Pivotal Response Training: A Naturalistic Approach to Applied Behavioral Analysis
What is Pivotal Response Training?
Pivotal Response Training (PRT), also known as Pivotal Response Treatment, is an evidence-based intervention developed by Dr. Robert Koegel, Ph.D. and Dr. Lynn Koegel, Ph.D. to provide a more naturalistic approach to the principles of applied behavioral analysis (ABA). PRT is child-led and rewards positive behavior with direct and natural reinforcers. The Koegel Autism Center at The Gevirtz School at the University of California, Santa Barbara describes PRT’s top-down approach as a way to target key developmental areas which will facilitate a child’s ability to learn a variety of skills.
According to The Gevirtz School (GGSE)-UC Santa Barbara website, “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.” Targeting these four areas affects behavior in many behavioral and social areas as the skills learned can be applied widely.
Doctors Robert and Lynn Koegel are both authorities in the area of autism and currently serve as a senior researcher and clinical professor, respectively, at Stanford University School of Medicine. They cite the goals of PRT as a tool to “teach language, decrease disruptive/self-stimulatory behaviors, and increase social, communication, and academic skills.” By meeting these goals, children with autism spectrum disorders (ASD) have a ‘skills toolbox’ for mastering more specific tasks and skills.
While PRT is based on the same principles as ABA, the facilitator during PRT follows the child’s lead, much like in DIR/Floortime. According to an article published in Issue 59 of Autism Parenting Magazine called Autism Therapies and Treatments, You Need to Know, “Instead of following the ‘child and teacher at the table’ model, PRT uses a more naturalistic approach. During therapy, the child is placed in a structured place where he/she has many opportunities for play and interact with surroundings…The child is also allowed to choose the toys, activities, and topics of conversation during the session.”
Is Pivotal Response Training a scientifically based treatment for autism?
Since it’s development, PRT has been recognized as an empirically supported treatment for autism. Over 200 research articles in peer-reviewed journals and 30 books and manuals support the effectiveness of PRT. Additionally, PRT has been called one of the 10 model programs for autism by the National Research Council and is one of four scientifically-based practices for autism intervention in the United States.
How are developmental delays addressed through behavioral intervention therapy?
Pivotal Response Treatment seeks to address four pivotal areas of development: motivation, initiation, responding to multiple cues, and self-regulation. According to Dr. Koegel and Dr. Koegel, motivation to learn and participate PRT is the foundational procedure for the other areas of PRT. A child’s desire to learn and participate in therapy is crucial to the success of PRT. A presentation by Greg Lyons, M.A., published by the University of Texas North Carolina, describes each of the four pivotal areas as they relate to toddlers participating in PRT:
A child with limited interests, hesitation to explore new ideas, or who struggles to engage in formal education will benefit greatly from increased motivation. According to Greg Lyons, a doctoral candidate at the University of Wisconsin-Madison, “PRT learning opportunities are specifically designed to increase child motivation to learn and interact. In PRT, motivation can be defined as a child seeking opportunities to initiate interactions and respond to others in social and academic settings.
PRT may increase a toddler’s desire to perform (and try to perform) skills and behaviors by using specific antecedents (events that happen before a behavior) and consequences (events that happen after a behavior) within PRT learning interactions.” Therapies will likely focus on finding ways to intrinsically motivate your child so that he/she not only initiates learning and interactions but also is encouraged to find worth in these experiences.
Children who have a desire to learn and interact with the world around them might be hesitant to do so if they lack the skills to successfully initiate learning experiences. These initiations might look like asking questions, expressing a need, or demonstrating their knowledge. In PRT, a toddler might be taught to ask who, what, where, when, and why questions to explore their world. Children are naturally curious and giving them the tools to express their curiosity and seek answers often motivates them to engage in both formal and passive learning. Another important initiation skill children are taught is to alert adults and authority figures to concerning situations.
Children who have hurt themselves can yell for help or say “Look!” when they see a foreign object. Teaching children expressive skills not only makes it easier for them to initiate conversation and have their questions answered but also ensures that they will not how to ask for help in unfamiliar or unsafe situations.
Responding to Multiple Cues
Responding to multiple cues is a foundational skill in the classroom and in social interactions. When children are able to respond to multiple cues, they will be able to follow a series of instructions (put away your pencil, then tuck in your chair), focus on more than one person or object (noticing both the speaker and the object about which they are speaking), and even making sense of short narratives or word problems in math class. Children with ASD often display traits over-selectivity, or the inability to focus on the big picture. This might look like a child who is more interested in the wobbly wheel on a toy fire truck than enjoying the fire truck as a whole.
A child might also present over-selectivity as the inability to focus on a speaker when there is background noise or track an object with other visual stimuli present. Gaining the skills to respond to multiple cues can help children build confidence in social situations by helping them gain the skills to participate in conversations, as well as understanding multifaceted ideas in the classroom.
For children who struggle with meltdowns, self-regulation is an important skill in managing overstimulation, intense emotions, and sensory dysregulation. Lyons writes, “Self-management for toddlers with autism looks different than self-management for older children, adolescents, and adults. For older children, self-management is sometimes defined as teaching children to self-monitor, self-evaluate and discriminate their own behaviors, and finally self-reinforce. Self-management strategies may lead to improved generalization of skills, as well as improved self-regulation, such as increased independence (i.e., less dependent on prompts by adults) and decreased challenging behavior.” (Lyons, Pivotal Response Treatment) While working on self-regulation, children will begin to learn how to identify triggers and form age-appropriate coping skills to handle charged situations.
In addition, children will build a skill set complementary to gaining more independence. Children will learn how to meet and identify their needs including activities of daily living, self-soothing techniques, and gaining insight into their own thoughts and behaviors.
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What kind of child exhibits behavioral changes from treatment?
Like any therapy, some children take to Pivotal Response Training while other children find other therapies more useful. Children who are most likely to experience behavioral changes are those who practice it frequently. Pivotal Response Training is considered a lifestyle treatment which means that it needs to be practiced 25 hours a week or more to be successful and requires integration into everyday life. Due to its naturalistic approach, many parents and caregivers find PRT easier to facilitate at home than other therapies.
When they were asked why they believe PRT is an effective therapy for so many children, Dr. Koegel and Dr. Koegel said, “Because PRT works with each child’s natural motivations and stresses functional communication over rote learning, this comprehensive model helps children develop skills they can really use. With this timely resource, educators, therapists, and parents can support children with autism as they enjoy more positive interactions, more effective communication, and higher academic achievement in natural, inclusive settings.” (Koegel & Koegel, 2006)
What is a typical Pivotal Response Training session like?
Due to the naturalistic nature of PRT, sessions are conducted in setting children are familiar with and interact with daily. By incorporating a variety of locations, such as school, home, the park, at extracurricular activities, etc., children will gain the confidence to practice PRT skills in many different settings and situations. Including people, your child regularly interacts with his/her sessions is also important. Your child’s therapists, teachers, parents, friends, and siblings can all participate in PRT.
Maintaining different people and places in your child’s Pivotal Response Training therapy will give your child the opportunity to learn how each of the four skills can be applied to the various aspects of his/her life. For example, your child’s teacher might help your child respond to multiple cues while giving verbal directions, or your child’s sibling might help him/her build skills to initiate social interactions by welcoming him/her to join in playing. The application of consistent PRT therapy across multiple areas of your child’s life is crucial to reinforcing PRT and helping your child hone the skills he/she is learning.
What are the goals of Pivotal Response Training?
When you first begin Pivotal Response Training, your child’s therapist will conduct an initial evaluation of your child in the four domains of PRT. Based on your child’s current abilities and strengths, he/she will meet your child where he/she is and set age-appropriate goals for progress. The therapist will likely encourage you to engage in 25 hours or more of PRT a week in various areas of your child’s life. As mentioned above, the more people who practice Pivotal Response Training skills with your child, the better. The goals you set with your child’s therapist will vary based on where your child is on the spectrum as well as their current abilities, but the end goal is always to help your child create healthy and productive behavioral patterns.
Studies supporting a naturalistic approach
Since its development in the 1970s, pivotal response training has garnered support from not only parents and clinicians who saw the effects of PRT firsthand, but clinicians around the world whose independent studies supported what was being reported anecdotally. Hundreds of studies have reported the PRT’s effectiveness, but in June 2017, the Dove Medical Press Limited published a study by Jiedi Lei and Pamela Ventola explaining why PRT works.
Lei and Ventola, of the Yale Child Study Center (Yale University School of Medicine), used neuroimaging to study how PRT elicits change as well as investigating biomarkers that can help determine which children are the best candidates for the therapy and how to offer the most precisely targeted intervention. While their findings are still preliminary, it lays an excellent groundwork for further research. As more is discovered about how PRT functions neurologically, the more refined it can become.
How do I find a Pivotal Response Training practitioner?
PRT practitioners are crucial for teaching parents and caregivers how to implement home treatment, properly documenting progress, and conducting regular sessions in addition to those done at home. Practitioners are often psychologists, but a variety of professionals can be trained as PRT practitioners. Your child’s pediatrician is an excellent place to start if you are looking for a recommendation. If your child is school-aged, he/she may qualify for PRT sessions at school through an individualized education plan or other accommodations on file. In addition, if your child already sees a psychiatrist, psychologist, occupational therapist, he/she may have recommendations as well. A call to local universities and/or your insurance company may also be helpful in identifying local resources.
Autism Therapies and Treatments You Need to Know. (2018, June 24). Retrieved from https://www.autismparentingmagazine.com/best-autism-therapies-and-treatments/
Koegel, R., & Koegel, L. (2006). Pivotal response treatments for autism: Communication, social, & academic development. Retrieved from https://scholar.google.com/scholar?hl=en&as_sdt=0,10&as_vis=1&qsp=1&q=pivotal response treatment autism#d=gs_qabs&p=&u=#p=lqHs6LvavE8J
Lei, J., & Ventola, P. (2017). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5488784/#!po=16.2281
Lyons, G., M.A. (n.d.). Pivotal Response Treatment. Retrieved 2018, from https://asdtoddler.fpg.unc.edu/book/export/html/310
The Gevirtz School (GGSE) – UC Santa Barbara. (2014). Retrieved from https://education.ucsb.edu/autism/pivotal-response-treatment
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