Abstract
This study examined the effect of Pivotal response treatment (PRT) to improve verbal initiations in children with Autism Spectrum Disorder, age 6–12 years old, using a Randomized Clinical Trial design. Intervention was conducted three times a week for 2 months, for a total of 24 one-hour sessions. The PRT intervention taught a variety of questions and attention/assistance-seeking initiations. The treatment as usual (TAU) group received standard language intervention. Results showed that the PRT group made significant improvements in their number of verbal initiations as well as collateral gains in general communicative skills and mean length of utterance (MLU) compared to the TAU group. Theoretical implications of including motivational approaches to develop social initiations are reviewed.
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References
Bishop, D. V. M. (2006). Children’s communication checklist (2nd ed.). Psychological Corporation.
Boucher, J., Bigham, S., Mayes, A., & Muskett, T. (2008). Recognition and language in low functioning autism. Journal of Autism and Developmental Disorders, 38(7), 1259. https://doi.org/10.1007/s10803-007-0508-8
Buggey, T., Toombs, K., Gardener, P., & Cervetti, M. (1999). Training responding behaviors in students with autism: Using videotaped self-modeling. Journal of Positive Behavior Interventions, 1(4), 205–214. https://doi.org/10.1177/109830079900100403
Charlton, C. T., Kellems, R. O., Black, B., Bussey, H. C., Ferguson, R., Goncalves, B., Jensen, M., & Vallejo, S. (2020). Effectiveness of avatar-delivered instruction on social initiations by children with autism spectrum disorder. Research in Autism Spectrum Disorders. https://doi.org/10.1016/j.rasd.2019.101494
Chiang, H. M., & Carter, M. (2008). Spontaneity of communication in individuals with autism. Journal of Autism and Developmental Disorders, 38(4), 693–705. https://doi.org/10.1007/s10803-007-0436-7
Dunlap, G. (1984). The influence of task variation and maintenance tasks on the learning and effect of autistic children. Journal of Experimental Child Psychology, 37(1), 41–64. https://doi.org/10.1016/0022-0965(84)90057-2
Eigsti, I. M., Bennetto, L., & Dadlani, M. B. (2007). Beyond pragmatics: Morphosyntactic development in autism. Journal of Autism and Developmental Disorders, 37(6), 1007–1023. https://doi.org/10.1007/s10803-006-0239-2
Esbenshade, P. H., & Rosales-Ruiz, J. (2001). Programming common stimuli to promote generalized question-asking: A case demonstration in a child with autism. Journal of Positive Behavior Interventions, 3(4), 199–210. https://doi.org/10.1177/109830070100300402
Fairhurst, C., Hewitt, C. E., & Torgerson, D. J. (2019). Using pairwise randomisation to reduce the risk of bias. Research Methods in Medicine and Health Sciences. https://doi.org/10.1177/2632084319884178
Gengoux, G. W., Abrams, D. A., Schuck, R., Millan, M. E., Libove, R., Ardel, C. M., & Hardan, A. Y. (2019). A pivotal response treatment package for children with autism spectrum disorder: An RCT. Pediatrics, 144(3), e20190178.
Gengoux, G. W., Berquist, K. L., Salzman, E., Schapp, S., Phillips, J. M., Frazier, T. W., Minjarez, M. B., & Hardan, A. Y. (2015). Pivotal response treatment parent training for autism: Findings from a 3-month follow-up evaluation. Journal of Autism and Developmental Disorders, 45(9), 2889–2898. https://doi.org/10.1007/s10803-015-2452-3
Goldstein, H. (2002). Communication intervention for children with autism: A review of treatment efficacy. Journal of Autism and Developmental Disorders, 32(5), 373–396. https://doi.org/10.1023/a:1020589821992
Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., & Minjarez, M. B. (2015). A randomized controlled trial of pivotal response treatment group for parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892.
Hume, K., Loftin, R., & Lantz, J. (2009). Increasing independence in autism spectrum disorders: A review of three focused interventions. Journal of Autism and Developmental Disorders, 39(9), 1329–1338. https://doi.org/10.1007/s10803-009-0751-2
Kazemi, Y., Afsharian, E., Mirzaei, B., Baghbani, M., Sademinejad, M., & Gheleyempour, L. (2007). Children’s communication checklist: The study of Persian children. Iranian Journal of Research in Rehabilitation Sciences, 2(3), 1–5.
Koegel, L. K. (2011). Teaching the pivotal behavior of initiations to children with autism. Koegel Autism Consultants.
Koegel, L. K., Ashbaugh, K., Koegel, R. L., Detar, W. J., & Regester, A. (2013). Increasing socialization in adults with Asperger’s syndrome. Psychology in the Schools, 50(9), 899–909. https://doi.org/10.1002/pits.21715
Koegel, L. K., Bryan, K. M., Su, P., Vaidya, M., & Camarata, S. (2019a). Intervention for non-verbal and minimally-verbal individuals with autism: A systematic review. International Journal of Pediatric Research, 5, 056. https://doi.org/10.23937/2469-5769/1510056
Koegel, L. K., Bryan, K. M., Su, P., Vaidya, M., & Camarata, S. (2020). Definitions of non-verbal and minimally verbal in the research for autism: A systematic review of the literature. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-020-04402-w
Koegel, L. K., Bryan, K. M., Su, P., Vaidya, M., & Camarata, S. (2019b). Intervention for non-verbal and minimally-verbal individuals with autism: A systematic review. International Journal of Pediatric Research, 5, 056. https://doi.org/10.23937/2469-5769/1510056
Koegel, L. K., Camarata, S. M., Valdez-Menchaca, M., & Koegel, R. L. (1997). Setting generalization of question-asking by children with autism. American Journal on Mental Retardation, 102(4), 346–357. https://doi.org/10.1352/0895-8017
Koegel, L. K., Koegel, R. L., Shoshan, Y., & McNerney, E. (1999). Pivotal response intervention II: Preliminary long-term outcome data. Journal of the Association for Persons with Severe Handicaps, 24(3), 186–198. https://doi.org/10.2511/rpsd.24.3.186
Koegel, R. L., Bradshaw, J. L., Ashbaugh, K., & Koegel, L. K. (2014). Improving question asking initiations in young children with autism using pivotal response treatment. Journal of Autism and Developmental Disorders, 44(4), 816–827. https://doi.org/10.1007/s10803-013-1932-6
Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism: Communication, social, and academic development. Brookes Publishing Company.
Koegel, R. L., Koegel, L. K., & Surratt, A. (1992). Language intervention and disruptive behavior in preschool children with autism. Journal of Autism and Developmental Disorders, 22(2), 141–153. https://doi.org/10.1007/BF01058147
Koegel, R. L., O’Dell, M. C., & Koegel, L. K. (1987). A natural language teaching paradigm for nonverbal autistic children. Journal of Autism and Developmental Disorders, 17(2), 187–200. https://doi.org/10.1007/BF01495055
Lane, J. D., Lieberman-Betz, R., & Gast, D. L. (2016). An analysis of naturalistic interventions for increasing spontaneous expressive language in children with autism spectrum disorder. The Journal of Special Education, 50(1), 49–61. https://doi.org/10.1177/0022466915614837
Lang, S., Bartl-Pokorny, K. D., Pokorny, F. B., Garrido, D., Mani, N., Fox-Boyer, A. V., Zhang, D., & Marschik, P. B. (2019). Canonical babbling: A marker for earlier identification of late detected developmental disorders? Current Developmental Disorders Reports, 6(3), 111–118. https://doi.org/10.1007/s40474-019-00166-w
Lee, G. T., Hu, X., Liu, Y., Zou, C., Cheng, X., Zhao, Q., & Huang, J. (2020). Increasing response diversity to intraverbals in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(1), 292–307. https://doi.org/10.1007/s10803-019-04250-3
Mason, R. A., Gregori, E., Wills, H. P., Kamps, D., & Huffman, J. (2020). Covert audio coaching to increase question asking by female college students with autism: Proof of concept. Journal of Developmental and Physical Disabilities, 32(1), 75–91. https://doi.org/10.1037/bdb0000057
McConnell, S. R. (2002). Interventions to facilitate social interaction for young children with autism: Review of available research and recommendations for educational intervention and future research. Journal of Autism and Developmental Disorders, 32(5), 351–372. https://doi.org/10.1023/a:1020537805154
Medavarapu, S., Marella, L. L., Sangem, A., & Kairam, R. (2019). Where is the evidence? A narrative literature review of the treatment modalities for autism spectrum disorders. Cureus, 11(1).
Miller, J. F., & Chapman, R. S. (1981). The relation between age and mean length of utterance in morphemes. Journal of Speech, Language, and Hearing Research, 24(2), 154–161.
Mitchell, S., Brian, J., Zwaigenbaum, L. I., et al. (2006). Early language and communication development of infants later diagnosed with autism spectrum disorder. Journal Developmental Behavioral and Pediatrics, 27(2), S69–S78. https://doi.org/10.1097/00004703-200604002-00004
Mody, M., Manoach, D. S., Guenther, F. H., Kenet, T., Bruno, K. A., McDougle, C. J., & Stigler, K. A. (2013). Speech and language in autism spectrum disorder: A view through the lens of behavior and brain imaging. Neuropsychiatry, 3(2), 223. https://doi.org/10.2217/npy.13.19
Mohammadzaheri, F., Koegel, L. K., Rezaee, M., & Rafiee, S. M. (2014). A randomized clinical trial comparison between pivotal response treatment (PRT) and structured applied behavior analysis (ABA) intervention for children with autism. Journal of Autism and Developmental Disorders, 44(11), 2769–2777. https://doi.org/10.1007/s10803-014-2137-3
Mohammadzaheri, F., Koegel, L. K., Rezaei, M., & Bakhshi, E. (2015). A randomized clinical trial comparison between pivotal response treatment (PRT) and adult-driven applied behavior analysis (ABA) intervention on disruptive behaviors in public school children with autism. Journal of Autism and Developmental Disorders, 45(9), 2899–2907. https://doi.org/10.1007/s10803-015-2451-4
National Research Council. (2001). Educating children with autism. National Academies Press.
Nelson, C., Nelson, A. R., McDonnell, A. P., Johnston, S. S., & Crompton, A. (2007). Keysto play: A strategy to increase the social interactions of young children with autism and their typically developing peers. Education and Training in Developmental Disabilities, 42(2), 165–181.
Newman, B., & Ten Eyck, P. (2005). Self-management of initiations by students diagnosed with autism. The Analysis of Verbal Behavior, 21(1), 117–122. https://doi.org/10.1007/BF03393013
Nikopoulos, C. K., & Keenan, M. (2003). Promoting social initiation in children with autism using video modeling. Behavioral Interventions: Theory and Practice in Residential and Community-Based Clinical Programs, 18(2), 87–108. https://doi.org/10.1002/bin.129
Nordahl-Hansen, A., Donolato, E., Lervåg, A., Norbury, C. F., & Melby-Lervåg, M. (2019). PROTOCOL: Language interventions for improving oral language outcomes in children with neurodevelopmental disorders: A systematic review. Campbell Systematic Reviews. https://doi.org/10.1002/cl2.1062
Odom, S. L. (2019). Peer-based interventions for children and youth with autism spectrum disorder: History and effects. School Psychology Review, 48(2), 170–176. https://doi.org/10.17105/SPR-2019-0019.V48-2
O’Donnell, C. L. (2008). Defining, conceptualizing, and measuring fidelity of implementation and its relationship to outcomes in K–12 curriculum intervention research. Review of Educational Research, 78(1), 33–84. https://doi.org/10.3102/0034654307313793
Palmen, A., Didden, R., & Arts, M. (2008). Improving question asking in high-functioning adolescents with autism spectrum disorders: Effectiveness of small-group training. Autism, 12(1), 83–98. https://doi.org/10.1177/1362361307085265
Paul, R., & Norbury, C. (2007). Language disorders from infancy through adolescence: Assessment and intervention (3rd ed.). Mosby.
Perkins, M. R., Dobbinson, S., Boucher, J., Bol, S., & Bloom, P. (2006). Lexical knowledge and lexical use in autism. Journal of Autism and Developmental Disorders, 36(6), 795–805. https://doi.org/10.1007/s10803-006-0120-3
Popovic, S. C., Starr, E. M., & Koegel, L. K. (2020). Teaching initiated question asking to children with autism spectrum disorder through a short-term parent-mediated program. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-020-04426-2
Rapin, I., Dunn, M. A., Allen, D. A., Stevens, M. C., & Fein, D. (2009). Subtypes of language disorders in school-age children with autism. Developmental Neuropsychology, 34(1), 66–84. https://doi.org/10.1080/87565640802564648
Rapin, I., & Dunn, M. (2003). Update on the language disorders of individuals on the autistic spectrum. Brain and Development, 25(3), 166–172. https://doi.org/10.1016/s0387-7604(02)00191-2
Raulston, T., Carnett, A., Lang, R., Tostanoski, A., Lee, A., Machalicek, W., Sigafoos, J. M., O’Riley, M. F., Didden, R., & Lancioni, G. E. (2013). Teaching individuals with autism spectrum disorder to ask questions: A systematic review. Research in Autism Spectrum Disorders, 7(7), 866–878. https://doi.org/10.1016/j.rasd.2013.03.008
Rogers, S. J. (2000). Interventions that facilitate socialization in children with autism. Journal of Autism and Developmental Disorders, 30(5), 399–409. https://doi.org/10.1023/a:1005543321840
Ronfard, S., Zambrana, I. M., Hermansen, T. K., & Kelemen, D. (2018). Question-asking in childhood: A review of the literature and a framework for understanding its development. Developmental Review, 49, 101–120. https://doi.org/10.1016/j.dr.2018.05.002
Ros-Demarize, R., Bradley, C., Kanne, S. M., Warren, Z., Boan, A., Lajonchere, C., Park, J., & Carpenter, L. A. (2020). ASD symptoms in toddlers and preschoolers: An examination of sex differences. Autism Research, 13(1), 157–166. https://doi.org/10.1002/aur.2241
Rubin, K. H., Bukowski, W. M., & Laursen, B. (2011). Handbook of peer interactions, relationships, and groups. Guilford Press.
Rutter, M., Mawhood, L., & Howlin, P. (1992). Language delay and social development. In P. Fletcher & D. Hall (Eds.), Specific speech and language disorders in children: Correlates characteristics and outcomes (pp. 63–78). Whurr Publishers.
Sadeghi, A., Rabiee, M., & Abedi, M. R. (2011). Validation and reliability of the Wechsler intelligence scale for children-IV. Developmental Psychology: Journal of Iranian Psychologists, 28, 377–386.
Schoen, E., Paul, R., & Chawarska, K. (2011). Phonology and vocal behavior in toddlers with autism spectrum disorders. Autism Research, 4(3), 177–188. https://doi.org/10.1002/aur.183
Scott, K. (2019). Teaching the hidden curriculum of group work for students with autism spectrum disorder. Open Education Studies, 1(1), 122–137. https://doi.org/10.1515/edu-2019-0008
Shabani, D. B., Katz, R. C., Wilder, D. A., Beauchamp, K., Taylor, C. R., & Fischer, K. J. (2002). Increasing social initiations in children with autism: Effects of a tactile prompt. Journal of Applied Behavior Analysis, 35(1), 79–83. https://doi.org/10.1901/jaba.2002.35-79
Shriberg, L. D., Paul, R., Black, L. M., & Van Santen, J. P. (2011). The hypothesis of apraxia of speech in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 41(4), 405–426. https://doi.org/10.1007/s10803-010-1117-5
Sigman, M., Ruskin, E., & Arbeile, S. (1999). Continuity and change in the social competence of children with autism, down syndrome, and developmental delays. Monographs of the Society for Research in Child Development, 64(1), 1–114. https://doi.org/10.1111/1540-5834.00002
Simpson, R. L. (2005). Evidence-based practices and students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 20(3), 140–149. https://doi.org/10.1177/10883576050200030201
Smith, V., Mirenda, P., & Zaidman-Zait, A. (2007). Predictors of expressive vocabulary growth in children with autism. Journal of Speech, Language, and Hearing Research, 50(1), 149–160. https://doi.org/10.1044/1092-4388(2007/013)
Sng, C. Y., Carter, M., Stephenson, J., & Sweller, N. (2020). Partner perceptions of conversations with individuals with autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(4), 1182–1197. https://doi.org/10.1007/s10803-019-04348-8
Stahmer, A. C. (1995). Teaching symbolic play skills to children with autism using pivotal response training. Journal of Autism and Developmental Disorders, 25(2), 123–141. https://doi.org/10.1007/BF02178500
Stedman, A., Taylor, B., Erard, M., Peura, C., & Siegel, M. (2019). Are children severely affected by autism spectrum disorder underrepresented in treatment studies? An analysis of the literature. Journal of Autism and Developmental Disorders, 49(4), 1378–1390. https://doi.org/10.1007/s10803-018-3844-y
Sutton, B. M., Webster, A. A., & Westerveld, M. F. (2019). A systematic review of school-based interventions targeting social communication behaviors for students with autism. Autism, 23(2), 274–286. https://doi.org/10.1177/1362361317753564
Vernon, T. W., Holden, A. N., Barrett, A. C., Bradshaw, J., Ko, J. A., McGarry, E. S., & German, T. C. (2019). A pilot randomized clinical trial of an enhanced pivotal response treatment approach for young children with autism: The PRISM model. Journal of Autism and Developmental Disorders, 49(6), 2358–2373.
Vogindroukas, I., Papageorgiou, V., & Vostanis, P. (2003). Pattern of semantic errors in autism: A brief research report. Autism, 7(2), 195–203. https://doi.org/10.1177/1362361303007002006
Volkmar, F. R., Lord, C., Bailey, A., Schultz, R. T., & Klin, A. (2004). Autism and pervasive developmental disorders. Journal of Child Psychology and Psychiatry, 45(1), 135–170. https://doi.org/10.1046/j.0021-9630.2003.00317.x
Warreyn, P., Roeyers, H., Van Wetswinkel, U., & De Groote, I. (2007). Temporal coordination of joint attention behavior in preschoolers with autism spectrum disorder. Journal of Autism and Developmental Disorders, 37(3), 501–512. https://doi.org/10.1007/s10803-006-0184-0
Wetherby, A. M., & Prutting, C. A. (1984). Profiles of communicative and cognitive-social abilities in autistic children. Journal of Speech and Hearing Research, 27(3), 364–377. https://doi.org/10.1044/jshr.2703.364
Williams, G., Donley, C. R., & Keller, J. W. (2000). Teaching children with autism to ask questions about hidden objects. Journal of Applied Behavior Analysis, 33(4), 627–630. https://doi.org/10.1901/jaba.2000.33-627
Wolfe, K., Pound, S., McCammon, M. N., Chezan, L. C., & Drasgow, E. (2019). A systematic review of interventions to promote varied social-communication behavior in individuals with autism spectrum disorder. Behavior Modification, 43(6), 790–818. https://doi.org/10.1177/0145445519859803
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., Brock, M. E., Plavnick, J. B., Fleury, V. P., & Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45(7), 1951–1966. https://doi.org/10.1007/s10803-014-2351-z
Acknowledgments
The authors would like to thank the Arak autism society for their generous support of our work. We also thank our participants and their families. Finally, we greatly appreciate the help from students who assisted with the data analysis and Dr. Steve Camarata for his assistance with the statistics. Dr. Lynn Koegel is a partner in the private firm Koegel Autism Consultants, LLC that provides PRT training.
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FM proposed the initial research and oversaw the conduction and organization of the study. LKK and FM coordinated on the implementation of the intervention, gathered literature for the review and wrote the study. ZS designed and supervised the research, provided feedback throughout, and edited the write up. EB performed analysis and interpretated results. RK contributed to draft manuscript preparation.
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Mohammadzaheri, F., Koegel, L.K., Bakhshi, E. et al. The Effect of Teaching Initiations on the Communication of Children with Autism Spectrum Disorder: A Randomized Clinical Trial. J Autism Dev Disord 52, 2598–2609 (2022). https://doi.org/10.1007/s10803-021-05153-y
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DOI: https://doi.org/10.1007/s10803-021-05153-y