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Pivotal response treatment for children with autism spectrum disorder: A

systematic review of research quality

Article  in  Developmental Neurorehabilitation · November 2013

DOI: 10.3109/17518423.2013.845615 · Source: PubMed

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ISSN: 1751-8423 (print), 1751-8431 (electronic)

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! 2013 Informa UK Ltd. DOI: 10.3109/17518423.2013.845615

SUBJECT REVIEW

Pivotal response treatment for children with autism spectrum disorder:

A systematic review of research quality
Sarah Cadogan & Adam W. McCrimmon

Faculty of Education, University of Calgary, Calgary, Alberta, Canada

Abstract Keywords
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Objective: Research has indicated support for pivotal response treatment (PRT) as an effective, ASD, intervention, PRT, research quality,
efficacious and naturalistic intervention for communication and social functioning of children systematic review
with autism spectrum disorder (ASD). Previously not undertaken, this article describes a
systematic evaluation of the adherence of PRT research studies to standards of ASD research History
quality.
Method: A systematic search was conducted on two databases. Seventeen PRT studies were Received 27 August 2013
evaluated on their use of seven specified research standards. Revised 12 September 2013
Results: Strong adherence to research quality standards was demonstrated in the use of Accepted 12 September 2013
standardized protocols, systematic application of intervention procedures, inter-rater reliability Published online 31 October 2013
and objective evaluators. Variation was found in adherence to treatment fidelity standards and
in the use of longitudinal designs. Only two studies implemented comparison designs.
Conclusion: It is recommended that researchers compare interventions, use longitudinal
For personal use only.

designs, better describe their methodology and implement greater adherence to treatment
fidelity to enhance research quality and strengthen conclusions.

Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental
disorder recognized by qualitative impairment of socio-
communicative functioning and repetitive and/or stereotyped
patterns of behaviour [1]. Individuals with ASD experience
primary social and communicative challenges resulting from
impairment in understanding and responding to social infor-
mation [2, 3]. Children with ASD typically do not imitate
others, share attention and focus with social partners, orient to
socially important stimuli, perceive and express emotions or
engage in pretence, all of which interfere with social
reciprocity [2, 4]. Affected individuals also demonstrate
atypical language development, including delayed acquisition
of single words and/or phrase speech, delayed or atypical
expansion of abilities, loss of previously developed skills,
atypical prosody and difficulties with conversation and
pragmatics [5]. Restricted and/or repetitive patterns of
behaviour can manifest as lower (e.g. repetitive motor
movements such as hand flapping, rocking and spinning)
and/or higher (e.g. circumscribed interests, fixations on
established behavioural routines, preoccupations and interests
with certain topics) level behaviours, as well as attachment to
unusual objects [6, 7]. Some individuals with ASD may also
demonstrate adverse reactions to sensory sensations [8].
According to the Centres for Disease Control and Prevention,
Correspondence: Sarah Cadogan, Faculty of Education, University of
Calgary, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada.
E-mail: scadogan@ucalgary.ca
one in 50 children have ASD in the United States, a figure that
has increased dramatically from one in 88 during the year
2012 [9, 10]. This increase in prevalence highlights the need
to better understand the aetiology as well as the nature and
scope of ASD in order to develop and implement effective
interventions.
Early intervention for ASD
ASD is a lifelong disorder that was once considered untreat-
able; however, general agreement now exists that early
intervention is considered essential, and children who undergo
early intensive behavioural intervention that targets both the
core symptoms of ASD and associated comorbid features
demonstrate dramatically improved outcomes [11–15]. Indeed,
75–95% of children with ASD who received intensive behav-
ioural intervention are reported to develop functional speech by
five years of age [16] and demonstrate remarkable reductions in
ASD symptomatology [16–19]. Since initial recognition in the
1940s, treatment approaches for ASD have ranged from
psychoanalytic therapies and electroconvulsive treatments to
the present-day focus on behavioural interventions and
enhancement of developmental abilities [20]. Moreover, iden-
tification of specific intervention approaches has been the
focus of targeted efforts, with specific intervention approaches
now recognized as having established empirical support (e.g.
behavioural approaches and pivotal response treatment),
emerging support (e.g. augmentative communication and
language training) or no support (e.g. auditory integration
training) [12].
 2 S. Cadogan & A. W. McCrimmon
The most widely used empirically supported intervention
approach is applied behaviour analysis (ABA), which involves
early, intensive and individualized behavioural intervention
[21]. In a one-to-one or small group environment, ABA
involves enhancing, reducing or maintaining targeted behav-
iours through manipulation of environmental variables [22].
When employed intensively in early life (20–40 hours a
week), ABA has been shown to have medium to large positive
effects, particularly on language acquisition and communica-
tion, adaptive skills, intellectual and social functioning and
academic performance [12, 23]. However, ABA has several
criticisms, including the intensity (20–40 hours per week),
potentiality of children becoming ‘prompt dependent’ [24]
and difficulty with generalization of learning [23].
Pivotal response training
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pivotal response treatment (PRT), also known as pivotal
response training or pivotal response therapy, was founded on
the premise that moderating pivotal areas in children with
ASD can have positive spill-over effects to other domains of
functioning [25–27]. Four main target areas have been derived
from PRT approaches: (1) motivation, (2) self-initiations, (3)
self-management and (4) responsivity to multiple cues [28].
Children are motivated to engage in PRT activities by
affording them the opportunity to select toy(s) to use or by
providing reinforcement in the form of social praise [27, 29].
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Subsequently, the likelihood of frustration and/or quitting
after repeated failures is reduced, and children are more likely
to generalize learned skills and present with reduced
incidence of disruptive behaviours. PRT promotes the devel-
opment of self-initiation in social interactions, and particu-
larly the initiation of multiple cues during social interaction,
both of which can facilitate a child’s exposure to extensive
learning opportunities and enhanced social engagement
across environments [29]. Self-management is conceptualized
as a pivotal intervention approach as it teaches children to
choose and self-monitor their own behaviour [27, 30]. Self-
management empowers children to become active agents
within their own intervention, and self-management practices
have been associated with reduced disruptive behaviours
in children with ASD [30, 31]. Known as stimulus over-
selectivity, many people with ASD tend to respond to
irrelevant features of stimuli, while not necessarily respond-
ing to relevant features of a stimulus [27]. PRT aims to reduce
stimulus overselectivity in children with ASD by teaching
them to respond to multiple relevant cues [27]. For example, a
child would be positively reinforced for initiation of multiple
cues when making verbal requests (e.g. asking for the ‘big
green truck’ as opposed to the ‘truck’).
At its core, PRT targets child motivation in naturalistic
settings to improve language and social interaction [27].
As such, PRT has been advocated as an alternative to ABA as
a method to improve social and communicative abilities such
as symbolic play, initiating conversations, joint attention,
turn-taking and requesting in children with ASD [23]. PRT
can be implemented by families, teachers and peers within the
home, school and/or community [29].
Renshaw and Kurikose discuss three principles for
optimizing the contextual nature of early intervention [30].
Dev Neurorehabil, Early Online: 1–8
First, early, intense and frequent intervention is fundamental;
however, efficiency in intervention is essential. More time in
intervention does not necessarily equate to greater gains, and
effective interventions produce results in a time-effective
manner. As PRT is less time demanding than ABA, it is
generally considered a more efficient early intervention
process. Second, PRT was designed for naturalistic environ-
ments as familiar toys, task variation and natural and direct
reinforcements are used. In contrast, ABA and many other
early intervention approaches are typically employed in
clinical settings. Third, as PRT is conducted in naturalistic
environments, it promotes family involvement that is crucial
for treatment fidelity, the degree to which the intervention is
supported and adhered to. This differentiation further
distinguishes PRT from ABA, as ABA generally takes place
in an educational setting and may not benefit from as much
family input.
Overall, it would seem that PRT is a viable and empirically
supported intervention for children with ASD. It promotes
family, peer and teacher-mediated approaches. Its grounding
in naturalistic environments suggests that it is generalizable
across home, school and community settings. Additionally, it
renders children as active agents of change in ameliorating
social/communication abilities while self-modulating their
behaviour. However, although research has supported the use
of PRT as a form of early intervention, the quality of PRT
research has yet to be addressed. Specifically, research that
evaluates intervention programmes should be grounded in
sound theoretical and methodological designs. In this regard,
research quality standards have been developed that can be
used to evaluate the reliability, validity, accountability and
scope for generalization in ASD interventions.
Standards of quality in ASD research
Specific standards of research quality that can be applied to
behavioural, social and communication intervention research
for ASD have been proposed [32–38]. Seven factors have
been selected to form the basis for the current systematic
review.
First, Smith et al. advocate for the systematic application
of procedures during intervention research [38]. Specifically,
they propose that single subject research designs should
incorporate a baseline stage where participant skills or
behaviours are measured prior to treatment administration.
This process allows for changes in the evaluated performance
or behaviour to be attributed to the intervention. Smith et al.
advocate for multiple baseline frameworks, in which the
amount of time that participants spend in the pre-treatment
stage differs (e.g. one month vs. two months) [38]. Smith et al.
also encourage the use of between group designs (e.g. an
intervention and a control group) that allow for comparison of
results between treatment and non-treatment conditions [38].
Second, Schreibman endorses the use of comparative
studies (i.e. between interventions and/or intervention com-
ponents) [37]. As ASD is complex and multifaceted, and
some individuals may respond more successfully to an
intervention approach than to others, intervention must
address and account for these individual differences.
Comparison group(s) should be utilized so that positive
 DOI: 10.3109/17518423.2013.845615 Pivotal response treatment for children with autism spectrum disorder
effects of the target intervention can be compared across
individuals and/or groups to determine relative effectiveness
(as opposed to comparing treatment vs. no treatment) [37].
Third, standard (manualized) intervention protocols should
be utilized [34, 38]. Manuals facilitate the uniform imple-
mentation of a particular intervention, outline the specific
behaviour(s) targeted by the intervention, and provide clear
guidelines for intervention implementation, and problem-
solving strategies. As such, they may enhance reliability of
intervention research.
Fourth, fidelity of treatment implementation is key to
instigating behavioural interventions [32, 34, 38]. Treatment
fidelity is defined as ‘the methodological strategies used to
monitor and enhance the reliability and validity of behav-
ioural interventions’ [32]. Treatment providers, including
parents or peers where indicated, should adhere to standar-
dized protocols and should be trained to consistently and
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correctly implement them [32, 29], with high treatment
fidelity defined as 0.80 (80% adherence to treatment
fidelity) [33].
Fifth, objective raters/observers who are not invested in
study outcomes should evaluate treatment effectiveness [34].
For example, objective ratings may be obtained from
individuals naive to experimental hypotheses who are typic-
ally better able to objectively study interventions, thus
reducing bias.
Sixth, inter-rater reliability, or the degree to which raters
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agree on whether or not a child performed a particular
behaviour (e.g. self-initiation), is considered a key indicator
of intervention research quality. Campbell states that high
inter-rater reliability may reflect greater treatment fidelity as
problematic behaviours are correctly defined and reliably
observed [35]. Agreement of 80% or greater is an indicator of
strong reliability [36], and low agreement levels could
adversely affect treatment efficacy analyses. Specifically,
group-designs should calculate inter-rater reliability across all
research stages, raters and participants, whereas single-
subject designs should calculate inter-rater reliability on at
least 20% of research stages, raters and participants [36].
Finally, longitudinal studies evaluating treatment impact
and long-term effectiveness are advantageous [34]. Bristol
et al. advocate for the use of longitudinal studies to assess
why ‘some children do well and some (do) poorly’ (p. 129)
[34]. Follow-up studies should also determine whether
treatment effects and/or fidelity were maintained.
Rationale and direction for the current review
Using the aforementioned standards, this review aimed to
systematically evaluate empirical PRT studies for adherence
to these seven standards of research quality. To our know-
ledge, no such review has been published. Such a review will
be beneficial in determining the validity, reliability and
accountability of empirical studies in this domain.
Method
The PsycINFO and Psychological and Behavioural Sciences
Collection were searched for peer reviewed articles published
on or before 11 June 2013 for the following terms: (1) autism,
or (2) autistic, and (3) PRT and (4) intervention. This initial
3
search yielded 30 citations. Abstracts of these articles were
then screened for empirical papers on the topic of PRT
intervention programmes for children with ASD under the age
of 18 years. Eight articles were rejected as they reviewed
intervention approaches, and were therefore were not empir-
ical. One was rejected as the study used a modified version of
PRT. One was rejected as it reviewed the PRT intervention
manual. Three articles were rejected as they were either
inapplicable to PRT or were corrections pertaining to
previously published PRT articles. The remaining 17 articles
were reviewed and coded according to the above outlined
seven indicators of research quality.
Results
As shown in Table I, a total of 17 articles focused on
empirical evaluation of PRT for children and adolescents with
ASD. The following section presents the common character-
istics across studies for each of the seven indicators of ASD
intervention research quality.
Systematic application of an intervention procedure
Five studies utilized a pre–post evaluative process using
standardized assessments and/or a videotaped recording of the
child(ren)’s behaviour pre- and post-treatment [39–43].
Eleven studies utilized a multiple baseline procedure, thereby
adhering to this indicator of research quality. However,
significant variation in the multiple baseline procedure was
found. Some studies stated the exact time frame for the
multiple baseline [11, 44–51], whereas others simply stated
that a multiple baseline procedure was implemented [52, 53].
The remaining study did not collect any baseline data;
however, baseline measures of behaviour may not have been
applicable due to the nature of their experimental hypotheses
and design (collecting undergraduate raters’ ratings of parent
affect between both conditions) [54]. In addition, one study
utilized a between groups design (albeit, partial), which may
be considered suitable adherence to this standard of research
quality [54].
Comparison of intervention approaches
Only two studies performed comparisons between interven-
tion approaches. One compared PRT and Individual Target
Training Behaviour [54], while a second compared the
efficacy of PRT vs. Video-Modelling [40].
Use of standard intervention protocols
Nine studies in the current review explicitly aligned PRT
instruction and implementation with Koegel et al.s’ PRT
manuals [11, 26, 31, 40, 41, 43–45, 49, 52, 53, 55, 56]. It is
noteworthy that six studies cited PRT manuals when
describing features of the manuals, but did not explicitly
state that the PRT intervention was aligned with a PRT
manual [42, 46–48, 50, 54]. Steiner et al. mentioned that
parent PRT training was based on literature and then cited
Koegel et al.s’ 2003 PRT manual [51, 55]. Additionally,
Schreibman et al. provided a web link to a list of PRT
manuals, and Baker-Ericzén et al. used an older PRT manual
[25, 39, 50].
 4 S. Cadogan & A. W. McCrimmon Dev Neurorehabil, Early Online: 1–8

Table I. Empirical studies on PRT in children with ASD.

Use of
Systematic Comparison of standardized Use of Evidence of
application of intervention intervention Treatment objective inter-rater Longitudinal
Authors and year an intervention approaches protocols fidelity evaluators reliability studies
Baker-Ericzén et al., Yes No Older version Yes Not required Not required No
2007 of PRT
manual used
Coolican et al., 2010 Yes No Yes Yes Yes Yes Yes
Lydon et al., 2011 Yes Comparison of Yes No Yes Yes No
PRT to video
modelling.
Minjarez et al., 2013 Yes No Yes Yes Not indicated Not indicated No
Minjarez et al., 2011 Yes No Yes Yes Yes Yes No
Pierce and Schreibman, Yes No Yes Yes Not indicated Yes Yes
1995
Pierce and Schreibman, Yes No Not specified No Not indicated Yes Yes
1997
Randolph et al., 2012 Yes No Not explicitly Yes Yes Yes Yes
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stated
Robinson, 2011 Yes No Not explicitly Yes Yes Yes Yes
stated
Schreibman et al., 1991 No baseline Comparison of Not explicitly Yes Yes Yes No
data collected. parental affect stated
between PRT
and ITTB
Schreibman et al., 2009 Yes No Not specified Yes Yes Yes No
Sherer and Schreibman, Yes No Yes Yes Yes Yes Follow-up data
2005 collected on a
portion of
the sample
Smith et al., 2010 Yes No Not explicitly stated Yes Not required Not required No
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Stahmer, 1995 Yes No Yes No Yes Yes Yes

Steiner et al., 2013 Yes No Not explicitly Yes Yes Yes No
stated
Thorp et al., 1995 Yes No Yes No Yes Yes Yes
Voos et al., 2013 Yes No Yes No Not indicated No No

Treatment fidelity
The current review found distinct patterns of variation
regarding adherence to treatment fidelity. Five studies made
no reference to treatment fidelity measures [40, 43, 46, 52,
53]. Two studies adhered to the recommended treatment
fidelity standard by requiring interventionists to implement
strategies correctly, 80% of the time prior to entering the
treatment stage [45, 50]. However, Pierce and Schreibman’s
1995 study did not re-assess treatment fidelity once interven-
tionists (peers) entered the treatment phase [45]. Schreibman
et al. [54] study conducted treatment fidelity measures until
parents met 80% implementation standards. Due to the nature
of this design, parents’ PRT implementation was no longer
required or measured. Despite addressing the treatment
fidelity criterion, many interventionists failed to meet and/or
maintain this standard in the reviewed articles. For example,
all three caregivers in Randolph et al.s’ study reached
treatment fidelity levels during the intervention stage; how-
ever, only two caregivers maintained these levels at the
follow-up stage [47]. Similarly, five of eight parents main-
tained treatment fidelity at the post-training phase, while only
four parents reached criterion levels at follow-up in Coolican
et al.s’ study [11]. Paraprofessionals in Robinson’s study
received video feedback until they had reached 80% treatment
fidelity [48]. However, only three of four paraprofessionals
reached criterion levels in the generalization phase. Minjarez
et al.s’ 2013 study reported that 16 of 17 families
demonstrated gains in treatment fidelity towards the end of
the programme, suggesting that treatment fidelity was not
reached prior to the treatment stage [41]. Parental treatment
fidelity levels varied during the intervention stage in Steiner
et al.s’ study (49–84% implementation) [51]. Minjarez et al.s’
2011 study reported that parental treatment fidelity signifi-
cantly increased from baseline to week 10 of treatment [44].
Although not completely adhering to the 80% standard,
Sherer and Schreibman ensured that interventionists main-
tained treatment fidelity by rating video segments for correct
usage of strategies 20% of the time (i.e. each of the tasks had
to be implemented correctly for 20% of the entire duration of
the video clip) [49].
Despite the above studies’ adherence to fidelity standards,
discrepancies in treatment fidelity adherence procedures were
found within two studies. One study indicated that parent PRT
trainers met the required treatment fidelity, but parental
treatment fidelity was not measured [42]. Additionally, these
researchers reported that 86% of interventionists met treat-
ment fidelity within the first three to four months; however,
the authors did not indicate how they addressed intervention-
ists who did not meet criteria. Baker-Ericzén et al.s’ study
included therapists who were trained to implement PRT with
fidelity and who then taught parents the intervention proced-
ure [39]. However, treatment fidelity assessments were
discontinued after parents were initially trained to fidelity
levels and therapists relied on parental feedback and weekly
 DOI: 10.3109/17518423.2013.845615 Pivotal response treatment for children with autism spectrum disorder
clinical sessions when evaluating treatment fidelity [39]. This
approach may not be conducive to ensure that treatment
fidelity levels were maintained.
Use of objective evaluators
Eleven articles utilized objective evaluators [11, 40, 44, 47–
54]. Four studies used objective evaluators for 27–34% of
probes [11, 49, 52, 53], whereas others incorporated
independent coders for all data collection measures [11, 40,
44, 47, 48, 50, 51, 54].
The remaining seven studies did not reference the use of
objective evaluators. Two of these did not require raters as
they utilized standardized assessments and thus did not
require objective ratings of behaviour [39, 42]. Of the
remaining studies, one indicated that a trained experimenter
conducted behavioural ratings; however, reference was not
made to external evaluators [43]. Although explicit reference
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was not made to external evaluators in Minjarez et al.s’
2013 study, readers were directed to the authors’ previous
study’s 2011 study [41, 44]. Finally, both of Pierce and
Schreibman’s studies did not refer to the use of objective
evaluators [45, 46].
Evidence of inter-rater reliability
Twelve studies conducted inter-rater reliability across all
stages of data collection. In general, a variety of percentage
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agreement and/or kappa values were reported. Kappa coef-
ficients are a more conservative statistical measure of inter-
rater reliability and account for an agreement happening by
chance. Kappa coefficients of 0.75 and up are considered to
demonstrate excellent reliability [57].
Excellent inter-rater reliability was demonstrated in
several studies [11, 40, 44, 47–49, 51, 54]. Twelve
studies surpassed Reichow et al.s’ [36] standard that reli-
ability be conducted across at least 20% of all sessions [11,
40, 44–53]. In nine studies, inter-observer reliability was
conducted for approximately one-third of sessions
across stages [44–46, 48–53]. One study utilized inter-
observer assessments for 50% of sessions [40], while
another coded for inter-observer reliability on 27% of
baseline, 33% of training and 50% of follow-up sessions
[47]. Coolican et al. conducted inter-rater reliability measures
for 30% of sessions [11]. Schreibman et al. conducted
reliability measures up until parents were deemed competent
in PRT and/or ITTB implementation [54].
Although Schreibman et al. reported excellent inter
observer reliability for cued vocalizations occurrence (84%)
and non-occurrence (99%), mean agreement for occurrence of
spontaneous vocalizations was only 67%, which signifies a
lower than optimal agreement level in this domain [50].
Conversely, spontaneous vocalizations non-occurrence
reported 99% agreement [50]. Similarly, Thorp et al. demon-
strated somewhat mixed results, ranging from 62 to 97%
reliability agreement [53]. These latter two studies suggest
ambiguities in certain behaviours or inadequate rater training.
Interobserver reliability was not conducted in four studies
[39, 41–43]. Notably, Voos et al. only referred to one rater,
thereby failing to meet this standard of research quality
[43]. Interobserver reliability was also not applicable in
5
Baker-Ericzén et al.s’ and Smith et al.s’ studies, as they
administered standardized measures [39, 42].
Longitudinal studies
Eight studies collected follow-up data after the post-treatment
stage. Follow-up data collection ranged from two weeks [47]
to nine months [49] after the intervention stage, with the
majority of follow-up data collection taking place two to four
months post-treatment [11, 45, 46, 52, 53]. For some studies,
follow-up data ranged over a specified timeframe. For
example, Robinson’s study stated that follow-up studies
ranged from four to eight weeks [48]. Similarly, Coolican
et al.s’ follow-up timeframe ranged from 2 to 4 months [11].
And finally, Sherer and Schreibman collected follow-up data
six to nine months after treatment cessation [49].
Nine studies did not incorporate follow-up data into their
designs [39, 40–44, 50, 51, 54]. Smith et al. employed a one-
year design, which seemed proactive and valuable in terms of
analyzing the effects of long-term PRT training [42].
However, a follow-up study was not conducted. Lydon et al.
claimed that follow-up data was collected when skill mastery
or intervention discontinuation criteria was met [40].
Similarly, Steiner et al. mentioned that follow-up data was
collected one week after the intervention ended; however, a
review of these two articles indicates that they collected post-
treatment data, and not follow-up data [40, 51].
Discussion
Given the ever increasing prevalence rates of ASD and
fundamental nature of early intervention [10, 16], it is
important to examine the viability of intervention research
studies. The current review evaluated PRT research studies’
adherence to seven research quality standards. Findings
revealed that all 17 reviewed studies addressed some of the
seven standards. However, varying degrees of adherence was
found.
The majority of studies implemented systematic research
procedures. However, significant variation existed within this
standard. Many studies provided specific detail regarding
implementation of a multiple baseline procedure [11, 44–51],
whereas others simply stated that a multiple baseline proced-
ure was used [52, 53], which may render future replications
difficult for researchers unfamiliar with the study’s method-
ology. Only one study implemented a partial between-group
design [54]; however, none of the reviewed studies imple-
mented between group designs that utilized treatment and
control groups. Overall, it is apparent that there are stark
differences regarding research methodology across PRT
research studies.
Two studies incorporated intervention comparisons into
their design [40, 54]. It is important to note that individuals
with ASD are idiosyncratic and may respond differently to
particular interventions (e.g. study by Schreibman et al. [50]).
Schreibman maintains that individual factors (such as: child,
family and ethnicity/cultural variables) should be known a
priori in order to tailor interventions towards individuals [37].
Conversely, empirical comparison of intervention approaches
may provide evidence supporting the efficacy and effective-
ness of different interventions across age, functioning level
 6 S. Cadogan & A. W. McCrimmon
and specific area(s) of need for individuals with ASD.
However, such research evidence is lacking regarding PRT,
resulting in a paucity of information regarding the overall
clinical effectiveness of the programme.
Strong adherence to the use of standard intervention
protocols was found as nine studies [11, 40, 41, 43–45, 49, 52,
53] explicitly stated their use of PRT manuals by Koegel et al.
[26, 31, 55, 56]. However, six simply cited the manuals when
describing PRT components without explicitly stating if PRT
manuals were used to teach PRT strategies [42, 46–48, 50,
54]. Steiner et al. stated that parents were taught PRT
strategies based on the literature, and then cited a manual
[51]. Baker-Ericzén et al. based their study on an older PRT
manual, which centred on increasing non-verbal children’s
vocabulary [25, 39]. Future replicability may be difficult
when the use of particular PRT manuals is not explicitly
stated in the methodology.
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Varying degrees of adherence to treatment fidelity stand-
ards were found within and across studies. For example, in
two parent implemented studies, interventionists were trained
to fidelity of treatment standards, while parental treatment
fidelity was not measured [39, 42]. Given large sample size by
Baker-Ericzén et al. and long intervention timeframes by
Smith et al., perhaps it may have been difficult to conduct
thorough treatment fidelity measures; however, such meas-
ures may have enhanced the studies’ robustness [39, 42].
Additionally, seven studies mentioned that interventionists did
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not fully meet and/or maintain treatment fidelity measures
[11, 41, 42, 44, 47, 48, 51], which raises the question of
whether the studies continued without modification, if these
interventionists received further training or if the interven-
tionists were excluded from the study.
Eleven studies adhered to and surpassed recommended
research standards when using objective behavioural coders
[11, 40, 44, 47–54]. However, one study used only one coder
[43], while one other study did not specify whether objective
coders were used [41]. Although objective coders may have
been used and not indicated, it raises questions about how
single coders are to resolve ambiguities in behavioural coding.
Overall, 12 studies demonstrated relatively strong adher-
ence to inter-rater reliability [11, 40, 44–53]. Schreibman
et al. 1991 study conducted inter-rater reliability until parents
met mastery status of PRT implementation [54]. The nature of
their study did not require further reliability probes [54]. The
strength of the conclusions from the four studies that did not
conduct inter-rater analyses [39, 41–43], excluding those that
relied exclusively on standardized measures, may be ques-
tionable. Additionally, it would be helpful to know why some
studies had greater ranges in inter-rater agreement to deter-
mine whether discrepancies were due to poor training
practices or ambiguities in coding behaviours [35].
Although follow-up data was collected in eight studies [39,
40–42, 44, 50, 51, 54], longer duration between post-
treatment and follow-up data collection may enhance the
empirical evidence for PRT. For example, it would have been
insightful to examine the long-term effectiveness of the
12-month intervention reported by Smith et al. [42]. Sherer
and Schreibman, conducted follow-up probes at varying
timeframes, while some participants were unavailable for
their follow-up study [49]. Importantly, researchers should
Dev Neurorehabil, Early Online: 1–8
ensure that follow-up data collection timeframes are consist-
ent across participants, as the follow-up data could be
confounded by maturation affects.
Future directions
This review indicates recommendations that may enhance
PRT research efforts. First, translucency in methodology
through clear description of research methodology, interven-
tionist training methods and the use of objective and/or naı̈ve
behavioural raters may strengthen research designs. It is
fundamental that PRT research studies conduct treatment
fidelity measures in order to ascertain whether it is being
implemented correctly. It would also be beneficial to state the
treatment fidelity standards that interventionists were required
to meet and maintain, and what steps were taken when these
standards are not met. Furthermore, it is recommended that
researchers continue to incorporate appropriate baseline and
follow-up designs to objectively measure treatment effective-
ness. Similar to recommendation by Skokut et al. recommen-
dation regarding the viability of follow-up studies, it would be
especially valuable to ascertain treatment effectiveness at
least one year post intervention [29]. Finally, comparison of
intervention approaches is highly recommended in determin-
ing which children with ASD respond best to particular
interventions. This is especially important given the increased
diversity of interventions for ASD as such comparisons may
build upon knowledge pertaining to intervention (in-
)effectiveness.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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