PRT research has shown that the development of skills and behavioural improvements are best promoted when two 'pivotal' areas are trained: "motivation and the ability to respond to multiple cues". Studies have shown that the development of these areas result in generalisation of behavioural improvements to other, often untrained, areas and in faster overall behavioural improvements in children with ASD.

Initially attempts to treat autism were mostly unsuccessful, and in the 1960s researchers began to focus on behavioural intervention therapies. Drs. Lynn and Robert Koegel, at the University of California in Santa Barabara, theorized that, if effort was focused on certain pivotal responses, intervention would be more successful and efficient. As they saw it, developing these pivotal behaviours will result in widespread improvement in other areas. Pivotal Response Theory (PRT) is based on a premise that autism is a much less severe disorder than originally thought.

Pivotal Areas to Promote in Autism

The two primary pivotal areas of Pivotal Response Therapy involve "motivation" and "initiation of activities". Three others are "self-management", "feelings" and the "ability to respond to multiple cues". Play environments are used to teach pivotal skills, such as turn-taking, communication, and language. This training is child-directed: the child makes choices that direct the therapy. Emphasis is also placed upon the role of parents as primary intervention agents.

The effectiveness of pivotal response therapies have now been proven and ongoing research of its effects on autistic children is being conducted. Pivotal response training is specifically designed to increase a child’s motivation to participate in learning new skills. Pivotal response training involves specific strategies such as

• clear instructions and questions presented by the therapist
• child choice of stimuli (based on choices offered by the therapist)
• intervals of maintenance tasks (previously mastered tasks)
• direct reinforcement (the chosen stimuli is the reinforcer)
• reinforcement of reason for purposeful attempts at correct respond
• Turn taking to allow modelling and appropriate pace of interaction

Pivotal response training has proven to be a naturalistic training method that is structured enough to help children learn simple, through to complex play skills, while still flexible enough to allow children to remain creative in their play. The child can be reinforced for single or multiple-step play. The therapist has the opportunity to model more complex play and provide new play ideas on his/her turn. Research indicates that children with autism who are developmentally ready to learn symbolic play skills can learn to engage in spontaneous, creative play with another adult at levels similar to those of language-age matched peers via pivotal response training .

Reciprocal Imitation Training

A variation on the pivotal response training procedure for teaching play skills is reciprocal imitation training (RIT). Reciprocal imitation training was developed to teach spontaneous imitation skills to young children with autism in a play environment; however, this intervention technique has also been shown to increase pretend play actions. Reciprocal imitation training is designed to encourage mutual or reciprocal imitation of play actions between a therapist and child.

This procedure includes unexpected simulation in which the therapist imitates actions and vocalizations of the child. A study found that very young children with autism learned imitative pretend play with an adult using this procedure and this play generalized to new settings, therapists, and materials. Several of the children also increased their spontaneous use of pretend play. In addition, the children exhibited increases in social behaviours such as coordinated attention after reciprocal imitation training, suggesting that both the imitative and the spontaneous play had taken on a social quality.

Self-Management Training

Self-management has been developed as an additional option for teaching children with autism to increase independence and generalization without increased reliance on a teacher or parent. Self-management typically involves some or all of the following components: self-evaluation of performance, self-monitoring, and self-delivery of reinforcement. Ideally, it includes teaching the child to monitor his/her own behaviour in the absence of an adult.

This therapy uses a self-management treatment package to train school-age children with autism to engage in increased levels of appropriate play. In a study children displayed very little independent appropriate play before training, and typically engaged in inappropriate or self-stimulatory behaviour when left on their own. With the introduction of the self-management training package, the children increased their appropriate play in both supervised and unsupervised settings, and across generalization settings and toys. Decreases in self-stimulatory and disruptive behaviours were maintained in the unsupervised environments.

The study shows preschool-age students using self-management training learned new activities using favorite toys that typically required assisted play. Children were prompted to engage in new behaviours with the toys, and were asked to take a token whenever they displayed a variation in the target behaviour. All the children exhibited increases in variability of play after self-management training, with the behaviour maintaining at a 1 month follow-up. Self-monitoring procedures have also been used to increase social initiations while reducing disruptive behaviour and to increase independent interactions with typical peers.

Video Modelling

Video modelling, like in vivo modelling, uses predictable and repeated presentations of target behaviours; however, these behaviours are presented in video format, thus reducing variations in model performance. Video modelling has been shown to improve various skills in individuals with autism, including conversational speech: verbal responding, helping behaviours, and purchasing skills. This medium has also been claimed to increase vocabulary, emotional understanding, attribute acquisition, and daily living skills.

Video modelling interventions have used both self-as-model and other-as-model methods. In the first performance, individuals act as their own models, and the video is edited so that only desired behaviours are shown. The second and perhaps more essential method of video modeling employs taping other individuals, typically adults or siblings, performing target behaviours.

Video self modeling has been theorized to be more effective than traditional video modeling because it may promote increased attention from the individual, although factual studies have not substantiated this claim. Applications of video modeling as an intervention technique are now being extended to teaching and increasing play in children with autism.

ABA (Pivotal Response Treatment) Used At the Clinic

The clinic can recommend or train ABA therapists and/or parents as required. ABA is the best method for managing undesirable and aberrant Autistic behaviours such as: self-injurious, repetitive, ritualistic, aggressive and disruptive behaviours. ABA can extinguish these behaviours, and promote alternative pro-social behaviours simultaneously. ABA is helpful in teaching academic, social and life skills (for example, shopping or work skills). The process of ABA is successful as it breaks complex tasks into smaller parts making them less daunting for the child. The proper application of behaviour modification principles also prevents behaviours from becoming problematic. ABA can also be used to train a child to learn a new adaptive behaviour, such as dressing and toileting and to promote functional communication.

All behaviours, whether they are being observed or taught, can be broken down into 3 parts;

• Antecedent (A) - what triggered a behaviour or what happens before the behaviour,
• Behaviour (B) - the behaviour itself, and
• Consequence (C) - what happens after the behaviour.

The consequence is whatever the behaviour accomplishes, for example it can be getting attention (negative or positive) or relief of stress. The consequence is not always obvious, especially in the case of stimming behaviour (odd behaviours the child does such as arm flapping or repetitive actions), which is why keeping data is helpful to identify what the function of the behaviours are, as well as what triggers them.

ABA Assessment

During ABA assessment, the Autistic child’s behaviors are carefully observed to assess:

• exactly what behaviours are performed by the child
• when these behaviours are performed
• at what rate the behaviours are occurring
• what happens before and after the behaviours.
• what purpose does the behaviour serves

Skills that are to be promoted are broken down into small sequential steps. The ABC principles of behaviour intervention are used to teach the child each step, :

• A (antecedent) – Each instruction is given clearly, in as few words as possible. Assistance is provided; for example prompting through demonstration or physically guiding.
• B (behaviour) – An appropriate behaviour is observed,
• C (consequence)– A consequence is an outcome that will reward the child and increase the likelihood that the behavior will be repeated again in the future, also called a positive reinforcer.

This "ABC" process is repeated frequently for each behaviour both in structured teaching situations and in the course of everyday activities using PRT techniques.

1. Instructions are given to emphasise metacognition (learning how to learn). In this case learning how to listen, to watch, to imitate, to ask and do.
2. As the child's learned behaviours improve, the structured guidance is systematically reduced and the prompts are used less frequently and eventually faded out. This so that the child learns to perform the trained behaviour independently.
3. It is also important to change the context of teaching (different people giving the antecedent, more people around, different situations, etc.) in order to generalise the learned behaviours.
4. When each behaviour consisting of single sequential steps are acquired, the person is taught to combine them to produce more complex behaviours.
5. Problematic behaviours are not reinforced, instead the child is consistently redirected to engage in appropriate behavior.
6. The child’s responses during each step is meticulously recorded. The information is later used to determine if the child is progressing at an acceptable rate. If progress is not satisfactory, the learning steps are analysed for possible flaws and the program modified.

The ABA Therapist

ABA therapy is highly intensive and requires the therapist to be pleasant, knowledgeable, consistent, patient and empathetic. In addition, the therapist must be capable of objectively observing and analysing the behaviours, design appropriate ABC steps and implement them effectively.

• A psychologist at the clinic designs an ABA program and monitors its application by parents and therapist
• The behaviour of the ABA therapist should also be observed regularly. Initially to train the therapist and then less frequently and as needed to ensure that ABC procedures are being applied correctly and safely.
• Recording the behaviours of both the child and the therapist is useful.
• There must be empirical observed evidence that the program is working.
• Even experienced behavior therapists need this form of feedback.
• The recorded data informs us about the effectiveness of the procedures applied, and how to improve the effectiveness of the intervention and allows the intervention to adapt as the child grows and changes.

Key Benefits of Pivotal Response Treatment

• Promotes generalisation of skills to untaught areas.
• Increases motivation.
• Enjoyed by the child, therapist and parents.
• Useful for managing behaviours and teaching new ones
• Reduces undesirable behaviours
• Promotes better and more functional communication

Final Comments

• ABA can be extremely labor-intensive and expensive and may continue for years.
• Parents and therapists should be taught PRT and consistently apply it's principles, to increase the effectiveness of ABA intervention and reduce cost.
• ABA may be a part of the treatment program which should also include Biomedical intervention.