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Pivotal Response Treatment for School-Aged Children and Adolescents with Autism Spectrum Disorder: A Randomized Controlled Trial

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Abstract

Pivotal Response Treatment (PRT) is promising for children with Autism Spectrum Disorder (ASD), but more methodologically robust designed studies are needed. In this randomized controlled trial, forty-four children with ASD, aged 9–15 years, were randomly allocated to PRT (n = 22) or treatment-as-usual (TAU; n = 22). Measurements were obtained after 12- and 20-weeks treatment, and 2-month follow-up. PRT resulted in significant greater improvements on parent-rated social-communicative skills after 12 weeks treatment (p = .004, partial η2 = 0.22), compared to TAU. Furthermore, larger gains in PRT compared to TAU were observed on blindly rated global functioning, and parent-rated adaptive socialization skills and attention problems. Implications for clinical practice and suggestions for future research are discussed.

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References

  • Achenbach, T., McConaughy, S., Ivanova, M., & Rescorla, L. (2011). Manual for the ASEBA brief problem monitor (BPM) (pp. 1–33). Burlington, VT: ASEBA.

    Google Scholar 

  • American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (DSM IV-TR). 4th edition. Washington, DC: APA  

    Google Scholar 

  • American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM-V). 5th edition. Washington, DC: APA.

    Book  Google Scholar 

  • Baker-Ericzén, M. J., Stahmer, A. C., & Burns, A. (2007). Child demographics associated with outcomes in a community-based pivotal response training program. Journal of Positive Behavior Interventions, 9(1), 52–60. https://doi.org/10.1177/10983007070090010601.

    Article  Google Scholar 

  • Ben-Itzchak, E., & Zachor, D. A. (2007). The effects of intellectual functioning and autism severity on outcome of early behavioral intervention for children with autism. Research in Developmental Disabilities, 28(3), 287–303. https://doi.org/10.1016/j.ridd.2006.03.002.

    Article  PubMed  Google Scholar 

  • Boudreau, A. M., Corkum, P., Meko, K., & Smith, I. M. (2015). Peer-mediated pivotal response treatment for young children with autism spectrum disorders: A systematic review. Canadian Journal of School Psychology, 30(3), 218–235. https://doi.org/10.1177/0829573515581156.

    Article  Google Scholar 

  • Brock, M. E., Dueker, S. A., & Barczak, M. A. (2018). Brief report: Improving social outcomes for students with autism at recess through peer-mediated pivotal response training. Journal of Autism and Developmental Disorders, 48(6), 2224–2230. https://doi.org/10.1007/s10803-017-3435-3.

    Article  PubMed  Google Scholar 

  • Browner, W. S., Newman, T. B., & Hulley, S. B. (2013). Estimating sample size and power: Applications and examples. In S. B. Hulley, S. R. Cummings, W. S. Browner, D. G. Grady, & T. B. Newman (Eds.), Designing clinical research: An epidemiologic approach (Vol. 4, pp. 55–83). Philadelphia, PA: Lippincott Williams and Wilkins.

    Google Scholar 

  • Castor, E. D. C. (2019). Castor electronic data capture. Retrieved 28 Aug 2019 from https://castoredc.com.

  • Constantino, J. N., & Gruber, C. P. (2005). Social responsiveness scale (SRS). Los Angeles, CA: Western Psychological Services.

    Google Scholar 

  • Dawson, G., & Bernier, R. (2013). A quarter century of progress on the early detection and treatment of autism spectrum disorder. Devopment and Psychopathology, 25(4 Pt 2), 1455–1472. https://doi.org/10.1017/s0954579413000710.

    Article  Google Scholar 

  • De Bildt, A., Greaves-Lord, K., & De Jonge, M. (2013). ADOS-2: Autisme diagnostisch observatieschema. Handleiding. Amsterdam: Hogrefe.

    Google Scholar 

  • De Marchena, A. B., Eigsti, I. M., & Yerys, B. E. (2015). Brief report: Generalization weaknesses in verbally fluent children and adolescents with autism spectrum disorder. Journal of autism and developmental disorders, 45(10), 3370–3376. https://doi.org/10.1007/s10803-015-2478-6.

    Article  PubMed  PubMed Central  Google Scholar 

  • Doggett, R. A., Krasno, A. M., Koegel, L. K., & Koegel, R. L. (2013). Acquisition of multiple questions in the context of social conversation in children with autism. Journal of Autism and Developmental Disorders, 43(9), 2015–2025. https://doi.org/10.1007/s10803-012-1749-8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Duifhuis, E. A., den Boer, J. C., Doornbos, A., Buitelaar, J. K., Oosterling, I. J., & Klip, H. (2017). The effect of pivotal response treatment in children with autism spectrum disorders: A non-randomized study with a blinded outcome measure. Journal of Autism and Developmental Disorders, 47(2), 231–242. https://doi.org/10.1007/s10803-016-2916-0.

    Article  PubMed  Google Scholar 

  • Fleiss, J., Tytun, A., & Ury, H. K. (1980). A simple approximation for calculating sample sizes for comparing independent proportions. Biometrics, 36, 343–346.

    Article  Google Scholar 

  • Flückiger, C., & Del Re, A. C. (2017). The sleeper effect between psychotherapy orientations: A strategic argument of sustainability of treatment effects at follow-up. Epidemiology and Psychiatric Sciences, 26(4), 442–444. https://doi.org/10.1017/S2045796016000780.

    Article  PubMed  Google Scholar 

  • Fossum, K. L., Williams, L., Garon, N., Bryson, S. E., & Smith, I. M. (2018). Pivotal response treatment for preschoolers with autism spectrum disorder: Defining a predictor profile. Autism Research, 11(1), 153–165. https://doi.org/10.1002/aur.1859.

    Article  PubMed  Google Scholar 

  • Gengoux, G. W., Abrams, D. A., Schuck, R., Millan, M. E., Libove, R., Ardel, C. M., et al. (2019). A pivotal response treatment package for children with autism spectrum disorder: An RCT. Pediatrics. https://doi.org/10.1542/peds.2019-0178.

    Article  PubMed  Google Scholar 

  • Gotham, K., Pickles, A., & Lord, C. (2009). Standardizing ADOS scores for a measure of severity in autism spectrum disorders. Journal of Autism and Developmental Disorders, 39(5), 693–705. https://doi.org/10.1007/s10803-008-0674-3.

    Article  PubMed  Google Scholar 

  • Guy, W. (1976). ECDEU assessment manual for psychopharmacology. Rockville, MD: U.S. Department of Healh, Education, and Welfare.

    Google Scholar 

  • Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., et al. (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. https://doi.org/10.1111/jcpp.12354.

    Article  PubMed  Google Scholar 

  • Harper, C. B., Symon, J. B. G., & Frea, W. D. (2008). Recess is time-in: Using peers to improve social skills of children with autism. Journal of Autism and Developmental Disorders, 38(5), 815–826. https://doi.org/10.1007/s10803-007-0449-2.

    Article  PubMed  Google Scholar 

  • Holm, S. (1979). A simple sequentially rejective multiple test procedure. Scandinavian journal of statistics, 1, 65–70.

    Google Scholar 

  • Huang, A. X., Hughes, T. L., Sutton, L. R., Lawrence, M., Chen, X., Ji, Z., et al. (2017). Understanding the self in individuals with autism spectrum disorders (ASD): A review of literature. Frontiers in psychology, 8, 1422–1422. https://doi.org/10.3389/fpsyg.2017.01422.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hus, V., Gotham, K., & Lord, C. (2014). Standardizing ADOS domain scores: Separating severity of social affect and restricted and repetitive behaviors. Journal of Autism and Developmental Disorders, 44(10), 2400–2412. https://doi.org/10.1007/s10803-012-1719-1.

    Article  PubMed  PubMed Central  Google Scholar 

  • Huskens, B., Reijers, H., & Didden, R. (2012). Staff training effective in increasing learning opportunities for school-aged children with autism spectrum disorders. Devolopmental Neurorehabilitation, 15(6), 435–447. https://doi.org/10.3109/17518423.2012.705910.

    Article  Google Scholar 

  • IBM-Corp. (2017). IBM SPSS statistics for windows version 25.0. Armonk, NY: IBM Corp.

    Google Scholar 

  • Keen, D., Couzens, D., Muspratt, S., & Rodger, S. (2010). The effects of a parent-focused intervention for children with a recent diagnosis of autism spectrum disorder on parenting stress and competence. Research in Autism Spectrum Disorders, 4(2), 229–241. https://doi.org/10.1016/j.rasd.2009.09.009.

    Article  Google Scholar 

  • Koegel, P., Sullivan, G., Burnam, A., Morton, S. C., & Wenzel, S. (1999). Utilization of mental health and substance abuse services among homeless adults in Los Angeles. Medical Care, 37(3), 306–317.

    Article  Google Scholar 

  • Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism: Communication, social, and academic development. Baltimore, London: Paul H. Brookes Publishing.

    Google Scholar 

  • Koegel, R. L., & Koegel, L. K. (2012). The PRT pocket guide: Pivotal response treatment for autism spectrum disorders. Baltimore, London: Paul H. Brookes Publishing Co.

    Google Scholar 

  • Kort, W., Schittekatte, M., Dekker, P., Verhaeghe, P., Compaan, E., Bosmans, M., et al. (2005). WISC-III NL Wechsler intelligence scale for children. Derde Editie NL. Handleiding en verantwoording. Amsterdam: Harcourt Test Publishers/Nederlands Instituut voor Psychologen.

    Google Scholar 

  • Little, R. J. A. (1988). A test of missing completely at random for multivariate data with missing values. Journal of the American Statistical Association, 83(404), 1198–1202. https://doi.org/10.1080/01621459.1988.10478722.

    Article  Google Scholar 

  • Minjarez, M. B., Mercier, E. M., Williams, S. E., & Hardan, A. Y. (2013). Impact of pivotal response training group therapy on stress and empowerment in parents of children with autism. Journal of Positive Behavior Interventions, 15(2), 71–78. https://doi.org/10.1177/1098300712449055.

    Article  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nefdt, N., Koegel, R., Singer, G., & Gerber, M. (2010). The use of a self-directed learning program to provide introductory training in pivotal response treatment to parents of children with autism. Journal of Positive Behavior Interventions, 12, 23–32. https://doi.org/10.1177/1098300709334796.

    Article  Google Scholar 

  • Ona, H. N., Larsen, K., Nordheim, L. V., & Brurberg, K. G. (2019). Effects of pivotal response treatment (PRT) for children with autism spectrum disorders (ASD): A systematic review. Review Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s40489-019-00180-z.

    Article  Google Scholar 

  • Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviors in children with autism: Effects of peer-implemented pivotal response training. Journal of Applied Behavior Analysis, 28(3), 285–295. https://doi.org/10.1901/jaba.1995.28-285.

    Article  PubMed  PubMed Central  Google Scholar 

  • Pijl, M. K., Rommelse, N. N., Hendriks, M., De Korte, M. W., Buitelaar, J. K., & Oosterling, I. J. (2018). Does the brief observation of social communication change help moving forward in measuring change in early autism intervention studies? Autism, 22(2), 216–226. https://doi.org/10.1177/1362361316669235.

    Article  PubMed  Google Scholar 

  • Rezaei, M., Moradi, A., Tehrani-Doost, M., Hassanabadi, H., & Khosroabadi, R. (2018a). A pilot study on combining risperidone and pivotal response treatment on communication difficulties in children with autism spectrum disorder. Advances in Autism, 4(2), 56–65. https://doi.org/10.1108/AIA-11-2017-0024.

    Article  Google Scholar 

  • Rezaei, M., Moradi, A., Tehrani-Doost, M., Hassanabadi, H., & Khosroabadi, R. (2018b). Effects of combining medication and pivotal response treatment on aberrant behavior in children with autism spectrum disorder. Children. https://doi.org/10.3390/children5020019.

    Article  PubMed  PubMed Central  Google Scholar 

  • Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7(2), 147–177. https://doi.org/10.1037/1082-989X.7.2.147.

    Article  PubMed  Google Scholar 

  • Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., et al. (2015). Naturalistic developmental behavioral interventions: Empirically validated treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(8), 2411–2428. https://doi.org/10.1007/s10803-015-2407-8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Schreibman, L., & Stahmer, A. C. (2014). A randomized trial comparison of the effects of verbal and pictorial naturalistic communication strategies on spoken language for young children with autism. Journal of Autism and Developmental Disorders, 44(5), 1244–1251. https://doi.org/10.1007/s10803-013-1972-y.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sparrow, S., Cicchetti, D., & Balla, D. (2005). Vineland adaptive behavior scales-second edition (Vineland–II). Circle Pines, MN: American Guidance Service.

    Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • Stock, R., Mirenda, P., & Smith, I. M. (2013). Comparison of community-based verbal behavior and pivotal response treatment programs for young children with autism spectrum disorder. Research in Autism Spectrum Disorders, 7(9), 1168–1181. https://doi.org/10.1016/j.rasd.2013.06.002.

    Article  Google Scholar 

  • vant Hof, M., Tisseur, C., van Berckelear-Onnes, I., van Nieuwenhuyzen, A., Daniels, A. M., Deen, M., et al. (2020). Age at autism spectrum disorder diagnosis: A systematic review and meta-analysis from 2012 to 2019. Autism. https://doi.org/10.1177/1362361320971107.

    Article  Google Scholar 

  • Ventola, P., Friedman, H. E., Anderson, L. C., Wolf, J. M., Oosting, D., Foss-Feig, J., et al. (2014). Improvements in social and adaptive functioning following short-duration PRT program: A clinical replication. Journal of Autism and Developmental Disorders, 44(11), 2862–2870. https://doi.org/10.1007/s10803-014-2145-3.

    Article  PubMed  Google Scholar 

  • Ventola, P. E. Y., et al. (2016). Brief report: Reduced restricted and repetitive behaviors after pivotal response treatment. Journal of Autism and Developmental Disorders, 46(8), 2813–2820. https://doi.org/10.1007/s10803-016-2813-6.

    Article  PubMed  PubMed Central  Google Scholar 

  • Vermulst, A., Kroes, G., De Meyer, R., Nguyen, R., & Veerman, J. W. (2012). Opvoedingsbelastingvragenlijst (OBVL). Handleiding. Nijmegen, Netherlands: Praktikon.

    Google Scholar 

  • Vernon, T. W., Holden, A. N., Barrett, A. C., Bradshaw, J., Ko, J. A., McGarry, E. S., et al. (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. https://doi.org/10.1007/s10803-019-03909-1.

    Article  PubMed  Google Scholar 

  • Verschuur, R., Didden, R., Lang, R., Sigafoos, J., & Huskens, B. (2014). Pivotal response treatment for children with autism spectrum disorders: A systematic review. Review Journal of Autism and Developmental Disorders, 1(1), 34–61. https://doi.org/10.1007/s40489-013-0008-z.

    Article  Google Scholar 

  • Verschuur, R., Huskens, B., & Didden, R. (2019). Effectiveness of parent education in pivotal response treatment on pivotal and collateral responses. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-019-04061-6.

    Article  PubMed  PubMed Central  Google Scholar 

  • Verschuur, R., Huskens, B., Verhoeven, L., & Didden, R. (2017). Increasing opportunities for question-asking in school-aged children with autism spectrum disorder: Effectiveness of staff training in pivotal response treatment. Journal of Autism and Developmental Disorders, 47(2), 490–505. https://doi.org/10.1007/s10803-016-2966-3.

    Article  PubMed  Google Scholar 

  • Wechsler, D. (2003). Wechsler intelligence scale for children-(WISC-IV). San Antonio, TX: The Psychological Corporation.

    Google Scholar 

  • World Health Organization. (2004). International statistical classification of diseases and health related problems (ICD). Geneva: World Health Organization.

    Google Scholar 

  • Zachor, D. A., & Ben-Itzchak, E. (2010). Treatment approach, autism severity and intervention outcomes in young children. Research in Autism Spectrum Disorders, 4(3), 425–432. https://doi.org/10.1016/j.rasd.2009.10.013.

    Article  Google Scholar 

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Acknowledgments

The authors gratefully acknowledge all of the families who participated in this study. We also like to thank all the clinicians of Karakter who made this research possible, specifically Marloes Rikken, Jenny den Boer and Iris Servatius-Oosterling who were involved in designing the PRT protocol. Furthermore we would like to thank Anoek Lusseveld, Nikki Rulof, Lotte Gosens, Julianne Joosten, and Anne Schruijer for their help in recruitment and data collection. IBS, MDB, JKB, and WGS contributed to the study conception and design. Material preparation, and data collection were performed by MWPK and IBS. Data analysis was performed by MWPK. IBS, MDB, JKB and WGS were involved in interpretation of the data. The first draft of the manuscript was written by MWPK and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The study was supported by Fonds NutsOhra (project 1405-307) and by Karakter, expert center for the child- and adolescent psychiatry in The Netherlands. The study was further supported by the EU-AIMS (European Autism Interventions) and AIMS-2-TRIALS programmes which receive support from Innovative Medicines Initiative Joint Undertaking Grant No. 115300 and 777394, the resources of which are composed of financial contributions from the European Union’s FP7 and Horizon2020 Programmes, and from the European Federation of Pharmaceutical Industries and Associations (EFPIA) companies’ in-kind contributions, and AUTISM SPEAKS, Autistica and SFARI, and by the European Union Horizon2020 programme CANDY (Grant No. 847818).

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  1. Wouter G. Staal and Martine van Dongen-Boomsma are shared last authors.

Authors and Affiliations

  1. Karakter Child and Adolescent Psychiatry University Centre, Reinier Postlaan 12, 6525 GC, Nijmegen, The Netherlands

    Manon W. P. de Korte, Iris van den Berk-Smeekens, Jan. K. Buitelaar, Wouter G. Staal & Martine van Dongen-Boomsma

  2. Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Centre, P.O. Box 9104, 6500 HB, Nijmegen, The Netherlands

    Manon W. P. de Korte, Iris van den Berk-Smeekens, Jan. K. Buitelaar & Wouter G. Staal

  3. Institute for Brian and Cognition, Leiden University, P.O. Box 9600 (C2-S), 2300 RC, Leiden, The Netherlands

    Wouter G. Staal

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Jan K. Buitelaar has been in the past three years a consultant to/member of the advisory board of/and/or speaker for Takeda/Shire, Roche, Medice, Janssen Cilag, Angelini, and Servier. He is not an employee of any of these companies, and not a stock shareholder of any of these companies. He has no other financial or material support, including expert testimony, patents, and royalties. All other authors declare that they have no conflict of interest.

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All procedures performed in this study involving human participants were in accordance with ethical standards of the institutional and national research committee an with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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de Korte, M.W.P., van den Berk-Smeekens, I., Buitelaar, J.K. et al. Pivotal Response Treatment for School-Aged Children and Adolescents with Autism Spectrum Disorder: A Randomized Controlled Trial. J Autism Dev Disord 51, 4506–4519 (2021). https://doi.org/10.1007/s10803-021-04886-0

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