Research Publications for PRT
Recent Publications
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2014
This article reviews the available literature on group-based social skills interventions for adolescents with autism. Forty-four studies were identified that were published in peer-reviewed journals. While each identified treatment utilized a group format, there was significant heterogeneity among the implemented procedures and evaluative methods. Studies were compared on a number of dimensions, and trends in the field were identified. The findings suggest that there is significant evidence for the usefulness of social skills groups as an intervention for adolescents with autism, and the evidence base is rapidly growing. In addition to a summary of the existing literature, recommendations for areas of future research are identified.
Individuals with autism spectrum disorders often exhibit difficulties with reciprocal social conversation, engaging in limited verbal exchanges, even when language structures are intact. This study employed a multiple baseline design to examine the effectiveness of a self-management intervention targeting (1) on-topic responsiveness to a conversational partner; (2) expansion of the conversational topic; and (3) on-topic question asking. Results demonstrated improved reciprocal social conversation through elaborated responses and on-topic question asking, which generalized and maintained. Social validity measures by naı¨ve observers indicated that theintervention led to meaningful improvements during conversation, including interest, naturalness, and desirability as a conversational partner.
An important line of research relates to whether school personnel, such as paraprofessionals, who are present during unstructured social periods, such as lunch-recess, could successfully implement interventions to improve socialization between students with ASD and their typical peers in a group setting. Therefore, within the context of a multiple baseline across participants design, we assessed whether training paraprofessionals to provide social interventions would enhance social development in students with ASD in a group setting. Results showed that paraprofessionals who were not providing any social opportunities during baseline were able to meet fidelity of implementation following a brief training. Consequently, the children with ASD increased their levels of engagement and rates of initiation with typically developing peers following intervention. Implications for training paraprofessionals to implement effective social interventions for students with ASD are discussed.
There has been a dramatic rise in the number of children being diagnosed with autism spectrum disorders (ASD), which has led to increased attention paid to assessment and intervention issues. This manuscript agrees with Camarata (2014) that the evidence base for early assessment and intervention should be expanded. However, it disagrees with Warren et al.'s (2011) assumption that there are not empirically validated early interventions. Reliable diagnosis has been documented during infancy and toddlerhood, and evidence suggests that the earlier the onset of intervention, the greater likelihood of an improved developmental trajectory. It is argued that early intervention is more cost and time efficient than a "wait and see" approach. With regard to published studies, the large amount of heterogeneity in the ASD population supports the use of rigorous single case experimental design research. It is an error to limit empirical evidence for treatments to only randomized clinical trials, which have the weakness of masking individual differences. Single case experimental designs examine the effects of intervention beyond typical maturation by allowing for clear estimations of developmental trajectories prior to the onset of intervention, followed by evaluation of the impact of the intervention. This commentary discusses the short- and long-term benefits of early diagnosis and intervention.
Social initiations make up a core deficit for children with autism spectrum disorder (ASD). In particular, initiated questions during social interactions are often minimal or absent in this population. In the context of a multiple baseline design, the efficacy of using the motivational procedures of Pivotal Response Treatment to increase social question-asking for three young children with autism was assessed. Results indicated that participants initiated a greater number of targeted questions following intervention. Additionally, all children exhibited increases in initiation of untargeted questions during social interaction in novel settings. Furthermore, post intervention data revealed collateral gains in communication and adaptive behavior. Theoretical implications of incorporating motivational strategies into intervention to improve social initiations in young children with ASD are discussed.
2013
Empirical studies have documented a variety of social abnormalities in infancy that indicate risk for later social and behavioral difficulties. There is very little research illustrating the presence of such behavioral vulnerabilities with frequent repeated measures, and the feasibility of designing interventions for improving social engagement in infants less than 1 year of age. In the context of a multiple baseline research design, three young infants, ages 4, 7, and 9 months, referred for concerns about social engagement were assessed for affect, social interest, eye contact avoidance, and response to name. In addition, the feasibility of implementing an intervention to target social behaviors was examined. Results demonstrated that (a) consistently low or erratic levels of social behavior were evident throughout the baseline assessment period, (b) these patterns could be improved with a brief intervention (a modified Pivotal Response Treatment) showing an immediate increase and stability of social engagement, and (c) social engagement remained at a stable and high level at follow-up. The results are discussed in terms of implications of early assessment and intervention for clinical populations, including infants with autism spectrum disorder.
There has been a paucity of research on effective social interventions for adolescents with autism spectrum disorders (ASD) in inclusive high school settings. The literature, however, suggests that incorporating the student with ASD's special interests into activities may help improve their socialization with typical peers. Within the context of a multiple baseline across participants design, we implemented lunchtime activities incorporating the adolescent with ASD's preferred interests that were similar to ongoing activities already available at the schools. Results showed this increased both level of engagement and their rate of initiations made to typical peers. Social validation measures suggest that both adolescents with ASD and typical peers enjoyed participating in these activities and that the results generalized to other similar activities.
Difficulties engaging in social activities are considered to be a core symptom of individuals with autism spectrum disorder (ASD). Both the literature and our clinical observations suggest that most individuals with ASD have a desire to engage in social activities, but social skill deficits make social interaction challenging, and in turn can lead to feelings of loneliness and isolation. Currently there are few resources to support adult students with ASD in forming friendships and involvement in the college community. Using a multiple baseline design over a 33-week period, this study evaluated the effectiveness of structured social planning for college students with ASD. Intervention included weekly sessions that included providing step-by-step social planning related to their interests, and feedback regarding their participation in social activities. In addition, training in specific organizational skills was implemented, such as determining activities, using a planner to ensure participation in the activities, inviting peers to activities, arranging for transportation, and so on. Results demonstrated that participants were not attending any social events throughout the baseline period. Following intervention, all participants increased the number of social events attended per week. Further, quality of life and satisfaction questionnaires all reported a higher satisfaction with their college experience and peer interactions following intervention. Finally, improvements were seen in other untargeted areas, including increases in non-structured social interactions, improvements in grade point averages, and employment. Results are discussed in regards to a creating a social support program for college students with ASD.
Prescription medications are commonly used for children with autism spectrum disorder (ASD), however, there is little research regarding how the effect of medication is monitored across settings once prescribed. The present study addressed this issue for children with ASD in school by administering a questionnaire to teachers of students with ASD who were and were not being given medication. Specifically, the questionnaire assessed the teachers' knowledge about whether the child was being given medication, and whether behavior changes or side effects were being communicated in any way to the child's family and prescribing physician. The results showed that for children who were being given medication, fewer than half of the teachers reported knowing the child was being given medication. For those children who were not being given medication, only 53% of the teachers reported correct information for their students. Of the teachers who knew their students were being given medication, all reported that they were not conferring with the child's prescribing physician regarding behavioral observations or side effects. Whether teachers are blind to the medication types and dosage the students are being given or not, some type of communication to physicians about the children's behavior at school is important. Given the importance of monitoring medication for children with ASD, implications for system change, for professionals and for funding agencies are discussed.
Verbal initiations, such as questions, are essential components of social conversation often lacking in children with autism. Building on research showing that single questions can be taught in isolation, this study used a multiple baseline design to investigate whether a self-management intervention was effective for teaching concurrent acquisition and discrimination of three social questions in the context of conversation. Following intervention, participants rapidly increased their appropriate use of all three questions in a conversational context and maintained these gains over time. The participants also used questions appropriately with partners uninvolved in treatment. Additionally, the occasional presence of appropriate questions during baseline coupled with rapid improvement during intervention support theories that a lack of question-asking may be motivation-based rather than ability-based.
2012
Pivotal response treatment (PRT) is an empirically validated behavioral treatment that has widespread positive effects on communication, behavior, and social skills in young children with autism spectrum disorder (ASD). For the first time, functional magnetic resonance imaging was used to identify the neural correlates of successful response to PRT in two young children with ASD. Baseline measures of social communication, adaptive behavior, eye tracking and neural response to social stimuli were taken prior to treatment and after 4 months of PRT. Both children showed striking gains on behavioral measures and also showed increased activation to social stimuli in brain regions utilized by typically developing children. These results suggest that neural systems supporting social perception are malleable through implementation of PRT.
Inflexibility is a major characteristic of autism. In the present study we addressed inflexible mealtime behaviors and collected longitudinal data across 48 foods for 3 children, ages 6.4-7.8 years, diagnosed with autism spectrum disorder, for up to 22 weeks. Participants exhibited severe challenges with adherence to an extremely restricted repertoire of foods. We employed clinical replication and multiple baseline designs across participants to assess the effects of individualized reinforcement and hierarchical exposure to increase flexibility. Results showed that following intervention, all participants expanded their food repertoire and spontaneously requested new foods during follow up/generalization. Implications for clinical practice and directions for further research are discussed.
The social vulnerabilities associated with young children with autism are recognized as important intervention targets due to their influence on subsequent development. Current research suggests that interventions that combine motivational and social components can create meaningful changes in social functioning. Simultaneously, it is hypothesized that parent delivery of such strategies can invoke increases in these core social behaviors and parent engagement. This study examined the effects of teaching parents to implement a social engagement intervention with their children. The results indicated that the use of this parent-delivered social intervention led to (a) increases in their children's use of eye contact, directed positive affect, and verbal initiations, (b) increases in parent positive affect and synchronous engagement, and (c) generalized increases in parent and child behaviors.
Social engagement by children with autism spectrum disorder (ASD) in unstructured school settings generally occurs at very low levels, if at all. Although many interventions improve peer socialization, generalization and maintenance of such gains when interventions are faded are typically low. The present study employed a multiple baseline design across participants to target generalization in the absence of interventionists in elementary school children with ASD at recess. Teaching initiations has been suggested as one method to increase generalization. The results of the present study showed that when initiations were targeted during intervention for social play, the participants demonstrated generalized peer social engagement, increases in unprompted peer-directed initiations, and more positive affect during peer interactions. Results are discussed in terms of theoretical and applied implications of incorporating initiations training into social interventions.
Research suggests that incorporating the circumscribed ritualistic interests of children with autism as a theme of activities can improve their socialization. The current study assessed whether socialization would improve if more general interests of children on the autism spectrum that would also be of interest to their typical peers were incorporated into activities. Three children with autism, who were included in regular education classes but did not seek out or interact with peers prior to intervention, participated. Data were collected in the context of a multiple baseline across-participants design, with a reversal for one child. Activities that were identified to be of interest to the study participants and their typical peers were implemented as clubs twice weekly during regular lunchtime periods. Results showed that all three children demonstrated large increases in their time engaged with peers as a result of the activities, with minimal training of the interventionist and without any specialized training of the children with autism or their peers. Furthermore, their untargeted verbal initiations greatly improved over baseline levels and often approximated the levels of their peers. Implications for further improving peer social interactions for children with Autism Spectrum Disorder are discussed.
The literature suggests that adolescents with Autism Spectrum Disorders (ASD) typically are not socially engaged during unstructured school activities and do not initiate social activities with typically developing peers. This study assessed whether implementing socialization opportunities in the form of lunch clubs based around aspects of the adolescents with ASD's perseverative interests would promote positive and direct social interaction between the target adolescent and their typically developing peers. A repeated measures multiple baseline experimental design (with two reversals) was implemented across participants. During baseline measures, the participants did not show social engagement or initiations. During intervention, results showed large increases in both social engagement and initiations. These results have implications for understanding variables related to social development in autism.
2011
Students with ASD present unique challenges to school systems. Despite these challenges, federal laws require that schools implement research-based practices in the least restrictive environment (LRE). The LRE is often deemed to be the general education classroom and the primary intervention agent is often the classroom teacher. Ensuring students with ASD receive effective intervention in these least restrictive and inclusive school settings will depend, in part, on the extent to which teachers and school personnel are prepared to implement research-based interventions. The purpose of this article is to provide a summary of research-based interventions for students with ASD. Our focus in this summary is on interventions that can be implemented in inclusive school settings by teachers and classroom support personnel. We first provide a general overview of interventions designed to reduce challenging behavior, teach communication skills, and improve social relationships. This is followed by a discussion of the obstacles to intervention implementation that may be present in school settings. Finally, we conclude by offering a list of intervention guidelines.
2010
The Nova Scotia early intensive behavior intervention model-NS EIBI (Bryson et al., 2007) for children with autistic spectrum disorders was designed to be feasible and sustainable in community settings. It combines parent training and naturalistic one-to-one behavior intervention employing Pivotal Response Treatment-PRT (R. Koegel & Koegel, 2006). We followed 45 children (33 males, mean baseline age = 50 months) for 12 months. Mean gains of 14.9 and 19.5 months were observed on expressive and receptive language measures, respectively, for children with an IQ of 50 or more at baseline versus 6.1 and 8.4 months for children with IQs less than 50. Behavior problems decreased significantly over the 1-year treatment for both groups, but autism symptoms decreased only for those with an IQ of 50 or more.
Studies involving physical exercise and individuals with autism spectrum disorders (ASD) were reviewed. Systematic search procedures identified 18 studies meeting predetermined inclusion criteria. These studies were evaluated in terms of: (a) participant characteristics, (b) type of exercise, (c) procedures used to increase exercise, (d) outcomes, and (e) research methodology. Across the corpus of studies, exercise was implemented with 64 participants with ASD aged 3–41 years. A variety of exercise activities were employed (e.g., jogging, weight training, bike riding). Following the exercise interventions decreases in stereotypy, aggression, off-task behavior and elopement were reported. Fatigue was not likely the cause of decreases in maladaptive behavior because on-task behavior, academic responding, and appropriate motor behavior (e.g., playing catch) increased following physical exercise. Results suggest that programs for individuals with ASD may benefit from including components designed to incorporate regular and specific types of physical activity. Areas in need of further research are discussed.
Objective: To review studies involving the treatment of anxiety in people with autism spectrum disorders (ASD) using Cognitive Behaviour Therapy (CBT) with the intent to inform practice and to identify areas for future research.Methods: Systematic searches of electronic databases, reference lists and journals identified nine studies. Each identified study that met pre-determined inclusion criteria was analysed and summarized in terms of: (a) participants, (b) intervention procedures, (c) dependent variables, (d) results of intervention and (e) certainty of evidence. To assess the certainty of evidence, each study's design and related methodological details were critically appraised.Results: Positive outcomes were ubiquitous, suggesting CBT is an effective treatment for anxiety in individuals with Asperger's. However, data involving other ASD diagnostic sub-types is limited.Conclusions: CBT has been modified for individuals with ASD by adding intervention components typically associated with applied behaviour analysis (e.g. systematic prompting and differential reinforcement). Future research involving a component analysis could potentially elucidate the mechanisms by which CBT reduces anxiety in individuals with ASD, ultimately leading to more efficient or effective interventions.
Many children with autism show very little interest in academic assignments and exhibit disruptive behavior when assignments are presented. Research indicates that incorporating specific motivational variables such as choice, interspersal of maintenance tasks, and natural reinforcers during intervention leads to improvements in core symptoms of autism and may possibly be effective in academic areas. Using a multiple baseline across children and behaviors design with four pre- and elementary school children with autism, we assessed whether the above variables could be incorporated into academic tasks to improve performance and interest. Results indicated that the intervention decreased the children's latency to begin academic tasks, improved their rate of performance and interest, and decreased their disruptive behavior. Theoretical and applied implications are discussed.
The literature suggests children with autism use communication primarily for requests and protests, and almost never for information-seeking. This study investigated whether teaching "Where" questions using intrinsic reinforcement procedures would produce the generalized use of the question, and whether concomitant improvements in related language structures, provided as answers to the children's questions, would occur. In the context of a multiple baseline across participants design, data showed that the children could rapidly acquire and generalize the query, and that there were collateral improvements in the children's use of language structures corresponding to the answers to the questions the children asked. The results are discussed in the context of teaching child initiations to improve linguistic competence in children with autism.
Comments on the original article, "Evaluation of comprehensive treatment models for individuals with autism spectrum disorders," by S. L. Odom, B. A. Boyd, L. J. Hall, and K. Hume (see record 2010-05204-005) and on the erratum to the same article (see record 2010-05204-006). The current authors feel the article by Odom et al as well as the erratum would have benefited from the following considerations. An important obstacle for attempts to identify an intervention is the difficulty in distinguishing prepackaged interventions from evolving scientific approaches. An important methodological weakness in such reviews is that they often imply static intervention packages are superior to individualized adaptive approaches, when, in fact, the data supporting the latter are much more plentiful and persuasive. The current authors suggest that such reviews should evaluate the empirical bases for approaches so that relevant supporting evidence is not excluded from the review.
Koegel, R.L., Koegel, L.K., Vernon, T.W., & Brookman-Frazee, L.I. (2010). Empirically supported pivotal response treatment for children with autism spectrum disorders. Weisz, J.R. & Kazdin, A.E.Evidence-Based Psychotherapies for Children and Adolescents. New York, NY, US: Guildford Press (327-344).
Autism spectrum disorders have received much attention because of both the steady rise in prevalence and the fact that the etiological basis continues to remain largely unknown. Since Kanner's recognition of autism as a distinct developmental disorder, the three defining characteristics (impairments in social interaction and communication and restricted and repetitive behaviors) have remained, although the specific diagnostic criteria have changed over the years. Early interventions, derived from speculative causation theories rather than empirical evidence, were generally ineffective in dealing with the comprehensive needs of children on the spectrum. Subsequent scientifically based treatment procedures in the 1960's used operationally defined behavioral principles and resulted in measurable improvements in several target areas of the disorder; however, the interventions proved to be extremely labor and time intensive. In an effort to improve the effectiveness and efficiency of intervention, researchers began to focus on the identification of pivotal responses. The theoretical underpinning of identifying pivotal responses was that if certain core areas were targeted, widespread collateral changes in numerous other untargeted behaviors would occur, resulting in very fluidly integrated behavioral gains. This concept of producing widespread generalized changes is also supported in the research literature in areas such as response covariation. This chapter focuses on the pivotal area of motivation for children with autism spectrum disorders, which appears to serve a particularly important role in causing widespread collateral behavioral gains in the core areas of the condition of autism as well as increasing the child's learning curve, improving parental and child affect, decreasing parental stress, and decreasing disruptive and interfering behaviors. This core area of motivation underlies other important pivotal areas such as child self-initiations discussed in this chapter. Motivation also underlies pivotal areas such as joint attention and responsivity to multiple stimulus input and self-regulation of behavior (not discussed in this chapter). In the next section, we focus on the basic core area of motivation, which appears to be pivotal to almost every area of functioning for children with autism.
There is increasing demand for access to effective interventions for families who have children with autism. Self-directed learning models have been successfully used with other populations as a way to reduce the service-need discrepancy. The purpose of this study was to evaluate, through a randomized clinical trial, whether the use of a self-directed learning program could result in changes in behavior for parents and their children with autism. Results indicated significant differences between treatment and control groups at posttest on all of the dependent measures. Furthermore, all of the parents who completed the self-directed learning program reported high ratings of satisfaction. The data suggest the efficacy and effectiveness of a self-directed learning program to serve as an initial step toward providing intervention for parents with children with autism.
2009
Though considerable progress has been made in developing techniques for improving the acquisition of expressive verbal communication in children with autism, research has documented that 10-25% still fail to develop speech. One possible technique that could be significant in facilitating responding for this nonverbal subgroup of children is the use of orienting cues. Using a multiple baseline design, this study examined whether individualized orienting cues could be identified, and whether their presentation would result in verbal expressive words. The results suggest that using individualized orienting cues can increase correct responding to verbal models as well as subsequent word use. Theoretical and applied implications of orienting cues as they relate to individualized programming for children with autism are discussed.
Children with autism often exhibit low levels of social engagement, decreased levels of eye contact, and low social affect. However, both the literature and our direct clinical observations suggest that some components of intervention procedures may result in improvement in child-initiated social areas. Using an ABAB research design with three children with autism, this study systematically assessed whether embedding social interactions into reinforcers, delivered during language intervention, would lead to increased levels of child-initiated social behaviors. We compared this condition with a language intervention condition that did not embed social interactions into the reinforcers. Results indicated that embedding social interactions into the reinforcers resulted in increases in child-initiated social engagement during communication, improved nonverbal dyadic orienting, and improvements in general child affect. Theoretical and applied implications are discussed. Adapted from the source document.
With the increasing numbers of children who qualify for a diagnosis of autism spectrum disorders (ASDs), researchers have also seen a contemporaneous increase in the number of interventions available to families of children with autism. Unfortunately, many interventions lack a sound research foundation and are minimally effective or ineffective altogether. Furthermore, research suggests that an eclectic approach to intervention for children with autism is less effective than a single, intensive, scientifically sound intervention in terms of improving cognition, language, and adaptive behavior (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005). Because the earlier that intervention starts the higher the likelihood of more positive outcomes (L. K. Koegel, 2000), ineffective and inefficient interventions can be damaging to the development of a child with autism. In short, if we are to accelerate the habilitation process during the early years, efficacious, effective, and efficient individualized interventions are critical.
Although considerable progress has been made in improving the acquisition of expressive verbal communication in children with autism, research has documented that a subpopulation of children still fail to acquire speech even with intensive intervention. One variable that might be important in facilitating responding for this nonverbal subgroup of children is the use of antecedent orienting cues. Using a multiple baseline design, this study examined whether individualized orienting cues could be identified, and whether their presentation would result in the production of verbal expressive words. The results showed that this antecedent stimulus control procedure produced improvements in responding to verbal models in all of the children, and subsequent gains in speech for some of the children. Theoretical and applied implications of orienting cues as they relate to antecedent stimulus control for children with autism are discussed.