Pivotal response therapy (PRT), also known as pivotal response training, is an evidence-based intervention treatment for children with autism. Autism is a brain disorder that affects a child’s communication, social, behavioral abilities, and academic areas. Its symptoms include self-stimulatory behaviors, such as repeatedly flapping arms, socially inappropriate behavior, being easily distracted, and inability to initiate social interactions. PRT encourages children to improve in the four broad pivotal areas (response to multiple cues, social interaction initiation, motivation, and self-management). These skills are considered pivotal because they are the foundational skills upon which learners with ASD can make widespread and generalized improvements in many other areas.
ABA therapists, psychologists, speech therapists, and special education teachers all are trained to use pivotal response therapy, which techniques have been around since the 1970s.
Pivotal response therapy can be highly effective when used with individuals with autism.
“More than 20 studies suggest that PRT improves communication skills in many (though not all) children who have autism. Most of these studies looked at PRT delivered by trained therapists in one-on-one therapy sessions. Others looked at PRT delivered in group settings by school teachers and by trained parents in their homes. A 2017 review of brain imaging studies showed evidence that PRT improves brain activity associated with sociability and communication,” (Autism Speaks).
Those who use PRT should have one or more of the following five goals in mind:
- Enhance skills across symptom areas
- Maintain a child-centered approach
- Encourage independence and success
- Increase motivation
- Encourage socially acceptable behavior
1. Enhance skills across symptom areas
PRT aims to help learners develop skills across many areas in each broad symptom group. For instance, a child learns to ask for a building piece to complete a tower they’re constructing. This develops the child’s communication abilities (he has to formulate the word or use the correct nonverbal cues, depending on where he is on the autism spectrum), social skills (using socially acceptable ways of getting an object he wants instead of just reaching out and grabbing the building piece), and behavior skills (the child must control the impulse to revert to a repetitive, instead he uses “his word”).
Every child, not only children with autism, benefit from working on response to multiple cues, social interaction initiation, motivation, and self-management, which are the four fundamental skills of pivotal response therapy.
It is important for therapists, educators, and whoever else uses PRT techniques with a child with autism to work together and communicate. This will help ensure that new learned skills are being taught consistently and are being generalized to other settings correctly.
See Also: 5 Goals of EMDR Therapy: EMDR Benefits
2. Maintain a child-centered approach
Since one of the broad symptom areas of autism is behavior problems, PRT focuses on helping the child improve his or her own behavior with fun activities that the child enjoys. Each session is individualized. Collaboration meetings take place at regular intervals so parents and professionals can discuss the child’s progress and goals. The PRT program is then changed for the benefit of the child.
An article from the University of North Carolina (ASD Toddler Initiative) emphasizes the teaching of skills and for therapy work to be done in a naturalistic setting; this means that each child’s regular day-to-day environment be taken into consideration, as well as what naturally reinforces the child.
They say that the pivotal target areas should be practiced:
- in naturally occurring contexts (e.g., taking turns during play, during daily routines in “everyday settings” at home and in the community)
- with natural stimuli (for example, favorite toys or activities, more typical and varied instructional antecedents, varied learning opportunities or tasks)
- with natural change agents (For example, parents, siblings, respite workers, center-based educators, and practitioners)
- with natural contingencies (For example, loose teaching contingencies based on reinforcing attempts; using natural/direct reinforcers; contingent recasts of child communication)
The goals for any interaction with a child with autism should be individualized and child-centered regardless of using PRT.
3. Encourage independence and success
One of the primary goals of PRT is to help the child self-manage his or her own behavior. This is done by helping the child first become aware of their own actions and consequences of those actions. This type of therapy is based on play and takes into account the child’s current abilities and intervention goals, which are determined by parents, teachers, and professionals. The activities are tailored to the individual child’s physical and cognitive abilities and are altered accordingly as the child’s skills become more advanced.
“The goal of self-management is to increase the independence of learners with ASD while decreasing their dependence on teachers/practitioners. To promote self-management, learners are taught to discriminate their target behaviors and then to record or monitor the occurrence (or absence) of them. Self-management is a strategy that is designed to take place in the absence of practitioners and provides learners with a set of procedures that promote autonomy and independence,” (NPDC).
In order to promote independence, it is important to first help the child learn the difference between appropriate and inappropriate behaviors. This can be done by delivering a variety of interventions, along with using reinforcements and consequences, of course.
Children with autism can help track and manage their behaviors. Depending on their level and skill, they can help set goals, self-monitor, and track those goals. An example of self-monitoring can be done through a tracking app, a sticker chart or other visual, the use of timers, etc.
The experts at Autism Speaks provide 10 ways to build independence.
- Strengthen communication
- Introduce a visual schedule
- Work on self-care skills
- Teach child to ask for a break
- Work on household chores
- Practice money skills
- Teach community safety skills
- Build leisure skills
- Teach self-care
- Work on vocational skills
4. Increase motivation
Professionals who administer PRT (they can be child therapists, psychologists, special education teachers, speech therapists, and any other professional who have PRT training) focus on encouraging future positive behavior. For this reason, positive reinforcement is used and the professional rewards the child for effort even if he or she doesn’t master a certain skill immediately. The goal is to motivate the child so that he or she finds the activities fun and engaging. By doing this, the professional intentionally leaves no downtime for kids to revert to problem behaviors and making skill development more likely.
There are various ways to increase motivation when working with children with autism. Providing choices, using task variation, and sharing control are three major ways to encourage positive behavior and get tasks completed.
“By sharing control of the activity and material selection, adults increase learners‟ motivation to participate and thus help them learn target behaviors and skills.
For example, if a teacher/practitioner has selected an activity to improve a learner‟s handwriting skills, the learner might exert shared control by deciding what type (e.g., pen, pencil, marker, crayon) and color utensil (e.g., red, green, blue) to use, what words to practice writing (e.g., preferred interest; student‟s name or names of friends, family), and what materials to write on (e.g., piece of colored paper, grid paper, index cards),” (NPDC).
It is important to not only reinforce when something is done appropriately but to reinforce task attempts to increase the likelihood that the learner will attempt again even when they are not successful each time.
5. Encourage socially acceptable behavior
Lastly, a goal of PRT is to help children substitute problem behavior for more positive behavior through Positive Behavior Support. Positive Behavior Supports (PBS) is a broad approach to behavior modification that is effective across disabilities, ages, and abilities. Simply, it means teaching individuals to replace socially inappropriate behavior with more socially acceptable behavior. For instance, a child who throws items he dislikes is rewarded (instantly) for asking or signing for a different toy. He is not allowed the new toy until he requests it properly.
In a school setting, this can be managed through a school-wide PBIS program. PBIS stands for Positive Behavioral Interventions and Supports. PBIS “is an evidence-based three-tiered framework to improve and integrate all of the data, systems, and practices affecting student outcomes every day. PBIS creates schools where all students succeed.”
PBS techniques can be used anywhere with anyone.
Conclusion to Goals of Pivotal Response Therapy
PRT techniques focus on the four pivotal areas that every child with autism needs to work on to be successful: response to multiple cues, social interaction initiation, motivation, and self-management.
Pivotal Response Therapy has been and continues to be one of the first methods of natural treatment used to help children with autism improve their skills. PRT treatment has also been shown to improve these same abilities in adolescents and adults, thus there is a constant need for professionals in this field.
Master of Education (M.Ed.) | Northeastern State University
Behavior and Learning Disorders | Georgia State University