Pivotal Response Research Articles

Feasibility and Acceptability of Delivering Pivotal Response Treatment for Autism Spectrum Disorder via Telehealth: Pilot Pre-Post Study.

BackgroundPivotal response treatment (PRT), an evidence-based and parent-delivered intervention, is designed to improve social communication in autistic individuals.ObjectiveThe aim of this study was to assess the feasibility, acceptability, and clinical effects of an online model of PRT delivered via MindNest Health, a telehealth platform that aims to provide self-directed and engaging online modules, real-time coaching and feedback, and accessible stepped-care to large populations of parents seeking resources for their autistic children.MethodsMale and female autistic children, aged 2-7 years with single-word to phrase-level speech, and their parents were eligible to participate in the study. Families were randomized to the online parent training condition or control condition. The online component of the intervention consisted of eight 20-minute online courses of content describing parent training principles in PRT. Four 1-hour videoconferences were held after course 1, course 3, course 5, and course 8. Parents were given 1-2 weeks to complete each course. Parents completed the Client Credibility Questionnaire (CCQ) at week 2 and at the study endpoint, as well as the Behavioral Intervention Rating Scale (BIRS) at the study endpoint to assess parental expectancies, and treatment acceptability and effectiveness.ResultsNine of 14 participants completed the study curriculum in the online parent training condition, and 6 of 12 participants completed the control condition. Thus, a total of 58% (15/26) participants across both groups completed the study curriculum by study closure. Within the online parent training condition, there was a significant increase in mean CCQ total scores, from 25.38 (SD 3.25) at baseline to 27.5 (SD 3.74) at study endpoint (P=.04); mean CCQ confidence scores, from 6.0 (SD 1.07) at baseline to 6.75 (SD 0.89) at study endpoint (P=.02); and mean CCQ other improvement scores, from 5.25 (SD 0.89) at baseline to 6.25 (SD 1.28) at study endpoint (P=.009). Within the control condition, a modest increase in mean CCQ scores was noted (Confidence, difference=+0.25; Recommend, difference=+0.25; Total Score, difference=+0.50), but the differences were not statistically significant (Confidence P=.38, Recommend P=.36, Total Score P=.43). Among the 11 parents who completed the BIRS at the study endpoint, 82% (n=9) endorsed that they slightly agree or agree with over 93% of the Acceptability factor items on the BIRS.ConclusionsThe feasibility of this online treatment is endorsed by the high rate of online module completion and attendance to videoconferences within the online parent training group. Acceptability of treatment is supported by strong ratings on the CCQ and significant improvements in scores, as well as strong ratings on the BIRS. This study’s small sample size limits the conclusions that can be drawn; however, the PRT MindNest Health platform holds promise to support parents of autistic children who are unable to access traditional, in-person parent-mediated interventions for their child.

Pivotal Response Treatment (PRT) parent group training for young children with autism spectrum disorder: a pilot study

Pivotal Response Treatment (PRT) is a promising intervention addressing core symptoms of autism spectrum disorder (ASD), with parent involvement as key component. Parent group-delivered PRT may be an effective treatment model, but currently the evidence is limited. Also, little attention has been paid to therapeutic involvement of multiple important contexts (e.g. home, school, community) of the young child. The current study explores a 14-week protocol of PRT parent group training (PRT-PG), complemented with individual parent–child sessions and involvement of teachers and other childcare providers. Children aged 2–6 years old with ASD and their parents (n = 20) were included. Preliminary results showed a significant increase in spontaneous initiations during a semi-structured therapist-child interaction together with widespread gains in clinical global functioning. No significant improvement on parent-rated general social-communication skills was observed. These findings justify further research on parent group delivered PRT models.

An Intervention Study on Children's Healthy Joint Attention Skills Based on a Mixed Instructional Approach of DTT and PRT.

Joint attention is an important element that influences children's early development of communication and sociality, and joint attention is more often than not the earliest incipient of their prosocial behavior. Joint attention skills are one of the core deficits of children with autism, and identifying and remediating the core problems of autism is a popular area of interest, with joint attention being the focus of attention. The aim of this study was to investigate whether the combined orientation model of Discrete Trial Teaching (DTT) and Pivotal Response Training (PRT) could improve the joint attention skills of children with autism. This study used a cross-behavioral multitest design in a single-subject study with two preschool children with autism as subjects, with the independent variable being joint attention teaching and the dependent variable being the three joint attention skills (eye gaze, following directions, and active display). After the instructional intervention, children with autism showed a significant increase in the correctness of “eye alternation,” “following directions,” and “moving displays.”

Testing a Theory of Implementation Leadership and Climate Across Autism Evidence-Based Interventions of Varying Complexity

Prominent theories within the field of implementation science contend that organizational leaders can improve providers’ fidelity to evidence-based practices (EBPs) by using focused implementation leadership behaviors that create an organizational climate for EBP implementation. However, this work has been criticized for overreliance on nonspecific, self-report fidelity measures and poor articulation of the boundary conditions that may attenuate leadership and climate’s influence. This study tests the predictions of EBP implementation leadership and climate theory on observed fidelity to three school-based EBPs for autism that vary in complexity: pivotal response training (PRT), discrete trial training (DTT), and visual schedules (VS). Educators in kindergarten to third-grade autism support classrooms in 65 schools assessed their principals’ EBP implementation leadership and school EBP implementation climate prior to the school year. Mid-school year, trained observers rated educator fidelity to all three interventions. Expert raters confirmed PRT was significantly more complex than DTT or VS using the Intervention Complexity Assessment Tool for Systematic Reviews. Linear regression analyses at the school level indicated principals’ increased frequency of EBP implementation leadership predicted a higher school EBP implementation climate, which in turn predicted higher educator fidelity to PRT—however, there was no evidence of a relationship between implementation climate and fidelity to DTT or VS. Comparing principals whose EBP implementation leadership was ±1 SD from the mean, there was a significant indirect association of EBP implementation leadership with PRT fidelity through EBP implementation climate (d = 0.49, 95% CI [0.04, 0.93]). Strategies that target EBP implementation leadership and climate may support fidelity to complex behavioral interventions.

Neural Correlates of Enhancing Question Asking and Initiations in Children with Autism Spectrum Disorders: A Randomized Clinical Trial

Children diagnosed with autism spectrum disorder (ASD) demonstrate challenges in various areas of social communication. The aim of this study was to examine the effect of Pivotal Response Treatment (PRT) targeting question-asking on brain activity in twenty 6–12-year-old autistic boys, using a Randomized Clinical Trial (RCT) design. Verbal children, diagnosed with autism, who lacked question asking in their communication were matched based on age and mean length utterance (MLU) and were randomly placed in either PRT intervention or treatment as usual (TAU) groups. Sessions were individually administered, lasting for 60 minutes three days a week for a two-month period. All children were tested before and after intervention to assess behavioral areas (questions, general communicative skills, and MLU) and both groups underwent electroencephalography for 10 minutes in open and closed eye resting-state conditions to assess neural correlates. Data were analyzed using covariance analysis and post-hoc using Mann-Whitney and Wilcoxon methods. Significant behavioral improvements in the PRT group were observed after intervention that correlated with changes in Electroencephalography (EEG) oscillations at several brain regions compared to the TAU group. The results of this study support other studies suggesting collateral neural changes following the PRT.

Pivotal Response Treatment (PRT) - Parent Group Training for Young Children with Autism Spectrum Disorder: A Qualitative Study on Perspectives of Parents.

Pivotal Response Treatment (PRT) is considered to be an empirically supported parent-mediated treatment for children with autism spectrum disorder (ASD), but research on parental experiences is lacking. This qualitative study examined the perspectives of parents of young children with ASD who participated in a 14-week PRT with parent group training (PRT-PG). Semi-structured interviews (n = 12) were carried out, based on Grounded Theory principles. Results indicated that facilitators and barriers were related to timing and expectations, training setting and characteristics, and participant characteristics. Perceived effects were related to improved child’s social-communication skills and well-being, parental insights into their child’s needs and own habitual patterns in communication and behavior, and positive changes in family cohesion. The findings indicate that in general parents value PRT-PG as feasible and effective. Supplementary InformationThe online version contains supplementary material available at 10.1007/s10803-021-05397-8.

Comparing the Effectiveness of Positive Psychotherapy and Pivotal Response Treatment in Family Satisfaction in Mothers of Children with Autism

Comparing the Effectiveness of Positive Psychotherapy and Pivotal Response Treatment in Family Satisfaction in Mothers of Children with Autism

A Systematic Review of Intervention Intensity in Pivotal Response Training and Scripting Research

A Systematic Review of Intervention Intensity in Pivotal Response Training and Scripting Research

Clinician Delivery of Virtual Pivotal Response Treatment with Children with Autism during the COVID-19 Pandemic

This concept paper describes how the evidence-based Pivotal Response Treatment (PRT) model of autism treatment was adapted for delivery via telehealth during the COVID-19 pandemic. Multiple features of existing video conference technology were utilized for implementation of PRT motivational strategies with young children with autism spectrum disorder (ASD). PRT is an empirically supported treatment for ASD which can be taught to parents and delivered directly by trained therapists. During the COVID-19 pandemic, when the majority of clinical care for children with ASD had to be transitioned to telehealth delivery, models for parent training had been previously established. However, no model for direct clinician delivery of virtual PRT existed. This manuscript outlines practical details of the model developed by our team and provided to a total of 17 families between April 2020 and May 2021. Key lessons from technological adaptations of the PRT motivational strategies are described in order to inform future empirical investigation of this approach. The virtual PRT delivery model can serve as a guide for engaging children in meaningful social interaction and communication practice via video conference software, with implications for expanding access to autism treatment as well as for motivating a wide range of children in distance learning activities.

Provider REport of Sustainment Scale (PRESS): development and validation of a brief measure of inner context sustainment

BackgroundImplementation scientists and practitioners often rely on frontline providers for reporting on implementation outcomes. Furthermore, measures of sustainment are few, and available sustainment measures are mainly setting or evidenced-based practice (EBP) specific, require organizational and system-level knowledge to complete, and often lack psychometric rigor. The aim of this study was to develop a brief, pragmatic, and generalizable measure for completion by frontline service providers of the implementation outcome, sustainment.MethodsWe utilized a Rasch measurement theory approach to scale the development and testing of psychometric parameters. Sustainment items were developed to be relevant for direct service providers to complete. In order to promote generalizability, data were collected and items were tested across four diverse psychosocial evidence-based practices (motivational interviewing [MI], SafeCare®, classroom pivotal response training [CPRT], and an individualized mental health intervention for children with autism spectrum disorder [AIM-HI]) and in four service settings (substance use disorder treatment, child welfare, education, and specialty mental health). Associations between the sustainment measure and sustainment leadership, sustainment climate, and attitudes towards the adoption and use of each of the EBPs were assessed to confirm construct validity.ResultsThree items for the Provider REport of Sustainment Scale (PRESS) were assessed for measuring the core component of sustainment: continued use of the EBP. Internal consistency reliability was high. The scale indicated fit to the Rasch measurement model with no response dependency, ordered thresholds, no differential item functioning, and supported unidimensionality. Additionally, construct validity evidence was provided based on the correlations with related variables.ConclusionThe PRESS measure is a brief, three-item measure of sustainment that is both pragmatic and useable across different EBPs, provider types, and settings. The PRESS captures frontline staffs’ report of their clinic, team, or agency’s continued use of an EBP. Future testing of the PRESS for concurrent and predictive validity is recommended.

The Effect of Teaching Initiations on the Communication of Children with Autism Spectrum Disorder: A Randomized Clinical Trial

This study examined the effect of Pivotal response treatment (PRT) to improve verbal initiations in children with Autism Spectrum Disorder, age 6-12years old, using a Randomized Clinical Trial design. Intervention was conducted three times a week for 2 months, for a total of 24 one-hour sessions. The PRT intervention taught a variety of questions and attention/assistance-seeking initiations. The treatment as usual (TAU) group received standard language intervention. Results showed that the PRT group made significant improvements in their number of verbal initiations as well as collateral gains in general communicative skills and mean length of utterance (MLU) compared to the TAU group. Theoretical implications of including motivational approaches to develop social initiations are reviewed.

Pivotal Response Treatment with and without robot-assistance for children with autism: a randomized controlled trial

Pivotal response treatment (PRT) is a promising intervention focused on improving social communication skills in children with autism spectrum disorder (ASD). Since robots potentially appeal to children with ASD and may contribute to their motivation for social interaction, this exploratory randomized controlled trial (RCT) was conducted comparing PRT (PRT and robot-assisted PRT) with treatment-as-usual (TAU). Seventy-three children (PRT: n = 25; PRT + robot: n = 25; TAU: n = 23) with ASD, aged 3–8 years were assessed at baseline, after 10 and 20 weeks of intervention, and at 3-month follow-up. There were no significant group differences on parent- and teacher-rated general social-communicative skills and blindly rated global functioning directly after treatment. However, at follow-up largest gains were observed in robot-assisted PRT compared to other groups. These results suggest that robot-assistance may contribute to intervention efficacy for children with ASD when using game scenarios for robot-child interaction during multiple sessions combined with motivational components of PRT. This trial is registered at https://www.trialregister.nl/trial/4487; NL4487/NTR4712 (2014-08-01).

A Systematic Review of Family-Mediated Social Communication Interventions for Young Children with Autism.

Social communication deficits are a core symptom of autism spectrum disorder (ASD). The present paper reviews 54 studies evaluating social communication interventions delivered by parents and siblings to children with ASD under 6 years old. Fifty studies evaluated parent-mediated intervention, and four studies evaluated sibling-mediated intervention. Fourteen studies evaluated interventions using telehealth. Treatment effects and research strength were variable across studies. Treatment modality, setting, and dosage had inconclusive impact on treatment effect. Parent-implemented intervention packages, Pivotal Response Treatment (PRT), Early Start Denver Model (ESDM), and Joint Attention, Symbolic Play, Engagement & Regulation (JASPER), qualified as established evidence-based practice for this population. Most studies reported successful generalization of skills for some, but not all, children. Telehealth and sibling-mediated intervention are promising areas of further research and clinical practice.

Pivotal response treatment for autism: A brief report on training for rural communities

Many providers from rural communities feel ill-prepared to treat children with autism spectrum disorder (ASD). Cost-effective training in Pivotal Response Treatment (PRT), an evidence-based ASD treatment, can address unmet needs for rural communities. The current study examined a 1-day general PRT workshop for parents and professionals followed by a 3-day small, intensive training for professionals. Fifty-two parents and providers completed surveys before and after Day 1, indicating improvements in perceived stress and confidence. Three providers were trained during Days 2-4, and submitted four 10-min videos (i.e., baseline, 1-week, 1-month, and 2-months post-training) working with a target child discussed in the training and another child. Videos were coded for correct PRT implementation and analyzed using a single-subject A-B design with generalization and maintenance probes. All providers learned to apply PRT techniques with the target child and generalized skills to another child within 1-week post-training, with partial maintenance. Implications for rural mental health training in evidence-based practices are discussed.

Comparison of the Effectiveness of Pivotal Response Treatment and Applied Behavioral Analysis on the Symptoms Severity and Executive Functions in Autistic Children

Comparison of the Effectiveness of Pivotal Response Treatment and Applied Behavioral Analysis on the Symptoms Severity and Executive Functions in Autistic Children

Pivotal Response Treatment for School-Aged Children and Adolescents with Autism Spectrum Disorder: A Randomized Controlled Trial

Pivotal Response Treatment (PRT) is promising for children with Autism Spectrum Disorder (ASD), but more methodologically robust designed studies are needed. In this randomized controlled trial, forty-four children with ASD, aged 9-15years, were randomly allocated to PRT (n = 22) or treatment-as-usual (TAU; n = 22). Measurements were obtained after 12- and 20-weeks treatment, and 2-month follow-up. PRT resulted in significant greater improvements on parent-rated social-communicative skills after 12weeks treatment (p = .004, partial η2 = 0.22), compared to TAU. Furthermore, larger gains in PRT compared to TAU were observed on blindly rated global functioning, and parent-rated adaptive socialization skills and attention problems. Implications for clinical practice and suggestions for future research are discussed.

The Efficacy of Pivotal Response Treatment in Teaching Question-Asking Initiations to Young Turkish Children with Autism Spectrum Disorder.

In the present study, a concurrent multiple baseline design across participants was used to evaluate the efficacy of pivotal response treatment (PRT) on the acquisition, maintenance, and generalization of the question-asking initiations by four children with autism spectrum disorder (ASD). The researchers also examined whether the implementation of PRT resulted in collateral changes in language development and other areas of development. The results of this study indicate that PRT is highly effective in teaching question-asking initiations. Participating children with ASD were able to generalize in natural settings and maintain long-term question-asking initiations. Furthermore, PRT resulted in positive collateral changes in language and other areas of development. Implications for future research and practice are then discussed.

The Effects of Individualized Peer Play Using Motivation Strategies of Pivotal Response Treatment on Peer Interaction of Children with Autism Spectrum Disorder in Elementary School

본 연구는 중심축 반응 중재의 동기 향상 전략을 적용한 개별화된 또래 놀이 활동이 자폐 범주성 장애 초등학생의 또래 상호작용에 미치는 영향을 알아보고자 하였다. 연구 설계는 대상자 간 중다 간헐 기초선 설계를 적용하였으며, 자폐 범주성 장애 초등학생 3명과 또래 아동 12명이 참여하여 기초선-중재-상황 일반화-대상 일반화-유지의 다섯 단계에 걸쳐 실행되었다. 중재는 중심축 영역 중 동기 향상을 위한 전략에 대한 또래 교육과 피드백으로 이루어졌으며, 또래 아동이 놀이 과정에서 자폐 범주성 장애 아동에게 전략을 실행하도록 하였다. 중재에 사용된 놀이 자료는 자폐 범주성 장애 아동의 특성과 선호도, 또래 아동의 연령과 선호도를 고려하여 개별화되었다. 중재가 실시된 후, 3명의 참여 아동 모두에게서 또래 상호작용 발생률이 증가하였고, 이러한 결과는 다른 상황과 대상으로 일반화되었으며, 중재가 종료된 후에도 유지되었다. 본 연구는 자폐 범주성 장애 아동의 또래 상호작용 증진을 위해 또래를 활용하여 상호작용 동기를 향상시키는 중재 방법을 제시하였다는 점에서 의의가 있다.

Language Improvement Following Pivotal Response Treatment for Children With Developmental Disorders.

Given the high prevalence of communication deficits in developmental disorders, there is need for efficient early interventions. The aim of this pilot study is to examine benefits of pivotal response treatment (PRT) for improving language in young children with developmental disorders without autism spectrum disorder. Parents of 15 children with developmental disorders received weekly PRT parent training for 12 weeks. Standardized parent-rated assessments were administered at baseline and post-treatment to measure changes in language. Structured laboratory observation indicated children demonstrated significantly greater frequency of utterances and improvement on standardized questionnaires measuring expressive language and adaptive communication skills following PRT. Findings suggest that PRT may be efficacious in improving language abilities among children with developmental disorders.

Embedding school cultures and climates that promote evidence-based practice implementation for youth with autism: A qualitative study.

Schools play a major role in providing services to youth with autism; however, not all schools use evidence-based practices, defined as interventions that are proven to improve youth well-being through rigorous research. School culture and climate are strong predictors of whether or not a school uses evidence-based practices; however, little is known about how principals can create school cultures and climates that support the use of these practices. This study interviewed 32 teachers in elementary schools that implemented three closely related evidence-based practices for youth with autism to better understand how principals create school cultures and climates that support effective services. Analysis of the teachers' responses identified seven strategies principals can use to create school cultures and climates that support the implementation of effective practices for youth with autism. The strategies include the following: (a) support teachers to obtain professional development focused on autism, (b) align performance expectations and evaluations with the needs of students with autism and evidence-based practice delivery, (c) allocate resources to ensure adequate staff, materials, and training are available to implement evidence-based practices, (d) be open and flexible to allow teachers to use the building and resources as needed to meet students' needs, (e) provide direct assistance, feedback, and coaching to troubleshoot challenges or involve outside experts to do so, (f) openly value the work of special education teachers and provide recognition to those who develop expertise in evidence-based practices, and (g) look for opportunities to integrate special and general education teachers and students to foster a truly inclusive climate.