Within an ABA program, there will be many opportunities for prompting a child with autism to succeed. It is sort of the cornerstone for a child with autism to learn and to succeed. If a therapist never prompted, a child will be incorrect and therefore motivation to learn drops. Prompting is just another word of helping or assisting the child to a correct response. Prompting is seen outside of an ABA context as it is a useful tool in school settings, corporate settings and home settings. Ever pointed to a puzzle piece with the intention of helping when doing a puzzle with your daughter? That’s prompting.

A Little More On Prompting

• Prompting always assists the child to a correct response
• It ensures the child to succeed and reduces frustration so that the therapist can deliver reinforcement
• A prompt can be anything as long as the therapist or family member knows they are using a prompt
• A prompt should be available to all therapists, teachers and family members.
• Prompts should be faded over time to ensure an independent response from the child. Some children will need a “built-in” prompt for a period of time for a success to occur. Such examples include training wheels on a bike, floaties for swimming, or a verbal reminder to wash hands after you use the bathroom.
• For new tasks that the child is learning always use the most intrusive prompt to ensure a high rate of success. For tasks that are mastered and known to the child, use a least intrusive prompt before moving on to more intrusive prompts. There will be some behaviors, though, that a more intrusive prompt such as a full physical prompt, is more appropriate than a less intrusive prompt like modeling the behavior. You can see this when teaching a child to imitate actions of a therapist. Most likely a therapist will say, “Do This” and make an action such as tap table. It is best then, that therapist physically guide the child to the behavior as the instruction already includes a model of the behavior (tap table).
• Be careful about inadvertent prompting, assistance that you are not aware of. Examples include looking at the correct response, mouthing the answer and leaning towards the correct response. Therapists may not even realize they are doing these behaviors.

When Does A Therapist Use A Prompt While Teaching?

• In Discrete Trial Teaching the prompt is delivered immediately after the SD, also known as the instruction:
  

  SD (prompt)→ R→ Consequence

• When a therapist is teaching a new skill or behavior. Prompting is always the heaviest when you are teaching a new skill to ensure success and therefore reinforcement.
• Prompts can be built into the teaching sequence if you find the child struggling with an independent response. Be careful that the child doesn’t become Prompt Dependent, whereby the child is waiting for the prompt. This usually occurs when the therapist cannot fade the prompt. You can get rid of prompt dependency by putting the behavior on hold and working on another behavior or getting a more experienced therapist to try and fade the prompt effectively

Types Of Prompts

• Full Physical Prompt aka HOH – HOH or hand-over-hand prompting is a full physical prompt. The therapist does the entire action while physically prompting the child.
• Partial Physical Prompting – Therapist partially assists the child to a correct response. If the therapist is teaching to “wave bye-bye” a partial physical prompt can look like tapping the elbow for the child to raise their hand and to wave.
• Model – Therapist models the correct behavior. If the therapist asks the child to “stand up” a therapist can model the stand up behavior.
• Positional – Many teaching opportunities require objects or 2D cards on a table. To utilize a positional prompt, the therapist can move the object or card closer to the child. This will make the child reach for the closest object or card.
• Within-Stimulus – This prompt is part of the object or 2D card. For example, when teaching Wet and Dry, having a wet cloth next to a dry cloth is a within stimulus prompt.
• Response-Delay – This type of prompt is useful for children who respond too quickly and may not even hear the instruction. So a therapist can give the instruction and then inhibit the child from responding for x amount of seconds. This will give the child time to process the instruction. A response-delay prompt shouldn’t be used on whim. It is a very specific prompt for a specific behavior response.
• Verbal – a full verbal prompt is saying the entire phrase or word. For example, if you are teaching the child to recognize objects and verbalize the object, a therapist can give the instruction, “What is it?” while hold up an object or 2d card and then give the prompt, “Say bear.” A partial verbal will fade back “say bear” to “bear” and then if needed, “buh.”
• Inflection/Deflection – used for verbal responses. A therapist may inflect a certain part of the word or phrase if you find the child not saying that part. For deflection, a therapist may note that the child is over emphasizing a sound or over inflecting a sound in a word so a therapist will model the correct way with a deflection prompt.
• Gestural – pointing is a common gestural prompt.

Once children can learn to imitate the therapists’ actions, imitation may involve going around the house and playing following the leader. As well, imitation of more than one action is also targeted as a method to teach a variety of skills such as putting on your shoes and even language production. Imitation can be targeted to doing fine motor tasks or oral motor tasks to work on writing skills and sound production.

So what does DTT actually look like? Within DTT, there are 3 components to effectively teach children with autism: the discriminative stimulus (SD) or the command, the behavior of the child, and the consequence of the child. Using these three simple components as well as using effective prompting strategies to help the child achieve success, children with autism soon begin to learn skills that they lack such as imitation, language, play, social skills and academic skills.

When done right, DTT ensures consistency across people since it always incorporates those three essential components. Consistency is also key to helping children maximally learn. When I mean consistency I mean that every one in the child’s life is doing the same thing each and every time. For example, if a team decides the child must request verbally for food or drink, then the parents and other care providers must also agree to this. It is extremely crucial, no matter how exhaustively draining it is, to be consistent as much as you can.

A properly run in-home ABA program for younger children will have consistency across therapists and family members, community outings, discrete trial teaching, pre-academic programs, leisure skills, self help skills, social programs, language promotion, behavior interventions, generalization of previous taught skills, play programs, and peer play when applicable.

Below is an instructional video on Discrete Trial Teaching or Discrete Trial Instruction. The video does state the DTT is composed of 4 parts, one of them being the “get ready” tapping prior to instruction. This is not necessary in DTT. Therapists should deliver the instruction 1-2 seconds after reinforcement was given for the previous trial.

Once the child can approximate some part of a correct response with the use of a prompt, the therapist then “ups the anty” by giving a lesser type of reinforcement (“good job”) and fading their prompt until the child responds correctly. For this response, reinforcement is delivered in larger quantities (when compared to the teaching phase) in order to increase the likelihood of the behavior.

This teaching strategy is called differential reinforcement. If the child responds independently without any assistance from the therapist, the quality and quantity of reinforcement is stronger than reinforcement at prompted trials.

Differential Reinforcement:
Using stronger reinforcement for independent success and using lesser reinforcement for non-success. Think of Differential Reinforcement as giving EXCELLENT feedback to an EXCELLENT response, GREAT feedback to a GREAT response, OKAY feedback to an OKAY response, and CORRECTIVE feedback to an incorrect or non-response that is poor in attention and motivation.

Choose your EXCELLENT reinforcer by finding food or items that the child loves but rarely gets. If you choose a food or item that the child normally gets, it will not be a powerful motivator for EXCELLENT responses and the child will not comply to the instruction given.

For anything less than an EXCELLENT response, the child will receive other reinforcers that will make him or her happy and content.

Remember that therapists need to avoid satiation by not always giving one type of food or item for responses. Therapist should have a variety of food and toys that the child absolutely loves and use them throughout their session. You can decide what type of food and toys to use to shape a desired behavior by doing a Reinforcement Sampling where you hold up two objects and see what the child chooses. From there you pair the chosen item with another item and see what they choose. From this sampling, you can get an idea of what the child really wants at that time.

An Example of Teaching the Label, “Apple” in an Expressive (Object) Labels Program by using differential reinforcement

If a therapist wants to teach the child the label, “apple,” the therapist or team must first decide what a correct response is. For verbal children it will be the full word, for non-verbal children, it may be picking the correct PEC, and for children who have a hard time with pronunciation, an approximation to the label can be considered a correct response.

During each teaching trial, a therapist must deliver a consequence for the child’s behavior. If the consequence is correct, reinforcement is given.

First Sitting:

Therapist: “What is it?—APPLE” (APPLE is a verbal prompt- voice is slightly above normal speaking voice)

Child: “Apple”

Therapist: “Good! That’s apple!” (reinforcement is appropriate for a full prompted response)

Therapist: “What is it?—Apple” (voice is normal speaking voice when giving verbal prompt)

Child: “Apple”

Therapist: “All right, that’s an apple!” (repeating the label is called an expressive follow-up and can be used to help learn the label)

Therapist: “What is it?—-Ahh…” (normal speaking voice when delivering a partial verbal prompt)

Child: “Apple”

Therapist: (lifts child up in the air, or gives food, toy etc..) “You did it! It’s apple!”

Therapist lets child go for a correct response with a faded prompt.

Second Sitting:

Therapist: “What is it?—Ahh” (whispers verbal prompt)

Child: “Apple”

Therapist: “Good!” (gives child tickles or some form of physical reinforcement for a correct response with a faded prompt)

Reinforcement at this level is quick as the pace of drills is essential to catch children “off guard.” If you run your drills fast, you can easily fade your prompt completely and hope that the child will automatically say the label. This method is called behavioral momentum.

Therapist: “What is it?—therapist mouths the sound “Ahh”

Child: “Apple”

Therapist: “Holy-Molly!”

Therapist: “What is it?

Child: “Apple”

Therapist: “Woo-Hoo, that’s apple!” let the child go play/ give food/ special toy.

Children learn at different paces, so this example can be stretched to several days at a certain level of prompting, such as a verbal prompt of, “Ah” over two or three days.

Here is an old video of a child learning some basic sounds using the so-called “lovaas method” of language acquisition.

The use of ABA therapy to teach a child with autism has changed the way we look at treatment for these individuals. In the past, some parents were told that these children did not learn and will not function in society. Limited options were given to parents of children with autism such that most children were institutionalized.

As well, mothers in the Bettleheim era were told that they were the cause of autism in their child. With such negative outlooks, it is no wonder that many parents felt hopeless in making a difference in the lives of their children.

Fortunately, Bettleheim’s “refrigerator mother” theory was disproved since autism is found to be a developmental, rather than a psychological, disorder.

Other theories about autism have surfaced since the time of Bettleheim. One such theory, behaviorism, became popular in the 1960’s, since it promoted change in children with autism.

The basic principles on which behaviorism uses is to introduce a stimulus as a method to increase or decrease the likelihood of a behavior. Since autism is objectively characterized by a series of behaviors, theorists of behaviorism felt that by changing maladaptive behaviors and teaching behaviors that were lacking in these children might result in increasing the likelihood of age-appropriate behaviors.

Applied Behavioral Analysis

One such theorist, Ivar O. Lovaas used behaviorism to teach children with autism. As well, he used a form of a teaching strategy called Discrete Trial Teaching (DTT) to maximize learning in children with autism.

In 1987, he organized the Young Autism Project to study the effects of ABA on autistic children under the age of 4 with IQ scores falling in the mild to retarded category.

His experimental group of 19 children received 40 hours a week of one-to-one intensive therapy and a control group only received 10 hours a week.

Lovaas’ short-term goals in an ABA program consisted of teaching compliance, imitation and appropriate toy play, generalizing treatment in the community, and reducing self-stimulatory behaviors such as hand-flapping. In essence, Lovaas was teaching these children skills that they lacked due to their diagnosis.

Long-term goals that were emphasized in years two and three of ABA therapy consisted of teaching language, playing with peers, emotions, pre-academic skills such as reading and writing, and observational learning.

His results revealed that children in the experimental group gained an average of 30 IQ points, and were higher than the control group in school and intellectual functioning.

Of the 19 children in the experimental group, 47% achieved normal or above average IQ scores, went on to a normal first grade, and were indistinguishable from their peers. This is a remarkable statistic considering that before the Lovaas Young Autism Project, the future of autistic individuals was bleak.

Children in the control group had IQ scores that remained stable over time (Lovaas, 1987).

In 1993, McEachin, Smith and Lovaas wanted to evaluate the long-term outcome of the children in Lovaas’ 1987 study.

They found that the 19 children in the experimental group maintained their level of intellectual functioning and had higher scores than the control group on adaptive behavior and personality at a mean age of 11.

The children in the control group did not gain such an outcome. In contrast, they fared poorly, which coincides with the poor prognosis of autistic children if no early intervention was administered.

These two reports prove that ABA is the only scientifically based treatment available at this time for children with autism.

While there are many other therapies out there for children with autism, there is no data to support them. This does not mean that ABA does not incorporate other forms of teaching.

ABA is a broad category that is not specific to children with autism. When it is applied to these children, ABA incorporates DTT, operant conditioning, with the possible use of Picture Exchange Communication (PEC) developed by Andrew Bondy, Ph.D. and Lori Frost, fluency teaching endorsed by Michael Fabrizio, errorless learning developed by Terrace, verbal behavior that is promoted by Dr. Vincent Carbone, Mark Sundberg and Jim Partington, or social stories developed by Carol Gray.
Autism Information References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, DC: Author.

Bondy, A. & Frost, L. (1994). The Picture Exchange Communication System. Focus on Autistic Behavior, 9, 1-19.

Grey, C. (2000). The New Social Stories Book. Future Horizons.

Lovaas, O.I. (1987). Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children. Journal of Consulting and Clinical Psychology, 55, 3-9.

Maurice, C. (1993). Let Me Hear Your Voice: A Family’s Triumph Over Autism. New York: Ballantine Books.

McEachin, J., Smith, T., & Lovaas, O.I. (1993). Long-Term Outcome for Children with Autism who Received Early Intensive Behavioral Treatment. American Journal on Mental Retardation, 97, 359-372.

Terrace, H.S. (1966). Stimulus control. In W.K. Honig (Ed.), Operant behavior: Areas of research and application. New York: Appleton-Century-Crofts.