A recent research study by Dawson and colleagues has created both excitement and frustration for some proponents of ABA therapy. The study, conducted in a randomized controlled trial design, was published in the November 2009 issue of Pediatrics and demonstrated that behavioral intervention with toddlers resulted "in significant improvements in IQ, language, adaptive behavior, and autism diagnosis." ("Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model" Pediatrics, November 2009). However, proponents of ABA have pointed out that the New York Times coverage failed to mention that the study uses applied behavior analytic principles (http://www.blogcatalog.com/search.frame.php?term=aba+therapy&id=905ac454e81811bf6f06a9117f2f8761) and that the CNN coverage perpetuated a common misconception about ABA by comparing the pleasing, playful therapy of the study with "ABA, which is delivered at a desk" (http://blog.navigationbehavioralconsulting.com/).

Here are a few examples of how eye contact may be focused on early in behavioral treatment. While I present the information in terms of programs that may be used in therapy, all of the examples reach a level (some quickly and some with practice) at which parents can also practice them at appropriate times throughout the day.

ABA therapy for children with autism is a science of both what to teach and how to teach. The more prominent discussions concerning ABA often revolve around how to teach. The use of discrete trials, incidental teaching, and generalization training are all examples of strategies of how to teach that have been assessed in the research. Yet just as important as how to teach is deciding what to teach. ABA therapy for children with autism has been engaged with this question through the years as well. One example of this engagement I find interesting is when and how to teach a child eye contact.

One issue I have always had in the field of education is the tendency of some advocates to take a theory or preliminary research and immediately apply it to educational endeavors as a whole. Those familiar with debates concerning whole language vs. phonics, open classrooms, and even whether or not elementary school children should receive grades are well aware that enthusiasm for the theory can supersede the evidence to support it.

I've spent a lot of previous blogs talking about the importance of 1) using appropriate terminology, 2) describing procedures fairly and accurately, and 3) assessing research in light of a specific child's characteristics and the skill to teach. Let me put that into practice by debating, "Which is better: initially emphasizing requesting or labeling (i.e., mands or tacts) in ABA therapy for children with autism?"

I'm sometimes asked how I make sure I'm using the "best techniques" in ABA to teach children. Since autism is a spectrum disorder, what's the best way to individualize a behavioral treatment program for a child with autism? Here's my response:

Teaching children to talk (i.e., speech) is one of the primary aims of behavioral treatment in the first year. While focusing on functional communication through requesting (i.e., manding) is an important part of the process, there are other key strategies that often play a role in helping children who are primarily nonverbal become vocal speakers. Here they are:

Some people reject ABA therapy on the grounds that it’s nothing more than a system that bribes children to do what they should be doing anyway. We want a child to come sit down, so we call him over and then give him a cookie. We want a child to play with peers in school, so we give him tokens for each peer he asks to play and when he earns 10 tokens, he gets to go to McDonald’s for french fries.

I just got an iPhone, and I'm an app addict. I've got a button to quickly check the weather in case of rain. I've got a button to get directions in case I'm lost. I've even got a lightsaber button with appropriate sounds and music...just in case. It's like the commercial says. Got a problem? "There's an app for that."

Competent programming in ABA therapy is like iPhone apps. Sure, there are basic programs like learning to request for objects or answer basic social questions. But a good behavior consultant can identify particular deficits for an individual child and design programs accordingly. Problems with joint attention? There's a program for that. Your child won't raise his hand in class? There's a program for that. Your child doesn't seem to care if he wins or loses a game?...Your child cares too much? Yep, there are programs for that too.

ABA therapy isn't a cookie-cutter approach with a list of specific skills that must be taught and mastered by all children. ABA therapy is an approach based on the scientific principles of applied behavior analysis, with different research studies demonstrating different results with different procedures used on different children, and all this information can be used by an experienced behavior consultant to design individualized programming for a child with autism.

Need to teach a skill? Let's design a program for that. That's a core philosophy I learned at the Lovaas Institute.

There have been many fad-like interventions for children with autism that have had little or no tangible results or in some cases caused harm (Smith, 2006; Association for Science in Autism Treatment, www.asatonline.org). It's understandable that insurance companies, school districts, and other government agencies that are governed by requirements to provide only evidence-based treatments are hesitant to provide benefits for specific interventions. However, the evidence supporting intensive behavioral treatment has grown to a level that is all but overwhelming. Numerous reviews of the quantity and quality of research on interventions for children with autism demonstrate the Lovaas Model of Early Intensive Behavioral Intervention to be "well established" based upon objective criteria for evaluating educational and social science research (Eikeseth, 2009; Rogers & Vismara, 2008, Odom et al., 2009).

As the school year approaches (and in some cases, begins) parents across the country are vexed with the same question: How do I find out what happened in school today?! While typically developing children can be pestered with questions until they finally say more than "nothing" (a use, by the way, of negative reinforcement), many children with autism will struggle to answer such questions. Below is one strategy that has been helpful in teaching children to recall events from school.

Basic Format

At the end of the day, the teacher or teacher's aide asks the student one question about the day (e.g., "What was for lunch in the cafeteria?" "What letter did we talk about today?" "What did you make (in art)?" "What book did we read?"). The student answers the question. If the student cannot answer the question, the teacher prompts an appropriate answer. The teacher writes the question on a note card, with the answer on the back, and indicates if the answer was prompted. When the student goes home, his parents say hi, take the note card out of his backpack, and ask that question.

I last mentioned 5 of my favorite reinforcers. Let me also add 5 of my favorite formats for receptively identifying pictures.

1. Place cards around the floor. Tell the child to "jump on the (apple)."
2. Hand child a fly swatter. Tell him to "slap the (apple)."
3. Laminate the cards or use objects. Fill a bucket with water. Tell the child to "dunk the (apple)."
4. Give child a flashlight and go in the bathroom. Tell him to "shine on (apple)."
5. Tape cards on the wall and give child a retractable metal pointer. Tell him to "point to (apple)."

Formats like these are sometimes considered more intrinsically motivating, at least for some children. However, we should be careful when we use the term motivation. Motivation is often used to refer to an internal state, but as behaviorists, we try to talk about what we can objectively see and measure. An objective analysis of the above motivational formats leads to a few helpful guidelines.

One last comment about effective, varied reinforcement. Since the beginning, the Lovaas Institute's newsletter Meeting Point has featured 5 surprisingly different reinforcer ideas in each issue. I'd like to add my 5 favorite reinforcers to the list:

1. Put a child's hands on top of your hands. Count down slowly and with anticipation 5-4-3-2-1. Then yell "blast off!" and fling the child's hands into the air.
2. Pick up a child's foot and pound on the bottom of it with the side of your fist (with or without shoes on the child).
3. Blow air into the sleeves or back of a child's shirt.
4. Slowly lower a Kleenex in front of your face, then blow forcefully on it and let go so it zooms across toward the child.
5. Hasbro Playskool Busy Ball Popper Hands down one of the most entertaining ball toys.

Anyone else have a favorite reinforcer?

Here's a follow up to the importance of effective, varied reinforcement. When I initially started working in a behavioral treatment program, I was obsessed with delivering varied reinforcement. I once figured that I would be delivering 100-150 reinforcers during a 3 hour time period. Fresh out of college, I also had a summer job at a national telemarketing office. Between reading the script for each call, there was typically a 15-30 second delay while being connected to another person. I started bringing loose leaf paper to work, and would write down as many reinforcers as I could think of during the 15-30 seconds. This would culminate in lists of hundreds of different reinforcers – just what I needed!

What I realized over time was that the same basic reinforcer could be delivered in a variety of different ways, and each of those ways could help prevent satiation of the reinforcer (losing its effectiveness). For example, let's say a child likes to be tickled for reinforcement. You can:

1. vary where you tickle the person (foot, tummy, sides, armpits, neck)
2. vary the length of time you tickle the person (short or long until they fall to the floor laughing)
3. vary how quickly you start to tickle (immediately and surprisingly tickle or slowly move in with the anticipation you will tickle)
4. vary how quickly you actually tickle (slowly and methodically, quickly and haphazardly)
5. vary the strength of the tickle (light, barely touching tickles or deep pressure tickles)

Take all of these factors, create all the combinations possible, and you have at least 80 different ways to tickle! (I think...it may be more...feel free to check my math). I obviously wouldn't use all of these variations back to back, but keeping in mind this variety made the number of reinforcers from which I could choose that much broader.

Mindi Fisher, the first behavior consultant from the Lovaas Institute to train me, was right:
"If you don't break a sweat, you're not doing Lovaas" Only sometimes, the sweat is mental, not physical!

One of the benefits of research into incidental teaching techniques has been the attention that is now paid to motivation when designing programs for children with autism. Labeling colors may be learned by teaching a child to touch different color cards, but this skill can also be approached by teaching a child to pick up different colored trains (if he demonstrates interest in trains). Another extension of this can be teaching a child first to request different colored trains, and later to expressively label them. The format used can be tailored to the specific interests and learning style of a particular child.

Some skills can take a very long time to teach. The length of time necessary to teach a skill can lead to the format of a program becoming less and less motivating. And, it's not always feasible to continually change the format of the program. However, one of the benefits of research into discrete trial teaching has been the attention that is paid to continually assessing and delivering a variety of reinforcers in treatment. This additional reinforcement can be included within the format of the program to keep a child from getting bored.

Whenever I hear an instructor say, "This child is bored of the program," my first inclination is to look at the reinforcement that is being used. Often, it seems more appropriate to say that the child isn't bored of the program; he's bored of the reinforcement that's being given in the program. Mindi Fisher, the first consultant from the Lovaas Institute who ever trained me, made a comment that remains my mantra when it comes to delivering effective, varied reinforcement.

"If you don't break a sweat, you're not doing Lovaas."