Clinic Notes: Discrete Trial Training

I have posted below the general procedure for discrete trial training from my web site. This is a very useful procedure for teaching children with autism or other neuropsychological disorders. In future posts I will have specific programs. If you are having problems teaching a child let me know and I will help.

10. Applied Behavioral Analysis (ABA) Program for Teaching
Children Shapes, Colors, Numbers, and Letters

Some children with neuropsychological disorders fail to learn different shapes, colors, numbers, or letters because of compliance problems, while other children with neuropsychological disorders do not learn because of sensory and/or neurological processing problems associated with certain disorders. If a reward is given to the child for a correct response, performance often dramatically improves in noncompliant children. On the other hand, the rate of improvement in children with actual sensory/neurological problems is much, much slower. In the beginning the best thing to do when we are trying to teach a child to learn the differences between stimuli, such as two colors or two shapes, is to run intensive drills using bite size rewards for all children, which we then fade out. The rate by which the child improves tells us if we are dealing with a noncompliant child or a true sensory processing problem. See Case History Number 1 in Little Bubba’s Not Ready For Nashville Yet for an example. (Available at http://wwwABA4autism.com).
Discrete Trial Training
Teaching discriminations between stimuli is easier if only two stimuli are used in the beginning. For example, take two objects, which are different colors. Start with the easiest discriminations first. The difference between blue and red should be easier to learn than the difference between red and orange.
Behavioral Assessment
Use objects which are identical but have different colors, such as pieces of cloth or pieces of construction paper. (It is better not to use different colored toys which the child would want to play with.) Ask the child to point to or hand you one color and record the number of correct responses and incorrect responses on the attached form. Do this for several days without comment or reward in order to obtain a baseline. (If you run blocks of ten trials, then it is easy to calculate the percentage of correct responses.) Only wait 3-5 seconds for a response and 3-5 seconds between trials. Be sure to switch the different colored objects from side to side so the child will not learn a position habit. (In other words, a child can learn right or left side rather than the color and still be correct.)
Behavioral Intervention
After you have a baseline, reward the child immediately for each time he/she correctly picks the right color with a bite size treat. (A Tupperware bowl full of bite size goodies is what we use as tangible reinforcers for most kids in our clinic. The child only gets to pick one bite size piece.) If the child gets it wrong say, “no,” and ask the child again. After the child receives a “no” response twice in a row, prompt the child with the correct answer (give no reward). Point to the correct color; move it closer--anything that will make the discrimination between the two colors easier for the child. Then fade the prompt on later trials by gradually moving the correct colored object back so it is in line with the colored object. Continue to wait 3-5 seconds for a response and 3-5 seconds between trials. And be sure to switch the objects from side to side so the child will not learn a position habit.
Once the child is picking the correct color, ask the child to point to or hand you the other color. When the child can discriminate between the two colors, move to another color. Again, make it easy for the child. Red and green would be easier than red and yellow. Children with neuropsychological disorders may not generalize from one set of colors to another so be prepared to spend a long time in discrete trial training. If you get no improvement after a large number of trials, try black and white discrimination because the child may be color blind.
Maintenance and Generalization
Deliver social reinforcement in the form of praise, hugs, pats on the back, etc. as often as you can once the child learns the difference between stimuli. Edible reinforcers, such as candy or other treats, may be faded out once a significant change from baseline is achieved. Only give the tangible reinforcer every other time, then every third time, etc. until it is no longer required to maintain appropriate behavior. Of course, social reinforcement should be given as often as possible.
If you are not getting anywhere after several weeks, contact a psychologist versed in ABA in your area, if at all possible. (Go to http://www.aabt.org/ to locate ABA therapists.) One possibility for the ABA program not working is satiation. In other words, your child is getting tired of whatever reinforcer you are using.
(See http://www.polyxo.com/discretetrial/ for a good overview of discrete trial training.)

Clinic Notes: Asperger's Syndrome and Bi-polar Disorder

There's is a lot in the literature about bi-polar disorder being co-morbid with the Autistic Spectrum Disorders, especially Asperger's Syndrome. Children with Asperger's Syndrome perseverate and also have social problems. One common perseveration in children with Asperger's is being right. Often I have been running ABA drills in my clinic with a child with Asperger's and noticed that if the child gives the wrong answer and I tell the child that they have made an error they will often insist that they have given the correct answer. When I try and explain why the answer is wrong the intensity of arguing often increases, sometimes to the point that it resembles manic behavior. Once the child calms down they seem often to become "hyper-calm" almost moody and depressed. I have also had two-year old children come to my clinic with a diagnosis of bi-polar disorder, and often heavily medicated. In our assessment we find that the child does display "manic" like bhavior, but the "manic" like behavior always follows the child being given a direction that the child did not want to follow. If the child is made to mind then they also become moody and depressed. These children do well on ABA programs for compliance.

Clinic Notes: Why the Causes of Autism Are so Illusive

Recently, a pediatrician who had just had a child diagnosed with autism, emailed me. "The neurologist told me that autism is a brain disorder," she wrote. "And the gastroenterologist told me that autism is a gut disease, and the immunologist says that it is an immune disorder. Please tell me what autism is and how to treat it."
Of course, I told her about ABA, speech, OT, and the meds pediatric neurologist prescribe, but I could not answer her question completely. I don't think her question will be answered until we get a better classification system of autism spectrum then we have now. If you saw the kids in my clinic who are diagnosed with autism you would see so much variation in symptoms that you would wonder if they all had the same disorder. Some self-stim others don't, some are verbal others are not, some are compliant others are not, some have sensory issues others don't, some are remote ohers are very loving, some have digestive problems others don't, some have immune problems others don't, and so on. If all these children all have the same disorder, then why the wide variation in symptoms? I think autism will turn out to be a disease like cancer. There are many different types of autism with different causes and different treatments.

Clinic Notes: Social Stories for Children with Autism or Other Neuropsychological Disorders

What is a Social Story?
Social stories are short descriptions of how a child should behave in a wide variety of situations. Children with autism and Asperger's, as well as children with other disorders, have problems socially because of an inability to understand the point of view of others and their expectations. Everyday activities such as how to behave during circle time, what to say if someone compliments you, or how to handle bullying can be addressed by using social stories.
How to Use Social Stories.
Social stories are useful in teaching a child how to behave in situations when the therapist cannot be there to prompt and reinforce appropriate behavior. For example, if a child becomes aggressive at day care when another child takes a toy away then a social story about sharing or how to behave when a child takes a toy away can be very useful. A social story describing what the child should do to obtain a positive outcome, personalizing as much as possible the story for the child, is written. After reading the story to the child several times the child can be asked, "What do you do when Billy takes a toy you are playing with and starts playing with it himself?" If the child cannot remember the story or the answered then he/she can be cued. The correct answer may vary for different children in different settings. Telling the teacher might be appropriate in one situation; playing with another toy may be appropriate in another. At any rate the story is repeated until the child has memorized the correct answer. If the therapist finds out that child did engage in the appropriate behavior described in the social story then reinforcement in the form of praise and tangible reinforcement can be given at a later time.
How to Write a Social Story.
Social stories should be written from the point of view of the child and provide information on how to behave, what other expect, and the positive consequences of appropriate behavior. Social stories should be short and the child may have to memorize the correct way to behave and then replay the social story in his or her head when in the actual situation.