudor, 1999, Finkel & Williams, 2001, Sundberg, Endicott, & Eigenheer, 2000). This can be conceptualized as a stimulus control transfer procedure for acquired verbal operants. An example of this is reliance on an established echoic repertoire to begin to teach a mand for a particular item. If the learner can vocally imitate the word "cookie," the instructor may say "cookie" in the presence of the learner, while holding up a cookie. If the learner imitates "cookie", the response results in access to the cookie. Ultimately the echoic prompt is faded until the learner can say cookie in the presence of the cookie, and the presence of the cookie (tact) is faded until the learner can request cookie when he or she is motivated to do so (EO/MO).
Traditional DTI programs place an earlier emphasis on receptive identification and/or expressive labeling (tacting) of objects or photos rather than teaching students to request desired items (manding). Conceptually, listener skills are targeted before speaker skills (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). As stated previously, Sundberg and Michael (2001) criticize DTI programs for failing to make use of the concepts and principles provided by Skinner in Verbal Behavior (1957), including early emphasis on mand training and use of stimulus control transfer procedures to teach across the classes of verbal operants (Carbone, 2004). In addition, efforts involving automatic reinforcement procedures, stimulus-stimulus pairing, differential reinforcement, and extinction are used in an effort to evoke vocal behavior such as an echoic repertoire from non-verbal learners (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). During the stimulus-stimulus pairing procedure, the child's naturally occurring vocalization(s) (i.e., babbling sounds) is established as a conditioned reinforcer through the temporal pairing of a therapist's vocal model with a desired item. The result is an increase in babbling sounds that are eventually brought under stimulus control (i.e., echoic control) (Miguel, Carr, & Michael, 2002; Sundberg, Michael, Partington, & Sundberg, 1996).
Once mand training is introduced, selection-based systems that rely on use of pictures such as the Picture Exchange Communication System (PECS) (Bondy & Frost, 1994) are often used for non-verbal learners participating in a DTI approach. The AVB approach however, has influenced the reemergence of sign language in the autism community (Carbone, 2003). Previously believed impediments to its use with ASD populations, such as poor fine motor skills, poor motor imitation skills, and lack of a community of signers can be overcome by a variety of prompting and teaching methods and a willingness for families to support the mode of communication in the home and community (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). In this approach, decisions about determining augmentative methods for non-vocal individuals are influenced by the literature on topography and selection-based verbal behavior (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). A comprehensive review of this literature is provided by Potter and Brown (1997).
Data collection systems will vary somewhat across the two approaches. Traditional DTI programs rely on teachers and therapists to collect trial-by-trial data that reflect student performances during teaching (Harris & Weiss, 1998), often yielding a percent correct in 10 or 20 trials. Task analytic data are collected on skills targeting leisure, self-care, and vocational domains.
AVB programs are characterized by first trial yes / no probe data. Probe data are often ideally collected in the morning (school-based probe) and evening (home-based probe) for evidence of generalization across settings and / or materials. The use of probe data may be used in either approach (Harris & Weiss, 1998) and may offer several advantages. Most importantly, it allows the teacher to be available to focus on teaching as opposed to recording each student response. It also facilitates a quicker pace of instruction (Carbone, 2003; Carbone, 2004; www.abatoolchest.com). In an AVB program, rate is used for fluency measures while number of prompted and spontaneous mands may also be graphed. Both approaches rely on visual displays of data as well as data-based decisions regarding student progress and program changes (Harris & Weiss, 1998). The AVB approach however favors cumulative graphing over traditional percentages or number correct (Carbone, 2003).
A summary of the distinctions described in this paper is provided in Table 1. Although both are behavior analytic in nature and share some commonalities, programs based in DTI and AVB will differ along several dimensions, such as curriculum scope and sequence, reinforcement and motivation, delivery of instruction, prompting and error correction, language acquisition, and augmentative communication. Currently, the Lovaas UCLA Project is the only outcome study available to consumers of these services. Regardless, behavior analytic programs remain best practice for autism intervention in the public school system, often at the request of the parents (Yell & Drasgow, 2000). It is important for school personnel and educational consultants to understand the distinctions involved in these approaches in order to adequately meet the expectations of the parents, as well as the needs of the students they serve.
Several important questions, however, remain unanswered. Future research should involve additional outcome studies for both approaches. There is also a need for comparison studies between the two approaches that might result in identification of learner characteristics that make one approach toward instruction and language acquisition a better match for a particular learner than another. In addition, an investigation into the development of spontaneous language in non-vocal learners as a function of type of augmentative system is warranted. A final research recommendation is to investigate the use of behavior analytic terminology such as DTI and AVB in teaching children with ASD as a function of geography. More specifically, there is a need for an investigation into whether the terms defined and interpreted in this paper reflect different types of programs nationally (or internationally), or whether their implications are commonly understood across parents, educators, and the behavior analytic community.
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Kelly Kates-McElrath and Saul Axelrod
Author contact information:
Kelly Kates-McElrath, M.A., B.C.B.A.
1641 Maritime Court
Bensalem, PA 19020
Saul Axelrod, Ph.D., B.C.B.A.
441 Ritter Hall
Broad and Montgomery Aves.
Philadelphia, PA 19122
215-204-1414 (Office FAX)
Table 1 Aspects of programs for ASD Program Aspects Lovaas' Discrete Trial Instruction (DTI) Curriculum * Teaching Developmentally Disabled Children, The Me Book (Lovaas et al., 1981) * Behavioral Intervention for Young Children with Autism (Maurice, Green, & Luce, 1996) * A Work in Progress (Leaf & McEachin, 1999) * Teaching Individuals with Developmental Delays, Basic Intervention Techniques (Lovaas, 2003) Reinforcement * Continuous schedules of reinforcement & Motivation * Fixed & variable ratio schedules of reinforcement * Token systems * Choice boards * Compliance * Escape extinction * Negative reinforcement paradigm Delivery of * 1:1 or 1:2 Instruction * distraction-free environment Prompting & Error * Most-to-least prompting Correction * Positional cues * No-no-prompt sequence * Model-prompt-switch-repeat Language Acquisition * Early emphasis on receptive language (listener skills) & expressive labels (tacting) Augmentative * Selection-based systems (PECS, Bondy & Communication Frost, 1994) Data Collection * Trial-by-trial * Task analysis * Percent correct Program Aspects Skinner's Analysis or Applied Verbal Behavior (AVB) Curriculum * Assessment of Basic Language and Learning Skills (ABLLS) * (Partington & Sundberg, 1998) Reinforcement * Variable ratio schedules & Motivation * Pairing procedures to establish teacher as conditioned reinforcer * Natural environment teaching (NET) * Access to reinforcement in areas designated for work Delivery of * 1:1 Instruction * distraction free-environment * Natural environment Prompting & Error * Most-to-least prompting Correction * Progressive time delay * Stimulus control transfer trials * Use of previously acquired verbal operants to prompt novel repertoires Language Acquisition * Early emphasis on mand training (speaker skills) Echoics to establish vocal imitation for manding Augmentative * Topography-based Communication systems (sign language) Data Collection * 1st trial probe data (AM and PM) in Y/N format * rate (per minute) * number of prompted & spontaneous mands * cumulative graphic display of data * fluency measures
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|Author:||Kates-McElrath, Kelly; Axelrod, Saul|
|Publication:||The Behavior Analyst Today|
|Date:||Mar 22, 2006|
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