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Pivotal Response Treatment and Autism Ranking: Strong positive evidence

Child with autism

Pivotal response treatment (previously known as pivotal response training or the natural language paradigm) is a form of teaching in which the teacher concentrates on changing certain 'pivotal' behaviours, such as motivation and self-management.

Pivotal response treatment is based on the idea that certain aspects of a child's development are considered to be 'pivotal', that is crucial for the behaviours which depend on them. The pivotal areas are motivation, self-management, self-initiation, and the ability to respond to multiple cues.

In pivotal response treatment the trainer concentrates on changing these pivotal areas in order to change the behaviours which depend on them, such as speech and language, social behaviour, and challenging behaviour.

There are several multi-component programmes (such as the Early Start Denver Model and the Nova Scotia early intensive behaviour intervention) which include pivotal response treatment as a key element.

Our Opinion

There is strong research evidence to suggest that pivotal response treatment provides a positive approach to targeting key developmental skills, such as language in some autistic children.

Reports have suggested that parents and non-autistic peers can be trained to implement this approach, and that the focus on naturalistic reinforcement may make it more accessible than more traditionally structured behavioural interventions such as discrete trial training.

However, there is a need for more large-scale randomised control trials of pivotal response treatment in real world settings and which compare pivotal response training to other, similar interventions.

There is a need for studies which examine whether pivotal response treatment is being implemented correctly and which look at effectiveness at least one year after the intervention.

There is also a need for research which involves autistic people to review the efficacy and ethical basis of pivotal response treatment including individuals who may be non-verbal.

Disclaimer

Please read our Disclaimer on Autism Interventions

Audience

According to Koegel et al (1998), pivotal response treatment is appropriate for

“Individuals with autism and other severe handicaps across a wide variety of ages and functioning levels.”

However, Stahmer (1999) notes that pivotal response treatment may be more appropriate for some children than others when being used to teach play skills.

“Because PRT is very flexible it can be used with children of varying developmental levels. Typically, however, to begin play training a child must firstshow some interest in object manipulation. Additionally, some ability toattend to the environment and at least some capacity for imitation are bothimportant for play training. Children who perform best in this type of training are those children who will interact with toys (regardless of whetherthey do so in an appropriate or inappropriate manner), and who do nothave an extreme amount of self-stimulatory behaviour that does not involve objects (e.g. hand-flapping, rocking). Surprisingly, children who engage in stereotyped play with particular toys or engage in self-stimulatory behaviour with objects areoften excellent candidates for PRT due to the presence of a very powerful reinforcer. “

Aims and Claims

Aims

According to the Autism Speaks website, accessed on 5 April 2016, the aims of pivotal response treatment,

“... include the development of communication, language and positive social behaviors and relief from disruptive self-stimulatory behaviors.

“Rather than target individual behaviors, the PRT therapist targets ‘pivotal’ areas of a child's development. These include motivation, response to multiple cues, self-management and the initiation of social interactions. The philosophy is that, by targeting these critical areas, PRT will produce broad improvements across other areas of sociability, communication, behavior and academic skill building.”

Claims

There have been various claims made for pivotal response treatment. For example, the Center for Autism Services Alberta website, accessed on 5 April 2016, claims,

“Evidence shows that PRT can result in the following:

• Increase in correct imitative utterances
• Increase in correct spontaneous language
• Increase in generalized spontaneous utterances
• Increase in generalization and maintenance of intervention gains
• Increase in positive child affect
• Lower percentages of disruptive behaviors
• Collateral gains in other often, untargeted behaviors”

Key Features

Pivotal response treatment (also known as pivotal response training, PRT or the natural language paradigm) is a form of teaching in which the teacher concentrates on changing certain 'pivotal' behaviours, such as motivation and self-management.

Pivotal response treatment is based on the idea that certain aspects of a child's development are considered to be 'pivotal', that is, crucial for the behaviours which depend on them. The pivotal areas are motivation, self-management, self-initiation, and the ability to respond to multiple environmental cues.

In pivotal response treatment the trainer concentrates on changing these pivotal areas in order to change the behaviours which depend on them, such as speech and language, social behaviour, and challenging behaviour.

There are several multi-component programmes (such as the Early Start Denver Model and the Nova Scotia early intensive behaviour intervention) which include pivotal response treatment as a key element.

·Motivation

The trainer aims to ensure the child is motivated throughout the learning process. For example, they may provide the child with choices, such as allowing him or her to decide which toy to play with. The trainer may reinforce learning with naturally occurring rewards, such as by giving him or her a toy if he or she can ask for it, instead of giving him or her a sweet instead. They may also teach new, more difficult tasks between easy tasks that the child has already mastered.

·Self-management

The trainer aims to teach the child individual to be aware of his inappropriate behaviours, to collect information on those behaviors, and to reward himself or to request rewards from others. For example, she may ask him to keep a star chart, which shows when he has done something right. When he gets enough stars, he gets a reward.

·Self-initiation

The trainer teaches the child to act spontaneously in response to natural cues. For example, she may encourage the child to ask questions about something he can see, such as a favourite toy, in order to get it.

·Multiple environmental cues

The trainer teaches the child to be aware of, and how to respond to, all of the relevant cues in a situation. For example, if the child already responds correctly to the request 'Get your jumper', the trainer can add another cue by saying 'Get your red jumper' or 'Get your jumper from your room'.

·Other key elements

There are a number of other elements which are considered to be important within PRT.

The trainer ensures that the child is paying attention to any instructions. This might be achieved by touching the child lightly on the arm and ensuring that he is looking at and/or listening to the instructor.

The trainer uses short, simple instructions such as 'Get your blue ball' instead of long, confusing instructions such as 'Why don't you get your blue ball so that we can play catch.'

The trainer arranges the child's immediate environment to encourage learning, for example by placing things that the child likes nearby in order to encourage conversation about those things.

Cost and Time

Cost

The costs of using PRT will depend to a large extent on who provides the training, how long it takes to implement the intervention, and whether support materials are purchased.

For example, according to the Koegel Autism Consultants website, accessed on 5 April 2016, Koegel Autism Consultants can provide a single 90 minute Skype consultancy session to parents for $280.00 or 12 monthly Skype consultancies over the course of a year for $1,600.

The Rush University Medical Center website, accessed on 5 April 2016, lists some suppliers, which provide hands-on, individualised training to parents at a cost of $330 (hourly rate at PhD level); $75-$200 (hourly rate at MA level).

Time

Like many other interventions, the length and frequency of treatment will depend to a large extent on the needs of the individual. In some cases, the intervention will require many hours of work each day and be implemented over many years.

For example, according to the Autism Speaks website, accessed on 5 April 2016,

“PRT programs usually involve 25 or more hours per week for the learner as well as instruction for parents and other caregivers. Indeed, everyone involved in the learner’s life is encouraged to use PRT methods consistently. PRT has been described as a “lifestyle” adopted by the affected family.”

Risks and Safety

Hazards

There are no known hazards for pivotal response treatment.

Contraindications

There are no known contraindications (something which makes a particular treatment or procedure potentially inadvisable in certain groups of people or under certain circumstances) for pivotal response treatment.

Suppliers and Availability

Suppliers

In theory, PRT is only available from a small number of agencies in the US, such as the Koegel Autism Center in California. In practice, PRT may actually be implemented by a variety of people, including parents and carers, as well as professionals such as teachers.

According to Simpson et al. (2005)

"Initial PRT sessions are provided with skilled facilitators for a large number of hours. However, as a child improves in pivotal areas, highly skilled facilitators are needed less, and the child's family members and teachers provide more natural support."

Support materials are also available from organisations such as the UCSB Koegel Autism Center in California.

Credentials

There is no internationally recognised qualification for the delivery of PRT but the UCSB Koegel Autism Center in California runs a PRT Certification programme, with certification available at various levels.

Related Suppliers and Availability

History

Pivotal response treatment was developed by a number of psychologists in the US in the 1990s, including Dr. Robert Koegel and Dr. Lynn Koegel at the University of California at Santa Barbara.

They developed pivotal response treatment as a more naturalistic, alternative to traditional behavioural techniques, such as discrete trial training.

Pivotal response treatment has since been incorporated into several multi-component programmes (such as the Early Start Denver Model and the Nova Scotia early intensive behaviour intervention).

Current Research

We have identified more than 40 scientific studies of pivotal response treatment as an intervention for autistic children, young people and adults peer-reviewed journals in English.

(Please note we have not included studies where pivotal response treatment was included as an element in multi-component programmes such as the Early Start Denver Model.)

These studies included more than 400 participants, with the majority aged between 2 and 7 years old - although 158 of those participants came from a single study by Baker-Ericzen, Stahmer and Burns (2007).

The majority of studies reported positive results for some participants. For example,

  • Some researchers (such as Baker-Ericzen, Stahmer and Burns, 2007)  reported significant improvements in adaptive functioning
  • Some researchers (such as Harper, Symon and Frea, 2008) reported improvements in social skills, such as social initiations and turn taking
  • Some researchers (such as Koegel et al, 1998)  eported improvements in communication, such as the ability to ask questions.
  • Some researchers (such as Hupp and Reitman, 2000) reported general improvements targeting one “pivotal” behaviour
  • Some researchers (such as Koegel, Koegel, Surratt, 1992) reported improvements in responding and considerably less disruptive behaviour
  • Some researchers (such as Stahmer, 1995) reported that children learned to perform complex and creative symbolic play.

Status Research

There are a number of limitations to all of the research studies published to date. For example

  • The vast majority of the studies had 3 or fewer participants and used a single-case design, such as a multiple baseline or alternating treatments design.
  • The one study (Baker-Ericzen, Stahmer and Burns, 2007) which had more than 100 participants was a retrospective case series, lacking any kind of experimental control.
  • Some of the controlled studies (such as Stahmerand Schreibman, 2006) were non-randomised and/or non-blinded.
  • Some of the studies (such as those involving staff from the Koegel Institute) were undertaken by researchers who were not independent of the intervention being studied.  Those researchers may therefore have been biased towards the intervention, however unconsciously.

For a comprehensive list of potential flaws in research studies, please see ‘Why some autism research studies are flawed’

Ongoing Research

This page provides details of ongoing research into pivotal response training and autistic people.

If you know of any other trials we should include please email info@researchautism.net with the details.

Future Research

Summary of Existing Research

There is strong research evidence to suggest that pivotal response treatment provides a positive approach to targeting key developmental skills, such as language in some autistic children.

Reports have suggested that parents and non-autistic peers can be trained to implement this approach, and that the focus on naturalistic reinforcement may make it more accessible than more traditionally structured behavioural interventions such as discrete trial training.

However, there are few large-scale randomised control trials of pivotal response treatment in real world settings or which compared pivotal response training to other, similar interventions.

There are few studies which examined whether pivotal response treatment was being implemented correctly or which looked at effectiveness at least one year post intervention.

None of the studies appeared to involve autistic people in reviewing the efficacy and ethical basis of the intervention.

Recommendations for Future Research

We agree with Cadogan and McCrimmon (2013) who made the following recommendations for future research on pivotal response treatment,

“This review indicates recommendations that may enhance PRT research efforts. First, translucency in methodology through clear description of research methodology, interventionist training methods and the use of objective and/or naive behavioural raters may strengthen research designs. It is fundamental that PRT research studies conduct treatment fidelity measures in order to ascertain whether it is being implemented correctly. It would also be beneficial to state the treatment fidelity standards that interventionists were required to meet and maintain, and what steps were taken when these standards are not met. Furthermore, it is recommended that researchers continue to incorporate appropriate baseline and follow-up designs to objectively measure treatment effectiveness. Similar to recommendation by Skokut et al. recommendation regarding the viability of follow-up studies, it would be especially valuable to ascertain treatment effectiveness at least one year post intervention. Finally, comparison of intervention approaches is highly recommended in determining which children with ASD respond best to particular interventions. This is especially important given the increased diversity of interventions for ASD as such comparisons may build upon knowledge pertaining to intervention (in-)effectiveness.”

In addition, we believe that future research should also involve autistic people to review the efficacy and ethical basis of pivotal response treatment including individuals who may be non-verbal.

Studies and Trials

This section provides details of scientific studies into the effectiveness of pivotal response treatment for autistic people which have been published in English-language, peer-reviewed journals.

If you know of any other publications we should list on this page please email info@informationautism.org

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Studies and Trials

Other Reading

This section provides details of other publications on this topic.

You can find more publications on this topic in our publications database.

If you know of any other publications we should list on this page please email info@informationautism.org

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Other Reading

Additional Information

According to the UCSB Koegel Autism Center website, accessed on 5 April 2016,

“In the past, Pivotal Response Treatment has been referred to as Pivotal Response Training, Pivotal Response Teaching, Pivotal Response Therapy, Pivotal Response Intervention, and the Natural Language Paradigm (NLP). These terms all indicate the same treatment delivery system, most commonly known as Pivotal Response Treatment.”

Related Additional Information

Updated
17 Jun 2022
Last Review
01 Oct 2016
Next Review
01 Feb 2023
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