Review Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s40489-018-0152-6

REVIEW PAPER

Training Behavior Change Agents and Parents to Implement Discrete

Trial Teaching: a Literature Review
Justin B. Leaf 1,2 & Wafa A. Aljohani 2 & Christine M. Milne 1,2 & Julia L. Ferguson 1 & Joseph H. Cihon 1,2 &
Misty L. Oppenheim-Leaf 3 & John McEachin 1 & Ronald Leaf 1

Received: 10 April 2018 / Accepted: 3 October 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Discrete trial teaching (DTT) is a commonly implemented and evaluated teaching procedure for individuals diagnosed with
autism spectrum disorder (ASD). As such, DTT is often a procedure that behavior analytic practitioners are required to learn how
to impliment. Additionally, parents are often encouraged to learn how to implement DTT to supplement intervention for their
child(ren) diagnosed with ASD. This review of the literature included 51 studies (57 experiments) that involved training behavior
change agents and/or parents on the implementation of DTT. Each of the studies was evaluated and quantified along several
dimensions including participant demographics, experimental design, outcome, DTT task analysis, training procedures, training
time, and the mastery conditions for the implementation of DTT. The results of the review indicated that there is a robust literature
on training individuals to implement DTT. However, results also revealed there are several areas that should be addressed by
future studies as well as implications for practitioners and certification standards.

Keywords Behavior analysts . Discrete trial teaching . Parent training . Staff training . And training

One commonly implemented procedure based upon the prin-
ciples of applied behavior analysis (ABA) is discrete trial
teaching (DTT; Lovaas 1981, 1987). DTT is a systematic
method of instruction consisting of three primary components
including (1) a discriminative stimulus (e.g., an instruction)
presented by the instructor, (2) a response from the learner,
and (3) a consequence based on the learner’s response (i.e.,
reinforcement or punishment) provided by the instructor.
Additional variables commonly involved within DTT are the
instructor providing a prompt to increase the likelihood of the
learner responding correctly (MacDuff et al. 2001), modifica-
tion of the intertrial interval (i.e., the time between trials;
Lerman et al. 2016), data collection on learner responding
(Gongola and Sweeney 2011), and developing establishing
operations (Michael 1988).
DTT has been described in a variety of commentaries (e.g.,
Ghezzi 2007; Leaf et al. 2016; Smith 2001), book chapters
(e.g., Leaf and McEachin 2016; Lerman et al. 2016), curricu-
lum books (e.g., Leaf and McEachin 1999; Lovaas 1981;
Maurice 1993), and research articles (e.g., Severtson and

* Justin B. Leaf Misty L. Oppenheim-Leaf

Jblautpar@aol.com mlo0411@gmail.com
John McEachin
Wafa A. Aljohani
jmautpar@aol.com
waljo346@mail.endicott.edu
Ronald Leaf
Christine M. Milne Rlautpar@aol.com
cmautpar@aol.com
1
Autism Partnership Foundation, 200 Marina Drive, Seal
Julia L. Ferguson Beach, CA 90740, USA
jfergusonautpar@aol.com 2
Endicott College, 376 Hale Street, Beverly, MA 01915, USA
3
Joseph H. Cihon Behavior Therapy and Learning Center, 200 Marina Drive, Seal
jcihon@autismpartnership.com Beach, CA 90740, USA

Carr 2012). DTT remains a well-researched and described
teaching procedure and a commonly implemented procedure
within autism intervention (Ghezzi 2007; Smith 2001). DTT
has been demonstrated to be an effective method to teach a
variety of skills including, but not limited to, receptive labels
(e.g., DiGennaro Reed et al. 2011), expressive labels
(Conallen and Reed 2016), play (Weiss et al. 2017), and social
behavior (e.g., Shillingsburg et al. 2014).
The findings of the research demonstrating DTT to be a
successful procedure may have contributed to the common
recommendation for the use of DTT for individuals diagnosed
with autism spectrum disorder (ASD) in clinical settings (e.g.,
Leaf and McEachin 1999). However, behavior change agents
(i.e., individuals implementing behavioral intervention) may
use DTT in multiple settings including, but not limited to,
clinic-based centers, university based centers, in the individ-
uals home and/or community, and in school settings (Leaf
et al. 2018). Additionally, parents have been trained to imple-
ment DTT with their children outside of formal intervention
sessions to supplement treatment (e.g., Lovaas et al. 1973).
This may be more likely to occur when parents live in rural
areas where access to services is difficult. Regardless of who
is implementing DTT, it is important that it be done with high
treatment fidelity so that optimal outcomes can be achieved
(Fryling et al. 2012; St Peter Pipkin et al. 2010). As such, it is
important for these individuals to be well trained in the imple-
mentation of DTT.
To help ensure that behavior change agents and parents
implement DTT with a high degree of fidelity, researchers
have explored the use of a variety of training procedures. In
an early example, Koegel et al. (1977) trained 11 teachers to
implement DTT and shaping procedures with individuals diag-
nosed with autism. In this study, the Koegel et al. utilized a
manual plus feedback to train teachers to implement DTT.
Using a modified multi-response baseline design, the authors
demonstrated that the teachers improved on the correct imple-
mentation of DTT. In a more recent example, Sarokoff and
Sturmey (2004) provided a task analysis of DTT consisting of
10 different components and utilized an adult confederate to
train teachers to implement the DTT components correctly.
Prior to intervention, the three teachers displayed low levels
of correct implementation of DTT. Following behavioral skills
training (BST), consisting of instructions, modeling, role-play,
and feedback, all three teachers implemented the 10 steps of the
DTT task analysis correctly across multiple sessions with an
adult confederate. There are several other training procedures
which have been evaluated to train behavior change agents how
to implement DTT including, but not limited to, video model-
ing (e.g., Catania et al. 2009), performance feedback (e.g.,
Gilligan et al. 2007), computer instruction (e.g., Higbee et al.
2016), and self-instructional manuals (e.g., Arnal et al. 2007).
Researchers have also evaluated a wide variety of training
procedures on training parents how to implement DTT with
Rev J Autism Dev Disord
their own children diagnosed with ASD. One of the first stud-
ies to evaluate parents’ implementation of DTT was conducted
by Koegel et al. (1978). In the first experiment within the
study, training occurred with four parents of children diag-
nosed with autism. Training consisted of three 30 min lectures,
parent trainer demonstrations (lasting between 10 and 15 min
per demonstration), and two 37 min videos which modeled
correct and incorrect implementation of DTT. Within this ex-
periment, Koegel et al. created a task analysis of DTT
consisting of 14 steps including how to present instructions,
provide prompts, use shaping strategies, provide conse-
quences, and implement each trial with discrete beginning
and ending. Total training time took between 2 h 54 min and
3 h 54 min. Using a multiple-response baseline design, Koegel
and colleagues demonstrated that all parents implemented
DTT correctly with their children. In the second experiment,
Koegel et al. evaluated the effects of video illustrations in
isolation on the implementation of DTT. Using a multiple-
response baseline design, Koegel and colleagues demonstrat-
ed that the parents implemented the 14-step DTT procedure
successfully with thier children diagnosed with ASD. Since
this study, there have been numerous investigations that have
demonstrated other behavior analytic interventions such as
video modeling (e.g., Young et al. 2012), instructional man-
uals (e.g., Summers and Hall 2008), and BST (e.g., Eid et al.
2017) to be effective procedures to train parents on the imple-
mentation of DTT with their children.
Given the breadth of the literature base on training behavior
change agents and parents to implement DTT, a review of the
current literature could provide a synthesis of the pertinent
information. Furthermore, there has been a growth in the num-
ber of certified professionals (e.g., Registered Behavioral
Technician™, Board Certified Assistant Behavior Analyst®,
Board Certified Behavior Analyst®, and Board Certified
Autism Technicians) who provide behavioral intervention
for individuals diagnosed with ASD, who may implement
DTT to individuals diagnosed with ASD, and who have to
demonstrate at least minimal competency in DTT as part of
receiving a certification (Behavior Analyst Certification
Board 2017; Behavior Intervention Certification Council
2015).
The purpose of the present paper was to provide this review
by analyzing and synthesizing the research that has evaluated
methods to train behavior change agents and parents on the
implementation of DTT. Specifically, we sought to identify (1)
participant demographics (e.g., educational level), (2) location
of training, (3) research designs used (e.g., multiple baseline
designs), (4) training variables (e.g., type of training proce-
dure), and (5) outcome measures (e.g., percentage of non-
overlapping data). After identifying this information, we syn-
thesized the information by (1) comparing differences in the
research findings across participants (e.g., differences in re-
sults between parents and therapists) and (2) comparing
Rev J Autism Dev Disord
differences in the research findings across training procedures
(e.g., differences in results between studies that used BST to
those that used video modeling). From this synthesis, we eval-
uated the current status of training behavior change agents and
parents to implement DTT, provided recommendations on
training, identified limitations in the research, and provided
recommendations for future research.
Methods
Search Procedure
First, the primary researcher conducted a search in peer-
reviewed journals from January 1950 to November 2017
using the PsychINFO database. The primary researcher used
the following keywords: Bdiscrete trial,^ Bdiscrete trials,^
Bdiscrete trial instruction,^ Bdiscrete trial training,^ BDTT,^
Btraining,^ Bdevelopmental disabilities,^ and Bautism^ in all
possible combinations. Next, the primary researcher conduct-
ed a search in the peer-reviewed journals form January 1950
to November 2017 in the Educational Resources Information
Center (ERIC) database using the same keywords and combi-
nations. All articles identified through initial search of the
PsychINFO and ERIC databases were reviewed if they met
the inclusion or exclusion criteria. There were a total of 198
articles located based upon these searches. Finally, the prima-
ry researcher manually checked the reference sections of the
198 articles for any additional studies that might meet the
inclusion criterion (stated below). No additional articles were
identified using this method. Thus, a total of 198 articles were
evaluated for inclusion.
Inclusion Criteria
There were four inclusion criteria. First, articles had to be
published in a peer reviewed journal. Dissertations and book
chapters were excluded. Second, articles had to be experimen-
tal. Reviews, commentaries, or programmatic descriptions
were excluded. Third, articles had to specifically state that
the experimenters trained behavior change agents (e.g., stu-
dents, teachers, therapists, staff, paraprofessionals, swim in-
structors, or adults) or parents on how to implement DTT.
Finally, articles had to provide objective and empirical data
on the individual implementing DTT. There were no
inclusion/exclusion criteria for with whom the behavior
change agent or parent was implementing DTT. That is, if
the study met the above four criteria, it was included regard-
less of other variables (e.g., age, multiple diagnosis). Based
upon these criteria, 51 out of the 198 initial articles were
included for further review and analysis.
Data Extraction and Synthesis
Each study that met the criteria for inclusion was evaluated
and quantified along several dimensions.
Participant Demographics Four participant variables were
evaluated within each study. First, we evaluated the partici-
pants’ roles and/or profession (e.g., teacher, parent, student).
Second, we calculated the total number of behavior change
agents and/or parents who received training on the implemen-
tation of DTT within each study. Third, we evaluated the
number of participants who had a previous history of training
with DTT prior to their inclusion within the current study.
Fourth, we evaluated the education level of the participants
in each study.
Setting We evaluated the environment in which training oc-
curred. We categorized training environments as an agency
(e.g., an organization that provides services outside of a uni-
versity and the home), home, university, school (which in-
cludes classrooms), and, in one instance, a swim school.
Experimental Design To provide and assessment of the meth-
odological rigor of each study, we recorded the experimental
design each study.
Training Variables We evaluated five variables that were relat-
ed to training. First, we measured the number of behavioral
steps or components the authors used to define DTT within
each study. Second, we evaluated the types of teaching proce-
dures (e.g., video modeling, BST, instructional manuals) that
were used to train participants on the implementation of DTT.
Third, we recorded the training time per session as directly
stated by the researchers. Fourth, we evaluated the total train-
ing time per study. There were two ways that we could calcu-
late this measure. First, the authors of the articles could provide
the information on total training time. The authors could pres-
ent this as a precise measure per participant, as the total amount
of training time across all participants, as an average across
participants, or as a range of training time across participants.
The other way that total time could be determined if the au-
thors did not provide information on total training time, but did
provide information on the training time per session, was
to calculate the approximate total training time. To obtain this
measure, we multiplied the number of sessions by the stated
amount of training time per session for each participant. In
some articles reviewed, it was impossible to determine the total
amount of training time; this was scored as could not determine
(CND). Finally, we recorded with whom the participants were
implementing DTT. This was divided into two categories, im-
plementation with a confederate or with an individual with
a developmental disability (DD). Confederate was defined as
an adult role-playing as an individual with a DD or ASD.

Outcome Measures We evaluated five different variables as it
relates to outcomes within the study. First, we evaluated the
percentage of non-overlapping data (PND; Scruggs and
Mastropieri 2001); scores from the participants performance in
the baseline condition to the intervention condition were record-
ed. To obtain a PND score, the authors calculated the total num-
ber of data points during intervention that did not overlap with
data during baseline and divided by the total number of sessions
in the intervention condition. There were instances in which a
PND score could not be determined which included group de-
signs, data not presented per session, or unreadable graphs.
Second, we evaluated the length of the probe session to
determine participants’ mastery on the implementation of
DTT. This could have been reported as the number of trials
the participant had to display DTT correctly or an amount of
time the participant was evaluated. Third, we measured the
inclusion or exclusion of maintenance data and when mainte-
nance data was collected. Fourth, we measured if an assess-
ment of generalization occurred, which could have been prior
to intervention and/or following intervention. Finally, we eval-
uated how generalization was measured (e.g., in another en-
vironment, with another individual).
Interobserver Reliability
The first level of reliability was on the screening of articles (i.e.,
two independent observers looking through electronic databases
to determine the number of studies that might fit the criterion to
determine eligibility). To calculate inter-rater reliability at this
level, we recorded the number of articles with agreement be-
tween the two reviewers (i.e., articles that were designated to be
reviewed and articles designated as not appropriate) divided by
the total number of articles evaluated. For this level, interrater
reliability was 95.4%. Any article for which there was disagree-
ment (i.e., one reviewer saying that it was appropriate and an-
other saying it was not appropriate) was reviewed by a third
rater to determine whether or not it should be included.
The second measure of reliability was in determining inclu-
sion eligibility of the articles (e.g., two independent reviewers
evaluating the 198 articles to determine if each article met the
inclusion criterion). Each reviewer evaluated if each of the ar-
ticles met all four of the aforementioned inclusion criteria. If
disagreements occurred, the lead reviewer’s score determined
inclusion or exclusion of the article. IOA for this level was
95.7% (i.e., the reviewers only disagreed on three articles).
Results
Number of Studies
There were a total of 51 studies published in peer reviewed
journals from 1950 to 2017 which evaluated methods to train
Rev J Autism Dev Disord
behavior change agents or parents how to implement DTT
(contact the corresponding author for a full list of the studies
included). In five studies, there were multiple experiments
(i.e., Arnal et al. 2007; Higbee et al. 2016; Koegel et al.
1978; Randell et al. 2007; Young et al. 2012); we evaluated
each experiment separately. In total, 57 experiments were
evaluated.
Participant Demographics
Table 1 provides information about participant demographics
across the 57 experiments. Across the 57 experiments, there
were a total of 510 participants who were trained to implement
DTT. Crockett et al. (2007) and Lerman et al. (2015) had the
fewest number of participants (i.e., 2), while the third experi-
ment conducted by Randell et al. (2007) had the most partic-
ipants (i.e., 75). Only 8.8% (n = 45) of participants across all
experiments had a previous history with DTT prior to the
study in which s/he was a participant. The most common
participants were college students (i.e., undergraduate or grad-
uate students) who participated in 19 experiments. Other com-
mon participants were therapists (13 experiments), parents (10
experiments), paraprofessionals (5 experiments), teachers (4
experiments), multiple identifications (3 experiments), indi-
viduals diagnosed with ASD (2 experiments), and swim in-
structors (1 experiment). The most common educational level
was some college which was reported in 28 experiments,
followed by a bachelor’s degree (20 experiments), education
level not reported (13 experiments), high school degree (11
experiments), masters degree (3 experiments), some graduate
training (1 experiment), and doctoral degree (1 experiment).
Training Locations
The most common setting in which training occurred was a
university (21 experiments; see Table 1) followed by school
(15 experiments), home (11 experiments), agency (9 experi-
ments), swim school (1 experiment), and not reported (1
experiment).
Research Designs
Seventy-nine percent of the experiments utilized a single sub-
ject design while 21% of the experiments used a group design
or a statistical analysis of the data (see Table 1). The majority
of the experiments (67%) utilized a multiple baseline design,
while multiple probe/multiple response was used in 12% of
the experiments. Overall, single-subject methodology was the
most common method of evaluating the training of behavior
change agents or parents on how to implement DTT.
Rev J Autism Dev Disord

Table 1 Demographic information, setting, and experimental design

First author and year Participant type Number Participants with Participant education Setting Experimental design
previous history level

Arnal (2007; Exp 1) Student 4 NS SC University AB

Arnal (2007; Exp 2) Student 3 NS SC University Multiple baseline
Babel (2008) Student 7 0 SC Not stated Correlational
Belfiore (2008) Therapist 4 4 BA School Multiple baseline
Bolton (2008) Para 3 1 Not stated Agency Multiple Probe
Catania (2009) Therapist 3 2 BA School Multiple baseline
Crockett (2007) Parent 2 0 SC University Multiple baseline
de Oliveira (2016) Student 32 0 SC and none University Group
Dib (2007) Para 3 3 Not stated School Multiple baseline
Downs (2008) Student 6 0 SC University Multiple baseline
Downs (2012) Student 8 0 SC University Group
Eid (2017) Parent 3 0 HS and BA Agency Multiple probe
Eldevik (2013) Therapist 12 0 MA, BA, and HS Agency Group
Fazzio (2009) Student 5 0 SC University Multiple baseline
Fetherston (2014) Therapist 4 NS BA School Multiple baseline
Garland (2012) Student 4 0 Some graduate University Multiple baseline
Gilligan (2007) Para 3 0 SC, BA, and BA School Multiple baseline
Hay-Hansson (2013) Teacher 16 2 SC, HS, and none School Group design
Higbee (2016; Exp 1) Student 4 0 SC School Multiple baseline
Higbee (2016; Exp 2) Student 4 0 BA School Multiple baseline
Jeanson (2010) Therapist and parent 12 6 Not stated University Pre-post
Jull (2016) Swim instructor 6 0 BA and SC Swim school Multiple baseline
Koegel (1977) Teacher 11 0 Not stated School Multi response baseline
Koegel (1978; Exp 1) Parent 4 0 HS School Multi response baseline
Koegel (1978; Exp 2) Therapist, parent, 3 0 BA and SC School Multi response baseline
and student
Lafasakis (2007) Parent 3 0 BA and HS School Multiple baseline
Lenlanc (2005) Therapist 3 0 NS Agency Multiple baseline
Lerman (2013) Individuals with ASD 4 1 BA, SC, and HS University Multiple baseline
Lerman (2015) Individuals with ASD 2 0 Not stated University Multiple baseline
Mason (2017) Para 16 16 MA, BA, and HS School Multiple baseline
May (2011) Therapist 3 3 Not stated Home Multiple baseline
McKinney (2014) Student 3 0 SC University Multiple baseline
McKenney (2015) Teacher, SLP, and para 8 0 Not stated University Multiple baseline
Neef (1995) Parent 26 0 Not stated Home Multiple baseline
Nosik (2011) Student 4 0 SC Agency Multiple baseline
Nosik (2013) Therapist 6 0 HS Agency Multiple baseline
Parnell (2017) Therapist 3 3 BA Home Multiple baseline with
changing criterion
Pollard (2014) Student 4 0 SC University Multiple baseline and AB
Randell (2007; Exp 1) Student 50 0 BA and SC University Group
Randell (2007; Exp 2) Student 50 0 BA and SC University Group
Randell (2007; Exp 3) Student 75 0 BA and SC University Group
Ryan (2005) Teacher 3 0 Not stated Home Statistical analysis
Salem (2009) Student 4 0 SC University Multiple baseline
Sarokoff (2004) Teacher 3 0 MA Home Multiple baseline
Sarokoff (2008) Therapist 3 0 Not stated School Multiple baseline
Severston (2012) Therapist 6 0 SC and HS Agency Multiple baseline
 Rev J Autism Dev Disord

Table 1 (continued)

First author and year Participant type Number Participants with Participant education Setting Experimental design
previous history level

Subramaniam (2017) Parent 4 0 Ph.D., BA, and SC Agency and home Multiple baseline
Summers (2008) Parent 4 0 SC Home Pre-post
Thiessen (2009) Student 4 0 SC University Multiple baseline
Thomas (2013) Para 3 0 BA School Multiple baseline
Thomson (2012) Therapist 8 0 SC University Multiple baseline
Valdescu (2012) Therapist 3 0 Not stated Agency Multiple baseline
Ward-Horner (2008) Parent 3 0 Not stated Home Multiple baseline
Wightman (2012) Therapist 13 1 SC University Multiple baseline
Young (2012; Exp 1) Parent 5 0 BA and HS Home ABC
Young (2012; Exp 2) Parent 5 0 BA and HS Home AB and multiple baseline
Zaragoza (2015) Student 5 0 SC Home Pre-post

HS high school degree, SC some college, BA bachelor degree, MA masters degree, Ph.D doctoral degree

Training Outcomes Unfortunately, in the majority of experiments (i.e., 51%),

Table 2 provides information about training outcomes across
the 57 experiments.
Discrete Trial Teaching Task Analysis Each experiment task
analyzed DTT into components or steps. Across the 57 exper-
iments reviewed, the most steps in a task analysis of DTT were
45 steps (i.e., Severtson and Carr 2012) and the least number
of steps was 2 (i.e., Fetherston and Sturmey 2014). The aver-
age number of steps across the 57 experiments was 16 with a
median of 14 steps.
Training Procedures Across the 57 experiments, only one
study did not specify the training procedures (i.e., Jeanson
et al. 2010). The procedures used to train participants on
how to implement DTT procedures included 9 broad catego-
ries: BST, BST with other procedures (e.g., in situ training),
computer training, lecture and role-play, manual and feed-
back, performance feedback/bug in ear/coaching, self-
instructional manuals, video modeling, and not stated. The
most commonly implemented procedure used was BST with
other procedures (n = 11 experiments) followed by BST (n = 9
experiments) and self-instructional manuals (n = 9 experi-
ments), computer training (n = 7 experiments) and manual
and feedback (n = 7 experiments), performance feedback/
bug in ear/coaching (n = 6 experiments), video modeling
(n = 4 experiments), lecture and role-play (n = 3 experiments),
and not stated (n = 1 experiment).
Training Time An important measure regarding training is
efficiency. Reporting the total amount of training time a
participant receives is critical. Total training time could be
reported as a precise number, an average, or a range.
the authors did not report the total amount of training time.
When training time was reported, it ranged anywhere from
30 min of total training (i.e., Fetherston and Sturmey
2014) up to 1500 min of total training (i.e., Koegel et al.
1977) across participants.
When the total training time was not directly reported
but the training session time was reported, it was possible
to determine the approximate total training time by calcu-
lating the duration of training per session and multiplying
it by the total number of sessions. Of those studies where a
total amount of training was not reported, we were able to
calculate an approximate average total in 43% of the stud-
ies. The approximate total training time ranged from
15 min of total training (i.e., Belfiore et al. 2008) up to
4200 min of total training (i.e., Ryan and Hemmes 2005)
across participants. The average total training and/or total
training time was able to be calculated or was directly
stated by the author in 70% (n = 40) of all studies.
Across the 40 experiments in which training time was either
reported or calculated, the average amount of training time per
participant was 353 min (5 h 53 min). Additionally, across the
57 experiments, the training time per session was reported in
67% of the studies, with a range from 7 min (i.e., Catania et al.
2009) up to 480 min per session (i.e., Downs et al. 2008;
Downs and Downs 2013).
DTT Probes We measured if the participant implemented DTT
with a confederate or an individual diagnosed with ASD and/
or a DD. In 28 experiments (i.e., 49%), the participants imple-
mented DTT with a confederate; in 28 experiments (i.e., 49%),
the participants implemented DTT with an individual diag-
nosed with ASD and/or a DD; and in one study (i.e., 2%),
the subjects implemented DTT with a virtual student.
Rev J Autism Dev Disord

Table 2 Independent variable information

First author and year DTT steps Training procedure Training time Total training time DTT implemented
per session with

Arnal (2007; Exp 1) 19 SI-manual NS Range, 110–177 min Confederate

Arnal (2007; Exp 2) 19 SI-manual and video NS Range, 20–240 min Confederate
Babel (2008) 21 SI-practice NS CND Confederate
Belfiore (2008) 5 Didactic, video self-monitoring 15 min Range, 15–45 min* Individual
Bolton (2008) 7 BST 180 min 180 min Confederate
Catania (2009) 10 Video modeling 7 min 36, 43, and 43 min* Confederate
Crockett (2007) 7 BST with video 120 min 540 and 780 min Individual
de Oliveira (2016) 21 Manual and peer review NS Avg, 447 and 350 min Confederate
Dib (2007) 14 BST NS CND Individual
Downs (2008) 30 BST and feedback 480 min 480 min Individual
Downs (2012) 35 BST 480 min 480 min Individual
Eid (2017) 8 BST NS CND Individual
Eldevik (2013) 22 Computer simulation 1–2 days Range, 300–540 min Individual
Fazzio (2009) 19 SI-manual, feedback, and 150 min 180 min* Confederate
demonstration
Fetherston (2014) 2 BST 20 min 40, 30, and 30 min Individual
Garland (2012) 13 Coach 15 min 90 min* Virtual Student
Gilligan (2007) 10 Performance feedback NS CND Individual
Hay-Hansson (2013) 22 BST and video coach 15 min 45 min Individual
Higbee (2016; Exp 1) 7 Computer 15 trials 316, 200, 200, and 369 min Confederate
Higbee (2016; Exp 2) 7 Computer 15 trials 333. 689, 287, 620 min Individual
Jeanson (2010) 21 NS NS CND Confederate
Jull (2016) 7 BST and feedback 180 min 690 min Individual
Koegel (1977) 13 Manual, video, and feedback 150–300 min 1500 min Individual
Koegel (1978; Exp 1) 14 Demonstration and lecture 10–37 min CND Individual
Koegel (1978; Exp 2) 14 Video 30 min CND Individual
Lafasakis (2007) 10 BST 10 min CND Individual
Lenlanc (2005) 10 Feedback 8–10 min 64–70, 30–40, 32–40 min* Individual
Lerman (2013) 11 BST and In situ 60 min 840, 600, and 1080 min* Confederate
Lerman (2015) 15 BST and video 120 min 270 and 510 min Individual
Mason (2017) 26 Manual and coach 90, 60, and 15–45 min 255–275, 285–555, 222–375 min Individual
May (2011) 7 BST and stimulus training 120 min CND Confederate
McKinney (2014) 20 Bug in ear NS CND Confederate
McKenney (2015) 6 Workshop, feedback, role-play NS CND Individual
Neef (1995) 6 BST and pyramidal 15–30 min CND Individual
Nosik (2011) 8 Video, feedback, and 19, 10, and 10 min 197, 128, 187, and 187 min* Confederate
competency based
Nosik (2013) 20 Computer and model or BST 34–43, 68–92 min 374–462, 374–462, 374–462, Confederate
748–1012, 1088–1472, and
1156–1574 min*
Parnell (2017) 11 Job aide, performance feedback 10 min CND Individual
Pollard (2014) 15 Interactive computer and NS Range, 109–122 min Confederate
performance feedback
Randell (2007; Exp 1) 30 Computer 25 min 50 min Confederate
Randell (2007; Exp 2) 30 Computer 25 min 40 min Confederate
Randell (2007; Exp 3) 36 Computer 25 min 50 min Confederate
Ryan (2005) 12 BST and peer feedback 60–120 min 1500–4200 min Individual
Salem (2009) 21 SI- manual NS Avg, 287 min Confederate
Sarokoff (2004) 10 BST 10 min CND Individual
Sarokoff (2008) 10 BST NS CND Individual
 Rev J Autism Dev Disord

Table 2 (continued)

First author and year DTT steps Training procedure Training time Total training time DTT implemented
per session with

Severston (2012) 45 SI-manual, video, and 140–150, 41, and 140–150, 140–150, Confederate
performance feedback 10–15 min 140–150, 201–211,
201–211, and 211–221 min*
Subramaniam (2017) 22 BST, manual, video, and 90, 60, 20 min Range, 229–349 min* Confederate
performance feedback
Summers (2008) 14 Manual NS CND Individual
Thiessen (2009) 21 Manual NS Range, 160–341 min Individual
Thomas (2013) 9 Peer observation and 5–10 min 30–60, 40–80, 20–40 min* Individual
performance feedback
Thomson (2012) 21 SI-manual and video NS Avg, 260 min Confederate
Valdescu (2012) Not stated Video modeling 9–16 min 57, 57, and 37 min* Confederate
Ward-Horner (2008) 10 BST NS CND Confederate
Wightman (2012) 20 SI and video modeling NS Range, 195–315 min Confederate
Young (2012; Exp 1) 21 Manual and video modeling 17 min Avg, 285 min Confederate
Young (2012; Exp 2) 21 Manual, video, and role-play 17 min Avg, 280 min Confederate
Zaragoza (2015) 21 Computer manual and SI manual NS Range, 563–1182 min Confederate

Avg average, NS not stated, SI self-instruction, CND could not determine

*Total training time was calculated by multiplying the number of sessions by the amount of training time per session across each participant

Outcome Measures
Table 3 provides information about outcome measures across
the 57 experiments.
PND The PND of each single subject study was calculated in
order to determine the effectiveness of the training procedures
on participant implementation of DTT. PND was calculated
with 73% (n = 42) of experiments; PND was not appropriate
for 23% (n = 13) of experiments and could not be determined
with 4% (n = 2) of experiments. Of the 42 experiments in
which PND was calculated, 40 experiments demonstrated
the training procedures to be highly effective (i.e., PND was
90% or above) and 2 to be effective (i.e., PND between 70 and
90%). The average PND scores across all 42 experiments
were 97.7% indicating that overall the procedures used to train
the implementation of DTT were highly effective (Scruggs
and Mastropieri 2001). The inclusion or exclusion of mainte-
nance was evaluated in each experiment as well as the time
between intervention and maintenance.
Duration of Probes The probes used to measure the partici-
pants’ implementation of DTT and whether the participant
implemented DTT correctly were also evaluated. First, we
recorded the reported length of sessions in which DTT was
implemented, which could either be equated based upon time
(e.g., 15 min) or number of trials (e.g., 10 trials). In 54% of the
experiments, the researchers reported the length of the imple-
mentation sessions in terms of number of trials. The average
amount of trials per implementation session was 15 (ranging
between 2 and 100 trials per session). In 30% of the experi-
ments, the researchers reported the length of the implementa-
tion sessions in terms of session duration. The average amount
of time per implementation session was 14 min (ranging be-
tween 2 and 60 min per session). In 16% of the experiments,
the length of the implementation sessions was not reported.
Maintenance Across the 57 experiments, maintenance mea-
sures were only evaluated in 28% of the experiments; in those
studies, maintenance was evaluated between 3 days after in-
tervention (i.e., Severtson and Carr 2012) and up to 26 weeks
after intervention (i.e., Subramaniam et al. 2017).
Generalization Generalization was not assessed in over half of
the experiments (i.e., 57%). In the remaining experiments,
23% assessed generalization prior to and following interven-
tion and 20% assessed generalization only following interven-
tion. When generalization measures were included, assess-
ment of generalization occurred with a different participant
in 37.5% of experiments, a different skill in 37.5% of exper-
iments, and a different participant and skill in 25% of
experiments.
Outcomes Across Different Participants
Table 4 provides information on outcomes across different
participant types. We divided participants into four broad cat-
egories: parents, students, professionals (e.g., therapists, para-
professionals, teachers), and other (i.e., individuals with au-
tism and swim teachers). Although therapists were evaluated
Rev J Autism Dev Disord

Table 3 Dependent variable information

First author and year PND Duration of probes Maintenance Generalization Generalization assessed with

Arnal (2007; Exp 1) 83.3% 12 trials None None N/A

Arnal (2007; Exp 2) 100% 12 trials None None N/A
Babel (2008) N/A 36 trials None None N/A
Belfiore (2008) 94.4% 12–15 trials 4 weeks None N/A
Bolton (2008) 100% 2–10 trials 19 weeks Post only Participant
Catania (2009) 100% 10 trials 1 week Pre and post Participant and skill
Crockett (2007) 51.2% 100 trials None None N/A
de Oliveira (2016) N/A 12 trials None None N/A
Dib (2007) 100% NS None None N/A
Downs (2008) 100% 10–15 min 10 weeks Post Participant
Downs (2012) N/A 60 min None None N/A
Eid (2017) 100% 10 trials 2 weeks Pre and post Skill
Eldevik (2013) N/A 15 min None None N/A
Fazzio (2009) 97.5% 15 min None Post only Participant and skill
Fetherston (2014) 100% 10 trials None Pre and post Skill
Garland (2012) 100% 15 min None None N/A
Gilligan (2007) 100% 11 trials 3 month None N/A
Hay-Hansson (2013) N/A 2.5 min None None N/A
Higbee (2016; Exp 1) 100% 15 trials None Pre and post Participant and skill
Higbee (2016; Exp 2) 100% 15 trials 1 month Pre and post Skill
Jeanson (2010) N/A 12 trials None None N/A
Jull (2016) CND NS None None N/A
Koegel (1977) CND NS None None N/A
Koegel (1978; Exp 1) 100% NS None Pre and post Skill
Koegel (1978; Exp 2) 100% NS None None N/A
Lafasakis (2007) 100% 10 trials None Pre and post Skill
Lenlanc (2005) 100% 10–15 min 11 weeks None N/A
Lerman (2013) 100% 5 trials None Pre and post Skill
Lerman (2015) 100% 6 trials None None N/A
Mason (2017) 100% 5 trials None None N/A
May (2011) CND 3 min None None N/A
McKinney (2014) 81.25% NS NS None N/A
McKenney (2015) 27% NS NS None N/A
Neef (1995) N/A 5 trials 6 weeks Pre and post Skill
Nosik (2011) 100% 10 trials 2 weeks Post only Skill
Nosik (2013) 100% NS 6 weeks None N/A
Parnell (2017) 97.5% 10–15 min 2 weeks None N/A
Pollard (2014) 96.2% 20 trials None Pre and post Participant and skill
Randell (2007; Exp 1) N/A 20 min None None N/A
Randell (2007; Exp 2) N/A 15 min None None N/A
Randell (2007; Exp 3) N/A 10 min None None N/A
Ryan (2005) N/A 2–15 min None None N/A
Salem (2009) 91.7% 12 trials None Post only Participant
Sarokoff (2004) 100% 5 min None None N/A
Sarokoff (2008) 100% 10 trials NS Pre and post Participant and skill
Severston (2012) 100% 10 min 3–5 days Post only Skill
Subramaniam (2017) 100% 12 trials 26 weeks Post only Participant
Summers (2008) N/A 5–10 min None None N/A
Thiessen (2009) 100% 12 trials None Post only Participant
 Rev J Autism Dev Disord

Table 3 (continued)

First author and year PND Duration of probes Maintenance Generalization Generalization assessed with

Thomas (2013) 100% 5–10 min None None N/A

Thomson (2012) 97.2% 36 trials None None N/A
Valdescu (2012) 100% 12 trials None Pre and post Participant and skill
Ward-Horner (2008) 97.9% 10 trials None Pre and post Participant
Wightman (2012) 92.3% 36 trials None Post (1 participant) Participant
Young (2012; Exp 1) 94.7% 12 trials 1 month Post only Participant
Young (2012; Exp 2) 93.9% 12 trials 1 month Post only Participant
Zaragoza (2015) N/A NS None None N/A

Avg average, NS not stated, SI self-instruction, CND could not determine, N/A not available

in almost half of the experiments (i.e., 43.8%), students rep-
resented the largest number of participants (n = 277). Overall,
PND scores showed that training was highly effective for stu-
dent participants (i.e., 97.2%) and for participants in the other
category (i.e., 100%). PND scores for parent participants were
66.7% and 73.6% for therapist participants. However, it
should be noted that only one study included poor PND
scores, and when the studies are excluded, PND scores are
97.3% and 98.4% for parent and therapist participants,
respectively.
Due to the varied methods of reporting training time, it was
not possible to obtain a precise number of the total duration of
training time; thus, results are reported as a range. Across the
four categories of participants, there was a wide and varying
range of the total duration of training time required. For exam-
ple, in some experiments, therapist participants required the
shortest duration of training (i.e., 15 min), but in others required
the longest duration of training time (i.e., 1574 min). Student
participants also included a wide range of total training time
(i.e., 20 to 1182 min), while parent participants included the
smallest range of total training time (i.e., 229 to 780 min).
Outcomes Across Different Training Procedures
Table 5 provides information about the outcomes across the
different training procedures used within the studies that met
our inclusion criteria. BST with other procedures represented
the most commonly implemented training procedure across
the studies, but computer training was used with the largest
number of participants. All training procedures had high PND
scores with the exception of BST with other procedures (i.e.,
71%) and lecture and role-play (i.e., 34%). However, outlier
studies (i.e., studies with PND scores that varied greatly from
others within that category) in each category are removed the
PND score was 100% and 96.4% for BST with other proce-
dures and lecture and role-play, respectively.
Discussion
This review included an evaluation of 51 studies (57 experi-
ments) in which researchers trained behavior change agents
and parents to implement DTT. Our evaluation permitted the
identification of (1) participant demographics (e.g., career),
(2) training location, (3) research designs used (e.g., multiple
baseline designs), (4) training variables (e.g., type of training
procedure), and (5) outcome measures (e.g., percentage of
non-overlapping data). The results revealed that over 500 in-
dividuals were trained on the implementation of DTT that
included a wide variety of participants, including parents, un-
dergraduate students, paraprofessionals, teachers, therapists,
and swim teachers. Across the studies, training took place in
a wide variety of setting including universities, homes, agen-
cies, and schools. Also, the majority of studies used single
subject methodology, specifically the multiple baseline
design.
Our results yielded numerous procedures that have been
used to train behavior change agents and/or parents that

Table 4 Results across different types of participants

Participant type Experiments Number Experiments’ PND PND Score Experiments’ total time Range of total
was calculable was interpretable training time (min)

Parents 12 66 8 66.7% (range, 51–100%) 4 229–780

Students 20 277 13 97.2% (range, 81–100%) 16 20–1182
Therapists 25 147 19 73.6% (range, 27–100%) 16 15–1574
Other 3 12 2 100% 3 270–1080
Rev J Autism Dev Disord

Table 5 Results across different training procedures

Procedure Experiments Number Experiments’ PND PND score Experiments’ Range of total
was calculable total time was training time (min)
interpretable

BST 9 33 8 99.4% (range, 98–100%) 3 30–480

BST with other procedures
Computer
Lecture and role-play
Manual and feedback
Not stated
Performance feedback,
bug in ear, and coaching
Self-instructional manuals
Video modeling
11 71 6 71% (range, 51–100%) 9 45–4200
7 199 3 98.7% (range, 96–100%) 7 40–689
3 16 3 34% (range, 27–100%) 1 15–45
7 77 5 96.5% (range, 94–100%) 5 160–555
1 6 0 N/A 0 N/A
6 19 6 95% (range, 81–100%) 3 20–90
9 55 7 95.7% (range, 83–100%) 8 20–1182
4 13 3 100% 3 36–197

N/A not available

included BST, BST plus other procedures (e.g., in situ train-
ing), computer training, lecture and role-play, manual and
feedback, performance feedback/bug in ear/coaching, self-
instructional manuals, and video modeling. The results also
showed that all of the procedures were successful regardless
of the participant demographic (e.g., therapist versus parent).
Furthermore, across these procedures, the total training time
varied across and within studies from as little as 15 min (e.g.,
Belfiore et al. 2008) to 4200 min (e.g., Ryan & Hemmes
2005). There were no large differences with respect to main-
tenance or generalization across the difference procedure, but
it should be noted that both were assessed in under half of the
studies included in the review. Additionally, no differences
were found when mastery was assessed with an individual
diagnosed with ASD or a confederate peer. These results have
several clinical and research implications.
Clinical Implications
As apparent from the results of this review, several procedures
can be used to effectively train individuals how to implement
DTT and that there is no substantial difference across training
procedures. This is an important finding as many profes-
sionals may have philosophical dispositions that one training
procedure is more efficacious than another, but this review
found that a variety of procedures are effective. What remains
unclear are the advantages and disadvantages of each proce-
dure used to train those to implement DTT. That is, the con-
ditions under which a supervisor should select one approach
over another have not been evaluated. Therefore, it may be
advantageous for future researchers to compare different train-
ing methods on the implementation of DTT to evaluate the
conditions under which one may be more efficient than anoth-
er, the results of which could assist clinicians determine the
best approach to training new staff and parents.
The results of this review also showed that a wide variety of
individuals have been trained how to effectively implement
DTT. Although, behavior analysts (e.g., RBTs®, BCaBAs®,
BCBAs®, BCATs) are commonly the ones implementing
DTT, other professionals such as teachers, paraprofessionals,
or other professionals may also implement DTT. Additionally,
the inclusion of parents in the intervention process for indi-
viduals diagnosed with ASD is also common as a means to
supplement or enhance intervention (e.g., Lovaas 1987). As
such, parents should continue to be trained in procedures such
as DTT if they are going to be a part of the intervention.
Furthermore, it would be beneficial for any person involved
in the intervention for an individual diagnosed with ASD or a
DD to be proficient in the implementation of DTT. The train-
ing of all individuals participating in intervention can help
ensure that individuals receive quality teaching across all as-
pects of intervention.
A third finding was that about half of the experiments in
this review (49%; n = 28) assessed mastery of DTT implemen-
tation with a confederate. While this is a common approach to
assessing mastery (e.g., RBT® certification), clinicians should
be cautioned about this method of assessment when the de-
sired outcome is implementation with individuals diagnosed
with ASD or a DD. Assessing mastery with a confederate may
not provide an ecologically valid way to evaluate mastery, as
the stimulus conditions may be much different from that of
intervention. Potentially important variables such as the pres-
ence of problematic behavior (e.g., aggression, self-injury,
stereotypic behavior) may not be present in the assessment
with a confederate which may limit generalization to the ac-
tual treatment environment (i.e., with an individual receiving
intervention). With 49% of the experiments (n = 28) assessing
mastery with an individual diagnosed with ASD or a DD and
the potential problems with assessing with a confederate, cli-
nicians should elect to assess the mastery of training with
populations with whom individuals are actually going to

provide intervention. It should be noted that no study to date
has compared mastery of skills with a confederate to an actual
client and therefore the concerns stated above are only poten-
tial concerns. Future researchers should evaluate the use or
non-use of confederates as part of training studies.
A final finding of this review was that participants reached
the mastery criterion after demonstrating correct implementa-
tion of DTT during brief probe periods (i.e., a small number of
trials or duration of time). Many of the experiments within this
review evaluated the implementation of DTT in relatively brief
periods of time (i.e., an average of 14 min) or brief number of
trials (i.e., an average of 15 trials). Once again, this may not
provide an ecologically valid assessment of mastery. It is com-
mon for intervention to occur for an average of 40 h a week
(e.g., Howard et al. 2014; Lovaas 1987), which makes it rea-
sonable to assume that DTT will be implemented for several
hours and, potentially, across hundreds of trials. Therefore, cli-
nicians may wish to evaluate an individual’s implementation of
DTT in a time frame that more closely resembles typically
therapy.
Research Implications
Several of the clinical implications just discussed could be
enhanced by addressing some of the gaps within the literature
which this review shed light upon. This review divulged that
maintenance following the training of the implementation of
DTT is not commonly assessed within the literature. While the
results of the experiments included within this review showed
that several procedures are effective at training several demo-
graphics of people to implement DTT, it is critical that these
skills maintain across time. Future researchers should include
assessment of maintenance when evaluating the training indi-
viduals in the implementation of DTT. This research could
help determine changes to current procedures or the develop-
ment of new procedures to train individuals on the implemen-
tation of DTT. Along these lines, generalization was not
assessed in a majority of the studies, and in several experi-
ments, generalization was only assessed as a post measure. As
such, little is known about the generalization effects of train-
ing individuals to implement DTT. Future researchers should
ensure measures of generalization within training studies, spe-
cifically across different individuals and skills.
The majority of studies identified within this review have
utilized single-subject methodology. Although single-subject
methodology has many strengths (e.g., subjects as their own
controls) and is a hallmark of behavior analytic research,
single-subject methodology has its limitations. For example,
single-subject methodology can impose limits on the general-
ity of the findings of a single study. Additionally, professionals
have stated that single-subject methodology is only the first
step within the evolution of research on interventions for in-
dividuals diagnosed with ASD (Smith 2012). Given the
Rev J Autism Dev Disord
abundance of studies using single-subject designs that have
documented the effectiveness of procedures to train individ-
uals to implement DTT, we encourage future researchers to
employ group design methodology (Smith 2012).
As previously stated, parents are commonly included as
part of a comprehensive intervention for individuals diag-
nosed with ASD or a DD. However, the results of the review
found that parents only accounted for 18% (n = 10) of the
experiments in this review. Furthermore, the majority of par-
ticipants within each experiment were college students. Given
the common inclusion of parents within interventions, re-
searchers should include parents as participants in future train-
ing studies, DTT, and otherwise. These studies should evalu-
ate effective training procedures in addition to the effects of
this training on the outcomes of children within comprehen-
sive behavioral interventions.
Finally, there were several methodological differences
across the studies which creates difficulties with respect to
comparing results. We suggest several areas of consistency
across research studies moving forward. First, researchers
should state the history participants have with the implemen-
tation of DTT. Second, researchers should provide more de-
mographic information on participants including gender,
race/ethnicity, SES, and duration of time working in the agen-
cy. Third, researchers should note training time per session
and provide the total training time per participant. Fourth, as
previously stated, a variety of measures (e.g., generalization
and maintenance) should also be included. Until maintenance
and generalization measures are more commonly assessed, it
may be beneficial for training to occur with the population
with whom the participant will provide intervention, given
that it remains unclear if training with a confederate will gen-
eralize to this population.
Global Implications
This review provided an analysis of the literature on training
individuals to implement DTT. Through this review, we were
able to provide several clinical and research recommenda-
tions. These recommendations may also be viewed in a larger
context with respect to ABA-based intervention and certifica-
tion. As DTT is commonly used within ABA-based interven-
tions, it is commonly included on task lists requirements for
certification (Behavior Analyst Certification Board 2013,
2017; Behavior Intervention Certification Council 2015),
which outline tasks that are likely to be performed by a pro-
fessional to ensure minimum competencies. Various certifica-
tions involve a variety of requirements in terms of the number
of hours of training required prior to becoming eligible for
citification. This analysis indicated that, on average, it takes
6 h to train individuals to implement DTT, but for some individ-
uals can take up to 70 h (i.e., Ryan and Hemmes 2005). This
amount of time, as evident within the research base, to train a
Rev J Autism Dev Disord
behavior change agent to implement DTT may not be a problem
if the certification requires a large amount of training (e.g.,
1500 h). However, if an individual is attainting a certification
that involves a low number of training hours (e.g., 40 h), it
would be unrealistic, based upon the research, to assume that
proficiency would be obtained for DTT in addition to all other
skills on a task list. This has implications for those planning
supervision and training for those seeking certifications. The
number of hours listed to provide training may not be adequate
to ensure competency in all the skills listed in the task list;
therefore, those providing supervision and training should be
prepared to provide more hours of training then required of
certifications. This also has implication for certifying organiza-
tions. Reviews like this one should be used to inform certifying
organizations and subject matter experts to determine and mod-
ify the number of hours required to achieve minimum acceptable
competence in all the skills on task lists. We hope that this
review helps to spark continued research on the training of future
behavior analysts and helps to inform those in positions to make
changes to training requirements of certification organizations.
Conclusion
This review showed that the experimental research on training
behavior change agents and parents is robust. The results in-
dicate that there are a variety of modalities that can be used to
train behavior change agents and parents to implement DTT
successfully. Although the research literature is robust, there
are still areas of limitations that could be addressed by future
researchers. Nevertheless, the research on training behavior
change agents and parents have direct implications for clini-
cians who provide training on discrete trial teaching.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Informed Consent As such, no informed consent was needed in this
study.
Human and Animal Rights This article does not contain any studies
with human or animal participants performed by any of the authors.
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