Pivotal Response Treatment Part 1

Dr. Bob Koegel Author

03/01/2018 Added

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This webinar provides an overview of the history and development of Pivotal Response Treatment.

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[00:00:00.940]Hello, and welcome to the Tri‐State ASD
[00:00:05.320]Webinar Series.
[00:00:07.100]This series is sponsored by
[00:00:10.160]the Colorado Department of Education,
[00:00:14.330]the Nebraska Autism Spectrum Disorders Network,
[00:00:18.760]and the Kansas Autism and Tertiary
[00:00:22.080]Behavior Supports Network.
[00:00:24.410]We're glad you could join us.
[00:00:30.240]Polling questions will be embedded throughout the webinar.
[00:00:34.880]Please listen to the question and respond to the poll.
[00:00:43.670]This webinar along with all of the Tri‐State webinars
[00:00:47.690]will be archived and available for future viewing
[00:00:51.550]on each of the Tri‐State websites.
[00:00:58.520]My name is Robert Koegel,
[00:01:00.030]from Stanford University School of Medicine,
[00:01:02.750]and today I'm going to talk about Pivotal Response Treatment
[00:01:06.330]and some of the variables that influence its effectiveness
[00:01:09.900]when trying to help children with autism.
[00:01:23.620]It's important to realize that
[00:01:27.080]Pivotal Response Treatment is a very new treatment,
[00:01:30.530]and even
[00:01:31.870]the behavioral procedures in general
[00:01:35.780]from the field of applied behavior analysis
[00:01:38.430]are relatively new in the scheme of things.
[00:01:41.400]Prior to the 1960s,
[00:01:44.200]really the only treatment that was available
[00:01:47.120]for children with autism was psychoanalytic treatment.
[00:01:50.490]This had some serious problems because the theory,
[00:01:55.320]and the entire approach was based on theory,
[00:01:58.620]it was not based on data,
[00:02:00.720]the theory blamed the parents,
[00:02:02.630]primarily the mothers, for causing the disorder.
[00:02:05.730]They said the mothers were cold, refrigerator mothers,
[00:02:09.260]that they were mentally ill, and that there interactions
[00:02:12.640]with their children were so severely hampered that
[00:02:17.430]they caused the children to withdraw into a shell
[00:02:21.680]and develop autism.
[00:02:26.040]However, in the 1960s, a new field began to develop,
[00:02:31.090]was called applied behavior analysis,
[00:02:33.870]went by the
[00:02:35.780]initials ABA,
[00:02:38.290]and
[00:02:39.700]also often was going by initials DTT
[00:02:43.460]for discrete trial treatment.
[00:02:46.034]Many variables were identified
[00:02:49.410]that individually produced a huge improvement
[00:02:53.270]in the children's' motivation
[00:02:55.240]to try to engage in social interaction
[00:02:58.080]and to try to talk, et cetera.
[00:03:00.550]This resulted in dramatic improvements
[00:03:03.920]in both the gains the children made,
[00:03:06.330]also the efficiency of the treatment
[00:03:08.320]and the generalization of the treatment results.
[00:03:12.970]Some of the basic assumptions of Pivotal Response Treatment
[00:03:17.350]were that treatment would be most effective
[00:03:20.190]in the natural environment.
[00:03:22.030]I've listed a few of the original references here,
[00:03:27.000]you know, bolstering that point.
[00:03:30.040]There are hundreds, if not thousands,
[00:03:31.960]of references since then,
[00:03:34.100]but these were some of the early references.
[00:03:37.600]So treatment was considered to be most effective
[00:03:41.690]if it was implemented in the natural environment,
[00:03:44.750]not in a mental hospital with the children locked in a ward
[00:03:49.421]or tied to their beds.
[00:03:52.190]This was not considered a good type of treatment.
[00:03:55.050]Instead, the ideal treatment would be
[00:03:57.170]to get the child into a natural environment,
[00:03:59.360]living in their home, going to schools.
[00:04:03.120]This is not a simple matter to accomplish back in those days
[00:04:07.850]and required a lot of research.
[00:04:10.280]A second big variable was family involvement.
[00:04:13.700]Instead of viewing the families
[00:04:15.530]as the cause of the disorder,
[00:04:17.900]they were actually viewed as the solution,
[00:04:21.540]that if you could get the parents involved
[00:04:25.150]and especially through something like parent training,
[00:04:28.180]then you could get the best gains for the children.
[00:04:33.220]Also, the third point here is that
[00:04:35.670]instead of treating individual target behaviors one by one,
[00:04:40.210]like teaching the child to tie their shoes,
[00:04:43.000]teaching them to print the letter A,
[00:04:45.360]teaching them to make the sound em, et cetera,
[00:04:48.570]instead of having to teach each one
[00:04:50.730]of these thousands and thousands of behaviors one at a time,
[00:04:54.490]you would focus on pivotal areas
[00:04:57.030]that would produce improvements
[00:04:59.390]in tens of thousands of behaviors simultaneously,
[00:05:03.450]not only lots of behaviors,
[00:05:05.350]but also behaviors that were fluidly integrated.
[00:05:10.500]Some of the pivotal areas that were identified,
[00:05:13.800]I mean, this is not a simple matter to identify them,
[00:05:16.940]and, you know, in the beginning,
[00:05:18.560]people searched and searched and didn't have much success,
[00:05:21.660]but eventually some real important
[00:05:24.070]pivotal areas were identified.
[00:05:26.000]And these were things like motivation,
[00:05:30.890]particularly motivation to try to talk
[00:05:33.240]and to engage in social interaction,
[00:05:36.160]multiple cues or joint attention
[00:05:39.470]where the children would have to take in
[00:05:41.700]a lot of sensory input simultaneously,
[00:05:46.060]initiations where the children would learn
[00:05:48.470]to initiate social interactions.
[00:05:51.380]That turns out to be much more effective
[00:05:54.300]than if the adults are initiating the interactions.
[00:05:58.420]Self-management was another one that's primarily effective
[00:06:01.810]as the children get older,
[00:06:03.580]where they take a major role in managing
[00:06:06.000]and regulating their own behavior.
[00:06:08.290]This is particularly important
[00:06:10.360]as the children move into adolescence and then adulthood,
[00:06:13.750]where they need to take considerable responsibility
[00:06:17.130]for their own behavior.
[00:06:18.860]Empathy is a more recent one, so it has much less data,
[00:06:23.210]but teach the children to actually be able to empathize
[00:06:28.310]with other people, put theirselves in other people's shoes.
[00:06:32.560]This looks like it's going to be
[00:06:33.870]an important pivotal area as well,
[00:06:36.070]but I put in progress because it's a new area.
[00:06:40.520]I put this slide up here because, in 2005,
[00:06:43.900]Richard Simpson from the University of Kansas
[00:06:48.000]published an article and also a book
[00:06:51.880]talking about the importance of empirical evidence
[00:06:56.140]to validate treatments.
[00:06:57.690]There were hundreds of treatments available
[00:07:00.150]for kids with autism, even back then.
[00:07:02.260]Now there's thousands.
[00:07:04.510]And how is somebody supposed to know what's
[00:07:07.050]a good treatment, what works, and what doesn't work?
[00:07:10.290]And Simpson said it's really important to know
[00:07:14.090]if there's data to show that the techniques actually work.
[00:07:18.370]Back in 2005,
[00:07:19.610]he really was only able to identify four treatments
[00:07:22.850]that had any solid empirical support.
[00:07:25.800]They were primarily coming from the field
[00:07:28.100]of applied behavior analysis and discrete trial teaching.
[00:07:31.860]Pivotal Response Training was one,
[00:07:34.060]and the LEAP approach, Learning Experiences:
[00:07:37.190]An Alternative Program for Preschoolers and Parents.
[00:07:40.290]Those were the only ones that,
[00:07:41.910]at that time, had solid support.
[00:07:44.420]There's a few more now.
[00:07:45.570]I think we might be up to maybe 11 or so treatments now
[00:07:48.650]that have some support.
[00:07:50.540]But out of the thousands of treatments that are out there,
[00:07:53.680]the large majority
[00:07:56.040]don't have any empirical support at all.
[00:07:59.500]And some have just a very small amount of empirical support,
[00:08:03.950]but most don't have any support at all.
[00:08:06.830]So now I want to talk about some of
[00:08:08.990]the core motivational variables of PRT.
[00:08:12.665]What were these variables that were
[00:08:16.040]documented to have empirical support?
[00:08:20.320]The first one is child choice
[00:08:21.820]of stimulus materials used during teaching.
[00:08:24.580]So a simple thing like,
[00:08:26.680]which we would all be able to guess,
[00:08:28.810]is using something like a red M&M to teach colors
[00:08:32.710]instead of, say, red construction paper,
[00:08:35.520]that is, assuming the children like M&M's
[00:08:38.030]and are choosing M&M's.
[00:08:39.540]If they actually like construction paper
[00:08:42.310]and are choosing construction paper to play with,
[00:08:44.660]then we'd want to teach them the colors
[00:08:46.530]with the construction paper.
[00:08:47.930]Main thing is that we're giving the child a choice
[00:08:50.930]in the stimulus materials.
[00:08:54.310]And secondly, we want to use natural reinforcers.
[00:08:57.610]Some of these things are so obvious now,
[00:08:59.510]but they weren't really obvious in the beginning.
[00:09:02.490]For example, you might teach a child to say
[00:09:06.200]something like red.
[00:09:07.790]You know, you'd be holding up a red card
[00:09:09.980]and teach the child to say red
[00:09:11.830]and then give them a potato chip for a reward.
[00:09:16.240]That's not really a direct reinforcer.
[00:09:20.230]A better way to teach that would be to hold up a red M&M,
[00:09:24.580]and when the child says red, you give the child a red M&M,
[00:09:28.620]making the reinforcer directly related
[00:09:31.840]to the child's response.
[00:09:34.790]Similarly, if you wanted to teach fine motor coordination,
[00:09:37.990]you might, say, use a slightly chilly room
[00:09:41.590]and teach the child to put on a sweater
[00:09:43.730]and button the buttons on the sweater or
[00:09:46.970]use a warm room and teach the child
[00:09:49.920]to unbutton the buttons on the sweater, something like that,
[00:09:52.760]again, where you're using the temperature,
[00:09:55.000]the child's comfort with the temperature
[00:09:57.720]as the natural reinforcer.
[00:10:01.050]Interspersal of maintenance and acquisition trials also
[00:10:04.970]really influences motivation.
[00:10:06.790]So instead of drilling, drilling, drilling
[00:10:09.120]on the same acquisition task over and over again,
[00:10:12.360]you intersperse a lot of maintenance trials
[00:10:15.090]on things the child already knows how to do,
[00:10:17.790]keeping their motivation high
[00:10:19.970]so they're willing to try the more difficult new tasks.
[00:10:23.200]Dunlap, in 1984, was actually using a ratio
[00:10:26.280]of about seven maintenance trials to one acquisition trial.
[00:10:30.900]At first, people said,
[00:10:31.743]"How are you going to ever teach anything that way?"
[00:10:33.720]You know, it's almost all trials
[00:10:35.930]on things the child knows how to do.
[00:10:37.860]But since the child's motivation was so high
[00:10:40.130]under those conditions, the children learned rapidly,
[00:10:43.950]and it turned out to be a very effective strategy.
[00:10:50.400]Task variation is kind of related to that.
[00:10:52.830]You keep varying the task over,
[00:10:56.230]so instead of always working on something like size,
[00:11:00.090]you might shift it to work on shape,
[00:11:03.610]or you might, for example, if you were going to the zoo,
[00:11:07.390]you might teach the child about the size of the animals,
[00:11:10.730]the big elephant and the little bunny
[00:11:13.070]or something like that.
[00:11:14.340]And then,
[00:11:16.210]when you're coming home and driving in the car
[00:11:20.500]and a big truck drives by,
[00:11:22.420]you could teach them about a big truck, you know,
[00:11:25.750]versus maybe a little Volkswagen goes by
[00:11:28.360]or something like that.
[00:11:29.370]You could teach big and little that way.
[00:11:31.230]So there's a lot of task variation going on,
[00:11:34.720]even teaching the same concept,
[00:11:37.280]but you can also go to other concepts as well,
[00:11:40.010]doesn't have to always be size, can change it.
[00:11:44.050]And this is an interesting one, reinforcing attempts.
[00:11:49.740]In the beginning, we thought we had
[00:11:51.530]to use a very strict motor shaping paradigm
[00:11:55.920]that
[00:11:58.060]would require, if we were going to, say,
[00:11:59.990]teach a non-verbal child to talk,
[00:12:02.180]that we would first teach the child
[00:12:04.240]to make a lot of vocalizations.
[00:12:07.220]And then we would shape those vocalizations
[00:12:10.440]into speech sounds.
[00:12:12.630]And then we would shape
[00:12:15.529]the speech sounds to be closer approximations to words.
[00:12:20.130]And then we chain the sounds together
[00:12:24.210]so that we could actually teach the child to say whole words
[00:12:27.720]and then multiple words and sentences and so forth.
[00:12:32.450]What we found is that took forever to do that.
[00:12:35.660]It could sometimes take 90,000 trials
[00:12:37.700]to teach a single word to a non-verbal child.
[00:12:41.120]But we didn't have to do that.
[00:12:43.470]We could actually reinforce the child for trying to talk.
[00:12:47.920]And when the kids
[00:12:50.160]tried to talk,
[00:12:51.900]they started coming out with whole words rapidly.
[00:12:56.120]It was mind-boggling to see just how effective this was.
[00:13:00.620]So the child might
[00:13:02.440]make just some sounds attempting to say a word,
[00:13:06.380]and we would say, "Nice try, nice try, good job!"
[00:13:10.490]at which point we might ask the child to say the word again,
[00:13:13.840]and the child might even say the entire word,
[00:13:16.750]which just about made us faint.
[00:13:20.430]It looked like there was a lot inside the kids
[00:13:23.020]that just needed to be brought out.
[00:13:24.980]And if we reinforced them for trying,
[00:13:27.630]they came out with much bigger responses
[00:13:30.510]than we had anticipated that they were capable of.
[00:13:34.100]Everybody that works with kids with autism
[00:13:36.700]has a feeling that there's a lot in there,
[00:13:39.460]a lot more in there than is being immediately evident.
[00:13:44.650]Reinforcing attempts brings that out.
[00:13:47.690]If you do all of these things at once,
[00:13:50.510]then you get this extremely strong motivational package.
[00:13:57.540]Each variable by itself is very powerful.
[00:14:01.860]Putting them all together
[00:14:03.820]in what we call the Natural Language Paradigm,
[00:14:08.000]and eventually that became
[00:14:09.820]called Pivotal Response Treatment,
[00:14:13.700]that resulted in very, very
[00:14:17.290]rapid treatment gains and naturalized treatment gains.
[00:14:21.770]So this whole approach,
[00:14:24.800]called the Natural Language Paradigm
[00:14:26.760]if it was focused on speech and language alone
[00:14:30.470]and called Pivotal Response Treatment
[00:14:32.580]if it was focused on the entire condition of autism,
[00:14:36.740]those approaches became very solidly documented
[00:14:40.730]in the scientific literature and are now very widely used
[00:14:45.940]and on the increase.
[00:14:48.090]They're still relatively new procedures.
[00:14:50.420]So there's a lot of people
[00:14:52.475]that are just first learning about them,
[00:14:54.760]and the techniques are really on the increase in their use.
[00:15:02.090]This is a very important slide
[00:15:04.540]because it illustrates the type of results you get
[00:15:08.200]when you do the Pivotal Response Treatment.
[00:15:11.480]And it compares it to
[00:15:14.510]an ABA approach that, while very effective,
[00:15:19.050]does not include the motivational variables
[00:15:21.660]that we've been talking about,
[00:15:23.260]choice, interspersal, reinforcing attempts, et cetera.
[00:15:28.460]So if you look at this slide,
[00:15:30.260]what you can see is, in the first part for child one there,
[00:15:34.820]on the top part of the slide,
[00:15:37.610]the beginning part of the slide shows
[00:15:41.330]what, in the slide, is labeled Analogue Teaching Paradigm,
[00:15:45.370]but was really a structured ABA approach
[00:15:49.130]without the motivational variables of PRT included in it.
[00:15:53.750]So if we're looking at ABA without
[00:15:56.750]the motivational PRT components,
[00:15:59.640]what we see in this slide is the generalization data
[00:16:04.540]to other environments outside of the clinic setting.
[00:16:08.780]So in other words, the child was learning
[00:16:12.780]to use speech in the clinic room,
[00:16:15.640]but when we go to an outside natural environment,
[00:16:20.400]we see that, in the first part of the slide there,
[00:16:23.770]all of the data points are at zero.
[00:16:26.810]There's three data points there,
[00:16:28.200]for child one in the first part of the slide,
[00:16:30.380]that all show zero responding,
[00:16:33.900]which means even though the child had been learning
[00:16:37.040]how to talk in the clinic sessions
[00:16:38.870]with the structured ABA approach,
[00:16:41.770]that's labeled Analogue Teaching Paradigm,
[00:16:44.190]but it's structured ABA,
[00:16:46.770]the child did not use that speech
[00:16:49.870]outside of the clinic setting.
[00:16:51.750]It was 0% outside the clinic setting.
[00:16:54.870]Now, in contrast, after the dotted line there,
[00:16:58.240]where it says Natural Language Teaching Paradigm,
[00:17:00.780]which is PRT,
[00:17:03.290]remember, in the beginning,
[00:17:04.670]it was called Natural Language Teaching Paradigm
[00:17:07.280]and ultimately was labeled PRT,
[00:17:10.290]or Pivotal Response Treatment,
[00:17:11.840]because of its broad application beyond language.
[00:17:15.860]But this beginning part here,
[00:17:18.510]when it says Natural Language Teaching Paradigm,
[00:17:21.000]we're only looking at the language.
[00:17:23.520]And what you can see happened,
[00:17:25.290]once we started using the PRT approach,
[00:17:28.740]the child started to use the speech
[00:17:31.760]outside of the clinic setting.
[00:17:33.870]So the first few sessions there were still at zero,
[00:17:37.590]but then the child rapidly began to use it
[00:17:40.390]and was using quite a bit of speech as the time progressed.
[00:17:46.370]If you look at child two, you can see that it wasn't
[00:17:49.550]just the passage of time that did it.
[00:17:51.790]It was the PRT that was responsible
[00:17:54.640]for the child's generalized use of speech.
[00:17:57.490]So if we look at child two here,
[00:17:59.840]we can see that way on up until 19 months,
[00:18:04.710]that's 19 months of structured ABA
[00:18:07.740]where the child was learning to use speech
[00:18:09.880]in the clinic sessions,
[00:18:11.510]but nevertheless, even after 19 months,
[00:18:14.700]was still not using speech
[00:18:16.710]in the generalization environments,
[00:18:18.640]was not using speech outside of the clinic room.
[00:18:22.460]Then again, after the dotted line, that's when we started
[00:18:26.080]using the Natural Language Paradigm or PRT,
[00:18:29.470]the child soon began to generalize the speech use
[00:18:33.810]and began to use the speech outside of the clinic setting.
[00:18:37.840]So you can see there,
[00:18:39.650]once the Natural Language Teaching Paradigm
[00:18:41.810]or Pivotal Response Treatment was used, then the
[00:18:47.350]generalization did occur.

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Pivotal Response Treatment Part 1

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