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SUBJECT REVIEW
Abstract Keywords
Dev Neurorehabil Downloaded from informahealthcare.com by University of Calgary on 11/01/13
Objective: Research has indicated support for pivotal response treatment (PRT) as an effective, ASD, intervention, PRT, research quality,
efficacious and naturalistic intervention for communication and social functioning of children systematic review
with autism spectrum disorder (ASD). Previously not undertaken, this article describes a
systematic evaluation of the adherence of PRT research studies to standards of ASD research History
quality.
Method: A systematic search was conducted on two databases. Seventeen PRT studies were Received 27 August 2013
evaluated on their use of seven specified research standards. Revised 12 September 2013
Results: Strong adherence to research quality standards was demonstrated in the use of Accepted 12 September 2013
standardized protocols, systematic application of intervention procedures, inter-rater reliability Published online 31 October 2013
and objective evaluators. Variation was found in adherence to treatment fidelity standards and
in the use of longitudinal designs. Only two studies implemented comparison designs.
Conclusion: It is recommended that researchers compare interventions, use longitudinal
For personal use only.
designs, better describe their methodology and implement greater adherence to treatment
fidelity to enhance research quality and strengthen conclusions.
Introduction one in 50 children have ASD in the United States, a figure that
has increased dramatically from one in 88 during the year
Autism spectrum disorder (ASD) is a neurodevelopmental
2012 [9, 10]. This increase in prevalence highlights the need
disorder recognized by qualitative impairment of socio-
to better understand the aetiology as well as the nature and
communicative functioning and repetitive and/or stereotyped
scope of ASD in order to develop and implement effective
patterns of behaviour [1]. Individuals with ASD experience
interventions.
primary social and communicative challenges resulting from
impairment in understanding and responding to social infor-
Early intervention for ASD
mation [2, 3]. Children with ASD typically do not imitate
others, share attention and focus with social partners, orient to ASD is a lifelong disorder that was once considered untreat-
socially important stimuli, perceive and express emotions or able; however, general agreement now exists that early
engage in pretence, all of which interfere with social intervention is considered essential, and children who undergo
reciprocity [2, 4]. Affected individuals also demonstrate early intensive behavioural intervention that targets both the
atypical language development, including delayed acquisition core symptoms of ASD and associated comorbid features
of single words and/or phrase speech, delayed or atypical demonstrate dramatically improved outcomes [11–15]. Indeed,
expansion of abilities, loss of previously developed skills, 75–95% of children with ASD who received intensive behav-
atypical prosody and difficulties with conversation and ioural intervention are reported to develop functional speech by
pragmatics [5]. Restricted and/or repetitive patterns of five years of age [16] and demonstrate remarkable reductions in
behaviour can manifest as lower (e.g. repetitive motor ASD symptomatology [16–19]. Since initial recognition in the
movements such as hand flapping, rocking and spinning) 1940s, treatment approaches for ASD have ranged from
and/or higher (e.g. circumscribed interests, fixations on psychoanalytic therapies and electroconvulsive treatments to
established behavioural routines, preoccupations and interests the present-day focus on behavioural interventions and
with certain topics) level behaviours, as well as attachment to enhancement of developmental abilities [20]. Moreover, iden-
unusual objects [6, 7]. Some individuals with ASD may also tification of specific intervention approaches has been the
demonstrate adverse reactions to sensory sensations [8]. focus of targeted efforts, with specific intervention approaches
According to the Centres for Disease Control and Prevention, now recognized as having established empirical support (e.g.
behavioural approaches and pivotal response treatment),
emerging support (e.g. augmentative communication and
Correspondence: Sarah Cadogan, Faculty of Education, University of
Calgary, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada. language training) or no support (e.g. auditory integration
E-mail: scadogan@ucalgary.ca training) [12].
2 S. Cadogan & A. W. McCrimmon Dev Neurorehabil, Early Online: 1–8
The most widely used empirically supported intervention First, early, intense and frequent intervention is fundamental;
approach is applied behaviour analysis (ABA), which involves however, efficiency in intervention is essential. More time in
early, intensive and individualized behavioural intervention intervention does not necessarily equate to greater gains, and
[21]. In a one-to-one or small group environment, ABA effective interventions produce results in a time-effective
involves enhancing, reducing or maintaining targeted behav- manner. As PRT is less time demanding than ABA, it is
iours through manipulation of environmental variables [22]. generally considered a more efficient early intervention
When employed intensively in early life (20–40 hours a process. Second, PRT was designed for naturalistic environ-
week), ABA has been shown to have medium to large positive ments as familiar toys, task variation and natural and direct
effects, particularly on language acquisition and communica- reinforcements are used. In contrast, ABA and many other
tion, adaptive skills, intellectual and social functioning and early intervention approaches are typically employed in
academic performance [12, 23]. However, ABA has several clinical settings. Third, as PRT is conducted in naturalistic
criticisms, including the intensity (20–40 hours per week), environments, it promotes family involvement that is crucial
potentiality of children becoming ‘prompt dependent’ [24] for treatment fidelity, the degree to which the intervention is
and difficulty with generalization of learning [23]. supported and adhered to. This differentiation further
distinguishes PRT from ABA, as ABA generally takes place
in an educational setting and may not benefit from as much
Pivotal response training
family input.
Dev Neurorehabil Downloaded from informahealthcare.com by University of Calgary on 11/01/13
pivotal response treatment (PRT), also known as pivotal Overall, it would seem that PRT is a viable and empirically
response training or pivotal response therapy, was founded on supported intervention for children with ASD. It promotes
the premise that moderating pivotal areas in children with family, peer and teacher-mediated approaches. Its grounding
ASD can have positive spill-over effects to other domains of in naturalistic environments suggests that it is generalizable
functioning [25–27]. Four main target areas have been derived across home, school and community settings. Additionally, it
from PRT approaches: (1) motivation, (2) self-initiations, (3) renders children as active agents of change in ameliorating
self-management and (4) responsivity to multiple cues [28]. social/communication abilities while self-modulating their
Children are motivated to engage in PRT activities by behaviour. However, although research has supported the use
affording them the opportunity to select toy(s) to use or by of PRT as a form of early intervention, the quality of PRT
providing reinforcement in the form of social praise [27, 29]. research has yet to be addressed. Specifically, research that
For personal use only.
Subsequently, the likelihood of frustration and/or quitting evaluates intervention programmes should be grounded in
after repeated failures is reduced, and children are more likely sound theoretical and methodological designs. In this regard,
to generalize learned skills and present with reduced research quality standards have been developed that can be
incidence of disruptive behaviours. PRT promotes the devel- used to evaluate the reliability, validity, accountability and
opment of self-initiation in social interactions, and particu- scope for generalization in ASD interventions.
larly the initiation of multiple cues during social interaction,
both of which can facilitate a child’s exposure to extensive
Standards of quality in ASD research
learning opportunities and enhanced social engagement
across environments [29]. Self-management is conceptualized Specific standards of research quality that can be applied to
as a pivotal intervention approach as it teaches children to behavioural, social and communication intervention research
choose and self-monitor their own behaviour [27, 30]. Self- for ASD have been proposed [32–38]. Seven factors have
management empowers children to become active agents been selected to form the basis for the current systematic
within their own intervention, and self-management practices review.
have been associated with reduced disruptive behaviours First, Smith et al. advocate for the systematic application
in children with ASD [30, 31]. Known as stimulus over- of procedures during intervention research [38]. Specifically,
selectivity, many people with ASD tend to respond to they propose that single subject research designs should
irrelevant features of stimuli, while not necessarily respond- incorporate a baseline stage where participant skills or
ing to relevant features of a stimulus [27]. PRT aims to reduce behaviours are measured prior to treatment administration.
stimulus overselectivity in children with ASD by teaching This process allows for changes in the evaluated performance
them to respond to multiple relevant cues [27]. For example, a or behaviour to be attributed to the intervention. Smith et al.
child would be positively reinforced for initiation of multiple advocate for multiple baseline frameworks, in which the
cues when making verbal requests (e.g. asking for the ‘big amount of time that participants spend in the pre-treatment
green truck’ as opposed to the ‘truck’). stage differs (e.g. one month vs. two months) [38]. Smith et al.
At its core, PRT targets child motivation in naturalistic also encourage the use of between group designs (e.g. an
settings to improve language and social interaction [27]. intervention and a control group) that allow for comparison of
As such, PRT has been advocated as an alternative to ABA as results between treatment and non-treatment conditions [38].
a method to improve social and communicative abilities such Second, Schreibman endorses the use of comparative
as symbolic play, initiating conversations, joint attention, studies (i.e. between interventions and/or intervention com-
turn-taking and requesting in children with ASD [23]. PRT ponents) [37]. As ASD is complex and multifaceted, and
can be implemented by families, teachers and peers within the some individuals may respond more successfully to an
home, school and/or community [29]. intervention approach than to others, intervention must
Renshaw and Kurikose discuss three principles for address and account for these individual differences.
optimizing the contextual nature of early intervention [30]. Comparison group(s) should be utilized so that positive
DOI: 10.3109/17518423.2013.845615 Pivotal response treatment for children with autism spectrum disorder 3
effects of the target intervention can be compared across search yielded 30 citations. Abstracts of these articles were
individuals and/or groups to determine relative effectiveness then screened for empirical papers on the topic of PRT
(as opposed to comparing treatment vs. no treatment) [37]. intervention programmes for children with ASD under the age
Third, standard (manualized) intervention protocols should of 18 years. Eight articles were rejected as they reviewed
be utilized [34, 38]. Manuals facilitate the uniform imple- intervention approaches, and were therefore were not empir-
mentation of a particular intervention, outline the specific ical. One was rejected as the study used a modified version of
behaviour(s) targeted by the intervention, and provide clear PRT. One was rejected as it reviewed the PRT intervention
guidelines for intervention implementation, and problem- manual. Three articles were rejected as they were either
solving strategies. As such, they may enhance reliability of inapplicable to PRT or were corrections pertaining to
intervention research. previously published PRT articles. The remaining 17 articles
Fourth, fidelity of treatment implementation is key to were reviewed and coded according to the above outlined
instigating behavioural interventions [32, 34, 38]. Treatment seven indicators of research quality.
fidelity is defined as ‘the methodological strategies used to
monitor and enhance the reliability and validity of behav- Results
ioural interventions’ [32]. Treatment providers, including
parents or peers where indicated, should adhere to standar- As shown in Table I, a total of 17 articles focused on
dized protocols and should be trained to consistently and empirical evaluation of PRT for children and adolescents with
Dev Neurorehabil Downloaded from informahealthcare.com by University of Calgary on 11/01/13
correctly implement them [32, 29], with high treatment ASD. The following section presents the common character-
fidelity defined as 0.80 (80% adherence to treatment istics across studies for each of the seven indicators of ASD
fidelity) [33]. intervention research quality.
Fifth, objective raters/observers who are not invested in
study outcomes should evaluate treatment effectiveness [34]. Systematic application of an intervention procedure
For example, objective ratings may be obtained from Five studies utilized a pre–post evaluative process using
individuals naive to experimental hypotheses who are typic- standardized assessments and/or a videotaped recording of the
ally better able to objectively study interventions, thus child(ren)’s behaviour pre- and post-treatment [39–43].
reducing bias. Eleven studies utilized a multiple baseline procedure, thereby
Sixth, inter-rater reliability, or the degree to which raters adhering to this indicator of research quality. However,
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agree on whether or not a child performed a particular significant variation in the multiple baseline procedure was
behaviour (e.g. self-initiation), is considered a key indicator found. Some studies stated the exact time frame for the
of intervention research quality. Campbell states that high multiple baseline [11, 44–51], whereas others simply stated
inter-rater reliability may reflect greater treatment fidelity as that a multiple baseline procedure was implemented [52, 53].
problematic behaviours are correctly defined and reliably The remaining study did not collect any baseline data;
observed [35]. Agreement of 80% or greater is an indicator of however, baseline measures of behaviour may not have been
strong reliability [36], and low agreement levels could applicable due to the nature of their experimental hypotheses
adversely affect treatment efficacy analyses. Specifically, and design (collecting undergraduate raters’ ratings of parent
group-designs should calculate inter-rater reliability across all affect between both conditions) [54]. In addition, one study
research stages, raters and participants, whereas single- utilized a between groups design (albeit, partial), which may
subject designs should calculate inter-rater reliability on at be considered suitable adherence to this standard of research
least 20% of research stages, raters and participants [36]. quality [54].
Finally, longitudinal studies evaluating treatment impact
and long-term effectiveness are advantageous [34]. Bristol Comparison of intervention approaches
et al. advocate for the use of longitudinal studies to assess
Only two studies performed comparisons between interven-
why ‘some children do well and some (do) poorly’ (p. 129)
tion approaches. One compared PRT and Individual Target
[34]. Follow-up studies should also determine whether
treatment effects and/or fidelity were maintained. Training Behaviour [54], while a second compared the
efficacy of PRT vs. Video-Modelling [40].
Rationale and direction for the current review
Use of standard intervention protocols
Using the aforementioned standards, this review aimed to
Nine studies in the current review explicitly aligned PRT
systematically evaluate empirical PRT studies for adherence
instruction and implementation with Koegel et al.s’ PRT
to these seven standards of research quality. To our know-
manuals [11, 26, 31, 40, 41, 43–45, 49, 52, 53, 55, 56]. It is
ledge, no such review has been published. Such a review will
noteworthy that six studies cited PRT manuals when
be beneficial in determining the validity, reliability and
describing features of the manuals, but did not explicitly
accountability of empirical studies in this domain.
state that the PRT intervention was aligned with a PRT
manual [42, 46–48, 50, 54]. Steiner et al. mentioned that
Method parent PRT training was based on literature and then cited
The PsycINFO and Psychological and Behavioural Sciences Koegel et al.s’ 2003 PRT manual [51, 55]. Additionally,
Collection were searched for peer reviewed articles published Schreibman et al. provided a web link to a list of PRT
on or before 11 June 2013 for the following terms: (1) autism, manuals, and Baker-Ericzén et al. used an older PRT manual
or (2) autistic, and (3) PRT and (4) intervention. This initial [25, 39, 50].
4 S. Cadogan & A. W. McCrimmon Dev Neurorehabil, Early Online: 1–8
Use of
Systematic Comparison of standardized Use of Evidence of
application of intervention intervention Treatment objective inter-rater Longitudinal
Authors and year an intervention approaches protocols fidelity evaluators reliability studies
Baker-Ericzén et al., Yes No Older version Yes Not required Not required No
2007 of PRT
manual used
Coolican et al., 2010 Yes No Yes Yes Yes Yes Yes
Lydon et al., 2011 Yes Comparison of Yes No Yes Yes No
PRT to video
modelling.
Minjarez et al., 2013 Yes No Yes Yes Not indicated Not indicated No
Minjarez et al., 2011 Yes No Yes Yes Yes Yes No
Pierce and Schreibman, Yes No Yes Yes Not indicated Yes Yes
1995
Pierce and Schreibman, Yes No Not specified No Not indicated Yes Yes
1997
Randolph et al., 2012 Yes No Not explicitly Yes Yes Yes Yes
Dev Neurorehabil Downloaded from informahealthcare.com by University of Calgary on 11/01/13
stated
Robinson, 2011 Yes No Not explicitly Yes Yes Yes Yes
stated
Schreibman et al., 1991 No baseline Comparison of Not explicitly Yes Yes Yes No
data collected. parental affect stated
between PRT
and ITTB
Schreibman et al., 2009 Yes No Not specified Yes Yes Yes No
Sherer and Schreibman, Yes No Yes Yes Yes Yes Follow-up data
2005 collected on a
portion of
the sample
Smith et al., 2010 Yes No Not explicitly stated Yes Not required Not required No
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Treatment fidelity
demonstrated gains in treatment fidelity towards the end of
The current review found distinct patterns of variation the programme, suggesting that treatment fidelity was not
regarding adherence to treatment fidelity. Five studies made reached prior to the treatment stage [41]. Parental treatment
no reference to treatment fidelity measures [40, 43, 46, 52, fidelity levels varied during the intervention stage in Steiner
53]. Two studies adhered to the recommended treatment et al.s’ study (49–84% implementation) [51]. Minjarez et al.s’
fidelity standard by requiring interventionists to implement 2011 study reported that parental treatment fidelity signifi-
strategies correctly, 80% of the time prior to entering the cantly increased from baseline to week 10 of treatment [44].
treatment stage [45, 50]. However, Pierce and Schreibman’s Although not completely adhering to the 80% standard,
1995 study did not re-assess treatment fidelity once interven- Sherer and Schreibman ensured that interventionists main-
tionists (peers) entered the treatment phase [45]. Schreibman tained treatment fidelity by rating video segments for correct
et al. [54] study conducted treatment fidelity measures until usage of strategies 20% of the time (i.e. each of the tasks had
parents met 80% implementation standards. Due to the nature to be implemented correctly for 20% of the entire duration of
of this design, parents’ PRT implementation was no longer the video clip) [49].
required or measured. Despite addressing the treatment Despite the above studies’ adherence to fidelity standards,
fidelity criterion, many interventionists failed to meet and/or discrepancies in treatment fidelity adherence procedures were
maintain this standard in the reviewed articles. For example, found within two studies. One study indicated that parent PRT
all three caregivers in Randolph et al.s’ study reached trainers met the required treatment fidelity, but parental
treatment fidelity levels during the intervention stage; how- treatment fidelity was not measured [42]. Additionally, these
ever, only two caregivers maintained these levels at the researchers reported that 86% of interventionists met treat-
follow-up stage [47]. Similarly, five of eight parents main- ment fidelity within the first three to four months; however,
tained treatment fidelity at the post-training phase, while only the authors did not indicate how they addressed intervention-
four parents reached criterion levels at follow-up in Coolican ists who did not meet criteria. Baker-Ericzén et al.s’ study
et al.s’ study [11]. Paraprofessionals in Robinson’s study included therapists who were trained to implement PRT with
received video feedback until they had reached 80% treatment fidelity and who then taught parents the intervention proced-
fidelity [48]. However, only three of four paraprofessionals ure [39]. However, treatment fidelity assessments were
reached criterion levels in the generalization phase. Minjarez discontinued after parents were initially trained to fidelity
et al.s’ 2013 study reported that 16 of 17 families levels and therapists relied on parental feedback and weekly
DOI: 10.3109/17518423.2013.845615 Pivotal response treatment for children with autism spectrum disorder 5
clinical sessions when evaluating treatment fidelity [39]. This Baker-Ericzén et al.s’ and Smith et al.s’ studies, as they
approach may not be conducive to ensure that treatment administered standardized measures [39, 42].
fidelity levels were maintained.
Longitudinal studies
Use of objective evaluators
Eight studies collected follow-up data after the post-treatment
Eleven articles utilized objective evaluators [11, 40, 44, 47– stage. Follow-up data collection ranged from two weeks [47]
54]. Four studies used objective evaluators for 27–34% of to nine months [49] after the intervention stage, with the
probes [11, 49, 52, 53], whereas others incorporated majority of follow-up data collection taking place two to four
independent coders for all data collection measures [11, 40, months post-treatment [11, 45, 46, 52, 53]. For some studies,
44, 47, 48, 50, 51, 54]. follow-up data ranged over a specified timeframe. For
The remaining seven studies did not reference the use of example, Robinson’s study stated that follow-up studies
objective evaluators. Two of these did not require raters as ranged from four to eight weeks [48]. Similarly, Coolican
they utilized standardized assessments and thus did not et al.s’ follow-up timeframe ranged from 2 to 4 months [11].
require objective ratings of behaviour [39, 42]. Of the And finally, Sherer and Schreibman collected follow-up data
remaining studies, one indicated that a trained experimenter six to nine months after treatment cessation [49].
conducted behavioural ratings; however, reference was not Nine studies did not incorporate follow-up data into their
made to external evaluators [43]. Although explicit reference designs [39, 40–44, 50, 51, 54]. Smith et al. employed a one-
Dev Neurorehabil Downloaded from informahealthcare.com by University of Calgary on 11/01/13
was not made to external evaluators in Minjarez et al.s’ year design, which seemed proactive and valuable in terms of
2013 study, readers were directed to the authors’ previous analyzing the effects of long-term PRT training [42].
study’s 2011 study [41, 44]. Finally, both of Pierce and However, a follow-up study was not conducted. Lydon et al.
Schreibman’s studies did not refer to the use of objective claimed that follow-up data was collected when skill mastery
evaluators [45, 46]. or intervention discontinuation criteria was met [40].
Similarly, Steiner et al. mentioned that follow-up data was
Evidence of inter-rater reliability collected one week after the intervention ended; however, a
review of these two articles indicates that they collected post-
Twelve studies conducted inter-rater reliability across all
treatment data, and not follow-up data [40, 51].
stages of data collection. In general, a variety of percentage
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and specific area(s) of need for individuals with ASD. ensure that follow-up data collection timeframes are consist-
However, such research evidence is lacking regarding PRT, ent across participants, as the follow-up data could be
resulting in a paucity of information regarding the overall confounded by maturation affects.
clinical effectiveness of the programme.
Strong adherence to the use of standard intervention Future directions
protocols was found as nine studies [11, 40, 41, 43–45, 49, 52,
This review indicates recommendations that may enhance
53] explicitly stated their use of PRT manuals by Koegel et al.
PRT research efforts. First, translucency in methodology
[26, 31, 55, 56]. However, six simply cited the manuals when
through clear description of research methodology, interven-
describing PRT components without explicitly stating if PRT
tionist training methods and the use of objective and/or naı̈ve
manuals were used to teach PRT strategies [42, 46–48, 50,
behavioural raters may strengthen research designs. It is
54]. Steiner et al. stated that parents were taught PRT
fundamental that PRT research studies conduct treatment
strategies based on the literature, and then cited a manual
fidelity measures in order to ascertain whether it is being
[51]. Baker-Ericzén et al. based their study on an older PRT
implemented correctly. It would also be beneficial to state the
manual, which centred on increasing non-verbal children’s
treatment fidelity standards that interventionists were required
vocabulary [25, 39]. Future replicability may be difficult
to meet and maintain, and what steps were taken when these
when the use of particular PRT manuals is not explicitly
standards are not met. Furthermore, it is recommended that
stated in the methodology.
Dev Neurorehabil Downloaded from informahealthcare.com by University of Calgary on 11/01/13
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