Pivotal response treatment (PRT), also referred to as pivotal response training, is a naturalistic form of applied behavior analysis used as an early intervention for children with autism that was invented by Robert Koegel and Lynn Kern Koegel. PRT advocates contend that behavior hinges on "pivotal" behavioral skills—motivation and the ability to respond to multiple cues—and that development of these skills will result in collateral behavioral improvements. It's an alternative approach to ABA from the more common form, sometimes called discrete trial training (DTT).
History
Initial attempts to treat autism were mostly unsuccessful and in the 1960s researchers began to focus on behavioral intervention therapies. Though effective, limitations included significant time investment, considerable expense, and limited generalization to new environments. Lynn and Robert Koegel incorporated ideas from the natural language procedures to develop verbal communication in children with autism. They theorized that, if effort was focused on certain pivotal responses, intervention would be more successful and efficient. As they saw it, developing these pivotal behaviors would result in widespread improvement in other areas.
Theory
Pivotal response treatment is a naturalistic intervention model derived from the principles of applied behavior analysis. Rather than target individual behaviors one at a time, PRT targets pivotal areas of a child's development such as motivation, responsiveness to multiple cues, self-management, and social initiations. By targeting these critical areas, PRT ideally results in collateral improvements in other social, communicative, and behavioral areas that are not specifically targeted.
The underlying motivational strategies of PRT are incorporated throughout intervention as often as possible, and they include child choice, task variation, interspersing maintenance tasks, rewarding attempts, mand training, and the use of direct and natural reinforcers. The child plays a crucial role in determining the activities and objects that will be used in the PRT exchange. Intentful attempts at the target behavior are rewarded with a natural reinforcer (e.g., if a child attempts to request for a stuffed animal, the child receives the animal, not a piece of candy or other unrelated reinforcer). Pivotal response treatment is used to teach language, decrease disruptive/self-stimulatory behaviors, and increase social, communication, and academic skills.
The two primary pivotal areas of pivotal response therapy are motivation and self-initiated activities. Three others are self-management, empathy, and the ability to respond to multiple signals, or cues. Play environments are used to teach pivotal skills, such as turn-taking, communication, and language. This training is child-directed: the child makes choices that direct the therapy. Emphasis is also placed upon the role of parents as primary intervention agents.
Support
A 2020 meta analysis which included 5 RCTs concluded there was a statistically significant positive effect of PRT on expressive language skills, social interaction, and reducing repetitive behaviour. However it also notes the quality of evidence was low, so further research about the effectiveness of PRT was required. One 2019 study, not covered by the review, directly compared PRT and DTT found its effects were heterogenous; DTT worked better in some children, whereas PRT worked better in others, depending on the child's characteristics.
References
- ^ Ona, Hanne Nordvik; Larsen, Kenneth; Nordheim, Lena Victoria; Brurberg, Kjetil Gundro (2020). "Effects of Pivotal Response Treatment (PRT) for Children with Autism Spectrum Disorders (ASD): a Systematic Review". Review Journal of Autism and Developmental Disorders. 7 (1): 78–90. doi:10.1007/s40489-019-00180-z.
- Koegel RL, O'Dell MC, Koegel LK (1987). "A natural language teaching paradigm for nonverbal autistic children". Journal of Autism and Developmental Disorders. 17 (2): 187–200. doi:10.1007/BF01495055. PMID 3610995.
- Koegel RL, Egel AL (1979). "Motivating autistic Children". Journal of Abnormal Psychology. 88 (4): 418–426. doi:10.1037/0021-843X.88.4.418. PMID 479464.
- Schreibman L, Charlop MH, Koegel RL (1982). "Teaching autistic children to use extra stimulus prompts". Journal of Experimental Child Psychology. 33 (3): 475–491. doi:10.1016/0022-0965(82)90060-1. PMID 7097156.
- Koegel LK, Camarata S, Valdez-Menchaca M, Koegel RL (1998). "Generalization of question asking in children with autism". American Journal on Mental Retardation. 102 (4): 346–357. doi:10.1352/0895-8017(1998)102<0346:SGOQBC>2.0.CO;2. ISSN 0895-8017. PMID 9475943. Retrieved 2008-07-18.
- Koegel RL, Dyer K, Bell LK (1987). "The influence of child-preferred activities on autistic children's social behavior". Journal of Applied Behavior Analysis. 20 (3): 243–252. doi:10.1901/jaba.1987.20-243. PMC 1286014. PMID 3667475.
- Dunlap G, Koegel RL (1980). "Motivating autistic children through stimulus variation". Journal of Applied Behavior Analysis. 13 (4): 619–627. doi:10.1901/jaba.1980.13-619. PMC 1308168. PMID 7204282.
- Koegel RL, O'Dell MC, Dunlap G (1988). "Producing speech use in nonverbal autistic children by reinforcing attempts". Journal of Autism and Developmental Disorders. 18 (4): 525–538. doi:10.1007/BF02211871. PMID 3215880.
- Williams JA, Koegel RL, Egel AL (1981). "Response-reinforcer relationships and improved learning in autistic children". Journal of Applied Behavior Analysis. 14 (1): 53–60. doi:10.1901/jaba.1981.14-53. PMC 1308185. PMID 7216932.
- Koegel RL, Koegel LK (1990). "Extended reductions in stereotypic behavior of students with autism through a self-management treatment package". Journal of Applied Behavior Analysis. 23 (1): 119–127. doi:10.1901/jaba.1990.23-119. PMC 1286216. PMID 2335483.
- Jobin, Allison (July 2019). "Varied treatment response in young children with autism: A relative comparison of structured and naturalistic behavioral approaches". Autism. 24 (2): 338–351. doi:10.1177/1362361319859726. ISSN 1362-3613. PMC 6962565. PMID 31311289.
