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Wednesday 22 Nov 2017

What is Pivotal Response Treatment?

Pivotal Response Treatment (PRT) is an intervention based on the science of Applied Behavior Analysis (ABA) which is implemented in the natural environment. Interventions which are implemented in the natural environment are typically called naturalistic, and they are implemented during regularly scheduled activities in the child’s life (i.e. play time, meals, school, playground, outings, etc). The unique characteristic of PRT is that intervention is focused on four pivotal areas of development. These fours areas have been identified through over 30 years of research conducted by Robert at Lynn Koegel at UCSB. They have found that when intervention is focused on these four pivotal behaviors positive collateral gains tend to occur.

The four pivotal areas are motivation, responding to multiple cues, self-initiations and self-management:

  • Motivation
  • “Motivation to respond to social and environmental cues is fundamental to development and a critical area of intervention. Learners with ASD appear poorly motivated to respond to and engage in the social world around them (R. L. Koegel, Dyer, & Bell, 1987). One possible explanation for this central deficit is that they have great difficulty learning the response-reinforcer contingency (i.e., the relationship between the learner’s response and direct reinforcement of the response), and instead view responses and reinforcers as unrelated (R. L. Koegel & Egel, 1979; R. L. Koegel, O’Dell, & Dunlap, 1988).

    This can lead to a vicious cycle, where low levels of correct responding lead to low levels of reinforcement, leading to even lower levels of responding. However, pivotal response interventions that emphasize associations between social-communicative responses and direct positive consequences lead to increased motivation, enhanced learning, more rapid acquisition of target behaviors, and less avoidance behavior (L. K. Koegel & Koegel, 1995; R. L. Koegel, Carter, & Koegel, 1998).

    Other theories suggest a neurobiological reason for the motivational problems often found among individuals with ASD, such as a lack of internal motivation due to abnormalities in the brain. As the learner’s motivation increases, so does the number of responses that he or she makes to teaching attempts. This, in turn, results in decreases in response latency (i.e., the time between initial stimulus and learner’s response) and increases in positive affect. The increases in motivation likely lead to more practice, which may be why increases in motivation lead to increases in student learning (R. L. Koegel et al., 1988).” from Autism Internet Modules

  • Responding to Multiple Cues
  • “Many learners with ASD demonstrate a characteristic called “stimulus overselectivity” (R. L. Koegel et al., 1989). For example, in a situation in which typically developing peers might use three cues (e.g., visual, auditory, tactile) together to identify a stimulus, learners with ASD tend to use only one or two cues while ignoring the others. In addition, learners with ASD are more likely than others to respond to small, irrelevant cues, which significantly limits their ability to understand and generalize more complex stimuli (Lovaas, Schreibman, Koegel, & Rehm, 1971). For instance, learners may come to recognize a familiar and preferred adult by a very limited detail, like his or her eyeglasses, a piece of jewelry, or a specific gesture instead of by the person’s face, hairdo, or body shape. If the detail changes, learners with ASD might fail to recognize that person (Rincover & Koegel, 1975; Schreibman & Lovaas, 1973). However, this characteristic appears to be malleable.

    Many learners with ASD can enhance their attention to multiple cues and increase their abilities to learn and generalize if this deficit is targeted (Burke & Cerniglia, 1990). These skills can be taught by building in multiple cues in activities and instructions. For example, in a pegboard task, instead of pointing to the desired peg and asking “May I have that one, please?” the adult might ask the learner for the “square, green peg” from a mix of pegs, including square pegs of different colors and green pegs of different shapes. This requires the learner to discriminate among multiple features of the pegs at once in order to correctly follow the request.” from Autism Internet Modules

  • Self-Initiations
  • “The definition of “initiations” is complex, as there are many different types of initiations (Fredeen & Koegel, 2006). L. K. Koegel, Koegel, Harrower et al. (1999) defined spontaneous initiations as “the individual beginning a new verbal or nonverbal social interaction, self-initiating a task that results in a social interaction, or changing the direction of an interaction” (p. 3). Typical examples of initiations include spontaneous verbal requests, commenting, or asking questions. In general, learners with ASD have been observed to have limited interest in asking questions or making comments, often using them only to request items, and rarely using them to inquire about their environment or to obtain social information about the individuals with which they are interacting (Tager-Flusberg, 1996; Wetherby & Prutting, 1984).

    Studies have demonstrated that initiations are pivotal behaviors and that increasing them yields gains in other areas of language and social development. For example, children who were taught to use the question “What’s that?” were able to increase their use of expressive labels and generalize their question-asking to the home (L. K. Koegel, Camarata, Valdez-Menchaca, & Koegel, 1998). Researchers also have found that, when children were taught the question, “What’s happening?,” they exhibited other general language gains, including an increase in the average number of words spoken per sentence(L. K. Koegel, Carter, & Koegel, 2003).

    Other important self-initiation skills that are targeted for intervention include learning how to use language to enter into a conversation or to start an interaction, such as asking people questions (e.g., “Can I play?” “What are you doing?” “Do you want to play hide-n-seek?” “What do you want to play?”). Once the game or activity has started, learners with ASD also need to know how to sustain the interaction. This requires teaching them how to listen to another person and then reflect back and make comments about what was just said. Teaching learners with ASD how to initiate questions and comments in different contexts reduces their symptoms of ASD. When children and youth with ASD learn to initiate, they no longer sit alone or respond just when spoken to. Their interactions involve turn taking, and are more complete. Thus, using self-initiations enables learners with ASD to be more social.” from Autism Internet Modules

  • Self-Management
  • “The ability to self-regulate and manage one’s behavior is a critical developmental task for all individuals. For learners with ASD, development of this skill usually takes time and planned teaching. The initial stage of self-regulation includes regulating arousal and responses to sensory stimulation (DeGangi, 1991). Later stages of self-regulation consist of inhibition, delay of gratification, and communication (Dodge, 1989). Learners with ASD appear to have difficulty regulating their own behavior, limiting their ability to attend to and be responsive to their environment and the learning opportunities around them (R. L. Koegel et al., 2001).

    Self-management is a positive behavior support strategy that decreases interfering behaviors (e.g., repetitive, disruptive, stereotypical) while more functional replacement behaviors are being learned. Development of self-management techniques has been shown to improve academic performance (Shimabukero, Prater, Jenkins, & Edelen-Smith, 1999), social functioning (L. K. Koegel, Koegel, Hurley, & Frea, 1992), and play skills (Stahmer & Schreibman, 1992). The benefits of teaching this skill include increased independence, personal competence, and reduced need for constant vigilance by a treatment provider (R. L. Koegel, Koegel, Frea, & Smith, 1995; Pierce & Schreibman, 1997a; R. L. Koegel & Koegel, 2006; Schreibman & Koegel, 1996).” from Autism Internet Modules

If PRT is implemented in the home, school and community consistently and intervention focuses on these four pivotal areas of development, our children or individuals with whom we work are likely to make gains in multiple areas. Intervention procedures are implemented in the natural environment and focus on items and activities which are of interest to the individual. By focusing our efforts on teaching in this way we are enhancing the potential for generalization and maintenance of skills.

In addition to being implemented by trained providers, PRT is an intervention which can, and should, be implemented by caregivers. When they are taught how to implement this intervention with fidelity (i.e. they are doing it correctly and consistently) the number of hours of quality “intervention” being experienced by the individual with autism can double or triple. The amazing thing is that when caregivers learn how to implement this intervention, it begins looking less like “intervention” and more like a new and effective way of interacting with the individual which is capitalizing on every teachable moment possible throughout the day.

To learn more about PRT, please visit the Koegel Autism Center website, sign up for Autism Internet Modules which is a free and comprehensive online educational resource, and check out the books listed HERE.

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