Child Language Teaching and Therapy

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Using pivotal response training to facilitate appropriate play in children with autistic spectrum
disorders
Aubyn C. Stahmer
Child Language Teaching and Therapy 1999; 15; 29
DOI: 10.1177/026565909901500104

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Using pivotal response training to
facilitate appropriate play in children
with autistic spectrum disorders
Aubyn C. Stahmer
Children’s Hospital and Health Center, San Diego, California

Introduction

Research examining symbolic play in children with autism indicates that

these children exhibit severe deficits in play skills and play complexity (e.g.
Wing et al., 1977; Jarrold et al., 1993). These children are deficient in
appropriate use of toys and have specific impairments in symbolic and
sociodramatic types of play which involve complex symbol use and social
interaction (e.g. Baron-Cohen, 1987; Stahmer, 1995). Children with autism
rarely engage in the types of creative, spontaneous play activities exhibit-
ed in typically developing children. They may engage in repetitive actions
with toys or become obsessive with them or use toys in stereotyped ways
such as acting out a scene from a favourite movie. Because play skills are
important to social integration, and have been correlated with language,
social skills and general cognitive functioning (e.g. Bates et al., 1979;
Sigman and Ungerer, 1984), it is important that children with autism, like
typically developing children, understand and participate in play.
Although there is overwhelming evidence that children with autism are
deficient in their spontaneous use of complex play skills, there is evidence
that children with autism may engage in higher levels of play (such as sym-
bolic play) when it is elicited either verbally or through modelling (Lewis
and Boucher, 1988; McDonough et al., 1996). Autistic children’s lack of
spontaneous play in free play settings is not, therefore, the result of a com-
plete inability to play, but may be due at least in part to the fact that chil-
dren with autism find play difficult, so they experience repeated task
failure. This in turn would lead to frustration and the pervasive lack of
motivation to play which we see in these children (e.g. Schreibman, 1988;
compare also Churchill, 1971; Koegel and Egel, 1979).

Address for correspondence: A. Stahmer, Children’s Toddler School, 3020 Children’s Way MC5042,
San Diego, CA 92123, USA.

© Arnold 1999 0265–6590(99)CT170OA

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30 Child Language Teaching and Therapy

Research suggests that increasing motivation has a dramatic effect on

children’s learning (e.g. Koegel and Mentis, 1985), and a training tech-
nique called pivotal response training (PRT) has been developed to
increase motivation in children with autism (Koegel et al., 1987). In PRT
the child is allowed to choose activities, they are provided with multiple
exemplars of the behaviour to be acquired within their chosen activity, and
they are systematically rewarded using natural reinforcers. Easy-to-achieve
maintenance tasks are interspersed with tasks involving new learning in
order to maintain the child’s experience of success. PRT has been widely
used to increase the motivation to acquire language skills in children
with autism (Koegel et al., 1987). More recently the technique has proved
to be extremely successful for increasing manipulative play (Stahmer
and Gist, 1997; Stahmer et al., 1998), symbolic play (Stahmer, 1995), and
sociodramatic play (Thorp et al., 1995) in children with autism. Other
behavioural programmes used for teaching play skills to children with
autism have tended to use a limited number of specific scripts and toys.
This has made generalization and maintenance of new skills difficult. This
technique is structured to assist children with understanding expectations
and increasing skill acquisition. The use of multiple examples and
natural reinforcers in PRT is designed to facilitate skill generalization
and maintenance.

Using PRT to teach play skills

PRT has provided interventionists with a naturalistic training method

that has proven structured enough to help the children learn complex
play skills, while still being flexible enough to allow the children to remain
creative in their play.
The following describes the PRT procedures used to facilitate play.

1) Clear instructions and questions. The play task is made clear to the child.
For example, the therapist might ask the child what could be done with
a particular toy. Modelling and the use of maintenance tasks (tasks the
child has already mastered) are used to clarify new tasks early in train-
ing. Care is taken to ensure that the child is attending to the therapist
and the training materials (e.g. Schreibman and Koegel, 1981).
2) Interspersal of maintenance tasks. Maintenance tasks which require
children to play at levels within their competence are interspersed
with training on new tasks which require the child to play at more

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 Using PRT to facilitate appropriate play in autistic children 31

advanced levels. This maintains the child’s experience of success, and

is consistent with the fact that typically developing children do not use
one type of play to the exclusion of another but instead tend to use
a mixture of play levels during any given play time.
3) Child choice. The child is allowed to choose the toys to be used in
training, and this enhances motivation and performance. In our
research we have found that children with autism will change their
choice of toys at a rate similar to that of typically developing children
(Stahmer, 1993). A variety of toys that support the type of play being
taught should be available. However, child choice only works up to a
point, and the therapist may provide a particular set of toys to choose
from if he or she is focusing on training a specific play skill. If a child
has a short attention span and tends to wander from toy to toy rather
than engage with any one toy or set of toys in extended play, the child
may be asked to play ‘one more time’, or they may be required to
clean up when they are finished, which often encourages children to
continue playing with the toy they are currently engaged with.
4) Direct reinforcement. The child’s choice of toys is used to reinforce the
child’s attempts at more advanced levels of play. For example, if a
child chooses to play with a train and track they might be required to
place a doll in the train, or wash the train before being allowed free
play with the train and track. Quite often, especially early in training,
children will revert to stereotyped or repetitive behaviour with a toy
(e.g. spinning the wheels of the train). This type of self-stimulatory
behaviour can be a powerful reinforcer and can be allowed for short
periods of time. However, as the child progresses in ability, more com-
plex play is required before self-stimulatory play is permitted. We have
found that as children become accustomed to performing more com-
plex play actions, they incorporate them into their play spontaneously
and self-stimulatory behaviour is reduced (Stahmer et al., 1999).
5) Reinforcement of goal-directed attempts. The child’s attempts at
correct responding are reinforced as well as fully correct responses,
because rewarding children for trying their best helps ensure that they
are more likely to maintain motivation at the next attempt. For
example, if a child is pretending to be a firefighter and wants to use
a hose, it would be appropriate to make water noises and point the
hose toward the imaginary fire. If the child makes the appropriate
motions but fails to use the appropriate sound effects, this would
be rewarded because the child has made an attempt at appropriate
sociodramatic play.

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32 Child Language Teaching and Therapy

6) Turn taking. The therapist takes turns performing appropriate play

actions at the child’s developmental level to provide examples as well
as to promote social interaction skills.

Appropriate candidates for PRT

Because PRT is very flexible it can be used with children of varying devel-
opmental levels. Typically, however, to begin play training a child must first
show some interest in object manipulation. Additionally, some ability to
attend to the environment and at least some capacity for imitation are both
important for play training. Children who perform best in this type of train-
ing are those children who will interact with toys (regardless of whether
they do so in an appropriate or inappropriate manner), and who do not
have an extreme amount of self-stimulatory behaviour that does
not involve objects (e.g. hand-flapping, rocking) (Sherer and Schreibman,
1998). Surprisingly, children who engage in stereotyped play with
particular toys or engage in self-stimulatory behaviour with objects are
often excellent candidates for PRT due to the presence of a very powerful
reinforcer.

Choosing a developmentally appropriate level of play

Children with autism vary greatly in the developmental level at which they
can use toys and other objects in play. Research indicates that teaching
children new plays skills which are developmentally appropriate for the
individual child is very important for acquisition of these skills. For exam-
ple, Lifter et al. (1993) found that when teaching new play skills to chil-
dren with autism, developmentally appropriate play skills tended to be
acquired quickly, to occur spontaneously, and to generalize to new toys.
This finding was contrasted with the fact that the children did not acquire
play skills that were too advanced, regardless of the number of trials in
which these activities were presented. An assessment of the child’s cur-
rent level of play is therefore important in identifying an appropriate level
at which to begin training.
There are many excellent descriptions of play development in the liter-
ature (e.g. Belsky and Most, 1981; Fein, 1981; Nicolich, 1977; Rubin et al.,
1983) as well as some more formal assessments of play development such
as the Developmental Play Assessment Instrument (DPA; Lifter et al.,

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 Using PRT to facilitate appropriate play in autistic children 33

1988) and the Transdisciplinary Play Based Assessment (Linder, 1990).

These descriptions and assessment procedures provide therapists with the
means of determining the child’s current developmental level of play, and
the appropriate level at which to begin a play training programme. Parents
and teachers may be enlisted to help determine play level by observing
their children in play both alone and with the help of an adult play
partner.
The following brief description of different play skills describes the hier-
archy of play skills in the order in which they are usually mastered by typ-
ically developing children, starting from the simplest forms of play and
working upwards.
Manipulative play skills are some of the first play skills a child learns.
Manipulative play often results in interesting visual and sensory stimula-
tion, for example, playing with a busy box or with bubbles, and for this rea-
son manipulative play is often the easiest type of play to teach a child who
has autism. Manipulative play also includes more advanced play skills such
as completing puzzles or colouring, and some children with autism may
progress to these more advanced manipulative skills before attempting
other forms of play.
Functional or representational play skills usually develop next, and
include play in which a child uses realistic objects, or miniature repre-
sentations of objects, in ways appropriate to their function. For example,
a child might place a toy tea-cup on a saucer or a spoon to a doll’s mouth.
A child with autism may show readiness for functional play training
through understanding relationships in the real world. For example, the
child may know what objects go together when setting the table, or be able
to sort objects by category such as colour or shape.
Symbolic play is play in which a child pretends one object is another (e.g.
a block is a cookie) or that an object has pretend properties (e.g. a toy
stove is ‘hot’), or that an absent object is present (e.g. eating a pretend
biscuit). Children are ready to learn symbolic play only after they have
been producing functional play regularly, and usually not until they have
an expressive vocabulary of at least two years. Symbolic play is one of the
more difficult types of play for children with autism to learn, as it requires
the capacity to use abstract concepts. Advanced symbolic and functional
play include putting steps together with the toys (using ‘scripts’), for exam-
ple cooking dinner, eating it, washing the dishes and so on.
Sociodramatic play is an advanced form of symbolic play in which chil-
dren engage in role taking and the development of a story, using object
substitution, imaginary objects, etc. Children with autism who have some

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34 Child Language Teaching and Therapy

symbolic play and who have expressive language at about the four-year-
old level should be ready for sociodramatic play training.
Interactive play skills should be taught at each level of play. Symbolic
and dramatic play often involve interaction with others. However, games
such as board games, playing ball, etc. also involve interactive play and can
be introduced to children whose play is at almost any level. Some children
may not understand the exact rules of a particular game but they may still
enjoy the participation and learn from the interaction.

Examples of play training using PRT

Once the therapist has determined the child’s level of play readiness PRT
can begin. The following are examples of using PRT to teach play to chil-
dren with varying levels of play skills. The examples go from least difficult
to most complex. However, it should be borne in mind that simpler types
of play continue to be practised throughout training, as children progress
from simpler to high levels.
Manipulative play. A child is playing in the sandbox, repetitively watch-
ing sand sift through his fingers. The therapist hands the child a shovel.
If the child does not respond, the therapist models digging with a shovel.
If the child still does not respond the therapist might help the child use
the shovel to put sand in a bucket. After a response (or a goal-directed
attempt such as picking up sand with the shovel but not putting it in the
bucket) the therapist rewards the child by allowing the child to return to
sifting the sand for a short period. The therapist can then repeat the
same action or do something different such as use a toy to sift sand, place
a bucket under the child’s hand so sand sifts into the bucket, build a
sandcastle, and so on.
Functional/representational and symbolic play. During functional play
training a child may choose to play with toy cars and a garage. The
child might be asked ‘show me what you can do with these toys’. The child
would be expected to drive the car into the garage, or to put ‘gas’ in the
car if there was a gas pump on the garage toy. If the child did not respond
the therapist would drive the car into the garage and make car sounds and
then return the car to the child. If the child still did not respond the ther-
apist might assist the child with moving the car into the garage. When the
child did respond (either independently or with assistance) the entire car
and garage set are given to the child to play with. In symbolic play a sub-
stitute object might be used, such as a block for a car, or pretending to

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 Using PRT to facilitate appropriate play in autistic children 35

wash the car with a block as sponge or a string as a hose. If the child makes
an attempt at appropriate symbolic play, for example, makes a ‘zoom’
noise and pushes the block along the floor, but does not wash the car after
being asked to do so, he or she may also be reinforced for the attempt.
As the child improves at one level of play he or she is expected to engage
in more complex play. For example, the child may choose to play with a
play house and people. The child may be prompted to wake the people
up from sleep, use a meaningless object to brush their teeth, set them down
for breakfast and use a meaningless object as food, and have the dolls
clean up the meal, before being allowed free access to the toys.
Sociodramatic play. Once the child has mastered symbolic play, socio-
dramatic play can be taught. For example, if the child expresses interest
in playing with a kitchen set, he or she would be encouraged to (1) devel-
op a play theme related to these toys (i.e. cooking dinner), (2) adopt a role
appropriate to this play (e.g. restaurant owner) and (3) assign a compli-
mentary role to the therapist (e.g. customer). Ensuing play would be inter-
active, and would develop these roles in the chosen play theme. The
therapist may prompt the child to assume the presence of an imaginary
character (i.e. a waiter), or to involve a doll in play (e.g. as another cus-
tomer in the restaurant). Play themes the child has already mastered would
be interspersed with novel plots to ensure success for the child.

Outcomes of play training

Our research indicates that PRT can increase play skills in children with
autism of varying ages and developmental levels, and that parents as well
as therapists can be successful at using these techniques. Types of play that
have been taught using these methods include manipulative play
(Stahmer and Gist, 1997; Stahmer et al., 1998), functional and symbolic
play (Stahmer, 1995) and sociodramatic play (Thorp et al., 1995). The best
researched are symbolic and sociodramatic play skills, as these are the
most difficult for children with autism.
Stahmer (1995) studied the use of PRT to teach symbolic play skills to
children with autism with language skills of at least two-and-a-half years. The
children in the project rarely exhibited any symbolic play before training or
after a control condition (PRT language training). After eight weeks of PRT
training (consisting of three one-hour sessions per week) all of the children
learned to perform complex and creative symbolic play actions at levels sim-
ilar to that of language-matched typically developing peers. In most

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36 Child Language Teaching and Therapy

instances skills generalized well to new toys and new settings as well as to
play with their parents and play skills were maintained over a three-month
follow-up period. The children were quite creative and flexible in their play
and did not appear to mind variation or interruption in their play themes.
They developed new themes of their own, and used as many unique play
actions as did the typical controls. Training also increased children’s inter-
action skills. The children began responding more positively to initiations
made by adults during the play sessions. These types of increases in play and
interactions skills were not seen after language training alone. Residual dif-
ficulties included a continued lack of interaction during play with peers and
very low levels of initiations by the children with autism to peers or adults.
Thorp et al. (1995) used PRT to teach more complex sociodramatic play
skills. The children in this project had vocabulary levels of at least four years
and were exhibiting some symbolic and functional play in their repertoire.
Two of the children had already received symbolic play training using the
same procedures. Results were similar to that of Stahmer (1995) in that
the children learned to engage in spontaneous, creative sociodramatic play
and these skills generalized to new environments and toys, and were main-
tained during the follow-up period. The children were very creative in the
development of new characters and themes as well.
Recent research has been looking into using these strategies to teach
new play skills to children who have very stereotyped or repetitive play.
The focus of one current project is to utilize as reinforcers the
toys/objects the child is most likely to use in a stereotyped manner, and
to incorporate these items into appropriate play themes (Stahmer et al.,
1998). For example, a child who enjoyed stacking toy plates from a tea set
for up to an hour at a time learned to use the tea set to feed dolls, pre-
tend to make tea, etc. Additionally, new toys were introduced into play
during the sessions, using the tea set as a bridge (e.g. placing the tea set
into a truck and ‘shipping’ it to the store). Children were able to gener-
alize play with the newly introduced toys to play settings which did not
include the ‘bridge toys’ (in this instance, the tea set).
Another recent study demonstrated that parents can be successfully
taught to use PRT to increase manipulative and functional skills in their
children with autism and other pervasive developmental disorders
(Stahmer and Gist, 1997). Play skills were shown to have increased as a
result of centre-based PRT sessions, and the gains were maintained at a
three-month follow-up.
Although these changes in play skills in children with autism are
impressive and encouraging, some difficulties remain. For example, when

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 Using PRT to facilitate appropriate play in autistic children 37

children in the Stahmer (1995) study were rated by naive observers for
creativity, spontaneity, and ‘typical’ play, children with autism improved
significantly after play training; however, their play was still qualitatively
distinguishable from the play of the typically developing children
(Stahmer et al., 1994). Even after play training the children continued to
have difficulty playing with peers. Although play skills had increased, play
with another child did not improve. Future research will focus on having
peers themselves teach play skills, as well as investigating methods of fur-
ther improving the quality of the children’s play. The use of home-based
PRT to increase quality, play generalization, and skill maintenance will
also be further investigated.

Summary and conclusions

PRT has proven a useful tool for increasing play skills in children with
autism. This type of training may provide children with a motivating, some-
what predictable context for learning complex skills that generalize to new
settings. The training is flexible and allows the therapist to require devel-
opmentally appropriate responses based on each child’s skill level. The
level of response can be increased as the child’s developmental level
improves. PRT is an excellent technique for parents to use to increase play
skills at home. It was designed as a parent training tool to be used in the
natural environment. Most parents find the steps relatively easy to imple-
ment and enjoy being able to play successfully with their difficult-to-engage
children. Teaching play skills to children with autism may be important for
community and classroom integration and improvement of interaction and
language skills. Future research should focus on teaching manipulative
play skills to children at the very early stages of play development, train-
ing parents to use these techniques to teach play, and improving inter-
action with peers during play.

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