Pivotal Response Treatment 2.0: Development and Evaluation of an Enhanced Model to Target Social Motivation and Engagement Using Microanalytic and RCT Methodologies

Background: Effective early intervention models have been a life-alternating development in the field of autism spectrum disorders, offering the hope of normalized developmental functioning and outcomes. Applied behavior analysis offered a transformative leap forward in intervention technology, offering a framework for systematically teaching children new behaviors through repetition and reinforcement. The introduction of Pivotal Response Treatment (PRT) and other Naturalistic Developmental Behavioral Interventions (NDBIs) constituted a paradigm shift of comparable magnitude, utilizing motivational and developmental elements within natural learning contexts to significantly increase skill acquisition. However, even with an ever-growing empirical foundation for PRT, the issue of differential response to intervention remains. Modification of the PRT model to directly target social motivation and engagement may further enhance developmental outcomes and eventually pave the way for third generation intervention paradigms.

Objectives: To use a series of studies to systematically develop and evaluate an enhanced PRT model's effect on child engagement, parent-child interactions, and developmental outcomes.

Methods: Across the three interrelated studies, the existing PRT framework was modified to embed engaging social components. Specifically, participants’ preferred nonsocial activities were analyzed to identify the motivating sensory elements that yielded high levels of engagement. These elements were extracted and embedded into socially analogous activities to leverage this existing motivation and transfer it into dynamic exchanges with adults.

Study I was an ABAB design with three children aged 3:1-3:5. Clinician-delivered traditional PRT and an enhanced social PRT model were contrasted to examine within session effects on child social engagement and eye contact.

Study II was a multiple baseline design with three children aged 2:0-4:11 and their parents. During baseline, parents were taught traditional PRT procedures. During intervention, enhanced social PRT model strategies were introduced. Session data were gathered on parent and child social behaviors using moment-by-moment sequential analysis techniques.

Study III was a randomized controlled trial with 24 children aged 1:6-4:6 and their parents. Twelve were randomly assigned to the enhanced social PRT condition (10 hours a week) and twelve were assigned to a community treatment group for six months. Mullen, ADOS-2, PLS-5, Vineland-II, and SLO data were analyzed using mixed MANOVA procedures.

Results: Studies I & II yielded data confirming superior child social engagement in the enhanced PRT condition. Study II’s lag sequential analyses revealed significant increases in the total number and transitional probability of parent-child social exchanges.

Study III yielded significant Group X Time effects across several measures, with the treatment enhanced PRT group experiencing superior improvements in developmental, autism symptom severity, language, and adaptive skill measures.

Conclusions: The results from this progression of studies demonstrate the potential of an enhanced social PRT framework. Specifically, Study I yielded a significant increase in child social initiations and responses at the micro level. Next, Study II demonstrated that increased child receptivity and parent-introduced motivational exchanges can generate crucial social momentum in the form of sustainable parent-child transactions and synchrony. Finally, Study III demonstrated that continued exposure to this enhanced PRT model has the potential to significantly alter the developmental trajectories of young children with ASD.