Pivotal Response Training for Children With Autism

Combining Behavioral and Developmental Models

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Pivotal response training (or treatment), also known as PRT, is a unique form of behavioral therapy for children with autism. It uses behavioral techniques in a natural setting to help children generalize new skills and apply them in the real world. PRT was developed by Drs. Robert and Lynn Koegel, and it offers a way to bring applied behavioral analysis (ABA) out of the therapist's office and into the real world.

The Koegel Autism Center at The Gevirtz School at the University of California, Santa Barbara differentiates PRT from ABA in this way: "Rather than target individual behaviors one at a time, PRT targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations. By targeting these critical areas, PRT results in widespread, collateral improvements in other social, communicative, and behavioral areas that are not specifically targeted."

In addition to targeting multiple areas of need at the same time, PRT also builds on a child's interests—rather than working on activities selected entirely by the therapist.

What Is Behaviorism?

The first person to experiment with and write about behaviorism from the psychological perspective was Pavlov, whose famous experiments with dogs showed that an animal (or person) could be taught to behave in a particular way through conditioning.

John Watson developed some of the principles of behaviorism and wrote in 1913 that the goal of it, in theory, is "the prediction and control of behavior." Watson is also quoted as saying, "Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I'll guarantee to take anyone at random and train him to become any type of specialist I might select—doctor, lawyer, artist, merchant-chief and, yes, even beggar-man and thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his ancestors."

While Watson first posited the theories behind behaviorism, it was B.F. Skinner who popularized behaviorism through his writings including the utopian novel "Walden Two" about a community built on behaviorist principles. It was Skinner who developed behavioral techniques called "operant conditioning" based on reinforcement and punishment. He also popularized behaviorism as a major focus of psychology during the middle of the 20th century.

Behaviorism for Autism

Autism was not named as a distinct disorder until 1943 when Dr. Leo Kanner published a paper called "Autistic Disturbances of Affective Contact." For decades, autism was thought of as a strictly behavioral disorder caused by environmental factors (mainly bad parenting). As a result, many of the treatments developed for autism were behavioral.

In 1987 Ivar Lovaas, a psychologist, wrote a paper entitled "Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children." The paper reported on a study in which children with autism received 40 hours a week of intensive behavioral therapy for two to six years. Lovaas found that the vast majority of children in the study saw significant improvements in their behavior. More impressive, perhaps, he also found that the children's social and cognitive skills improved.

Lovaas became the "father" of applied behavioral therapy (ABA), a technique which quickly became the "gold standard" of autism therapy. Based on Lovaas's ideas, most behavioral therapy for autistic children was (and often still is) provided in a clinician's office in a one-on-one situation. After evaluating the child, a set of goals and milestones are created and the therapist works with the child to master each milestone.

When the child masters a skill, she is rewarded with a reinforcer (a reward). While ABA initially used aversive techniques (punishments) when a child failed to learn a skill, aversives are very rarely used today. This specific form of ABA—intensive, therapist-initiated, one-on-one therapy in an office setting—is sometimes called "discrete trials."

While Lovaas-style ABA had and still has its supporters, the approach became less popular for several reasons.

  • The intensive nature of Lovaas-style ABA is very expensive and makes it difficult for children with autism to participate in daily activities of life.
  • While some children undergoing intensive ABA gained a wide range of skills, many had less impressive outcomes.
  • Autistic self-advocates spoke up, describing Lovaas-style ABA (particularly but not exclusively with aversive methods) as disrespectful and, in some cases, emotionally damaging.
  • Parents and other advocates began to question the value of teaching "appropriate" behaviors without helping children to understand or engage with the purpose behind those behaviors.
  • New developmental treatments began to emerge, which focused on the idea that taught behaviors are less meaningful to an autistic child than emotional and social engagement.

ABA researchers and theorists began exploring new directions for behavioral therapy. Several highly regarded pioneers in the field were interested in merging child-led, developmental techniques with tried-and-true behavioral techniques. Their hope was to not only teach behaviors and skills but also to engage the autistic child emotionally and socially.

About Pivotal Response (PRT) Therapy

Pivotal Response Training is solidly based in behaviorism but borrows from developmental theory. As a result, it is both similar to and different from "classic" ABA.

Like ABA, PRT focuses on behavioral as opposed to emotional growth. Unlike ABA, however, PRT focuses not on individual behaviors (labeling an object, for example) but on "pivotal" areas of child development. This approach makes it possible to improve social, communicative, behavioral, and cognitive skills all at the same time. There are four pivotal areas. They include:

  • Motivation
  • Response to multiple cues
  • Self-management
  • Initiation of social interactions

Like ABA, PRT therapists use "reinforcement" (rewards) to motivate children with autism to learn new skills. Unlike ABA therapists, however, who may give candy or toys as motivators, PRT therapists use "natural reinforcement" to encourage compliance.

In other words, while an ABA therapist may reward a child with a candy treat for putting on his coat when asked to do so, the PRT therapist would be more likely to take the child outside to play. Putting on the coat leads naturally to the opportunity to play outside.

Like ABA, PRT therapists use multiple trials that start with a prompt (antecedent) to do the desired behavior (for example, the therapist tells the person with autism to put on the coat). Unlike ABA, PRT therapists reward not only success but also good attempts at success (starting to put on the coat or putting it on incorrectly). The theory is that rewards for "good tries" increase a child's motivation to keep trying, even when the work is difficult.

PRT in Practice

PRT starts with an evaluation to determine a child's challenges and strengths in the pivotal areas of motivation, response to multiple cues, self-management, and initiation of social interactions.

The PRT therapist will set appropriate goals for the child, and will likely recommend a particular number of hours of therapy per week (25 hours is typical).

The basic structure of PRT is similar to that of ABA: a set of repeated behavioral trials consisting of antecedent, behavior, and consequence. Because the setting is natural, the motivators are selected by the child, and any attempt at compliance is rewarded. This makes the experience generally much more fun for a child than typical ABA.

A child who is having fun is, of course, is more likely to engage, learn, and connect socially to the people around him.

PRT sessions can occur in almost any setting but are usually most effective in situations that include multiple peers and opportunities for building and exercising new skills. PRT methods can be taught to parents, siblings, and other supportive individuals in an autistic child's circle, making it possible to integrate the approach across all aspects of daily life.

Effectiveness

Many studies have found PRT to be effective at various levels. In other words, some children make great strides using PRT while others have only moderate improvements. The reality is that no autism treatment leads to a "cure," but studies suggest that PRT can help your child to gain new skills.

One randomized study, for example, found that "specific instruction in PRT results in greater skill acquisition for both parents and children, especially in functional and adaptive communication skills."

Another found that "The results indicated that verbal communication improved as a consequence of the intervention, with concomitant improvements in untreated areas for all participants. Following the intervention, symptoms of autism decreased and parents reported satisfaction with the program's ease of implementation and observed child gains."

As with most autism therapies, the likelihood and extent of improvement depend on a number of factors which really don't relate to the specific therapy. Some key factors include:

  • the quality of the evaluator and therapist
  • the number of hours of therapy per day or week
  • the ability of a child's school and family to adopt the therapeutic principles and use them outside of therapy sessions
  • the child's level of motivation and engagement
  • the child's strengths and challenges (children who start out with stronger skills are more likely to build skills, no matter what therapy is used)

Finding and Affording PRT

While classic ABA therapy is available almost everywhere, PRT therapy can be harder to find. That's because PRT was developed recently, and training programs are still expanding. There are several options for finding PRT therapists or therapy.

  • Check with your local pediatrician, neurologist, autism clinic, or psychologist; often they can refer you to a local resource.
  • PRT training on-site is only available in California at the Koegel Autism Center, but the Koegel Center does offer options for parents including manuals, books, videos, and (in some cases) online parent training.
  • Use a search engine to search for PRT therapy in your area.
  • Ask local parent support groups whether they can suggest resources in your area.

In addition to accessing private PRT therapy (which may or may not be funded through your healthcare provider), it's also worthwhile talking with your child's school team. Some schools are willing and able to implement PRT during the school day as part of your child's "Free and Appropriate Education."

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