Pivotal Response Treatment: An Overview & Case Study Items to print and post for workshop: PRT screener Fidelity form Feedback form Summary of steps Jena K. Randolph, PhD Kathleen Larocco, MEd Elizabeth Mrozowicz, PhD, BCBA, LBA

Overview Why PRT? What is PRT? Practical Impact

Children must be MOTIVATED to learn to communicate

Children Learn Through Play… & Play should be FUN!!!

Following the Child’s Lead Typical Adult-child interactions Adult-directed Child-control Adult-monitored Following a child’s lead = sharing control See what they are interested in An engaging environment will assist in keeping the child interested If the child appears disinterested or requests a change in activities- do so! This teaches valuable language

Pivotal Response Treatment Evidence Based Practice for Autism Highly effective for children with ASD ages 3-9 years Shown to improve: Social skills Communication skills Play skills

Pivotal Response Treatment Understanding Child Characteristics Profile of “Responders”: Have some established social initiation skills Have some established toy play skills Have low rates of social avoidance Have low levels of self- stimulatory behavior Responders: Have increases in language abilities and social interactions ·      participated in moderate levels of object manipulation and verbal self stim ·      Minimal rates of avoidance and minimal non-verbal self-stimulatory behavior ·      Participate in some basic toy play ·      Moderate to high rates of object manipulation, approach and verbal self- stim behaviors with low avoidance- responders (Sherer & Shreibman, 2005) ·      Meeting the cutoffs of percentage of intervals of occurrence of “responders” at least 4/5 of the screened behaviors (using partial interval) o   Appropriate toy play: 61% of intervals o   Approach – 15% o   Verbal self stim 17% o   No more than the maximum percentage of avoidance 13% o   No more than maximum for non-verbal self stim 34%

Pivotal Response Treatment Method of instruction which systematically applies the principles of Applied Behavior Analysis Direct caregivers (parents/teachers) have a critical role Majority of research on parent implementation More support is needed for classroom use Focus on developing language, play and social behaviors through child motivation Considered a naturalistic intervention Naturalistic: Providing instruction in the child’s everyday environments with common items/activities Promotes generalization and maintenance of skills Intervention can be implemented more seamlessly and therefore more likely to be implemented Child lead: Using the child’s interests and preferences to guide activities Changing focus or activity when the child is not engaging This does not mean the child is in control of the environment and can engage in inappropriate behavior

Pivotal Behaviors PRT targets pivotal behaviors, meaning they are thought to have larger impact and change across other domains: Motivation Responding to Multiple Cues Self-Management Self-Initiations Today we are focusing on the first two, Motivation and Responding to Multiple Cues- as these are the core PRT procedures that are utilized in the evidence base to target social, communication and play skills.

General Strategy Communication elicited by adult or environment Embedded into natural social/play routines The adult creates a situation to elicit communication Communication elicited by adult or environment Child responds Adult provides natural consequence Antecedent Behavior Consequence

Beginning to Implement Arrange the environment: Make it interesting to the child Keep preferred materials in sight but out of reach Make it easy for the adult to regain control if needed Plan for strategies to get the student to communicate with you “Gatekeeper” of materials Portions of materials Sabotaging the routine

Beginning to Implement Identify preferred activities/toys that the child is interested in The adult SHARES CONTROL of preferred toys Create opportunities with materials: Multiple activities and toys planned for and ready to use Items that can be used in several ways Variety of shapes/colors/sizes Break toys into multiple parts

Components of PRT Gain Attention Shared Control Responsivity to Multiple Cues Intersperse Maintenance Tasks Contingent Response to Behavior Reinforce Attempts Direct Response-Reinforcer Relationship

Gain Attention

Gain Attention We want to do this in the least intrusive way possible: Pause activity Position object or self in line of sight Make an expectant noise Tap shoulder Physically interrupt line of sight Say “look” Call name Regain control of object prior to statement Least Intrusive Most Intrusive

Shared Control

Sharing Control What activity to play Where to play the activity Consider two strategies: Providing choice (between and within activities) Taking turns with items/activities By doing this you: Enhance child motivation in participation Expand play scheme and flexibility in activities Big choices: What activity to play Where to play the activity Smaller choices How to engage with the objects (e.g., throw or roll the ball) Color of materials Be aware, at times it is not appropriate or not possible to follow the child’s lead-redirect to an appropriate activity Under no circumstances should the child be allowed to engage in an activity that is hazardous (aggression, self-injury) or unacceptable because it is inappropriate (self-stimulation, compulsive rituals). In these circumstances the implementer must assume control until the child is able to assume appropriate control

Shared Control Shared control primarily includes: Taking turns Short turn with resistant turn-takers Discontinue if unable to build in short turn (highly preferred items) Providing choice Using shared control Enhances student motivation in participation Expands play scheme and flexibility within play

Response to Multiple Cues

Response to Multiple Cues Multiple components, draws awareness to and work towards response to more units within the environment Examples: Colors red pen, v. red crayon or blue pen Size big bubble v. little bubble Speed fast car v. slow car Embed into play activities Steps: Adult labeling in environment Work towards receptively responding (first without distractors then with distractors) Encourage child expressive use of cues Color Shape Size Texture Quantity Quality Specific position/ location (e.g., sticker on bottom)- not “here or there” Speed (fast/slow) Children are more likely to learn to respond to these cues when they are used

Reinforcement: Contingent Direct Reinforce Attempts

Contingent to Behavior Reinforcement MUST be contingent upon the correct behavior or attempt The response must be: As immediate as possible after the child’s response Appropriate to the response Dependent upon the response Reinforce immediately for correct responses or attempts

Reinforce Attempts Honor attempts to initiate and to respond to questions or instructions Must be a “reasonable attempt” Child’s attention is directed to the task The attempt is related to the task Used a reasonable amount of effort (at the child’s level of ability)

TO SUMMARIZE PRT COMPONENTS… The question/ instruction/ opportunity to respond should be… 1. Clear, uninterrupted, and appropriate to the task 2. Interspersed with maintenance tasks 3. Chosen by the child 4. Include multiple components And the reinforcer should be…. 5. Contingent upon behavior 6. Administered following any attempts to respond 7. Related to the desired behavior

Putting It All Together Embedded into natural social/play routines -Set-up environment -Gain attention -Share control with choices and turns -Use multiple cues Child is motivated to play and communicate Actively engaging with you -Reinforce what they ask for -Reinforce attempts and expand Antecedent Behavior Consequence

Practical Implications

Training Process

Training Process Training and Feedback 2 hour overview training (in person) Weekly session: Observe 10-minute independent PRT session 10 minutes of feedback and modeling with student Fidelity: 3 consecutive sessions at 80% or higher or 3/4 consecutive sessions at 80% (no session below 70%) One monthly 10 minute follow up session

Feedback Process Coding sessions based on specific definitions (all staff trained and reliable) Educators given feedback on each of the targeted components and general session structure Percentage of fidelity reported to educator

Training Model Graph here showing after Change Average to 4.8 sessions

Outcomes

Child Benefits See child progress Social-communication Engagement Increase in their use of descriptive language Social attention Engagement Increased engagement Decreased behavior Willingness to engage AND sustain engagement

Case Example #1

Case Example #2

More Child Benefits Reduction in restrictiveness of programming Amount of cues/redirections needed decreases Independence increases Child is continuously provided a language model Increase in child’s self-esteem / excitement

Team Benefits Foundational Naturalistic Intervention ESDM Forms stronger relationship with child More reinforcing for staff child gives more back Confidence in their skills Teachers share strategies/successes together Everyone is using the same language

More Team Benefits Training both teachers & paraprofessionals Teachers have tools to train paraprofessionals when turnover occurs Makes classroom “downtime” meaningful Cost Easily generalizable Across activities Small group/large group

Challenges When teacher doesn’t specify to the team WHEN to use PRT Challenging for staff who have foundation in DTT (at first) Coaching can be uncomfortable Not having ENTIRE team trained SLP, OT Child characteristics can make it challenging to get to fidelity Decreases staff motivation

Contact Information For questions or more information, please contact the Thompson Center TEAM Program: Louis Nevins, Staff Specialist (573) 884-1619 NevinsLP@health.missouri.edu

Thank you! Questions?