Pivotal Response Treatment: Identifying and Targeting Areas of Need in Children with ASD

Applied Behavior Analysis (ABA) continues to enjoy the most solid research base of any intervention approach for autism spectrum disorder, and Pivotal Response Treatment (PRT), an advanced type of ABA approach, also has an abundance of data to support its effectiveness. Research in PRT began when we noticed that many children didn’t seem to be enjoying the drill-practice format used in early ABA discrete-trial teaching sessions. Moreover, targeting individual behaviors was extremely time consuming, laborious and inefficient. Thus, over the past two decades, we have focused on “pivotal” areas that, when taught, have a widespread positive effect on numerous symptoms of autism.

Philosophy of PRT

Before discussing PRT in more detail, it’s important to mention the underlying philosophies of the approach. First, intervention is implemented in natural settings to maximize the likelihood of producing a normalized developmental trajectory. This may seem obvious to those who read the literature showing that intervention in more clinical, segregated or analog settings results in difficulties with generalization, slower academic gains, less socialization and a greater challenge getting the children on a typical developmental trajectory. However, many families and practitioners are faced with schools and community settings that just don’t embrace the idea of inclusion. It’s often an uphill battle to get a child into (and keep a child in) regular education settings, afterschool community activities and summer recreational programs. PRT emphasizes inclusion—that all children should be educated and involved in environments they would be in if they didn’t have a disability.

A second underlying philosophy relates to family involvement. First, families take an active role in the development of intervention goals and the implementation of procedures to achieve these goals. Intervention is coordinated across all settings, with parents learning, through practice-with-feedback, to implement the procedures. We’ve learned from our research that the procedures need to be incorporated into everyday routines and activities to decrease parental stress and to maximize the normalcy of developmental gains. Assignments that require parents to take time out of their busy schedules to sit down and drill their children actually increase stress and can produce artificial responses. We can’t overemphasize the need to reduce parental stress, which we have not dealt with adequately as a society. Stress indexes indicate that parents of individuals diagnosed with autism experience very high levels of stress, which are very difficult to reduce. This may, in part, relate to society’s lack of willingness to fully include and support children on the spectrum in schools and other community activities. Parental stress may also relate to the difficulties, and lack of proper training and support, in raising a child who is affected by the disability in many areas. And parents of older children worry about what will happen to their child after they are no longer able to care for them. Will others love them as much they have, treat them with respect and dignity, and advocate for them? Our goal is to help families reduce their stress, enjoy full and happy lives with the support of the community, create more positive long-term outcomes and help adults on the spectrum have lifestyles that their parents feel good about.

The third aspect of PRT is identifying pivotal areas of need in children, so that the intervention is more effective and efficient.

Motivation

The first important pivotal area discovered was motivation. Early on, we were working on teaching speech to nonverbal children using a drill-type format in a structured setting with flash cards and a variety of treats (usually edibles) as rewards. While some children developed verbal communication using these procedures, a fair number remained nonverbal and/or failed to show spontaneous generalized gains. Also, we noticed that most of the children didn’t seem happy, nor did their interventionists. At that point, we began a mission to develop procedures for making learning fun. We stumbled across a number of individual components that improved the children’s rate of learning and resulted in better affect—the children (and interventionists) smiled more, seemed more interested and were more engaged during the teaching sessions. The procedures included giving the child a choice of materials and activities, varying the tasks instead of utilizing repeated drills, incorporating easy tasks with more difficult ones so the children would feel a sense of accomplishment, rewarding any attempts the child made, and tying the rewards into the task itself so that engaging in the target behavior would be naturally rewarding. We threw out the flash cards and bought a whole bunch of fun activities and games, which we provided contingently when the child said a word or made an attempt at a word. In a sense, this made the difficult challenge of learning communication fun. Because these new and improved techniques closely resembled the way typical children learn language, we titled our first publication “A Natural Language Teaching Paradigm” (Koegel, O’Dell, & Koegel, 1987). These procedures were far more effective in terms of communication gains, with over 90 percent of young children acquiring functional verbal communication as a primary means of communication. Since that time, the same motivational procedures have been effectively applied to a host of different behaviors in such areas as play, academics and socialization. Because the motivational procedures are effective in so many areas beyond communication, the intervention, which dramatically improved all of the symptoms and the overall condition of autism, was re-named “Pivotal Response Treatment.”