One of the most proven behavioral approaches for treating children with autism spectrum disorders is pivotal response treatment, or PRT. But what is PRT? PRT is a naturalistic intervention model derived from applied behavioral analysis, PRT is a play-based method that targets improving “pivotal” child development areas instead of individual behaviors. It’s based on the idea that changes in pivotal responses would spark widespread progress in other developmental areas.
PRT was initially established in the 1970s by Dr. Robert Koegel and Dr. Lynn Kern Koegel at the University of California- Santa Barbara. First called Natural Language Paradigm (NLP) or pivotal response teaching, PRT combined several research-based behavioral interventions to improve autistic children’s:
- social skills
A study published in Behavior Modification journal showed that pivotal response treatment is highly effective at improving pivotal areas of a child’s development for preschool, elementary, and middle school students with autism spectrum disorders.
Four Main Pivotal Areas Targeted
Pivotal response treatment strives to thwart negative, self-stimulatory behaviors associated with autism by addressing four main “pivotal” areas of a child’s development. These four areas include:
- Response to multiple cues
- Encourage initiation of social interactions
The central area is motivation. PRT therapy works to increase children’s desire to learn and perform skills associated with good consequences. Rather than force tasks, PRT uses the child’s interests to reinforce pro-social behaviors and trigger enthusiasm. Therapists use several motivational procedures including task variation and interspersing maintenance and acquisition tasks.
The second “pivotal” area is initiations. PRT encourages the child to initiate social interaction by asking questions or obtaining attention.
Next comes self-regulation. This “pivotal” area teaches children to self-evaluate and discriminate their behaviors for greater independent.
Finally, PRT trains autistic youth to respond to multiple cues rather than focus on specific details or stimuli.
What’s Involved in PRT Sessions
PRT therapy sessions involve using positive reinforcement to address the above “pivotal” areas, which will result in broad progress for sociability. Pivotal response treatment is customized to meet the unique needs of individual children and their routines. Most school based PRT programs will consist of 25 or more hours weekly. Parents or guardians should also adopt PRT methods in the home environment for consistency. Pivotal response treatment uses play therapy to target social skill development, so unstructured interactions are common. Lessons could include:
- taking turns
- joint attention
- peer interaction
Here are some pivotal response treatment examples:
- transitioning from one activity to another
- daily chores
- daily routines
A basic introductory PRT session might look like this:
- A parent takes out a toy bin with several toys that the child has shown to enjoy
- The parent asks the child to select a toy to play with
- The child points to the toy they would like to play with
- The parent might ask the child, “You want to play with the toy car?”
- When the child provides an appropriate response, they are rewarded with the car
- The parent can then use the opportunity to ask additional questions about the car like “what color is the car”
- The parent could play with their own car alongside the child, using the opportunity to demonstrate appropriate play and social skills during the session.
The important aspects of the session are that the child was motivated to participate (they liked the toy selection), they chose the toy they wanted to play with, and they were rewarded with a natural reward for a correct response. Parent training is a critical component of PRT as an autism intervention since training needs to take place in a natural setting.
Is There Evidence that Pivotal Response Training Works?
PRT is one of the most studied ABA treatment options for children with autism. PRT is shown to improve communication skills in autistic children. Most of these studies look at PRT delivered by credentialed therapists in a one-on-one therapeutic setting. A few others looked at PRT in group settings with teachers or parents.
Most children with autism (although not all) respond favorably to ABA. The positive, naturalistic aspects of this training make it an effective method for parents to use at home.
Qualifications to Provide PRT Therapy
Practitioners of pivotal response treatment typically need special certification beyond their training and licensing. Examples of pivotal response training providers include:
- school psychologists
- special education teachers
- speech-language pathologists
- occupational therapists
Some applied behavior analysts may dabble in PRT therapy since it’s derived from ABA. Most PRT providers attain at least a master’s degree in:
Accredited master’s programs will require clinical practicum to satisfy the contact hours for licensing, which varies greatly by state and title.
After licensing, providers should pursue certification from the UCSB Koegel Autism Center. Three levels of PRT certification can be obtained with workshops. Level I Certification requires attending the two-day Pivotal Response Treatment Conference. The conference covers PRT content areas that include:
- Delineation of Pivotal Areas
- Motivational Procedures of PRT for Teaching Social Communication
- Facilitating Social Interactions with Typically Developing Peers
- Motivational Academics
- Functional Behavior Assessment
- Other applications of PRT/Emerging PRT Interventions and Research
- History and Development of PRT
- Characteristics of Autism Spectrum Disorder (ASD)
The Level II Certificate is for individuals who have completed Level I Certification. Participants are introduced to introductory PRT motivational procedures for teaching communication. This Level certification validates participants have met fidelity of implementation criteria for PRT with one child with autism spectrum disorder.
The Level III Certificate is an advanced certificate for individuals who have completed Level I and Level II Certification. This training focuses on the participants’ ability to generalize their PRT procedures for teaching communication across a broad range of children with ASD. The Level III Certification validates participants have met fidelity for implementing PRT with three different children with ASD.
Will Insurance Cover PRT Treatment?
The answer largely depends on the type of insurance you have. Many private health insurance companies cover therapies like PRT. PRT is considered an evidence-based approach to helping children with autism. Since Pivotal Response Training is applied behavior analysis, many companies cover all or part of treatment. You will need to reach out to your individual insurance company to check coverage.
If your child has a Medicaid plan, PRT is likely to be covered if it is prescribed by a physician. Medically necessary treatments are covered by Medicaid.
Related Resource: What is Naturalistic Teaching ABA?
Overall, pivotal response treatment was recognized by the National Research Council as one of the top 10 model programs for autism. Motivation strategies utilized in PRT therapy helped 85% of toddlers with autism develop verbal language as their primary communication. PRT is an evidence-based behavioral approach targeting critical behaviors in natural environments for better social skills. As the diagnosis of children with autism spectrum disorders grows more prevalent, pivotal-response treatment is expected to become a leading form of early intervention.
Related Resource: What Can Be Done To Prevent Autism?