Pivotal Resonse Treatment with children with Autism Spectrum Disorder

Pivotal Response Treatment (PRT) is an intervention model that incorporates a “developmental approach” and “applied behavior analysis (ABA) procedures” (Koegel & Koegel, 2006). It attempts to treat children in their natural home and school environments and provide them with “the social and educational proficiency to participate in enriched and meaningful lives in inclusive settings” (Koegel, Koegel, Harrower, & Carter, 1999). The PRT model is based on the theory that when targeting “pivotal” areas, success will generalize to other skills and other areas of the child’s life. Identified pivotal areas include: motivation, responsivity to multiple cues, self-management, self-initiations, and empathy (Koegel & Koegel, 2006). PRT includes several critical features that make it similar to, and distinguish it from, other interventions. These features include early intervention, hours and intensity of intervention, family involvement, natural environment and a specialized curriculum.

Early Intervention is critical to Pivotal Response Treatments for children with Autism. Not only has it been found to “maximize long-term benefits and prevent developmental problems for children with developmental disabilities”, but it has also been found to help children with Autism “make substantial developmental gains” (Koegel & Kegel, 2006). Because of this, early intervention is critical when providing PRT. An additional benefit of early intervention using PRT is that it helps to teach the response-reinforcer contingency, which is often critical for language development and is delayed in children with autism. The response-reinforcer contingency is the ability for children to learn that “their behavior [and communication] produces desired consequences from others in their environment” (Koegel & Koegel, 2006).
PRT, which incorporates ABA procedures, helps to teach this to children with Autism early on.

The PRT model strives for consistency and cohesion throughout all of the child’s environments, as it emphasizes the importance of spreading the service delivery “across all of the significant individuals and settings in the child’s life” (Koegel & Koegel, 2006). Thus, PRT is an hour intensive intervention. However, in an ideal model, parents, teachers, caregivers, and those who interact with the child are taught appropriate procedures for implementing PRT in natural environments. Therefore, it is a cost efficient model as the number of hours of “direct contact from a highly skilled specialist” is “relatively small” (Koegel et al., 1999).

In the PRT model, family involvement is key as it allows intervention to be continued at home. Lovaas, Koegel, Simmons, and Long (1973) studied the generalization of behavior therapy in children with autism and found that “groups whose parents were trained to carry out behavior therapy continued to improve”. Family education and training allows therapy to be conducted in the natural environment of the home by people that the child trusts and interacts with constantly.

As previously mentioned, providing therapy in the natural environment is vital in PRT. Research by Koegel, O’Dell and Koegel (1987) showed that providing treatment in naturalistic contexts helped to result in “broadly generalized treatment gains”. Naturalistic language approaches also allow for greater maintenance of gains made in intervention, and often provide more motivation for children.

The specialized curriculum in PRT refers to the specialized content and instruction that addresses “central deficits in autism through a focus on core areas of intervention in autism, particularly motivation” (Koegel & Koegel, 2006). Specifically, the PRT curriculum focuses on motivation while following and adhering to the general education curriculum. A great advantage to this model is that it allows for children with autism to be educated in the natural environment of the classroom with their typically developing peers. Accommodations in the classroom set the children up for success and make it possible for them to learn while the material and content remain constant. This helps to achieve the goals of PRT and the specialized curriculum, which are to “produce improvements that allow children with autism to move toward a typical developmental trajectory and to provide them with the opportunity to lead meaningful lives in natural, inclusive settings” (Koegel & Koegel, 2006).

One if the central aspects of the PRT specialized curriculum is its focus on motivation. Motivation is one of the “pivotal” areas of intervention and therefore, allows for generalization into other skills. In other words, when focusing on motivation, success is seen in multiple areas of treatment including “communication, self-help, academic, social, and recreational skills” (Koegel et al., 1999). Focusing on motivation not only facilitates improvements in children with autism, but Koegel & Koegel suggest that incorporating motivational activities into the classroom may benefit all students. The PRT motivational procedures include “using child choice, rewarding attempts, interspersing maintenance and acquisition tasks, and using natural and direct consequences” (Koegel & Koegel, 2006). All of these procedures can be included in the general education classroom, and can be used with all students or with individual students in need.

Another pivotal area targeted in PRT is responsivity to multiple cues. Children with autism have been found to have “stimulus overselectivity” which is “the child’s tendency to respond to an irrelevant component of a stimulus rather than to select the appropriate component” (Koegel & Koegel, 2006). Thus, targeting this area “may produce collateral changes in joint attention as children with autism learn to respond to multiple cues and, perhaps, to both the object and the communicative partner” (Koegel & Koegel, 2006).

PRT also targets the pivotal area of self-management. This is the ability for individuals to “discriminate and self initiate their own appropriate behavior, and then self-reinforce or self-recruit reinforcement for their appropriate behavior” (Koegel et al., 1999). This skill can benefit all areas of a person’s life and can generalize across many different environments.

Self- initiations also show broad benefit and generalization across multiple areas. Self-initiations consist of an “individual beginning a new verbal or nonverbal social interaction, self-initiating a task that results in social interaction, or changing the direction of an interaction” (Koegel et al., 1999). Children with autism are typically lacking in this area. It is suggested that deficits here can lead to an individual being judged socially, whereas skills can result in self-learning and can have great affects across many different areas.

Empathy has also been suggested to be a “pivotal” area of intervention and is known to be of deficit in children with autism (Koegel & Koegel, 2006). However, more detailed description on the effect of intervention in this area was not found.

The PRT model is most effective with children who have good social relationships with more than one person, are demonstrating some joint attention skills, and have an interest in toy play. With these characteristics, a child may benefit more from the PRT model. Those providing the intervention include parents, teachers, caregivers, therapists, and all involved in the child’s life. Training is suggested for all who provide treatment to increase its fidelity. PRT training manuals can be ordered from UC Santa Barbara for $7.00.

Research on the effectiveness of PRT is showing positive results in all areas. Pierce and Schreibman (1997) studied the effects of PRT on social behavior when using peer trainers. They conducted a multiple baseline experiment with two children with autism, and ultimately concluded that “naturalistic interventions such as PRT are effective in producing positive changes in the social behavior of children with autism”.

Koegel, Bruinsma, and Koegel looked at the developmental trajectories of 5 children with autism before and after PRT early intervention. They found that following the intervention, the children made “rapid gains” and “considerable progress” as their range of words increased, spontaneous use of those words increased, and their “vocabulary was marked by both diversity and spontaneity” (Koegel & Koegel, 2006). In addition, “three of the five children’s developmental trajectories accelerated to near the level for typically developing children” (Koegel & Koegel, 2006).

A study by Vismara and Lyons (2007) looked at the affect of PRT on joint attention in 3 children with autism. Although all three children were showing zero joint attention initiations toward their caregivers at baseline, all increased “as a collateral gain when incorporating children’s PI (perseverative interest) stimuli as natural reinforcers within the motivational procedures of PRT” (Vismara & Lyons, 2007). In addition, “all children demonstrated improvements in qualitative measures of interaction with their caregivers in response to using perseverative and nonperseverative interests within the PRT methods” (Vismara & Lyons, 2007).

A larger scale study has begun to look at the implementation of PRT in a province-wide early intervention program for preschoolers with autism. In this study, intensive training was conducted to increase treatment fidelity. Specifically, one training was held for parents and interventionists, and one was held to train the trainers who would be teaching PRT to other trainees throughout the remainder of the province. Follow up measures are currently being scored and sample data is being collected. Data on one 5-year-old boy shows “a concomitant increase in child verbal utterances associated with the trainees’ improved fidelity of PRT implementation”. In addition, this data suggests a “dramatic increase in contingent reinforcement by trainees of the child’s verbal attempts” which is associated with an “equally dramatic increase in the child’s functional verbalizations” and “a corresponding increase in the child’s social engagement” (Bryson, Koegel, Koegel, Openden, Smith, & Nefdt, 2007). Additional results from this research will help to determine the effectiveness of PRT in large-scale dissemination and community implementation.

While the overwhelming majority of research suggests that PRT is an effective method of intervention, there are still some downsides. It is an hour intensive service delivery model and requires full participation of parents, teachers, and clinicians to be effective. In addition, PRT requires the child to have good social relationships with more than one person, demonstration of joint attention skills, and an interest in toy play. So, while it is a very effective method of intervention, it is not appropriate for all children with autism spectrum disorder.

Overall, PRT is proving to be an effective intervention model. Its “pivotal” areas of focus seem to have wide spread positive effects and help to increase the generalization of treatment gains. In addition, it allows children to receive intervention within naturalistic contexts and across all environments. PRT is seen as an empirically derived intervention and research continues to support its implementation.

References

Bryson, S. E., Koegel, L. K., Koegel, R. L., & Openden, E., Smith, I. M., Nefdt, N. (2007). Large Scale Dissemination and Community Implementation of Pivotal Response Treatment: Program Description and Preliminary Data. Research & Practice for Persons with Severe Disabilities, 32(2), 142-153.

Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal Response Intervention I: Overview of Approach. The Journal of the Association for Persons with Severe Handicaps, 24(3), 174-85.

Koegel, R. L., & Koegel, L. K. (2006). Pivotal Response Treatments for Autism: Communication, Social, & Academic Development. Baltimore, MD: Paul H. Brookes Publishing Co.

Koegel, R. L., O’Dell, M. C., & Koegel, L. K. (1987). A Natural Language Paradigm for Teaching Non-Verbal Autistic Children. Journal of Autism and Developmental Disorders, 17, 187-199.

Lovaas, O. I., Koegel, R., Simmons, J. Q., & Long, J. S. (1973). Some Generalization and Follow-Up Measures on Autistic Children in Behavior Therapy. Journal of Applied Behavior Analysis, 6, 131-166.

Pierce, K., Schreibman, L. (1997). Multiple Peer Use of Pivotal Response Training to Increase Social Behaviors of Classmates with Autism: Results from Trained and Untrained Peers. Journal of Applied Behavior Analysis, 30, 157-160.

Vismara, L.A ., & Lyons, G. L. (2007). Using Perseverative Interests to Elicit Joint Attention Behaviors in Young Children with Autism: Theoretical and Clinical Implications for Understanding Motivation. Journal of Positive Behavior Interventions, 9(4), 214-228.