How Does Pivotal Response Training (PRT) for Children With Autism Work?

PRT is based on four pivotal areas: motivation, initiation, responding to multiple cues, and self-management. Working on these four key areas, PRT enables widespread improvement in not only behavior but also social interactions and communication with others. PRT is based on applied behavioral analysis (ABA) but departs from ABA in important ways.

This article discusses key components of PRT, its effectiveness, and how it works to help children with ASD develop crucial social skills necessary for everyday life.PRT is based on four pivotal areas: motivation, initiation, responding to multiple cues, and self-management. Working on these four key areas, PRT enables widespread improvement in not only behavior but also social interactions and communication with others. PRT is based on applied behavioral analysis (ABA) but departs from ABA in important ways.

This article discusses key components of PRT, its effectiveness, and how it works to help children with ASD develop crucial social skills necessary for everyday life.

What Are the Components of Pivotal Response Training?

Pivotal response training (PRT) is a treatment for ASD that targets skills pivotal to a child’s development. The goal of PRT is that by targeting these pivotal skills, children with autism can improve general, everyday functioning, including communication, behavioral, and social skills.

Another key component of PRT is using strategies to increase a child’s motivation during treatment. For example, instead of the therapist choosing the activities during treatment, the PRT approach is to let the child choose the activities to keep them intrinsically motivated. Other PRT strategies include:1

Using play-based interactions

Asking the child to do new behaviors as well as ones they’ve already mastered

Giving the child clear opportunities to demonstrate skills

Rewarding desired behaviors or attempts at desired behaviors

PRT vs. ABA Therapy

PRT is based on applied behavioral analysis principles. What makes PRT different from ABA is that it focuses on pivotal areas of a child’s development rather than targeting specific behaviors. By doing so, PRT allows for improvements in not just behaviors but also social interactions and communication.

In addition, PRT reinforces desired behaviors and any valid attempts the child makes toward a desired behavior, thus increasing the frequency of reinforcement and keeping the child motivated throughout treatment.2

What Are the Pivotal Areas in PRT?

PRT focuses on four areas that are thought to lead to broad improvements in other core areas of functioning. The four pivotal areas that PRT targets are:2

Motivation: Using the child’s interest to increase their desire to learn and perform social skills

Initiation of social interactions: Encouraging the child to initiate social interactions by asking questions or getting someone else’s attention

Responding to multiple cues: Training a child to respond to multiple cues rather than specific details

Self-management: Teaching the child to evaluate their behaviors themselves

These crucial skills can improve communication, social, and behavioral skills.

How Does PRT Treatment Work?

One of the major advantages of PRT is that it’s flexible — it can be adapted to the individual child based on their unique skill set. Thus, a PRT treatment plan will be tailored to the child's unique needs.

PRT treatment can be delivered by:

• Therapists/clinicians

• Teachers

• Parents

  For example, parent group–delivered PRT is effective in improving children’s social communication skills, improving parents’ self-efficacy, and helping families feel more empowered.3 Training parents to provide PRT at home also promotes consistency in treatment. Similarly, training teachers in PRT not only helps them feel supported when teaching children with ASD but also enables children with ASD to receive PRT in natural environments like the classroom rather than in a clinic.

  The number of hours spent in PRT varies. For example, some PRT interventions have included seven to 18 hours of PRT per week for 16 weeks.2 Some PRT treatment plans may require as many as 25 hours per week, depending on the needs and social development of the child.

PRT Treatment Examples

PRT treatment techniques will vary based on the child’s needs and progression. One key component of treatment is listening to the child’s preferences for which activities to engage in and using those to implement PRT techniques and build social skills.

For example, a child may be given a choice of toys to choose from, and when they respond appropriately as to which toy they want, they are given that toy as a “natural” reward4—one that matches what they showed interest in. This is an opportunity to demonstrate play and social skills, like talking about the toy.4

How Effective Is PRT?

PRT has been proven to be an effective treatment for children with ASD. For example, research has shown that PRT has led to better social communication skills, such as responding to social interactions and gaining language skills from asking more questions.2 Such improvements have led to secondary improvements, such as reducing disruptive, restrictive, and repetitive behaviors.

In addition, focusing on intrinsic motivation—that is, doing activities that the child prefers and completing those tasks—may be especially beneficial for bringing about opportunities for the child to engage with another person over a shared object or activity (joint attention) and engage in pretend play, both of which are important social skills.2

PRT is shown to be effective, yet estimates of how many children achieve an optimal, or best, outcome after PRT vary. For example, some studies have suggested that 2% to 25% of individuals had an optimal outcome, while another showed 47% achieved an optimal outcome.1 Estimates vary widely due to the various ways that “optimal outcome” is defined.

For example, the researchers that found a 47% rate of success defined "optimal outcome" as average IQ and being placed in a mainstream classroom (as opposed to special education), while others have had stricter criteria, such as not having ASD symptoms any longer and having communication and social skills typical of someone without ASD.1 More research is needed to determine the expected results after a typical PRT treatment program.

Is PRT Covered by Insurance?

Whether PRT is covered by insurance may depend on the type of insurance. Most private insurance companies are required to cover behavioral health services and therapies.5 Given that PRT is considered an evidence-based behavioral therapy for autism, it may fall into that category. It’s best to call your insurance company to learn exactly what’s covered and for how many sessions.

Medicaid, a public insurance plan, covers medically necessary treatments. Thus, if a physician prescribes PRT for a child with autism, it is likely covered by Medicaid.

Summary

PRT is an evidence-based therapeutic approach shown to be effective in treating children with ASD. PRT includes four pivotal areas: motivation, initiation, responding to multiple cues, and self-management. PRT is different from ABA in that it focuses on pivotal areas of a child’s development rather than specific behaviors and reinforces both desired behaviors and attempts at desired behaviors.

Clinicians, teachers, and parents can deliver PRT with the ultimate goal of widespread improvements in the child’s communication, behavioral, and social skills.