Pivotal response training (PRT) is one approach used in applied behavior analysis (ABA) therapy to encourage children with autism to learn and monitor their behaviors. The therapy uses play between the therapist and the child to communicate and socialize more effectively with others.

Pivotal response training (PRT) is an evidence-based practice that is considered a subset of applied behavior analysis (ABA). PRT focuses on less structured playtime, guided more by the child than by a therapist.

Parents who have children with autism may be trained in PRT. They can then encourage behavioral change through a set treatment plan by using time with their children while at home.

During a PRT session, which often involves playing with the parent or therapist, the adult will allow the child to make some choices but reward specific behavioral changes, like using a full sentence to ask for a particular toy.

PRT is believed to make changes in broad categories of behavior and development, like socializing and communication, by allowing the child with autism to monitor their own behavioral reactions and learn to self-regulate and motivate.

What Is Pivotal Response Training? 

PRT also supports children with autism in reducing self-stimulating behaviors, or stimming, which can be disruptive when teachers, parents, or peers are trying to interact with the child.

Unlike some other approaches used in ABA therapy, PRT focuses on “pivotal” points in the child’s development, which can cover a broad range of interactions and responses rather than focusing on learning one new thing at a time. Some of these pivotal areas might be:

  • Motivation to communicate, socialize, and focus on specific activities.
  • Social interactions, especially choosing to initiate these.
  • Self-regulation or self-management.
  • Responses to multiple cues at the same time.

When areas of development become the focus of change, positive changes are believed to impact other areas of the child’s life, leading to widespread improvements. Rewards for positive behaviors should correlate with what the therapist or parent needs from the interaction. For example, if a child struggles with communication and makes an attempt at requesting a specific food as a snack, even if they do not perform the behavior perfectly, the attempt should be rewarded with that snack rather than an unrelated prize.

Although parents are trained to be the primary implementors of PRT, other people who interact with autistic children like siblings, extended family, teachers, school administrators, and other therapists can all benefit from learning this approach. It is important that PRT is an option for children with autism in a variety of settings, including their home, school, and greater community.

The History of Pivotal Response Training

This specific ABA therapy approach was developed by Dr. Robert L. Koegel and Dr. Lynn Kern Koegel at Stanford University in the 1970s. PRT was originally called the Natural Language Paradigm, but it was soon applied to other behavioral changes in children with autism, not just encouraging use of language.

PRT finds pivotal moments in a child’s behavior and development. When these pivotal responses are targeted, they can cause changes in behavioral cusps. These changes then spread out across several aspects of the child’s life, improving their interactions with others. These positive interactions then become reinforcing experiences.

As of a report published in 2010, there are nine single-subject studies that support PRT as an evidence-based practice with important approaches to teaching new behaviors. The process is most effective for children with autism, between the ages of 2 and 16. When PRT is used to help children with autism who are 5 years old or younger, research shows that 85% to 90% of those children develop verbal communication skills, and use these as their primary mode of communicating with peers and caregivers.

How Pivotal Response Training Is Currently Implemented

There are six motivational procedures used in pivotal response training. They are:

  1. Offering choices based on following the child’s lead.
  2. Gaining the child’s attention.
  3. Providing clear opportunities for the child to respond, such as taking turns.
  4. Varying tasks, and interspersing maintenance of previous learning with learning new tasks.
  5. Using both natural reinforcement and contingent reinforcement.
  6. Reinforcing attempts at learning new or specific skills.

A typical session may look like this:

  • The parent or therapist provides specific instructions.
  • They have the child choose a stimulus, like a toy.
  • They focus the child’s attention.
  • The parent or therapist encourages the desired behavior, like asking for the toy using verbal skills.
  • The therapist or parent then models the desired behavior, such as saying out loud, “May I please have the toy?”
  • They then provide rewards for attempts at implementing this behavior.

Activities during the play session maintain existing behavioral changes from previous sessions and also implement the new behavioral change.

It is important to note that floor time or play time in PRT sessions is much less structured than other ABA therapy approaches. Children are allowed to guide the sessions, and the parent or therapist rewards behaviors that show improvement, but they do not push for specific learning outcomes. PRT practitioners believe that allowing children more freedom improves their ability to self-motivate, to be curious, and to desire their own change after seeing that there are benefits.

PRT may also work better for parents or teachers in prekindergarten or special education classes because they do not have to create specific drills or practices for specific behaviors. Instead, they can support ongoing behavioral change. 

Evidence for Pivotal Response Training Shows It Helps Children With Autism

While several scientific studies show that PRT can help with specific behaviors, few studies support the approach’s claim to improve behaviors that are not directly targeted. If pivotal behaviors are not pivotal, and do not cascade into larger, long-lasting behavioral improvements, then PRT may not be as effective as claimed. However, as part of ABA therapy, it does appear to be effective in some circumstances.

Other studies show that PRT is effective in areas involving social communication in children with autism, compared to more rigorous and structured ABA therapy.

One study published in 2014 found that children with autism who participated gained better skills in targeted areas and improved their pragmatic skills in general, including self-regulation of inappropriate social initiation, use of context, building rapport, and stereotyped language. One suggestion was that children with autism demonstrate less disruptive or off-task behavior when their therapy includes stronger motivational components.

Ultimately, PRT supports children with autism changing behaviors so they can be independent and fulfilled adults. Because it is listed as one of the evidence-based approaches to helping children with autism, many insurance companies will cover part or all of this treatment. If you want to undergo PRT training or find other PRT-based interventions, you can work with your health insurance provider to find these options.