Pivotal response treatment improves social communication in children with autism spectrum disorder

1. Pivotal response treatment (PRT) is an intervention designed to increase motivation to interact by rewarding effort with natural reinforcement. Children with autism spectrum disorder (ASD) randomized to receive 24 weeks of PRT showed improved frequency of functional utterances compared to children randomized to the control group.

2. Parents of children in the PRT group also reported significant improvement in number of words used after 24 weeks.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Pivotal response training is a naturalistic behavioral intervention designed to increase motivation to interact through modeling appropriate language during play and rewarding attempts at communication. While there is growing support for this intervention in ASD, there has not previously been rigorous empirical testing in this population. In this randomized controlled trial, researchers assigned children and parents to 24 weeks of PRT or delayed treatment. Frequency of functional utterances and other measures of social communication were measured at baseline, 12 weeks, and 24 weeks using a 10-minute structured laboratory observation, parent-report questionnaire, and other scales. At 24 weeks, children receiving PRT demonstrated significantly improved number of functional utterances between baseline and week 24, compared to children in the delayed treatment group. They also had significant improvement in number of words used, based on a parent-report questionnaire.

These findings are limited by the small sample size, and the study was underpowered to evaluate predictors of treatment response. Furthermore, researchers were unable to determine the individual effects of parent-training and clinical-delivered PRT, as these components were combined in the treatment group. Nonetheless, the study is strengthened by its randomized, controlled design examining the efficacy of a novel treatment. For physicians, these findings suggest that PRT is effective for improving social communication behaviors among children with ASD.

Click to read the study, published today in Pediatrics

Click to read an accompanying editorial in Pediatrics

Relevant reading: Naturalistic Developmental Behavioral Interventions: Empirically Validated Treatments for Autism Spectrum Disorder

In-Depth [randomized controlled trial]: Researchers recruited 48 children aged 2 to 5 years old with ASD and significant language delay. Children were excluded if they had >1 hour of weekly individual speech therapy, severe psychiatric disorders, genetic abnormality, active medical problems, a primary language other than English, or anticipated treatment changes during the trial. Subjects were randomly assigned to receive 24 weeks of either PRT or delayed treatment (DTG). The PRT arm consisted of weekly 60-minute parent training sessions and 10 hours per week of clinician-delivered in-home treatment for children; children assigned to DTG continued their stable community treatments and were offered PRT at the end of the study. Children were assessed for the primary outcome, frequency of functional utterances during a 10-minute structured laboratory observation, at baseline, week 12, and week 24.

Children receiving PRT showed significantly improved number of utterances between baseline and week 24, compared to children in the delayed treatment group (F_1,41 = 6.07; P = .026). At 24 weeks, 91% of parents in the PRT group were able to implement PRT with fidelity. Children receiving PRT also had significant improvement in social communication, as measured by the Brief Observation of Social Communication Change scale, and in number of words used, based on a parent-report questionnaire.

Image: PD

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