Pivotal Response Treatment Part 2

Dr. Lynn Koegel Author

03/01/2018 Added

276 Plays

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This webinar will provide an overview of using Pivotal Response Treatment to teach academic skills to individuals on the autism spectrum.

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[00:00:00.870]Hello and welcome to the Tri-State
[00:00:04.110]ASD webinar series, this series is sponsored by the
[00:00:10.310]Colorado Department of Education, the Nebraska
[00:00:15.330]Autism Spectrum Disorder Network and the Kansas
[00:00:19.159]Autism and Tertiary Behavior Supports Network.
[00:00:24.440]We're glad you can join us.
[00:00:30.270]Polling questions will be embedded throughout the webinar.
[00:00:34.910]Please listen to the question and respond to the poll.
[00:00:43.710]This webinar along with all of the tri-state webinars
[00:00:47.207]will be archived and available for future viewing on
[00:00:51.890]each of the tri-state's websites.
[00:00:58.915]Hey thank you for joining me today this
[00:01:01.620]is Lynn Koegel and I'm from Stanford University school
[00:01:05.950]of Medicine, the Department of Psychiatry and Behavioral
[00:01:08.720]Sciences and I'm doing this follow up PRT webinar after
[00:01:13.929]Bob's and Bob Koegel went over the first one with sort
[00:01:18.400]of a motivational procedures and how we incorporate that
[00:01:20.916]into different situations and this is a follow-up.
[00:01:24.169]Showing that applicability of PRT
[00:01:27.590]to other types of behaviors.
[00:01:29.720]I'm gonna start with just talking about how to use the
[00:01:33.090]motivational procedures of PRT to improve
[00:01:36.560]academics in children with autism.
[00:01:40.730]So we see now the we're getting a lot more children with
[00:01:43.720]autism spectrum disorder in the general education
[00:01:47.115]classrooms and a lot of times they're exposed to that
[00:01:50.540]grade level academics and sometimes that's a little
[00:01:52.809]challenging for them so we see a lot of times
[00:01:55.850]behavior problems during academics.
[00:01:57.690]And this doesn't always happen just during class time
[00:02:00.690]or full inclusion it can happen in almost every setting.
[00:02:03.140]If the activity is difficult or challenging the child
[00:02:07.610]might engage in disruptive behavior to escape or avoid
[00:02:10.820]the task and usually in school settings there's a wide
[00:02:14.347]range of negative consequences.
[00:02:17.020]We see the kids being sent to the office or being sent
[00:02:19.370]out of the classroom or kind of just missing out on
[00:02:21.866]that curriculum and for them that could kind of be a
[00:02:24.299]motivator sometimes because if they get disruptive and don't
[00:02:28.310]have to complete the assignment they've just been
[00:02:30.140]rewarded for their disruptive behavior .
[00:02:33.189]And a lot of the kids with autism their behaviors are
[00:02:38.640]resistant to the traditional behavior management techniques.
[00:02:41.540]So while maybe calling parents or sending the child home
[00:02:43.883]or sending them to the office might be functional and
[00:02:46.201]and work for typical children.
[00:02:49.033]Children with autism who aren't quite as socially concerned
[00:02:52.760]or aware, might not be so bothered by that and again
[00:02:57.680]because they're trying to escape or avoid
[00:02:59.560]the activity sometimes it's even a reward.
[00:03:03.704]So what we wanted to do is see how we could increase the
[00:03:06.346]motivation and responsivity and provide more opportunities
[00:03:09.360]through success using these motivational components.
[00:03:12.830]So we've that sometimes we can modify the curriculum
[00:03:15.462]and that's really helpful for kids with autism.
[00:03:18.071]So in this particular study the purpose of it was to
[00:03:23.470]investigate whether the use of motivational PRT procedures
[00:03:26.218]could improve basic academic skills and in this particular
[00:03:31.120]study we worked with writing and math.
[00:03:33.200]But it could almost be done with everything, we've worked
[00:03:35.990]with reading and just about any academic task can have
[00:03:38.840]motivational components involved.
[00:03:41.625]So the specific question was will the use of motivational
[00:03:45.860]procedures during writing and math result in faster
[00:03:48.727]completion because you know some of these it's so hard
[00:03:50.885]to get them over to the table and so hard to get them
[00:03:54.314]to start these activities and you think oh my gosh we
[00:03:57.400]could've had the whole assignment done by now.
[00:03:59.660]They're just doing all this avoidance behavior
[00:04:02.140]and not getting over to the table and it just seems
[00:04:04.690]like it takes forever and of course we also want
[00:04:07.077]to reduce their disruptive behaviors
[00:04:09.510]that interferes with learning completely.
[00:04:11.940]And also we wanted to see if we can increase their interest
[00:04:15.031]of course we all know if we're interested in something
[00:04:17.255]we're more likely to spend time engaging in that activity
[00:04:20.884]outside of the particular class assignment and it just
[00:04:23.687]sort of, we want them to get a love for learning instead
[00:04:27.095]of trying to avoid all the learning activities.
[00:04:30.350]And then in this study we also wanted to see
[00:04:32.490]if the gains would maintain and generalize.
[00:04:36.670]So let's talk a little bit specifically about what we
[00:04:40.220]did to kind of tweak the traditional teacher driven
[00:04:43.993]assignment to make the PRT components to incorporate those.
[00:04:48.244]So for example with the materials and the setting what we
[00:04:53.260]did is in the baseline they were all chosen by the adult.
[00:04:56.870]The children didn't have any choice in what was provided
[00:04:59.990]with them and with the PRT intervention they were chosen
[00:05:03.810]by the child, so they had a say in what their interest was.
[00:05:08.460]We incorporated their interest into the same activity.
[00:05:12.130]In the baseline for the non motivational assignment it was
[00:05:19.010]a fixed difficulty level and in the PRT intervention we
[00:05:23.100]interspersed easy and more difficult tasks and then the
[00:05:26.540]reinforcer was unrelated to the task in the baseline
[00:05:30.560]and during the PRT intervention it was embedded
[00:05:33.640]it was embedded within the task.
[00:05:36.122]So lemme give you a few examples, so for writing
[00:05:39.150]in the regular baseline the teacher might have assigned
[00:05:43.340]the students to write about their weekend or write
[00:05:45.680]about their Christmas or their holiday vacation
[00:05:47.795]or something that was not really necessarily
[00:05:52.540]motivating to the children but in the PRT condition
[00:05:55.850]we let them write about they want.
[00:05:57.960]So for example maybe they liked the Lego's and the can write
[00:06:03.960]about Lego's or maybe they liked little animals, they could
[00:06:07.780]write about the little animals or maybe they
[00:06:09.500]liked a particular game, they could
[00:06:11.160]write about that particular game.
[00:06:14.329]And we also made it easy and difficult so we might
[00:06:16.282]have interspersed some longer sentences in with the
[00:06:19.380]shorter sentence and then when they were done with the
[00:06:22.380]writing they would be able to engage in that activity
[00:06:25.615]during that PRT intervention and that was in contrast
[00:06:28.711]to the baseline where they might have gotten to some
[00:06:34.260]extrinsic reward for like if you complete your writing
[00:06:37.330]assignment you could have some points or go to the computer.
[00:06:41.040]So we just tweaked that a little, so in other words
[00:06:44.110]it was embedded within the task if they like being on
[00:06:47.150]the computer in the PRT intervention they could write about
[00:06:50.840]the computer but in the baseline it was just
[00:06:53.180]a randomly teacher assigned activity.
[00:06:56.310]Same thing with math for example if they usually it was just
[00:07:01.190]worksheets the teacher gave to complete with the math
[00:07:05.406]assignments but let's say they were working on fractions
[00:07:07.520]and the PRT condition we might have them adding fractions
[00:07:12.463]to make a recipe which they would get to eat
[00:07:15.246]whatever they made at the end.
[00:07:17.590]Or if they were adding maybe they could add their favorite
[00:07:21.620]items and then they would get to play with them.
[00:07:23.840]So basically you could see how we just tweaked
[00:07:26.560]it a little bit to have the motivational components
[00:07:29.196]incorporated and it was exactly the same activity,
[00:07:32.587]we didn't give them a different end goal, a different
[00:07:36.260]target behavior it was exactly the same target behavior
[00:07:39.640]but in one condition we have the motivational components
[00:07:43.157]incorporated and the other condition we didn't.
[00:07:48.000]And what we found was that when we incorporated the
[00:07:51.170]motivational components the students all completed their
[00:07:54.374]assignments faster, they all had lower levels of
[00:07:58.681]disruptive behavior and we had some affect scales
[00:08:02.115]we're we rated them how interested they seem in the
[00:08:05.457]assignment and they were always rated as having higher
[00:08:09.720]affect when the motivational components were involved
[00:08:12.910]compared to when they weren't involved.
[00:08:14.700]So we really saw a big difference in how much they smiled
[00:08:17.287]and how much they looked interested and things like that,
[00:08:21.080]that are really important for learning.
[00:08:22.730]We want them to have fun and enjoy the
[00:08:24.650]learning so that was a big improvement
[00:08:26.830]with the PRT motivational components involved.
[00:08:29.310]We also found that they maintained and generalized
[00:08:32.246]so for example when we worked on assignments at home
[00:08:36.919]and had the motivational components and the writing
[00:08:40.060]and reading or spelling or whatever the activity was we
[00:08:44.060]noticed that it generalized his school so that even when we
[00:08:47.540]went back after a period of time to the more teacher
[00:08:50.496]assigned assignments then they were still having
[00:08:56.080]higher motivation and were more
[00:08:59.055]engaged and less disruptive behavior.
[00:09:00.783]So it might be just like they learn that it's not so bad
[00:09:03.440]doing math or reading it can be kind of fun
[00:09:05.530]but they had so much avoidance behavior that they
[00:09:07.590]just really didn't get much done.
[00:09:10.640]Another very exciting thing about the intervention
[00:09:14.089]was that we noticed that after and after we started
[00:09:18.300]incorporating the motivational components the children
[00:09:21.080]had a lot of self initiated activities and they didn't
[00:09:24.694]do so much avoidance behavior, for example we had one
[00:09:28.647]student who wanted to play teacher and he ended up
[00:09:33.498]asking the person that was working on his homework
[00:09:38.420]with him if she would be the student
[00:09:39.980]and he was giving her assignments and things.
[00:09:42.130]They also started engaging in different games on their own
[00:09:45.770]and writing stories and even drawing pictures in fact
[00:09:49.230]the picture that I'm showing now you can see that this
[00:09:51.480]one child who had a lot of avoidance behavior and really
[00:09:54.479]was like pulling teeth getting him to engage in his
[00:09:57.415]homework assignments he sat down one day and drew a map
[00:10:00.778]of Santa Barbara and all of the streets were correct.
[00:10:04.083]We didn't know that he knew how to, where the streets were
[00:10:09.193]and geographically they were correct and he spelled
[00:10:13.110]out most of the streets correctly and it was really
[00:10:15.830]exciting because like I said we had never knew that
[00:10:17.731]he knew all that so that was very exciting.
[00:10:20.830]We saw a lot of different collateral gains,
[00:10:24.072]so just in a discussion what we found was that these
[00:10:29.197]collateral gains they were engaging in a lot more
[00:10:33.370]academic assignments and more academic activities
[00:10:35.846]on their own rather than completely avoiding them.
[00:10:39.467]We found some generalization into the school settings
[00:10:42.750]so when we had for example activities that we did after
[00:10:46.888]school on their homework PRT motivated activities in their
[00:10:51.158]assignments they had better behavior in the school setting.
[00:10:55.340]So we have these better outcomes and I think when thinking
[00:10:58.439]about pivotal response treatments since children with
[00:11:01.470]autism we see a good percentage of them will have some
[00:11:05.860]kind of disruptive behaviors or even if it's a small
[00:11:09.165]number of children the ones that do
[00:11:12.560]have disruptive behaviors that can be really problematic
[00:11:15.170]in a classroom so what we want to kind of think of is
[00:11:18.878]what we can do as an antecedent intervention to prevent
[00:11:22.119]problem behaviors and by motivating the children to want
[00:11:26.142]to engage in the activity we just see a whole lot of
[00:11:29.662]really positive outcomes and it really makes a big
[00:11:33.320]difference and then we don't have to spend all that time
[00:11:35.244]trying to develop behavior intervention programs to decrease
[00:11:39.215]their disruptive behavior because we've avoided them all
[00:11:41.629]together by making the curriculum really exciting.
[00:11:47.190]So in summary when we do this home school coordination
[00:11:51.170]where we involve the motivational components we see
[00:11:55.033]the reduction of disruptive behavior, the kids aren't
[00:11:58.420]engaging in this avoidance behavior or escape once they
[00:12:02.100]hand out the assignment the kids are trying to get out
[00:12:05.090]of it and we've seen from some of the research.
[00:12:07.721]That a lot of times the kids that have disruptive
[00:12:10.760]behavior can really alter the teachers' curriculum.
[00:12:13.950]So she might start at the beginning of the year,
[00:12:15.750]she or he at the beginning of the year with a age
[00:12:19.063]appropriate curriculum based on what the child really needs
[00:12:24.102]and then the child has a lot of disruptive behavior
[00:12:26.880]and then the teacher often times will make it a little
[00:12:30.250]easier and a little easier and a little easier until
[00:12:32.700]they're really just doing maintenance tasks with the kids
[00:12:35.480]just to keep their disruptive behavior.
[00:12:37.250]And it's nothing that's planned it's just sort of
[00:12:39.500]gradually evolved 'cause who likes disruptive behavior.
[00:12:42.650]None of us wanna work with a child engaging in all this
[00:12:45.490]disruptive behavior so this is really the great
[00:12:48.810]way to make it motivational for the child
[00:12:50.840]so we don't have to worry about them.
[00:12:53.030]We also find that it increases the child's responsiveness
[00:12:55.661]the kids are more engaged, there's more learning
[00:12:59.533]and it also improves team work.
[00:13:01.730]Because when you have a child with disruptive behavior
[00:13:03.890]it's usually stressful for everybody so just
[00:13:06.514]by incorporating these PRT motivational components
[00:13:09.949]into the academics we see great widespread positive
[00:13:14.530]improvements in the children's behavior both during
[00:13:17.080]the particular assignments that the motivational
[00:13:20.480]components and during other assignments.
[00:13:23.670]So now I'm gonna move on another area that's kind of near
[00:13:27.412]and dear to my heart which is teaching initiations to
[00:13:30.598]children with autism using PRT.
[00:13:34.384]And it was interesting we had some children and we'd been
[00:13:40.090]in the field for a long time Bob and I and we had some
[00:13:44.967]children that did pretty well and some that did really
[00:13:47.989]and some that didn't do so well and then pretty much
[00:13:52.490]everything in between and we started talking about,
[00:13:56.300]gosh we thought we were giving them al this sort of state
[00:13:58.780]of the art treatments and why was it that some children
[00:14:01.340]did so much better than other children.
[00:14:03.720]So we began a bit of a literature review and we looked
[00:14:07.236]to see what the literature said about children that
[00:14:10.940]would have the best outcomes and it was pretty consistent
[00:14:14.817]showing that if children had verbal communication before
[00:14:17.949]the age of five years old and a measurable IQ
[00:14:22.738]of over 50 they should have pretty good outcomes.
[00:14:28.160]However, we had quite a few children that had those
[00:14:31.137]characteristics and some of them had great outcomes.
[00:14:34.330]Some of them ended up going to college, getting married,
[00:14:38.680]having friends, talking on the phone, having sleepovers
[00:14:41.246]but we also had quite a few children that had verbal
[00:14:45.730]communication and relatively high IQ's and didn't have
[00:14:50.530]such good outcomes and ended up just
[00:14:52.470]really not doing so well in their life.
[00:14:54.639]First of all we did at this prognosis study and we looked
[00:14:59.010]at adolescents and young adults that had good outcomes
[00:15:01.940]and had poor outcomes, we kind of wanted to just sort
[00:15:04.882]of see of there's something that we had missed.
[00:15:07.750]And we looked at everything you could look at and what we
[00:15:11.759]did is we selected adolescents and young adults and we
[00:15:15.380]looked back at their video tapes when they were little
[00:15:18.470]tiny pre-schoolers to see if there was something that
[00:15:21.250]we had missed back then, that might have been a good
[00:15:24.170]a good or poor prognostic indicator.
[00:15:27.300]And we looked at their communication, repetitive behaviors,
[00:15:30.940]play, disruptive behaviors, levels of engagement so
[00:15:34.350]we tried to look at just about everything.
[00:15:37.550]And here's what we found just to give you an idea,
[00:15:41.410]this is the children when they were in preschool
[00:15:45.182]and you can see on the bottom they all have about the
[00:15:48.770]same language age, they're all like maybe sort of in the
[00:15:50.820]range of 22 to 24 months so they have a good vocabulary.
[00:15:54.890]They're verbal, they can combine words and word combinations
[00:16:00.873]maybe even making a couple of short sentences.
[00:16:03.724]But you can see as adults or adolescents they have really
[00:16:08.440]different outcomes so in the top left hand you can see some
[00:16:13.846]of these had really great scores and these are pragmatic
[00:16:17.250]ratings where we had people just say kind of how normal
[00:16:20.040]do you think they look, how typical do you think these
[00:16:22.470]kids look and people are rating them seven, eights, nine's
[00:16:25.740]so they're looking really, really good but the other
[00:16:28.850]group doesn't look so good, they have like two, one, three.
[00:16:33.810]So they're scoring really low, people are saying they just
[00:16:37.259]don't look that great to me and this is despite the fact
[00:16:40.910]that there's no difference really in their language.
[00:16:43.899]But we did find one interesting thing, we found that
[00:16:48.129]if we looked at their number of initiations when they
[00:16:52.610]were in preschool the children that had these better
[00:16:54.929]outcomes had more initiations so they were doing quite
[00:16:59.448]a few 32, 21, 16 so we see all these great initiations
[00:17:03.896]and then the children that had the poor outcomes
[00:17:07.583]the three children that we compared them with that
[00:17:11.330]had the poorest outcomes had zero, some of them
[00:17:13.670]had zero or very few initiations.
[00:17:16.700]So you can imaging when kids are initiating on their
[00:17:21.770]own spontaneously they're engaged with adults.
[00:17:26.100]These were things that maybe were like asking a question
[00:17:29.054]or pointing to something or bringing a toy to their parents.
[00:17:32.153]And in contrast the children with the poor outcomes they
[00:17:36.730]just didn't bring things to their parents or show
[00:17:39.290]them things and when you're not doing things like you're
[00:17:42.040]probably engaging in kinda spacey behavior
[00:17:45.010]and things that won't produce brain growth
[00:17:48.380]and won't help you really learn more.
[00:17:51.532]So we did a second study and in the second study we
[00:17:54.625]thought okay maybe this is an important behavior that the
[00:18:01.790]kid should learn and if they could learn them would
[00:18:06.590]they have better outcomes better long term
[00:18:09.320]outcomes as adolescents and adults.
[00:18:11.920]So we in our study focused on expressive verbal initiations
[00:18:17.620]since the children that we studied were verbal
[00:18:20.120]and the children we looked at.
[00:18:21.840]So we started with the basic PRT motivational components
[00:18:27.770]for first words since Bob mentioned in his webinar focused
[00:18:30.704]on those and then as they progressed and could say at least
[00:18:34.834]50 to 70 words and were beginning to combine words.
[00:18:37.718]Then we started focusing on these initiations and you've
[00:18:43.779]probably seen typical kids that in their first group of
[00:18:47.596]words they'll point to things and say that or this.
[00:18:50.463]And that's a specific queue for a parent to label items
[00:18:55.130]and that's how they get these huge vocabularies
[00:18:57.470]and sometimes they ask that and this about everything
[00:19:00.680]over and over and over again so it gets exhausting
[00:19:02.551]for parents but it's so wonderful because they're learning
[00:19:05.915]so much from these child initiations.
[00:19:09.360]And then in contrast when we took these language samples
[00:19:12.900]of the children with autism we were noticing that they just
[00:19:16.380]don't really initiate that much and this leads it up to
[00:19:19.371]the adult all of their learning opportunities have
[00:19:22.170]have to be set up by an adult.
[00:19:24.200]So you can imagine if we can switch that so that the
[00:19:26.900]children are initiating their own learning activities
[00:19:30.312]that would be really helpful for them and it would be
[00:19:34.170]more balanced as far as sort of pragmatics going
[00:19:36.660]back and forth instead of always every interaction
[00:19:39.290]or learning interaction being initiated by the adult.
[00:19:43.120]So we went through a couple of different iterations
[00:19:46.590]and most of them didn't work because they didn't have
[00:19:49.750]anything motivational, we tried to kind of work with
[00:19:52.120]storybooks and stuff but that didn't work too well.
[00:19:55.150]So finally we came up with a motivational procedure
[00:19:57.972]for teaching what's that and that's the first as I mentioned
[00:20:01.720]question learned that typical children learn.
[00:20:04.250]So that's why we started with that one and what we did
[00:20:07.600]in our first step was we began with the children's
[00:20:10.580]favorite items and we put them in an opaque bag
[00:20:13.062]and then we prompted the children to say what's that.
[00:20:16.465]And once the children responded with what's that then
[00:20:20.380]we brought out a favorite item out of the bag and we
[00:20:23.210]said oh it's an M and M or it's a Kush ball
[00:20:26.645]or it's a gummy bear or whatever their favorite thing
[00:20:30.130]was, how to repeat the label and then we gave it to them.
[00:20:33.183]So that way we had these motivational components in there
[00:20:37.057]and they were getting things they liked and once we got that
[00:20:40.327]question asking those first questions started and the
[00:20:44.660]kids got really excited and were like what's that
[00:20:47.890]and kept asking the question over and over agan.
[00:20:49.898]And then we gradually and systematically started fading
[00:20:53.667]in items that they didn't know how to label.
[00:20:56.950]So we first started with every fourth item so they might
[00:21:00.470]say what's that and we say oh gummy bear you think
[00:21:03.300]I mean gummy bear and then they repeat it what's that
[00:21:06.040]M and M they eat it, say M and M then eat it.
[00:21:08.579]What's that, kush ball they say kush ball the play with it
[00:21:11.960]for a little while and what's that, pencil or some other
[00:21:14.414]item they didn't know how to label and it was very
[00:21:18.030]interesting 'cause they had really small vocabularies.
[00:21:20.720]In fact most of them had these vocabularies that consisted
[00:21:23.800]of primarily things they really wanted but they didn't have
[00:21:27.850]that wide spread large number of words that you need to
[00:21:31.230]be communicatively competent so we started feeding in
[00:21:36.360]every fourth item, and then every third, then every second
[00:21:40.306]and then every item, then we faded out the bag.
[00:21:43.372]And we took measures on their generalization, they both,
[00:21:48.037]well they learned the question and generalized it to other
[00:21:52.880]settings so that was really exciting.
[00:21:56.006]They generalized to other settings and as a consequence to
[00:21:58.310]that question they also learned the vocabulary words
[00:22:01.630]that we presented with and not the neutral items
[00:22:04.130]that they didn't know how to label previously.
[00:22:06.540]So that was really exciting and after that first study
[00:22:10.420]we published we were kinda hoping that they would start just
[00:22:14.072]exploding in their questions but they actually didn't
[00:22:16.480]they didn't start asking where questions and who
[00:22:18.770]questions and any other questions.
[00:22:20.930]So we had to let me go back a few slides,
[00:22:23.580]we also did a little work on verbs, what we found was that
[00:22:27.104]children with autism ended up having small number
[00:22:31.229]of verbs that they use that's really kind of surprising
[00:22:35.050]how you can get by with not using too many verbs
[00:22:38.290]in your communication so we wanted to not only expand the
[00:22:42.324]verb conjugation so that they were able to use like
[00:22:46.560]ing endings and past tense and also to expand the
[00:22:50.078]diversity of verbs that they use.
[00:22:53.120]And for this study what we did is we got some pop-up
[00:22:56.690]books around the kids' interest, so let's say they
[00:22:59.712]liked trucks so we might get the book with trucks
[00:23:03.140]and then we'd manipulate the tab and have the children
[00:23:08.130]say what's happening and when they would ask what's
[00:23:11.730]happening we'd say he's driving or he's stopping
[00:23:14.988]or he's moving and all kinds of different verbs.
[00:23:18.633]And have the children repeat that then they could
[00:23:21.250]play with the little tabs, just a note of caution
[00:23:23.950]you have to buy a lot of pop-up books when you let
[00:23:25.870]the kid's play with the tabs and also have a lot of tape
[00:23:28.160]on hand because they do rip the tab's off a lot.
[00:23:31.097]And so that's a way to get them to expand the different
[00:23:33.965]verbs the different verbs they're using and also be able
[00:23:37.534]to use that ing present progressive tense.
[00:23:40.979]The other area that we worked with verbs was on the
[00:23:45.640]past tense and in this one we used the same pop-up
[00:23:50.130]books but what we would do is we would manipulate the
[00:23:53.060]tab and then we'd stop and then we'd prompt the child
[00:23:57.080]to ask what happened and when they asked what happened
[00:23:59.906]we'd say oh he jumped or he ran or he slithered
[00:24:05.670]or any kind of verb that you can use best.
[00:24:08.840]Like I said to do some diverse verbs and lots so that they
[00:24:12.890]get a wide variety of verbs and then once the children ask
[00:24:17.023]that and we responded we let them play with the tab
[00:24:19.968]on the book so they're learning past tense that way
[00:24:24.130]and I think it's kind of a nice for past tense a nice
[00:24:27.420]concrete way for them to learn the verbs.
[00:24:29.650]Because when you think about it, let's say a truck
[00:24:33.090]is driving by and you say oh the truck drove by
[00:24:35.718]you're trying to teach your child the past tense but
[00:24:38.540]they look up and the truck is gone.
[00:24:40.290]So they maybe hooking on the irrelevant queue
[00:24:43.430]because they're looking up there and it's gone and so it's
[00:24:45.790]kind of a complicated thing in real life to teach the
[00:24:48.470]past tense but with the manipulating the tabs you could
[00:24:52.110]make a really clear on set and off set time so you
[00:24:55.770]manipulate it and stop and then prompt the question
[00:24:58.530]so it's really clear and what happened is just a great
[00:25:02.508]question for the kids to know in general.
[00:25:05.010]Because they can show empathy, you can also prompt it
[00:25:08.210]once they learn during other times if some other child
[00:25:11.928]or student falls have them say what happened.
[00:25:14.989]So it's just a nice question in general but in addition
[00:25:19.310]with the treatment that we did with the pop-up books
[00:25:21.700]they were able to learn their past tense endings.
[00:25:25.370]We also did a little work with attention seeking like
[00:25:28.530]look so the way we teach that is we'll have the child
[00:25:31.748]maybe give the child a favorite item like maybe.
[00:25:37.490]So for example yesterday I was working with a little boy
[00:25:40.040]and he had a box of snacks, it was after school and his
[00:25:43.270]mom had sent some crackers and some chips and some
[00:25:46.150]popcorn and he was saying I want popcorn and I'd give
[00:25:48.789]him a piece of popcorn but just kind of hold his hand
[00:25:51.298]gently and to have him say look mom popcorn or his
[00:25:54.888]babysitter was there look Susie popcorn or look mom
[00:25:58.517]a chip and then he gets to eat it.
[00:26:03.172]Then he gets to eat it so that way you could kind of teach
[00:26:05.587]them a way of getting attention but then it's naturally
[00:26:08.113]reinforcing again going back to those basic PRT procedures
[00:26:10.980]as often as we can incorporate them into any learning
[00:26:15.760]activity the children will do a lot better.
[00:26:18.390]They have those child choice items and then they have
[00:26:20.640]the natural reinforcer and help is another word that
[00:26:26.530]we like the kids to learn and we like
[00:26:28.310]them to be able to say help spontaneously.
[00:26:30.720]Because a lot of times the children will
[00:26:32.900]be in class and kind of disruptive 'cause
[00:26:34.950]somethings hard or they're frustrated and then the parents
[00:26:38.003]or the mom or the father or the teacher would come over
[00:26:42.700]and say oh if you need help you need to say I need help and
[00:26:45.431]the child will say I need help and then someone helps them.
[00:26:48.372]But what they pretty much learn is first they can have
[00:26:51.810]disruptive behavior and then someone will come over and
[00:26:54.440]then that person will prompt them and then
[00:26:57.304]they say help and they get the help.
[00:26:59.201]But we don't want them to learn that chain so we want them
[00:27:01.070]to be able to spontaneously say help when they need help
[00:27:04.630]so we kind of set it up where we'll have some situations
[00:27:07.660]like for example we may put some of their treats in a jar
[00:27:11.560]that's screwed pretty tightly and then they start to open
[00:27:15.610]and they can't get it open we'll prompt them to say help
[00:27:18.320]spontaneously before they get frustrated so they get a lot
[00:27:22.347]of practice that's one of the things when teaching a new
[00:27:26.640]behavior we just want the kids to have a lot of practice
[00:27:29.230]with the appropriate kind of placement behavior rather
[00:27:32.390]than get upset and then have that lead to a chain of events.
[00:27:35.460]So help is just a great way that the kids
[00:27:38.400]can keep their frustration down.
[00:27:40.120]They can get some assistance so you see we have all these
[00:27:46.090]different initiations that we work with the children
[00:27:49.110]and once they've learned all these different initiations
[00:27:52.270]then initiations gets pretty good.
[00:27:54.730]So lemme just go back to some data here, this is our second
[00:27:59.080]study that we did, we asked if we teach initiations to
[00:28:03.200]children with autism who don't use initiations will they
[00:28:06.691]have better outcomes, so you can see this group of children
[00:28:10.339]is very similar, they're preschool children they're very
[00:28:13.610]similar in language age to the first group of children
[00:28:17.320]that we looked at to assess their longterm outcomes.
[00:28:20.792]The prognostic indicators they're just a little over 24
[00:28:24.113]months right around there they have a pretty good
[00:28:28.230]vocabulary 50, 60, 70 words at least
[00:28:31.260]and they're starting to combine words.
[00:28:34.910]And then in the next slide what we can see is the top
[00:28:38.360]is the number of initiations the children had
[00:28:41.050]and you can see each light colored bar on the left of the
[00:28:45.880]dark colored bar shows the pre intervention number
[00:28:49.670]of initiations so they range from about 14 to zero.
[00:28:52.937]Some of the kids had just really, didn't initiate very much
[00:28:56.103]and then we did the intervention with them and after the
[00:29:00.573]intervention the children increased significantly in
[00:29:05.820]their number of initiations you could see lots
[00:29:08.750]of initiations and look at their pragmatic rating.
[00:29:14.130]When they're not doing very many initiations similar to
[00:29:17.330]the first study the children are getting rated really low
[00:29:22.150]like a two a one a zero, people are saying they don't
[00:29:26.640]look very good but the darker bars show their rating after
[00:29:31.072]they learn all these initiations they getting like
[00:29:34.910]six, seven, eight, nine so people are, some of them still
[00:29:38.590]have a little bit of something that people score them as you
[00:29:43.890]know there's a little bit of quirkiness or something.
[00:29:45.880]But they're really, really much higher so when the kids
[00:29:49.882]have these initiations they really, really have
[00:29:53.489]these much better long term outcomes.
[00:29:56.114]So verbs again we talked about how to use the pop-up
[00:30:00.930]books around their interest, how to use look
[00:30:03.427]and how to use help this is just a little
[00:30:06.068]overview you can use for your notes.
[00:30:08.197]And so in summary what we found is when we taught these
[00:30:13.590]initiations they generalized both the home and school
[00:30:16.930]so our first couple of studies we taught them in a
[00:30:19.450]clinic setting sort of one on one with the children.
[00:30:22.350]But they can easily be taught the questions in a school
[00:30:28.510]or in any other setting, we just kind of did
[00:30:31.070]it in a clinical setting in the University to see how
[00:30:33.740]they would do and they were able to learn them and not
[00:30:36.680]only were they able to learn them they
[00:30:37.730]generalized a home and school.
[00:30:39.890]Another exciting thing was that they learned the targets
[00:30:42.610]as the result of the intervention.
[00:30:44.890]So whether we we working on vocabulary, verbs, prepositions
[00:30:51.620]possessive endings, whatever we targeted as a result
[00:30:58.875]of the initiation they learned those target linguistic
[00:31:02.590]structures or whatever we did.
[00:31:04.530]And the other nice thing was it increased functions
[00:31:06.880]of the language so if you look at language samples of kids
[00:31:11.310]with autism or in the literature it pretty much shows that
[00:31:14.669]kids with autism will really use a minimal functions
[00:31:18.447]of language and primarily they're using language for
[00:31:21.810]request which is kinda how we start teaching them.
[00:31:24.490]We get their favorite things and we have them request
[00:31:27.260]those items and that's an awesome perfect great way
[00:31:29.550]to start teaching them however oh and also in addition
[00:31:34.520]to the request we all know they use protest like no,
[00:31:37.390]bye bye, go away and things like that.
[00:31:40.020]But they're not using these wide variety of linguistic
[00:31:43.355]functions like questions and other expressions that you
[00:31:49.430]need to get attention seeking, all these different
[00:31:52.180]expressions and functions of language that you need
[00:31:54.850]to be communicatively competent.
[00:31:56.900]So by teaching them these initiations we increase their
[00:31:59.930]functions of language and it would also improve their
[00:32:02.890]social interactions so for example if it's all teacher
[00:32:06.860]driven it's gonna be pretty much one-sided.
[00:32:09.300]The teacher is always gonna be initiating all
[00:32:12.220]the interactions and as we saw from our pragmatic ratings
[00:32:14.650]people look at the kids and say or adults or adolescents
[00:32:18.250]and say something looks really wrong with this person.
[00:32:21.320]If everything is adult initiated, if the only time they
[00:32:25.200]ever talk even if though they're verbal the only time they
[00:32:27.430]ever talk is when someone asks them a question.
[00:32:30.460]In contrast when they're asking questions and they're
[00:32:33.960]initiating the conversation people say wow those kids
[00:32:37.650]they look pretty good and for a small number of kids
[00:32:40.870]they're saying we don't really see anything going wrong
[00:32:44.750]there with the kid they look really good.
[00:32:47.180]So it's important just to realize that these initiations
[00:32:52.838]seem to be really important for long term prognosis
[00:32:55.710]and this has kind of changed the way I do my assessments
[00:33:00.390]when families come in, I kind of look at the kids
[00:33:03.650]and if they're not initiating I know we have to put
[00:33:06.220]initiations in their IEP and in their program or their
[00:33:10.080]intervention targets because I know now I feel like they
[00:33:14.050]don't have these initiations they probably won't have
[00:33:16.510]a very good long term outcome.
[00:33:18.520]The good news is that we can teach the initiations
[00:33:21.110]to most children and I wanna thank you very much
[00:33:26.380]for joining me we have a couple of websites.
[00:33:28.941]autismPRThelp.com and also if you wanna email me I
[00:33:32.476]have my email lynnk@Stanford.edu and thank you
[00:33:37.147]very much for joining us we hope you enjoyed the webinar
[00:33:40.263]on Pivotal Response Treatment and it's application
[00:33:44.120]to various behaviors thank you very much.

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Pivotal Response Treatment Part 2

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