A preliminary assessment of teachers' implementation of pivotal response training.
Many school districts and early intervention programs are struggling to provide appropriate, evidence-based services for children with autism. Pivotal Response Training (PRT) is a naturalistic behavior form of therapy shown to be effective for increasing language and play skills in children with autism. This study examines implementation of PRT in community programs where teachers have received varying levels of training. Results indicate that ongoing supervision and feedback may be a necessary component of effective training. Additionally, years of teaching experience may affect implementation in group settings. Implications for translation of evidence-based practices to community settings are discussed.
Keywords: autism, pivotal response training, teacher training.
Autism is a pervasive developmental disorder, characterized by impairments in communication and social functioning along with restricted, repetitive, and stereotyped patterns of behavior (American Psychiatric Association, 1994). Social deficits manifest in avoidance of eye contact, failure to develop peer relationships, resistance to affection, high levels of isolated play, and limited play skills (e.g., Cox & Mesibov, 1995; Harris, Belchic, Blum & Celeberti, 1994; Rimland, 1964; Schreibman, 1988). Many children with autism do not develop language. Children who acquire speech often develop non-communicative speech patterns, use language sparingly, or the language they do develop is often quite rote in nature (Schreibman, 1988). Self-stimulatory and repetitive behaviors can interfere with learning new skills.
Over the last two decades, estimates of the prevalence of autism have increased from 4 to 5 per 10,000 children to nearly 10 times that number, with current estimates at 3 to 4 per 1000 children (Baird, Charman, et al., 2001; Fombonne, 2003). This rapid acceleration in diagnosis rate has placed significant strain on service providers. Many school districts, early intervention programs, and speech therapists are struggling to provide appropriate, evidence-based services for children with autism. The pervasive nature of the deficits associated with autism has challenged educational programs to provide intervention methods that are both intensive and practical in terms of requirements for implementation.
In response to this growing need, many early intervention programs are attempting to use evidence-based practices. Autism researchers report that translation of evidence-based interventions to service settings is important (McGee, Morrier, & Daly, 1999), but express concerns about the current quality of these interventions when applied in community programs. Due to limited funding and training researchers are skeptical about the ability and/or willingness of public programs to utilize evidence-based practices to provide quality treatment (McGee et al., 1999). There is concern that service systems attempting to replicate research models may not assess fidelity of implementation (the accuracy with which the intervention is implemented) or replicate all aspects of the program (Cohen, 1999). Interventions for young children with autism must be implemented with precision to substantially alter developmental trajectory (McGee & Morrier, 2005). Therefore, a great deal of training is needed in order to implement evidence-based practices with the precision used in a majority of research programs. Teachers, therapists and paraprofessionals who provide treatment for children with autism in public schools often have limited access to effective training in empirically based therapy methods (Lord & McGee, 2001). Although public school teachers report wanting to use empirically supported methods, their enthusiasm for using these techniques wanes when the necessary training is not provided (Norsworthy & Sievers, 1987).
One evidence-based method that teachers report using in their classrooms is Pivotal Response Training. Pivotal Response Training (PRT) is a form of naturalistic behavioral intervention that is supported in the scientific literature (cf.., National Research Council, 2001). PRT was developed to facilitate stimulus and response generalization, increase spontaneity, reduce prompt dependency, and increase motivation. The development of PRT was based on a series of studies identifying important treatment components. The "pivotal" responses trained in PRT vary based on a child's developmental level, but may include motivation and responsivity to multiple cues (i.e., increasing breadth of attention), and initiation. Specific elements include clear and appropriate prompts, child choice, turn-taking, interspersal of maintenance tasks, reinforcing attempts, responding to multiple cues, and a direct response-reinforcer relationship (see Table 1). PRT was developed and has been supported as a method to increase verbal (language) and nonverbal communication skills. An independent review of the research-base for use of PRT recommends the intervention as an efficacious evidence-based intervention for children with autism (Humphries, 2003). When compared with other more structured techniques, PRT has been found to be more effective for increasing verbalizations and contingent language use (Koegel, Koegel, & Surrat. 1992; Koegel, O'Dell, & Koegel, 1987). PRT has been shown to be effective for improving a variety of language functions including speech imitation (Koegel, Camarata, Valdez-Menchaca, & Koegel, 1998; Laski, Charlop, & Schreibman, 1988), labeling (Koegel et al. 1998), question asking (Koegel et al. 1998), spontaneous speech (Laski et al., 1988), conversational communication (Koegel et al. 1998), and rapid acquisition of functional speech in previously nonverbal children (Sze, Brookman., Koegel & Koegel, 2003). PRT has also been adapted to teach symbolic play (e.g., Stahmer 1995) and socio-dramatic play (e.g., Thorp, Stahmer, et al. 1995), peer social interaction (e.g., Pierce & Schreibman, 1997), self-initiations (Koegel, Carter, & Koegel, 2003), and joint attention (e.g., Rocha, Schreibman, & Stahmer in press; Whalen & Schreibman, 2003). Two recent studies have provided evidence for the effectiveness of PRT for individual parent training in community settings (Baker-Eriksen, Stahmer & Burns, in press; Stahmer & Gist, 2001). However, there is limited evidence of how PRT is being translated into school programs for children with autism.
A recent study examining community early intervention programs in the Southern California region indicates that over 70% of the 80 providers surveyed reported using PRT, or some variation of PRT in their programs (Stahmer, in press; Stahmer, unpublished data). Although many providers reported using PRT as a primary or secondary intervention in their programs, accuracy of use has not been systematically monitored. Providers reported combining several methodologies to develop individualized programs based on each child's specific characteristics and adapting the program from the training protocol to fit their own program or teaching preferences. Additionally, the majority of participants felt that adequate training for themselves and the paraprofessionals in their programs had not been provided (Stahmer, Collings & Palinkas, 2005). Training and experience varied greatly, but most participants reported taking a course that covered PRT in their educational program, or learning the technique "on the job." These provider-reported data indicate issues for the translation of evidence-based practices from research settings to community settings, and suggest the need to assess fidelity of implementation of these practices by type of community program. Additionally, methods of translating evidence-based practices to community programs may need to vary by setting.
A majority of children with autism receive an educational program as part of early intervention. A multidisciplinary team of providers, including teachers, psychologists, speech and occupational therapists are typically involved in programming. A key factor in increasing the accessibility and quality of educational services for children with autism is provision of effective training in evidence-based therapies. While evidence-based practices for children with autism exist, the fidelity of implementation of these interventions has not been systematically tested in community settings. Additionally, the training and experience of community personnel and supervision varies substantially. The goal of this research is to assess the fidelity of implementation of early intervention teachers who received training in a specific evidence-based methodology, Pivotal Response Training. This study was designed to analyze the fidelity of teachers' implementation of each specific component of PRT by setting, and more broadly, the effectiveness of training that teachers currently receive in PRT across programs.
Participants included 10 female teachers working in early intervention classrooms in one Southern California County (Table 2). Two programs were examined. Four teachers worked in public special education preschool classrooms. These classrooms served students with diagnoses of autism, Pervasive Developmental Disorder--Not Otherwise Specified (PDD-NOS), mental retardation and general language disorders. These classrooms will be referred to as "public school" programs. Six teachers worked in a publicly funded specialized inclusive preschool program for toddlers with autism. This program was created to serve the specific needs of children who have a diagnosis of autism or PDD-NOS, as well as typically developing children. This classroom will be referred to as "specialized" program. Teaching experience ranged from 1-16 years. All participants reported that they had some training in PRT and currently taught full or part-day in a special education classroom and had at least two students with a diagnosis of autism.
Teachers were recruited through district or school supervisors. Supervisors were asked to refer any teachers who had some training in PRT, taught part or full-day in a special education classroom, and who served at least two students with a primary educational classification of autism. All referred teachers were informed that participation was voluntary and their decision for or against participation would be kept confidential. Consent was obtained to videotape all participating teachers and consent was obtained from parents of all students in the classrooms who might be filmed during individual or group sessions.
Teachers completed a brief questionnaire describing their educational background, teaching experience and the type of training they had received in PRT. Each teacher selected students with autism spectrum disorders from her own classroom to participate in individual fidelity of implementation sessions. All sessions were conducted in the participating teachers' classrooms, therapy rooms at their school site, or outdoor play areas. Treatment sessions occurred at various times throughout the day, at the teachers' convenience. For each teacher, data were collected by videotaping two, 10-minute fidelity of implementation sessions on two separate days for a total of 40 minutes. On these two separate days, the experimenter instructed the participating teacher to use PRT for 10 minutes while working individually with one child and 10 minutes with a group of children. Sequencing of group sessions and one-on-one sessions were counterbalanced across days to protect against any order effects.
Fidelity of implementation of PRT was assessed by coding videotaped sessions. Videotaped sessions were coded by trained undergraduate research assistants who were blind to each participant's level of training.
Fidelity of Implementation of PRT. Behavioral definitions for each component of PRT provided by the program developers were used to examine use of PRT (Koegel, O'Dell, & Koegel, 1987). Specific definitions and mastery criteria for each component of PRT are listed in Table 3. Participants received either a positive or negative score for each component of PRT during each teaching trial. An average percent of correct implementation was determined for each component of PRT by calculating the mean, over the two one-on-one sessions and the then the two group sessions. The use of multiple cues was not coded due to the age and developmental levels of the children in the classrooms.
Teacher Demographic and PRT Training Survey. Each teacher completed a three-page pen and paper survey before the fidelity of implementation sessions were videotaped. The survey requested general demographic information (e.g. education, number of years teaching, hours typically spent on specific classroom activities) as well as more PRT specific information. Participants were asked to "describe the training you have received in Pivotal Response Training (PRT)." Additional questions included: "What methods did the instructor use?" "Did you receive a PRT manual?" and "Did you receive supervision while implementing PRT in your classroom?"
Reported type of PRT training varied among teachers (Table 4). Teachers with the lowest level of training reported receiving a PRT manual and observing someone else conducting PRT only. Other teachers were categorized as having a more moderate level of training which included receiving the PRT manual, didactic instruction, and observation. Teachers receiving the highest level of training received feedback from a professional while they performed PRT with a child in addition to other aspects of training. Although training varied, type of training was confounded with teaching environment. Teachers in the public school settings received low or medium levels of training. However, teachers at the specialized autism program received more systematic training that included on-going feedback from a supervisor. Teacher education level and experience also varied by setting (see Table 1); Teachers in the public school setting all held teaching credentials and had 8-12 years of teaching experience, while specialized program teachers had only 1-2 years of teaching experience.
Overall Fidelity of Implementation
None of the participants met the criterion for fidelity of implementation across all components of PRT, however all participants met the criterion for the majority of PRT skills (See Figure 1). As a group, on average, the teachers met criterion on all components except turn taking. All participants were likely to effectively gain the child's attention before providing a discriminative stimulus (SD) and follow the child's lead or interest in activities. Participants were less consistent when providing reinforcement and sharing control of the activity. One aspect of shared control, turn taking, was not implemented at a mastery level by any of the participants.
[FIGURE 1 OMITTED]
Fidelity of Implementation by Training Level and Setting
One-on-One Sessions. Level of training did have an effect on the use of PRT. However this varied by specific PRT skill (see Figure 2). Teachers with all levels of training met criterion for presenting instructions when the child was attending, and for providing child choice. No teachers met criterion for turn taking. Teachers with low or medium levels of training had more difficulty providing clear instructions ([S.sup.D]), reinforcing attempts, or providing reinforcement contingent upon child behavior. Teachers with low levels of training had great difficulty with providing direct reinforcement as well.
[FIGURE 2 OMITTED]
Group Sessions. Training seemed to have less of an effect on use of PRT in group teaching settings, where teachers with low to medium training were better able to provide clear instructions, reinforce attempts at correct responding, and provide direct and contingent reinforcement. Turn-taking remained difficult for all teachers in the group setting.
Fidelity of Implementation by Years of Experience and Setting
When examining the use of PRT strategies by years of experience of the teachers an interaction between setting and years of experience is evident. Figure 4 depicts the average percent of PRT components on which the teachers met fidelity criterion in each setting. Teachers with less experience (all of whom worked in the specialized setting) performed better in the one-on-one setting than in the group setting. These teachers did not meet overall criterion for use of PRT in the group setting. Teachers with greater experience (all of whom worked in the public school setting) did not meet overall criteria in either setting; however, they did show an improvement in overall percentage of PRT skills they correctly implemented in group teaching environments. This is the opposite pattern observed for teachers with less experience.
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
Many interventions for children with autism, including PRT, have been developed and tested in one-on-one environments with staff specializing in autism or behavioral psychology. Expecting evidence-based programs to work in public schools or other community settings where children are often taught in group settings by teachers and paraprofessionals may be unrealistic. Therefore, in order to move evidence-based programs effectively into community settings it is necessary to consider the context of the educational environment, including teacher experience and education and modify the intervention accordingly.
None of the 10 participating teachers met the criteria for correct implementation for all areas of PRT, and overall, participants used PRT correctly more often in one-on-one teaching situations than in groups. The fidelity of implementation appeared to vary systematically according to the type of training received. Specifically, teachers that received some feedback from a professional, in addition to a combination of other types of training, used PRT more accurately than those who did not receive feedback. These data indicate the need for effective procedures, materials, and assessment of PRT as well as specialized training in how to use PRT for group-based instruction.
The teachers assessed here completed several of the components very consistently regardless of the level of training they had received in PRT. It is possible that specific components such as gaining a child's attention and providing choices are taught in teacher training programs as part of other procedures, or that these components are especially intuitive for teachers or useful in the classroom. The use of other components, especially various aspects of appropriate reinforcement, were more difficult for teachers who had not received direct feedback on their implementation of PRT. This may indicate that researchers can identify aspects of evidence-based practices for autism that are consistent with teacher training in general, and capitalize on these aspects as strengths that many teachers may already have, or that they can learn quite easily.
Conversely, training in applied behavior analysis may need to focus on how to appropriately use contingent consequences. Teachers had great difficulty implementing feedback strategies. This is consistent with other observational research indicating that teachers provide feedback to students with autism for only about 30% of the instructions provided to students (Stahmer & Reed, in preparation). Researchers in the area of applied behavior analysis have clearly demonstrated the importance of clear and consistent contingencies in teaching children with autism (e.g., Schreibman, 1988). If teachers are implementing evidence-based behavioral practices without providing contingent feedback to the children, then there is a very low likelihood that the procedures will be effective. Additional research is needed to examine methods of training teachers how to use contingent responding with children who have autism in classroom settings.
Teachers with more experience appeared to be better at generalizing PRT steps to group settings. This provides promise for the use of PRT in classroom settings. Had these teachers with more experience also had higher levels of training, which included feedback they may have been able to implement PRT correctly in a group setting. Teachers with high levels of training and less experience did not generalize their skills well to a group setting. It is possible that experience managing a classroom and implementing procedures in a hectic environment needs to be specifically trained. Providers with less experience may meet fidelity of implementation requirements in one-on-one settings but have more difficulty in group settings. Therefore, developing methods of training specifically address the adaptation of one-on-one programs to classroom settings is imperative.
Research on training providers in behavioral modification procedures has shown feedback to be an important component in effective training programs (Jones, Wickstrom, & Friman, 1997). This study supports that notion. Teachers who received direct feedback on their use of the techniques during their initial PRT training performed better overall than teachers who did not receive such feedback. Many community providers attend a workshop or lecture on a procedure and begin to implement it with children who have autism. McGee and Morrier (2005) argue that effective training is dependent on both the initial training and an on-going supervisory system, and that supervision effectiveness is directly related to the amount of time the supervisor is present. Developing training methods that are cost-effective and include direct supervision appears to be necessary for the appropriate translation of evidence-based programming to usual care environments.
There are several limitations to this preliminary investigation into the use of PRT in classroom settings. First, the level of training and experience was confounded with setting. There may be specific differences between the specialized and public school programs that made use of PRT easier or more difficult in one setting or the other, rather than the training that was responsible for improved performance in the specialize setting. Additionally, the public school programs may have some aspect that made their classroom more conducive to the use of PRT in group settings. Additional research examining the fit of PRT into specific settings will be important. Also, we do not have data on teachers' implementation of specific components of PRT before receiving the training. Teachers may have been able to implement the techniques at similar levels before training. Finally, additional data will need to be obtained to generalize these finding to other therapists (e.g., speech therapists) and other intervention procedures. Understanding the techniques used in usual care would be helpful in developing evidence-based methods that will fit the context of usual and will be easier for teachers to use.
Naturalistic evidence-based practices such as PRT can be implemented effectively in community early interventions programs when providers, in this case teachers, have adequate training and supervision. Some aspects of PRT were especially difficult for these providers, therefore the program or the training may need to be adapted to fit more easily into classroom settings. More research is needed to examine the role of education and experience on the use of specific strategies in community programs. A wider variety of providers that serve children with autism should be examined to determine whether PRT would be useful in other community settings such as speech therapy or mental health settings.
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Author Contact Information
Jessica Suhrheinrich, M.A.
University of California, San Diego
9500 Gilman Drive, MC 0109
La Jolla, California 92093
Aubyn Stahmer, Ph.D.
Rady Children's Hospital, San Diego
3020 Children's Way, MC 5033
San Diego, CA 92123
Laura Schreibman, Ph.D.
University of California, San Diego
9500 Gilman Drive, MC 0109
La Jolla, California 92093
Table 1. Components of PRT (1) Child attending/ Clear [S.sup.D]: The instruction should be clear, appropriate to the task, uninterrupted, and the child should be attending to the therapist or task (2) Maintenance Tasks: Maintenance tasks should be interspersed frequently (3) Multiple Cues: Conditional discrimination should be required to broaden attention if developmentally appropriate (4) Shared Control: The child should be given a significant role in choosing activities and materials, and the therapist should take turns with the child to model appropriate play skills (5) Contingent Reinforcement: The reward should be effective and should be presented immediately, and contingently upon the child's behavior (6) Direct Reinforcement: The reward should be directly related to the child's behavior (7) Reinforcement of attempts: The child's goal-directed attempts should be rewarded Table 2. Teacher Demographics Teaching Experience Student Teacher School Setting Teacher Education (years) Ages 1 Public School B.A., Special Educ. 12 3 yrs Credential 2 Public School B.A., 8 3-4 yrs Special Educ. Credential 3 Public School B.A., M.A. 16 4-5 yrs Special Educ. Credential 4 Public School B.A. 10 4-5 yrs Special Educ. Credential 5 Specialized B.A. 1 2 yrs 6 Specialized B.A. 1 2 yrs 7 Specialized B.A. 2 2 yrs 8 Specialized B.A. 1 2 yrs 9 Specialized B.A. 1 2 yrs 10 Specialized B.A. 2 2 yrs Table 3. Scoring Definitions for PRT Fidelity of Implementation PRT Component Behavioral Scoring Definition Mastery Criterion Child Attending The child should be oriented Correct toward, or looking at the implementation in toy/stimuli or the therapist. 80% of trials The child should not be playing, crying or engaging in self-stimulatory behavior. Clear [S.sup.D] A verbal cue should be concise, Correct consistent, and it should be implementation in clear what response is expected 80% of trials from the child (e.g. Therapist says, "Ball" when the child looks at or reaches for the ball). Shared Control: The therapist should follow the Correct (Child Choice) child's interests; the implementation in therapist should offer choices 80% of trials of activities. Shared Control: The therapist should engage the Correct (Turn Taking) child in back-and-forth play implementation in by exchanging control of a 33% of trials stimulus item or activity. The child should attend to the therapist. Reinforcement of The therapist should reinforce Correct Attempts the child's goal directed implementation in attempts even if the child's 80% of trials response is not accurate. Direct All reinforcing items or Correct Reinforcement activities should have a direct implementation in relationship to the behavior 80% of trials of the child. Contingent A consequence should be Correct Reinforcement contingent upon and immediately implementation in follow a child's response. If 80% of trials the child is engaged in an inappropriate behavior (e.g. self-stimulatory behavior) at the same time as the correct response, the correct response should not be reinforced. Table 4. Teacher reported training in PRT Dydactic Training Level Instruction Observation Feedback Manual High (n=6) X X X X Medium (n=2) X X X Low (n=2) X X
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|Author:||Suhrheinrich, J.; Stahmer, A.C.; Schreibman, L.|
|Publication:||The Journal of Speech-Language Pathology and Applied Behavior Analysis|
|Date:||Dec 22, 2006|
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