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Pivotal Response Treatment

  • A behavioral treatment for autism that uses play to teach and reinforce new, pro-social behavior
  • Used to help children build social skills needed to function in the world
  • Some children have a more dramatic response to PRT than others
  • Involves Child Study Center, pediatric neurology, and neurogenetics program

Overview

Modern medicine has brought new hope in the treatment of autism. In the 1970s, researchers began to achieve success with behavior modification, specifically in the use of positive reinforcements to teach children to interact with others. Pivotal response treatment (PRT) builds and improves on the basic principles of behavior modification. PRT uses a child’s natural motivations (toys, games and activities that a child wants and cares about) to teach and reinforce new, pro-social behaviors.

At the Yale Medicine Child Study Center, we offer research and experience with behavior modification that is adapted throughout the world. 

The Child Study Center offers a unique blend of experience, expertise and novel approaches to treatment not available elsewhere. “We are doing cutting edge, innovative research,” says Pam Ventola, PhD, an expert in PRT. “Our experience with patients and their families informs clinical research around the world.”

What is Pivotal Response Treatment?

PRT focuses on supporting “pivotal areas of development” to help children build the social skills they need to function well at home, at school and in the larger world. Pivotal areas are key skills that underlie successful communication, such as learning to start a conversation, to respond to questions, and to take part in ongoing dialogue. PRT is play-based and uses natural reinforcements. For example, the “reward” for a child who makes a meaningful attempt to ask for a toy is that he or she gets to play with it. 

“The hallmark of PRT is that it is designed to motivate the child to want to interact,” Ventola says. “PRT centers around the idea of increasing a child’s natural motivation to engage with other people, to talk with us, to want to play.” 

Though it is most often used with preschool or school-age children, PRT can be used to help people of all ages, infancy through adulthood. Motivators for teens or adults may be games, conversations, activities or outings.

How does Pivotal Response Treatment work?

According to Ventola, there is “a large downstream impact” when a child masters a new skill or set of skills. As an example, she offers the ability to initiate a conversation. PRT provides a structured way to give a child plenty of practice in developing this skill in a way that is fun. The treatment is individualized to each child’s interests, such as trains or dinosaurs or balls. 

“By increasing the frequency of opportunities to seek contact and a child’s skill at doing so, you improve a child’s ability to increase initiations,” she says. “You’ll then see a huge impact on the child’s development. A lot of other things in their lives get better too.” 

PRT also includes a significant amount of parental support and guidance; it helps parents learn how best to support their child’s social and communication development. And while not every interaction can be PRT-based, parents are encouraged to use it as much as possible because PRT works best when it is used consistently. 

“PRT is very accessible to parents,” Ventola says. “It becomes a primary way of interacting.” She adds, “It’s not that parents do PRT all the time,” noting that some interactions don’t lend themselves to PRT.

What makes Yale Medicine’s approach to Pivotal Response Treatment stand out?

The Child Study Center offers a unique blend of experience, expertise and novel approaches to treatment not available elsewhere. “We are doing cutting edge, innovative research,” Ventola says. “Our experience with patients and their families informs clinical research around the world.”

Ventola says that finding providers who treat autism, in general, and are also trained to deliver PRT can be “exceptionally challenging.” PRT is one of just a couple of evidence-based treatments shown to be effective for autism. It has similarities to another approach, applied behavioral analysis (ABA), which is more widely known and available. And while “it helps children with autism,” Ventola says, some children have a more dramatic response to PRT than others.

That’s why Ventola’s current research focuses on ways to identify which patients will get the greatest benefit from PRT, so that providers can find the best treatment approach. “It’s like precision medicine for autism,” she says.

While factors such as autism severity or the presence of some types of behaviors don’t predict a person’s response to PRT, Ventola says, her lab is finding evidence that brain markers may be an indicator. Functional MRIs performed on children getting PRT (before and after treatment) show certain biomarkers that may predict what she calls “the magnitude of response,” or how well it will work for a particular child.

A key challenge for families seeking PRT for children with autism is getting access to trained providers. Yale Medicine not only provides access to PRT at the Child Study Center in New Haven, but has also developed a new telemedicine application to offer long distance—even international—treatment. “I videoconference with families around the world and teach the basics of PRT,” Ventola says. “We are able to talk about PRT, to see the family interact with their child and to provide live feedback, in real time.”