Research in Autism Spectrum Disorders 3 (2009) 590606

Contents lists available at ScienceDirect

Research in Autism Spectrum

Disorders
Journal homepage: http://ees.elsevier.com/RASD/default.asp

Review

Instructing individuals to deliver discrete-trials teaching

to children with autism spectrum disorders: A review
Kendra Thomson a, Garry L. Martin a,*, Lindsay Arnal a,
Daniela Fazzio b, C.T. Yu a,b
a
b

University of Manitoba, 129, St. Pauls College, Winnipeg, MB, Canada R3T 2M6
St. Amant Research Centre, Canada

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 22 December 2008
Accepted 6 January 2009

Early intensive behavioral intervention (EIBI) has been identied as

the treatment of choice for children with autism spectrum
disorders. A common strategy for conducting EIBI is discrete-trials
teaching (DTT). There is a demand for research-based, economical,
rapid training techniques to teach tutors and parents of children
with autism to conduct DTT. This paper provides a review of
research that has focused on teaching individuals how to conduct
DTT. Considering the high demand for personnel trained in
delivering DTT to children with autism, research in this eld is
highly warranted.
2009 Elsevier Ltd. All rights reserved.

Keywords:
Discrete-trials teaching (DTT)
Autism spectrum disorders
Instructing DTT

Contents
1.
2.

Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . .
Summary of the research . . . . . . . . . . . . . . . . . . .
2.1.
Denition and measurement of DTT skills
2.1.1.
Dening DTT components . . . . . .
2.1.2.
Measuring DTT components . . . .
2.1.3.
Effectiveness of DTT . . . . . . . . . .
2.2.
Participant characteristics . . . . . . . . . . . . .
2.3.
Training characteristics . . . . . . . . . . . . . . .
2.3.1.
Written instructions . . . . . . . . . .
2.3.2.
Lectures . . . . . . . . . . . . . . . . . . . .
2.3.3.
Videotaped modeling. . . . . . . . . .

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* Corresponding author. Tel.: +1 204 474 8589.

E-mail address: gmartin@cc.umanitoba.ca (G.L. Martin).
1750-9467/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2009.01.003

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3.

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

591

2.3.4.
Verbal feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.5.
Visual training and feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.6.
Written feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.7.
Rehearsal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.8.
Treatment integrity and procedural reliability. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.9.
Social validity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Early intensive behavioral intervention (EIBI) based on applied behavior analysis (ABA) has been
identied as the treatment of choice for children with autism (Green, 1996; NYSDOH, 1999; Schreibman,
2000). Although the pioneering outcome study of EIBI by Lovaas (1987) has been criticized on
methodological grounds (Gresham & MacMillan, 1998; Matson & Smith, 2008), and although outcomes
are highly variable, EIBI programs that use direct, systematic delivery of ABA techniques for
approximately 35 h per week for up to 23 years has resulted in dramatic gains in children with autism in
cognitive, social, and communication skills (Eikeseth, Smith, Jahr, & Eldevik, 2007; Howard, Sparkman,
Cohen, Green, Stanislaw, 2005; Lovaas, 1987; Lovaas, Smith, & McEachin, 1989; Luiselli, Cannon, Elis, &
Sisson, 2000; McEachin, Smith, & Lovaas, 1993; Sallows & Graupner, 2005; Sheinkopf & Siegel, 1998;
Smith, Eikeseth, Klevestrand, & Lovaas, 1987; Smith, Groen, & Wynn, 2000).
A common strategy for delivering EIBI is discrete-trials teaching (DTT). DTT is made up of a series of
discrete-trials, small units of instruction that typically last 520 s. Each discrete-trial is made up of
several component parts: rst, an instructor (e.g., therapist, teacher, parent) presents an antecedent
cue, or discriminative stimulus (SD), which can be a verbal instruction and/or another teaching
stimulus. Second, the instructor may prompt the child (e.g., guide his/her hand) in order to minimize
errors. Third, the instructor waits for the childs response and then delivers an appropriate
consequence; typically verbal praise or a small reinforcer for correct behavior or saying, no and
removing teaching items to indicate an incorrect response. Finally, the instructor pauses for a 15 s
inter-trial interval before presenting the antecedent for the next trial (Smith, 2001). DTT is useful for
teaching children with autism spectrum disorders (ASDs) new discriminations such as responding
correctly to a verbal statement such as, Give me the pencil. and for teaching new behaviors such as
speech sounds and motor movements (Smith, 2001).
Considering that a large number of instructors (parents, educators, and tutors) are typically needed
to provide DTT training sessions in EIBI programs for children with autism, there is a need to develop
efcient, effective and economical training procedures for teaching individuals to apply DTT. A
literature search of evaluations of the effectiveness of training packages for teaching DTT lead to 16
publications plus one article in press, for a total of 17 publications. The remainder of this paper
provides a review of these studies.
1. Inclusion criteria
We used three inclusion criteria for selecting studies to be reviewed. First, the focus of the study
had to be an evaluation of the effectiveness of training packages for teaching DTT. Studies that focused
just on how the application of DTT changed the behavior of the individuals receiving DTT were
excluded (e.g., Downs, Downs, Johansen, & Fossum, 2007; Ferraioli, Hughes, & Smith, 2005; Sigafoos
et al., 2006).
Second, the dependent variable in the experiments had to include some measure of the
participants ability to deliver DTT skills after they received training. This was considered in order to
remain consistent with Baer et al.s (1968) behavioral dimension; interventions should focus on what
participants can actually do, not what they say they can do. For example, experiments that used DTT
training procedures that assessed participants procedural or declarative knowledge, but did not
measure the application of DTT, were excluded (e.g., Randell, Hall, Bizo, & Remington, 2007).
Moreover, studies that focused on teaching procedures for skills other than DTT, such as acquisition of

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K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

functional analysis skills or preference assessment delivery, were also excluded (e.g., Moore & Fisher,
2007; Roscoe, Fisher, Glover, & Volkert, 2006).
Third, consistent with the behavioral dimension in Baer, Wolf, and Risley (1968), studies were
included only if they reported an acceptable level of interobserver reliability (IOR), which is typically
80% in behavioral research (Kazdin, 1994; Martin & Pear, 2007).
A comprehensive literature search was done by searching the university online library/web
resource. No restrictions were placed on year of publication or journal. Key words such as discretetrials teaching were entered in the search. Additionally, articles that were cited in papers that were
retrieved were also included, if the articles also met the inclusion criteria.
2. Summary of the research
Seventeen publications met the inclusion criteria, summarized in Table 1. If a publication
contained 2 experiments, each of those is listed as a separate experiment in Table 1 (for a total of 20
experiments). It seemed warranted to address multiple experiments separately because the
participants and the procedures for teaching the participants how to conduct DTT were often
modied across experiments within a study (e.g., Arco, 1997). By reviewing each experiment
individually, important distinctions between training packages could be addressed.
2.1. Denition and measurement of DTT skills
2.1.1. Dening DTT components
As mentioned previously, an important inclusion criterion was that there had to be an objective and
reliable measurement of the DTT skills that were being taught. In most of the studies, the number of DTT
components ranged from 3 to 14. Downs, Downs, and Rau (2008) reported using a 30-component
checklist to rate instructor performance, but only mentioned a few of the DTT components in the article.
Because of the obvious need for a measurement tool to assess the quality of one-to-one DTT sessions
conducted by instructors and parents with children with autism, we recently developed and eld-tested
the 21-item Discrete-Trials Teaching Evaluation Form (DTTEF; Fazzio, Arnal, & Martin, submitted for
publication; see Fig. 1). An early version of the DTTEF (consisting of 19 of the 21 components) was used in
the studies by Arnal et al. (2007) and Fazzio, Martin, Arnal, and Yu (2009) listed in Table 1. The 21-item
DTTEF (shown in Fig. 1) was used in the study by Thiessen et al. (in press) listed in Table 1. The components
of the DTTEF used in other studies summarized in this review are listed in Table 2. The DTTEF has been
shown to have high face validity, high interobserver reliability for live scoring of trainees DTT
performances, high concurrent validity, and it differentiated between the DTT performances of trainees
before and after receiving instruction in applying DTT (Babel, Martin, Fazzio, Arnal, & Thomson, in press).
It is important to consider that it was often difcult to report on the DTT items used in each study,
as most studies reports of DTT items were very brief or not included (e.g., McBride & Schwartz, 2003).
Further, in some instances, studies may have reported a certain number of DTT items, but when
compared to the DTTEF, they actually contained more DTT items according to the DTTEF than what
was reported. For example, Arco (1997) reported teaching participants four DTT components, but
when analyzed compared to the DTTEF, there were actually seven DTT items identied. In contrast,
Downs et al. (2008) reported using a 30-item checklist to rate instructor performance, but only
mentioned a few of the DTT components. Therefore, only the DTT components that were mentioned
(and corresponded to the DTT components in the DTTEF) are indicated in Table 1.
From Table 1, it is evident that the DTTEF contains all of the DTT items that were used in the
majority of the reviewed studies. There were a couple of exceptions including Ryan and Hemmes
(2005), which included 12 DTT components seven of which are included in the DTTEF. The additional
components not included in the DTTEF (not included in Table 2) included participants use of
incidental or additional teaching (e.g., during the interval following the consequential stimuli
presentation the instructor made a response related to the reinforcing stimulus or event) and
participant use of voice tones (e.g., neutral for instructions, positive for reinforcers, etc). Downs et al.
(2008) reported using a 30-item DTT checklist but they only mentioned a few of the DTT items so it
was difcult to compare to the items of the DTTEF.

Table 1
Summary of 20 experiments that met inclusion criteria.
Participants who
were instructed
in DTT

Clients who
received DTT

Design

# of DTT Mean Instruction

items
IOR characteristics

Mean
duration
of training

PI/PR

Social
valid.

Change in DTT
accuracy from
baseline

Koegel et al.
(1977)

11 special
education
teachers
Gender not
specied

12 children
with autism

Multiple baseline
across participants

13

25 h

No

No

37%
(no instruction)

4 mothers
Koegel et al.
(1978)
Experiment 1

6 children
with autism

AB within subjects
with multiple
baseline across
participants
component

14

Not clearly
stated

No

No

67.5%
(no instruction)

3 adults
Koegel et al.
(1978)
1 mother
Experiment 2
1 male
1 gender not
specied

6 children
with autism

Multiple baseline
across participants

14

Not clearly
stated

No

No

56%
(no instruction)

Arco (1997)
4 adults
Experiment 1

1 child with
autism

Multiple baseline
across participants

33 sessions
(length of
sessions not
stated)

No

No

N/A

females

94.6% Training manual

Videotaped
demonstrations
Practice
Brief immediate
vocal feedback
Intermittent detailed
vocal feedback
92%

Lectures
Videotaped demonstrations
Opportunity to ask questions
specic to behavioral task
being taught

91%

Written instructions
Videotaped demonstrations

>80% Written instructions

reiterated vocally by
experimenter
Description of error
correction and praise
Modeling
Written feedback (docket)
with vocal explanation
Vocal feedback on graph
of their performance and
childs behavior

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

Experiment

593

594

Table 1 (Continued )
Experiment

Participants who
were instructed
in DTT

Design

# of DTT Mean Instruction

items
IOR characteristics

Mean
duration
of training

PI/PR

Social
valid.

Change in DTT
accuracy from
baseline

1 child with
autism

Multiple baseline
across participants

30 sessions
(length of
sessions
not stated)

No

No

N/A

Written DTT information

(overview, rationale
for using DTT, description
of components)
Hand-on training (practice
with child not in study,
with trainer feedback)
Vocal feedback (praise
for correct behaviors,
explanation of how to
correct errors)

Approx. 2 h

Yes

Yes

N/A

53% (denitions
of components
of DTT)

>80% Same instructions as Study 1

Vocal feedback
Withdrew written feedback

McBride and
Schwartz
(2003)

3 teachers
Females

3 children
1 MR
1 autism

Multiple-probe
across participants

97%

Multiple baseline
across participants

10

92%

Written instructions reviewed

vocally by experimenter
Visual feedback (shown
graph of their baseline
and DTT performance)
Rehearsal with vocal
feedback
Modeling

Approx.
30 min

No

No

Multiple baseline
across participants

10

97%

Abbreviated performance
feedback (vocal praise for
100% accuracy;
gave clarication and
vocal instruction
for all other performance)
Vocal instruction (reviewed
DTT checklist)

Not clearly
stated

No

Yes (good) 56.7%

(knowledge
of ABA only)

PDD-NOS

Sarakoff &
Sturmey
(2004)

3 special education 1 child with

teachers
autism
2 females
1 gender not
specied

Leblanc et al.
(2005)

3 teaching
assistants
Females

3 children
with autism

100%

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

Arco (1997)
3 adults
Experriment 2 Females

Clients who
received DTT

Ryan and
Hemmes
(2005)

3 special education Children

teachers
with autism
(number not
Gender not
specied)
specied

No baseline data
on participants

12

98%

N/A (no baseline

scores)

21-page self-instructional
manual
Study questions to
assess mastery
Summary sheet of
teaching DTT

2h

Yes (good) 23% (brief written

description of DTT)

21-page self-instructional
manual
Study questions to assess
mastery
Summary sheet of teaching
DTT
Scoring of demonstrational
video
Vocal feedback on scoring
accuracy

3.7 h

Written and oral quizzes

and demos
Demonstrations
Practice
Training manual with
workshop

Confederate
role-playing a
child with autism

19
AB within subjects
design with replication
across participants

94%

3 undergrad
Arnal et al.
students
(2007)
Experiment 2
Female

Confederate
role-playing a
child with autism

Multiple baseline
across participants

19

95%

Crockett et al.
(2007)

2 children
with autism

Multiple baseline
across behaviors

91%

Yes
100%

Lecture
1218 h
Demonstration video
Role-playing with vocal feedback
Video taped sessions of parent
teaching child (also used
for additional training
with other child)

Yes
100%

Yes (good) 55% (brief written

description of DTT)

No

No

68.33% (one skill

class-using DTT
to teach attending)

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

Yes

Role-playing
Vocal feedback (praise/error
correction)

Treatment sample
accuracy compared
to normative sample
accuracy

4 undergrad
Arnal et al.
students
(2007)
Experiment 1
1 male,
3 female

2 mothers

No
25 to 35
sessions (12 h
per session)

Instructions (vocal, written,

videotaped)

595

596

Table 1 (Continued )
PI/PR

Change in DTT
accuracy from
baseline

No

98.3%
(no instruction)

No

No

38% (some
written instruction
in baseline)

Not clearly
stated

No

No

20.85% (denition
of 10 DTT
components)

8h

No

No

N/A (some scores

not reported)

Participants who
were instructed
in DTT

Clients who
received DTT

Design

# of DTT Mean Instruction

items
IOR characteristics

Mean
duration
of training

Dib and
Sturmey
(2007)

3 teaching
assistants
Females

3 children
with autism

Multiple baseline
across participant

14

95%

Vocal instructions (reviewed

DTT checklist)
Experimenter reviewed
participants data from
previous sessions with
each female
Modeled target behaviors
Practice with vocal feedback
and modeling

No
Not clearly
stated (Took
place during
school hours)

Gilligan et al.
(2007)

3 teaching
assistants
Females

3 children
with DD

Multiple baseline
across participant

10

92%

Written instructions

Not clearly
stated
Review of protocol and
question session with trainer
Vocal feedback on performance
(praise and error correction)
Follow-up evaluation with
1 participant

Lafasakis and
Sturmey
(2007)

3 mothers

3 children
with DD:
1 autism
1 MR
1 Down
syndrome

Multiple baseline
across participants

10

94%

Vocal description of DTT

components
Discussed graphs of each
participants performance
Modeling
Rehearsal with corrective
vocal feedback
Videotaped each session
to be score

Downs et al.
(2008)

6 undergrad
research
assistants
Females

4 children
with DD:
1 autism
1 PDD

Multiple baseline
across participants

30

97%

Didactics

1 global DD
1 cerebral palsy

Modeling of correct/
incorrect procedures
Practice with corrective
vocal feedback

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

Social
valid.

Experiment

Fazzio et al.
(2009)

5 undergrad
students
3 females

1 Adult-confederate Modied multiple

role-playing a child baseline across
participants
with autism
3 children
with autism

97%

4 staff from
state-approved
private facility
Female

Children with
ASD

Multiple baseline
across participants

92.5 Didactic instruction

4 undergrad
university
students
Female

Modied multiple
Confederate
baseline across
role-playing
a child with autism participants
Child with autism
(generalization
phase)

21

Yes
100%

Yes (good) 58% (brief written

description of DTT)

No

3h

Yes

Had previous
experience

92%

96.5% Video self-monitoring

training (instructions on DTI
SM checklist, questions, etc)
Video self-monitoring
(score performance from
video using SM checklist)

15 min

Yes100% No

91%

4.4 h (manual) Yes

Demonstration
General case instruction
Practice with performance
feedback

Prior DTT
experience
Bachelor degree
Thiessen et al.
(in press)

2.6 h

Role-play and feedback

1 with DTT
Belore et al.
(2008)

Self-instructional manual

37-page self-instructional
manual
Summary of DTT
21-item checklist for
conducting DTT

9.67% (general
description of DTT)

75%
(no instruction)

Follow-up
training

98.5%

Yes

36% (brief
description of DTT)

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

Bolton & Mayer 3 university grads 4 children

Delayed multiple
(2008)
Female
1 with PDD-NOS baseline across
participants
Experience with
2 with autism
children with DD
1 with PDD-NOS

19

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K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

Fig. 1. The 21 components of the Discrete Trials Teaching Evaluation Rating Form (reprinted with permission from Babel et al.).

The DTT items from the DTTEF that were most often reported in other studies included: (a) securing
the childs attention; (b) presenting the instruction; (c) prompting; (d) providing positive
consequences following a correct response; and (e) negative consequences or error correction
following an incorrect response.
The DTT components that were more specic to the DTTEF and rarely mentioned in other studies
included: (a) the prompt fading procedure, with a few exceptions (Arco, 1997; Dib & Sturmey, 2007;
Ryan & Hemmes, 2005); (b) the specic aspects of the error correction (e.g., such as representing
materials, and offering praise only); and (c) items relating to preparing for the session (e.g., developing
rapport). These items were either not mentioned or not used in the descriptions of the DTT procedures
in the majority of the studies.
2.1.2. Measuring DTT components
In 19 of the 20 experiments, participants DDT skills were observed and recorded by trained
observers under structured testing conditions or from videotapes of the sessions. In those 19
experiments, the participants performance was reported as percent correct. In addition to percent
correct, Arco et al. also reported performance error, which was calculated by subtracting the correct
behavior percentage from the total behavior percentage (the sum of the correct plus incorrect
occurrences of the behavior, divided by the number of trials, and multiplied by 100). McBride and
Schwartz (2003) was the only study that did not use percent correct to measure correct DTT
performance; they used event recording and 10-s interval recording to measure the rate of
instructional opportunities that participants presented to young children with disabilities in four
conditions (baseline, activity-based intervention, activity-based intervention with discrete-trials, and
generalization).

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599

2.1.3. Effectiveness of DTT

In addition to measuring acquisition of DTT skills by participants, some studies evaluated whether
children showed improvement when taught by the participants after being trained to use DTT. For
example, to evaluate whether the DTT training that participants received was effective in teaching
skills to children with autism, Koegel, Russo, and Rincover (1977) had observers record the behavior of
children before and after receiving DTT from the participants who had just received DTT training. Any
improvement in the childrens behavior from baseline to post-DTT instruction was used as an
indication of the effectiveness of the training procedures to teach the participants how to effectively
deliver DTT. Ten of the 20 experiments included measures of childrens behavior before and after
receiving DTT instruction from the participants who had received DTT training similar to Koegel et al.
(1977). The remaining 10 studies did not include such measures.
2.2. Participant characteristics
There were a total of 77 participants in the 20 experiments. Of the 77 participants, 57 were female,
4 were male, and the gender of 16 of the participants was not specied. Participants ranged in age from
18 to 50 years.
Each participants amount of experience with children with ASD or related disorders varied
depending on factors such as the participants relationship with the child (e.g., parent or teacher), their
occupation (e.g., special education teacher, or university student), and their education level (e.g., high
school diploma or Masters degree in special education). Fifty-seven of the 77 participants had some
degree of direct experience with children with autism and other developmental disabilities (e.g.,
parents or educational professionals). The remaining 20 participants (e.g., university psychology
students) were not reported as having had direct experience with children with autism or other
related disorders. For example, in Arnal et al. (2007), university students were instructed to teach DTT
to an adult confederate role-playing a child with autism.
Thirty-six of the 77 participants were educational professionals; 20 were special education
teachers and 16 were paraprofessionals who worked with children with ASD and other developmental
disabilities (i.e., teaching assistants, staff at facilities for children with DD). Of the 20 special education
teachers, only 3 had formal training in DTT and also had a Masters degree in special education
(Sarakoff & Sturmey, 2004). Eleven of the teachers had read about behavioral principles, but had no
formal training in the application of behavioral methods or DTT (Koegel, Russo, & Rincover, 1977). The
level of experience of the remaining 6 teachers was not stated.
A total of 8 out of 16 paraprofessionals had some form of DTT training. Three worked at a private
school for children with autism and had training in behavioral teaching techniques and some training
in DTT (Dib & Sturmey, 2007). Four of the 16 paraprofessionals were trained in DTT and worked at a
state facility for children with DD (Belore, Fritts, & Herman, 2008). The remaining 8 paraprofessional
was a DTT-trained graduate student (Bolton & Mayer, 2008). The remaining paraprofessionalss had
basic training in ABA techniques, but no experience with administering DTT (Leblanc, Ricciardi, &
Luiselli, 2005), or did not have experience with basic behavioral techniques or DTT (Bolton & Mayer,
2008; Gilligan, Luiselli, & Pace, 2007).
Eleven of the participants were mothers of children with autism or other developmental disorders
(8 of the children had autism and the diagnoses of the remaining 3 children were not specied). Only 1
of the 11 mothers had formal training in behavioral principles, but did not have experience in
conducting DTT (Arco, 1997). The remaining 30 of the 70 participants were adult research participants
(e.g., university students, research assistants); 4 of the adults had some minimal experience with
behavioral principles (Arco, 1997). The remainder of the adult participants did not have any formal
experience in delivering behavioral principles or DTT (Arco, 1997; Arnal et al., 2007; Downs et al.,
2008; Koegel, Glahn & Nieminen, 1978; Ryan & Hemmes, 2005).
2.3. Training characteristics
Overall, the training packages used to teach participants how to conduct DTT varied across studies
and often include a combination of antecedent (e.g., written instruction, lectures, and video modeling)

600

Table 2
Components of the DTTEF used in other studies.
Koegel
et al.
(1977)

Koegel
et al.
(1978)

Determine teaching task

Gather materials
Select effective reinforcer(s)
Determine prompt fading
procedure and initial step
Develop rapport/positive mood
Check data sheet for
arrangement of materials
Secure childs attention
Present teaching materials
Present correct instruction
Present prompts (gradual)

Correct Response
Praise and present
additional reinforcer
Record correct response
immediately and accurately

Belore
Downs Bolton
Arco
McBride & Sarakoff & Leblanc Ryan and Crockett Dib and Gilligan Lafasakis
and Mayer et al.
and Sturmey et al.
Sturmey et al.
Hemmes et al.
et al.
(1997) Schwartz Sturmey
(2008)
(2008) (2008)
(2007) (2007)
(2007)
(2007)
(2005) (2005)
(2004)
(2003)
U

U
U

U
U

U
U

U
U

U
U
U
U
U
U (to evoke
cor. resp.)

U
U
U
U (to evoke
cor. resp.)

U
U
U
U

Incorrect Response
Block gently, remove materials,
look down (23 s)
Record incorrect response
immediately and accurately
Secure childs attention
Re-present materials
Re-present instruction,
prompt immediately
(guarantee correct response)
Praise only
Record error correction
immediately and
accurately
Allow brief inter-trial
U
interval (35 s)
Fade prompts
across trials

Verbal
pun.
U

U
U
U

U
U
U
U

U
U

U
U

U Error U
cor./
prompt

U Error
cor

U Error
cor.

Verbal
pun.

U Error
cor.

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

DTTEF

K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

601

and consequence (e.g., feedback and quizzes) methods. The descriptions of the training methods were
often very brief; therefore, we discuss some of the more common teaching methods that were used.
2.3.1. Written instructions
Over half of the studies included some form of written instructions to teach individuals how to
conduct DTT. Five experiments used a training manual that could be used for self-instruction. Koegel
et al., 1977 created one of the rst training manuals and used it for instructing 11 teachers to conduct
DTT sessions to teach children with autism. Their manual included examples of correct and incorrect
use of the ve components of their DTT teaching procedure (e.g. how to correctly deliver a prompt).
This manual was used in tandem with other training procedures, such as videotaped demonstrations
of the trainer modeling correct and incorrect delivery of the DTT components, and practice with
feedback. The training took the participants approximately 25 h to complete and results indicated that
the training procedure was effective in increasing the teachers correct application of DTT. There was
also a positive relationship between the teachers correct implementation of the DTT procedures and
improvement in the childrens behavior, and vice versa. The authors did not conduct a component
analysis of the training procedures so it is unclear which aspect of the training procedure was most
effective.
Ryan and Hemmes (2005) also used a training manual to implement a performance-based training
procedure with three special education instructors employed in an early intervention program for
children with autism. In addition to the manual, the training procedure included: (a) verbal
instructions; (b) videotaped instructions; (c) role-playing; (d) quizzes; and (e) in vivo training.
Unfortunately, there were no baseline measures of the instructors DTT performance, although, results
indicated that the instructors post-training DTT correct performance was high (all above an average of
85% correct). Again, it is unknown whether the manual component of the training was responsible for
the high DTT accuracy post-training, or whether the other aspects included in the training procedures
were responsible. It is also important to note that DTT was not the only focus of their manual as it
included additional information about autism, service delivery, etc.
Fazzio and Martin (2006) prepared a 21-page self-instructional manual on how to conduct DTT
training sessions with children with autism. The manual contained self-test questions to assess
mastery and DTT summary sheets. Arnal et al. (2007) assessed the effectiveness of the manual for
teaching undergraduate university students to apply DTT to teach three tasks to a confederate roleplaying a child with autism. In Experiment 1, the manual was evaluated in an AB design with
replication across 4 undergraduate university students. In Experiment 2, the manual was evaluated in
a multiple baseline design across 3 undergraduate university students, and the manual was evaluated
in combination with the participant scoring a video (with feedback) of an experienced tutor
demonstrating correct DTT implementation to a confederate. Arnal et al. (2007) found that after an
average of 2.2 h to master the manual, the four participants improved from a mean of 44% in Baseline
to a mean of 67% on the DTTEF. Following the treatment package in Experiment 2, all three participants
showed a dramatic improvement in the accuracy with which they used discrete-trials teaching
following implementation of the training package (Arnal et al., 2007).
Using a modied multiple baseline design across participants, Fazzio et al. (2009) replicated
Experiment 1 of Arnal et al. (2007) with ve additional participants. They found that participants
mastered the manual after an average of 2.6 h and participants DTT accuracy while teaching a
confederate improved from a mean of 34% in baseline to a mean of 66% on the DTTEF. The results from
these two studies suggest that the self-instructional DTT training manual may be a cost-efcient and
effective method for teaching individuals how to conduct DTT.
Based on the results from these studies and feedback from participants, the initial manual by Fazzio
and Martin (2006) was revised to a 37-page version (Fazzio & Martin, submitted for publication). The
revised manual contains more study questions, and a practice component in which participants
imagine teaching the DTT components learned in the manual. Using a modied multiple baseline
design across participants, Thiessen et al. (in press) investigated the effectiveness of the manual alone
for teaching four university students to apply DTT to confederates role-playing children with autism.
They also included a generalization phase in which participants whose DTT performance was at 80%
accuracy or higher when teaching a confederate, attempted to apply DTT to teach a child with autism.

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K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

The participants DTT performance improved substantially and immediately following mastery of the
self-instructional manual (52% in Baseline to 88% on the DTTEF). Performance dropped slightly in the
generalization phase (77%). The self-instructional manual was an efcient tool for DTT self-instruction
as training time averaged 4 h and 34 min.
2.3.2. Lectures
Four of the 18 experiments included lectures as part of their training package aimed to train
participants how to conduct DTT. In two studies, the duration of the lectures was approximately 20
30 min and occurred on more than one occasion (Crockett, Fleming, Doepke, & Stevens, 2007; Koegel
et al., 1978, Experiment 1). In another study, duration and frequency of the lectures were not stated
(Ryan & Hemmes, 2005). Downs et al. (2008) also included lectures but used an in-service-like
training for educators and paraprofessionals.
2.3.3. Videotaped modeling
Some of the earliest studies that assessed training packages for instructing others how to deliver
DTT, included videotaped demonstrations as part of the training package (Koegel et al., 1977, 1978).
Videotaped instruction continues to be used in more recent research. For example, Ryan and Hemmes
(2005) used videotaped instruction as part of their training package. One recent study did report that
their decision to use videotaped instruction was because they were modeling earlier training
procedures by Koegel and colleagues (Crockett et al., 2007).
2.3.4. Verbal feedback
All except two of the 18 studies (Arnal et al., 2007; Thiessen et al., in press) used verbal feedback in
some form; it usually occurred relatively immediately after participants performed instances of DTT.
Verbal feedback typically consisted of praise for correct implementation of DTT procedures and
corrective feedback for incorrect implementation of DTT procedures. The training procedures used in
two studies by Koegel et al. (1978) did not mention using any form of verbal feedback. Across the two
studies, the training packages included lectures, videotaped demonstrations, written instructions, and
an opportunity for participants to ask questions (Koegel et al., 1978).
2.3.5. Visual training and feedback
Three studies presented graphs to participants of their DTT performance in order to assist in giving
feedback to the participants (Dib & Sturmey, 2007; Lafasakis & Sturmey, 2007; Sarakoff & Sturmey,
2004).
Other studies used videotapes as a feedback tool. One study videotaped participants DTT
performance and provided feedback to the participants using the video (Crockett et al., 2007).
Videotapes were also used in more indirect ways to provide feedback for teaching delivery of DTT. For
example, Arnal et al. (2007) had participants watch a video of an experienced instructor delivering DTT
to a confederate role-playing a child with autism. The participants scored the instructors behavior and
received feedback on the accuracy of their scoring from the trainer. In another experiment,
participants watched videos of demonstrations of trained individuals delivering DTT and then had the
opportunity to ask the trainer questions and receive answers (Koegel et al., 1978).
Belore et al. (2008) used video self-monitoring to train staff to use a DTT self-monitoring checklist.
In baseline, staff members were videotaped conducting 1215 discrete-trials with a child with whom
they worked. They were then trained to use a ve-component checklist for tracking correct or
incorrect administration of DTT. The staff members viewed the video tapes of themselves conducting
DTT in baseline and were asked to score themselves using the checklist. When the staff scores of their
own DTT performance was in at least 90% agreement with the authors master checklist, the staff
members were administered an intervention. The intervention was the same as baseline, except that
staff members were asked to review the video tape from a session with a child and complete the DTT
checklist immediately after their session with a child. Staff self-monitoring improved the integrity of
teaching sessions and increased the accuracy of staff members implementation of DTT. This study
differed from the previously mentioned self-instructional packages in that the participants all had
previous experience delivering DTT (Belore et al., 2008).

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603

2.3.6. Written feedback

Written feedback was used in only 3 of the experiments. Arco (1997) used a feedback docket,
which was a summary sheet of participants performance to provide participants with feedback on
their DTT performance. This was discussed with participants. Two experiments included written
feedback in that participants wrote quizzes to test for mastery and received feedback about their
answers that were scored correct or incorrect, and questions that were answered incorrectly were
retested (Arnal et al., 2007; Ryan & Hemmes, 2005).
2.3.7. Rehearsal
Role-playing and rehearsal were also highly emphasized and common components of the training
packages. During rehearsal, participants displayed their DTT skills and were typically given praise and
corrective feedback from the trainers (Downs et al., 2008; Gilligan et al., 2007; Ryan & Hemmes, 2005;
Sarakoff & Sturmey, 2004). Often during rehearsals or role-plays the trainers modeled correct DTT
performance for participants (Dib & Sturmey, 2007) or instructed participants how to correctly apply
DTT (McBride & Schwartz, 2003).
2.3.8. Treatment integrity and procedural reliability
Treatment integrity (TI) typically refers to a measure of whether procedures were applied as
intended and described. Often a procedural checklist is prepared, and an observer uses the checklist to
evaluate the extent to which the experimenter follows the procedures as listed on the checklist. In
order to obtain a procedural reliability (PR) score, two independent observers will record whether or
not the experimenter performed the components of the procedure correctly. A PR score is then
calculated from the two individuals observations. Only seven of the 19 experiments reported TI or PR
scores, all of which were 100% (Arnal et al., 2007, Experiments 1 and 2; Belore et al., 2008; Bolton &
Mayer, 2008; Fazzio et al., 2009; McBride & Schwartz, 2003; Thiessen et al., in press).
2.3.9. Social validity
Kazdin (1977) and Wolf (1978) introduced strategies to help researchers to answer 3 questions
about their research: (a) What do the participants (and perhaps family members) think about the
goals of the intervention? (b) What do they think about the procedures that were applied? (c) What
do they think about the results that were obtained? Of the 20 experiments included in this review,
seven included a formal social validity assessment. In all instances, the results from the social
validity assessments were positive (Arnal et al., 2007, Experiments 1 and 2; Fazzio et al., 2009;
Leblanc et al., 2005; McBride & Schwartz, 2003; Thiessen et al., in press; Ryan & Hemmes, 2005). For
example, teachers in McBride and Schwartz (2003) reported in face-to-face interviews that the
teaching methods were helpful and DTT had a positive impact in classrooms. Participants also
indicated satisfaction with the procedures by lling out appropriate variations of acceptability
questionnaires (Arnal et al., 2007; Experiments 1 and 2, Fazzio et al., 2009, Leblanc et al., 2005; Ryan
& Hemmes, 2005). For example, teaching assistants in Leblanc et al. (2005) completed the
Acceptability Rating Scale (Davis, Ramana, & Capponi, 1989), which revealed high acceptability of
the intervention.
3. Discussion
Twenty published experiments were reviewed that have evaluated training procedures for
instructing individuals how to conduct DTT. The most common training methods included in the
studies were: (a) various forms of instruction (written, verbal, videotaped); (b) demonstration/
modeling; (c) feedback from the experimenter (praise and error correction); and (d) role-playing and
practice.
There are some limitations in the research are worth noting. First, the descriptions of training
procedures were often very brief, which makes systematic replication difcult. Second, it is difcult to
assess whether or not all the experiments were carried out as intended by the experimenters as many
of the studies lacked TI or PR measures. Third, the duration of the training was often not clearly stated,
so that mean training time is difcult to determine. Fourth, very few of the studies provided

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K. Thomson et al. / Research in Autism Spectrum Disorders 3 (2009) 590606

concurrent assessments of the behavior of the children who received the DTT instruction. Its one thing
to claim that a training package is effective for teaching an instructor or parent to apply DTT reliably.
Its something else again to demonstrate that that instructor or parent is more effective at teaching the
child new skills.
It is difcult to draw conclusions across the various studies about the relative effectiveness of the
various training methods for three reasons. First, the participants in the various studies differed on an
important variable, their prior DTT experience, before receiving a training strategy. For example,
Leblanc et al. (2005) studied participants who had received prior training in behavioral principles, and
two studies (Belore et al., 2008; Sarakoff & Sturmey, 2007) included participants that had received
previous formal training in DTT. On the other hand, some studies had participants with no prior
experience in behavioral principles or DTT (e.g., Crockett et al., 2007). Second, across the various
studies, there was a difference in the amount of DTT instruction that participants received during
Baseline sessions before any actual training. For example, some studies provided some form of
description of DTT in Baseline (Arnal et al., 2007; Fazzio et al., 2009; Gilligan et al., 2007; Lafasakis &
Sturmey, 2007), while other studies provided no information about DTT at all (e.g., Dib & Sturmey,
2007; Koegel et al., 1977, 1978). This may be why there was a widespread range of Baseline scores
reported. For example, Dib and Sturmey (2007) reported that participants DTT accuracy was low
before receiving additional training (0%), and in other cases, individuals started with high (98%)
baseline scores in DTT performance (Bolton & Mayer, 2008). Third, as discussed previously, there was
considerable variability across studies in the number of DTT components that were measured as the
dependent variable.
Additional research is needed to address the above limitations and concerns. Future research is
needed to clearly establish the reliability and validity of a measurement tool, such as the DTTEF, to
assess the quality of DTT sessions conducted by instructors and parents. Future research on DTT
training should also include some form of component analysis of the effectiveness of the various DTT
training methods. Because the training packages contained so many methods for teaching DTT, it is
difcult to assess which components of training were responsible for any change in the participants
DTT behavior (e.g., Ryan & Hemmes, 2005; Sarakoff & Sturmey, 2004).
Considering that millions of dollars are being spent on public programs to fund EIBI treatment of
children with autism, reviewers of outcome literature (e.g., Matson & Smith, 2008; Perry, Pritchard, &
Penn, 2006; Tews, 2007; Wolery & Garnkle, 2002) have identied several important needs that must
be addressed, two of which are: (a) quality assessment systems to evaluate specic components of EIBI
interventions, such as a measurement tool like the DTTEF to assess the quality of the one-to-one DTT
sessions conducted by instructors and parents; and (b) the development of research-based,
economical, rapid training procedures to train instructors and parents to conduct DTT with children
with autism. As demonstrated by this review, a start has been made to address these needs. However,
much remains to be done.
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