Pivotal response treatment involving parents works better than other existing therapies at motivating children with autism and significant speech delays to talk, according to the results of a large study by researchers at the Stanford University School of Medicine.
Because children with autism are less socially motivated than typically developing children, parents' instincts about how to engage them often don't succeed, said Grace Gengoux, PhD, clinical associate professor of psychiatry and behavioral sciences. PRT gives parents a way to breach this barrier.
"We were teaching parents how to set up situations where their child would be motivated to communicate," Gengoux said. "The results of our study are exciting because we found that children in the PRT group improved not just in their communication skills, but also in their broader social abilities."
Heidi Pim of Palo Alto, California, participated in the study with her son, James, who was diagnosed as a toddler with autism and speech delays.
"I was really worried and anxious about not knowing if he would ever be able to talk," Pim said. She was impressed by the changes she saw in James, who was 3 at the time of the study. "I feel so grateful now to see how many words and phrases he knows," she said. "He's able to speak clearly and socialize as well, to go up to people and ask them questions."
A paper describing the study will be published online Aug. 5 in Pediatrics. Gengoux is the lead author. The senior author is Antonio Hardan, MD, professor of psychiatry and behavioral sciences.
The six-month study enrolled 48 children who were 2 to 5 years old and had autism and significant language delays. Half the children received PRT treatment from therapists and their parents, while the remaining children continued to receive whatever autism treatments they had been getting before the study began, which included other types of applied behavior analysis and conventional speech therapy.
For the first 12 weeks of the study, children in the PRT group underwent 10 hours per week of PRT from a trained therapist, and their parents received training for one hour per week in how to use the treatment's techniques during everyday interactions with their children. For the second 12 weeks of the study, children in the PRT group received five hours per week of therapist treatment, and their parents had monthly instruction sessions.
In PRT, the therapist or parent notes what the child is interested in, and uses the object to encourage speech. For example, if James wanted a toy car, Pim, his mother, learned to pick up the car, hold it where he could see it and encourage him to say "car." When he tried to say the word, he was rewarded with the toy.
At first, James learned single words. He then progressed to phrases such as "green car" and "ready, set, go." Pim also used PRT to help James learn to express his needs, such as by saying "bottle" if he was thirsty.
"He used to not be able to point to something or ask," Pim said. "PRT really improved his vocabulary skills and communication back and forth. It helped us understand what he needs and wants."
As the trial progressed, Pim also saw James' frustration levels decrease. "Before, he didn't know how to express his feelings," she said. "When I would leave for the day and come back, he didn't know how to say 'Mommy, I missed you,' so instead he would hit me or cry. That has lessened."
Today, James, now 8, is a happy kid who attends school in a mainstream classroom and enjoys playing with his twin sister, Jessica. Pim still uses PRT techniques to engage James in conversation on his favorite topics, such as elevators.
At the end of the study, the children in the PRT group spoke more than those in the comparison group, and were using common words that could be recognized by others, an important marker of progress given that many children spoke unintelligibly at the start of the trial. The children in the PRT group also showed greater improvement in a measure of their overall social communication, which is critical for an optimal long-term outcome, the researchers reported.
They also found that children who began with lower developmental abilities benefited more from the intervention, a surprising finding since many autism therapies are of greater benefit to higher-functioning children.
"It's discouraging for parents of lower-functioning kids if we tell them that higher-functioning kids do better, because higher-functioning kids are already doing better," Gengoux said. The new findings suggest that parents can play an especially valuable role in assisting children who have the greatest needs, she said, adding, "This provides a lot of hope."
Stanford researchers believe that findings from this trial are promising but that they need to be replicated in larger investigations. They are also currently recruiting young children with autism for a new study of how the brain changes in PRT. Interested parents can call (650) 736-1235 or e-mail firstname.lastname@example.org for more information.
Parents and teachers who want to learn PRT techniques can attend a one-day conference being held at Stanford in September. More information about the conference is available at http://med.stanford.edu/autismcenter.html.
The study's other Stanford co-authors are Daniel Abrams, PhD, clinical assistant professor of psychiatry and behavioral sciences; research coordinators Rachel Schuck and Maria Estefania Millan; clinical research manager Robin Libove; clinical research coordinator Christina Ardel; and Jennifer Phillips, PhD, clinical associate professor of psychiatry and behavioral sciences.
Researchers from Palo Alto University and Autism Speaks, an autism advocacy organization, also contributed to the research.
Gengoux and Hardan are members of the Stanford Maternal & Child Health Research Institute. Hardan is also a member of Stanford Bio-X and the Wu Tsai Neurosciences Institute at Stanford.
The research was supported by grants from the National Institute on Deafness and other Communication Disorders (grant DC01368902), the National Institute of Mental Health (grant MH102428), and the National Center for Research Resources and the National Center for Advancing Translational Sciences (grant UL1TR001085).
Stanford's Department of Psychiatry and Behavioral Sciences also supported the work.
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