Trevor 141 the procedure is the same. Eventually these component skills are put together, and the child now has to group pictures together that tell a story in a logical sequence. That helps sequencing in general, an important basic skill in learning to use language. This strategy is ideally suited for children with autism but has never been evaluated on children with AS. Indeed, young children with AS seem more suited for a treatment program that focuses on social skills and on attempts to promote a wider range of interests. This second approach is more naturalistic and involves promoting social and communication skills in general by targeting the key deficits of children with ASD. The focus here is on basic social skills in eye contact, sharing an activity with an adult or another child, indicating wants and needs with respect to food or snacks, indicating pleasure in response to an adult activity such as tickling or singing a song. Interactions are often initiated by the child rather than by an adult; the adult tries to synchronize his or her responses to the child’s behavior. These interventions usually start at home or with an adult therapist too but soon move into community settings such as school or day care, with appropriate professional and clinical supports. By encouraging children with ASD to be in such settings, the opportunity to learn more appropriate social and communication skills from other children is also enhanced. The idea is that children with ASD have excellent visual learning skills. But instead of using these skills to mimic TV characters or Disney videos, they might use them to learn from other children. The teacher or therapist sets up situations that encourage or facilitate social interaction and communication between the child with ASD and a typical child. For example, a child with ASD may learn to take turns in a favorite game with a therapist. Then, once that is mastered, the therapist may introduce another typical child so that the three of them take turns. Then the therapist backs off and provides support for the child with ASD to play with the typical child and intervenes only when necessary. However, sometimes the behavior of the child with ASD is just too challenging to begin in this fashion, and some children need some form of discrete trial training to begin. Working on attention span, compliance, and understanding simple language can make it much easier to implement these more “naturalistic” interventions. Both of these forms of ABA have been shown to be effective compared to doing nothing. However, we do not know which type of ABA is more effective and efficient—that is, gives the most gain for the least cost—because the different forms have never been compared directly.
142 A MIND APART Neither do we know how to combine them most effectively into one program, nor what type of intervention works best for what type of child with ASD. There are no evidence-based principles by which to choose interventions, and these types of treatment decisions are best made through educated guesses by both parents and professionals based on the individual characteristics of the child, the particular situation and context of the child, and the child’s response to the intervention (hence the need for an extended assessment time). Trial and error is often warranted: “If it works, go with it!” For some time, the therapeutic claims for discrete trial training were exaggerated in the popular press and by some professionals given the quality of the evidence so far published. The possible gains are now understood to be more modest but are still clinically important. In fact, the gains for children with autism who also have severe learning disability are limited. The approach seems to work best with children who have at least moderate degrees of learning disability. Social–communication therapies may be just as effective, cost much less, and be more naturalistic for some higher-functioning children who are able to benefit from this form of intervention. Many experts feel this is the preferred treatment for children with AS and even for children with high-functioning autism who are verbal. The problem is that not all children with autism or PDDNOS have the attentional, social, and communication skills to make the best use of naturalistic settings. In these circumstances it may be best to start with a program of discrete trial training and then move on to more naturalistic and incidental teaching when the prerequisite skills appear or alternatively to work on both approaches simultaneously. Identifying essential skills needed for social interaction, teaching them using discrete trial training, and then moving on to the social– communication therapies is a useful strategy adopted by many professionals who like to take the best of both approaches and combine them. * * * Because Trevor had a moderate degree of learning disability based on cognitive testing and was just starting to communicate with pointing and pulling, we decided to start working on some other pivotal skills using discrete trial training. Attending is an important prerequisite skill for many other social, communication, and play skills. We taught Trevor to come sit, look at an object, and look at the therapist in response to having his name called. Each time he did the correct action,