Evidence-based psychotherapies for children and adolescents by Weisz and Kazdin (third edition) – Chapter 17 summary

Difficulties in social communication in ASD may result in disruptive behaviours (e.g. aggression). This is a significant source of stress to families.

Researchers have attempted to identify pivotal responses. The idea is that when certain core areas are targeted, widespread changes in numerous other untargeted behaviours would occur, leading to fluid and integrated behavioural gains.

Motivation to respond to social and environmental stimuli is essential for typical development. However, children with ASD may fail to understand the interconnection between their behaviour and the consequences from their environment as a result of repeated failures and non-contingent assistance and reinforcement from adults as a result of their social communication problems. This will, eventually, lead to an overreliance on adult support (i.e. learned helplessness).

Pivotal response training (PRT) focuses on decreasing the presence of learned helplessness by enhancing the relationship between children’s responses and reinforcement. This can help children to become motivated to respond, which leads to a positive feedback loop where more learning opportunities are provided. This, in turn, generates the social-environmental conditions for the development of more complex behaviours which are necessary for social, communicative and cognitive competence. PRT makes use of operant conditioning format of ABA but focuses more on increasing and maintaining the intrinsic motivational qualities within the ABA interaction. It uses the motivational strategies child choice (1), task variation (2), interspersal of maintenance tasks (3), reinforcement of response attempts (4) and the use of natural and direct reinforcement (5).

Children respond better to PRT when they begin before the age of 3. Fewer children respond with increasing age.

Self-initiation is common in typically developing children and serves multiple functions (e.g. information seeking). The form of self-initiation differs (e.g. joint attention; elaborate questions) but is inherently social in nature. Self-initiation occurs infrequently or is absent in children with ASD. Children who are taught to use self-initiations have more favourable outcomes. This means that motivating children to self-initiate can result in learning that increases autonomy as children become less reliant on adult-delivered learning opportunities. Motivating children to self-initiate provides them with tools that result in self-learning.

Children with ASD are often unmotivated to socialize but are motivated to engage with the non-social aspects of their immediate environment. The salient characteristics of non-social interests may be identified and embedded within a reciprocal social activity. This can enhance motivation to socialize, which, in turn, can lead to improvements in other areas of functioning. Incorporating restricted interests in mutually-reinforcing social activities (i.e. for the child with ASD and the typically developing peer) can lead to intrinsic motivation for social play.

The goal of PRT is to provide comprehensive intervention in key areas that increase independence and self-education throughout the day with rapid, widespread improvement of ASD. The teaching of pivotal areas is coordinated throughout the children’s day with parents, teachers and other service providers. Treatment is provided in a natural and inclusive setting to maximize the likelihood of typical development. PRT should be delivered by parents as well as they can provide consistency for the child with ASD, which can lead to a range of positive outcomes. It can be blended into daily routines and developed within individual family values.

PRT can be delivered across different settings and can differ in levels of intensity. The parents should eventually implement the procedures of PRT throughout the child’s waking hours during family routines and daily activities. Parents typically participate with their children in intensive training programmes.

PRT procedures are manualized and the motivational procedures are taught during parent education sessions. PRT provides teaching examples and opportunities for parents to apply the procedures to their own children. It makes use of activities the child would engage in if there were no disability. The therapist should provide feedback to the parents while they work directly with their children. The initial focus of intervention is on using motivational strategies to increase the child’s responsivity to learning opportunities. Parent intervention sessions begin with feedback on the following:

1. Use of child-selected stimulus materials
   This regards feedback as to whether the parent used stimulus materials that the child has selected or prefers. Giving the child input maximizes interest in the learning situation and improves the rate and generalization of learning.
2. Direct, natural reinforcers are used whenever possible
   This regards feedback as to whether parents used direct and natural reinforcements whenever possible. Doing this can enhance the response-reinforcer relationship and improve overall motivation to respond to the interaction.
3. Interspersing maintenance trials
   This regards feedback as to whether parents intersperse previously learned task with new acquisition tasks. This can increase the success a child experiences and lead to behavioural momentum.
4. Reinforcing attempts
   This regards feedback as to whether parents provide reinforcement for children’s attempts to respond to instructional materials or natural learning opportunities. Response attempts should be reinforced even if the attempt is not successful.

A coordinated effort across all settings and significant individuals can result in large amounts of intervention being delivered on an ongoing basis throughout the child’s day. Children are taught to use self-initiation by having them ask “what”, “where” and “whose” questions.

There is strong support or the use of each of the individual motivation components of PRT. The treatment is more effective when it is delivered by parents compared to clinicians. PRT seems to lead to greater treatment gains than treatment as usual.