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."

As early as 1978, Sepler and Myers noted in the Journal of Applied Behavior Analysis that learning to effectively implement behavioral treatment was not easy. Attending a series of lectures or reading books on behavioral treatment does not generalize into an ability to provide quality treatment (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1311286). Again in 2000, Dr. Lovaas emphasized the importance of quality control in behavioral treatment replication research. In fact, both replication research studies – Sallows, 2005 and Howard, 2006 – not only required years of experience from those supervising treatment, they also included checks for accuracy through direct observation of the staff implementing treatment.

Currently at the Lovaas Institute, we train instructors in such a way that emphasis is placed on the evaluation of performance-based objectives, relevant to the implementation of behavioral treatment for children with autism. Our internal certification process requires a demonstration of the skills you have learned. Certification indicates to parents and other professionals that you not only know what to do, but can actually do it.

Question 8:
What is incidental teaching?

My Answer:
Incidental teaching is a precise procedure that builds off of discrete trial teaching and mand training. If you recall, discrete trial training is a potentially five-part unit of instruction consisting of:

1. the discriminative stimulus (i.e., what the instructor says or does)
2. a prompt (i.e., any help the instructor gives to the child)
3. a response (i.e., what the child does)
4. a consequence (i.e., whether or not the response is reinforced)
5. an inter-trial pause (i.e., the few seconds before the next discriminative stimulus is presented).

Mand training is a potentially four-part unit of instruction consisting of:

1. establishing operations (i.e., environment is created in which objects become valuable)
2. a prompt (i.e., any help the instructor gives to the child)
3. a behavior (i.e., what the child does)
4. a consequence (i.e., whether or not the behavior is reinforced)

Incidental teaching is not the same as mand training. Incidental teaching can include mand training, discrete trial teaching, or both. In incidental teaching, mand training or discrete trial teaching are implemented in a specific way. That specific way is as follows:

One of my favorite ABA comments is the following, "It doesn't take a rocket scientist to implement ABA therapy...It's much more difficult than that!" Rocket scientists get to work with numbers and formulas that stay constant. 2+2 always equals 4. Behavior therapists get to work with children whose attitudes and desires vary from day to day. The rewards and prompts a child needs today may not be the same rewards and prompts he needs tomorrow, let alone a month from now. Still, like any science, I've found some basic guidelines that I return to frequently when behavioral treatment isn't going as well as planned.

Let’s stop mentioning errorless learning when comparing different behavioral treatments for children with autism. The discussion, as currently framed, isn’t really helpful.

In the late 90’s, the term “errorless learning” started to appear in discussions of behavioral treatment for children with autism. Unfortunately, rather than contributing to the dialogue on effective treatment, the use of the term simply caused confusion. Upon closer scrutiny, it turns out errorless learning has been a part of behavioral treatment for children with autism for a long time. The only thing new in the 90’s was calling it “errorless learning.”

Ever since the 1987 Lovaas study, a lot of attention has been paid to the way in which behavioral treatment occurs in a 1:1 setting. Ongoing research is helping us recognize which procedures or guidelines are helpful when teaching a particular skill or teaching a child with particular characteristics. However, all of this attention on behavioral treatment in a 1:1 setting has made it easy to forget that Dr. Lovaas’ behavioral treatment program was not simply 1:1 treatment. That’s one of the reasons I reject labeling Dr. Lovaas’ work as synonymous with Discrete Trial Teaching. In both the 1987 study and replication studies of 2005 and 2006, the treatment progressed to include play dates with peers and time in school. These interactions were carefully planned, were initially facilitated by a trained aide, and included systematic progression that required just as much time and effort as the 1:1 treatment. It is unfortunate when a behavioral treatment program places all of its emphasis on the 1:1 treatment component while ignoring the importance of these other critical elements of treatment.