Journal of Child Psychology and Psychiatry 51:12 (2010), pp 1321–1330 doi:10.1111/j.1469-7610.2010.02326.

Brief parent training in pivotal response

treatment for preschoolers with autism
Jamesie Coolican, Isabel M. Smith, and Susan E. Bryson
Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada

Background: Evidence of improved outcomes with early behavioural intervention has placed the early
treatment of autism as a health priority. However, long waiting lists for treatment often preclude timely
access, raising the question of whether parents could be trained in the interim. Parent training in pivotal
response treatment (PRT) has been shown to enhance the communication skills of children with autism.
This is typically provided within a 25-hour programme, although less intensive parent training may also
be effective. The main objective of the present study was to evaluate the efficacy of brief training in PRT
for parents of preschoolers with autism, who were awaiting, or unable to access, more comprehensive
treatment. Method: Eight preschoolers with autism and their parents participated in the study. A non-
concurrent multiple (across-participants) baseline design was used, in which parents were seen indi-
vidually for three 2-hour training sessions on PRT. Child and parent outcomes were assessed before,
immediately after, and 2 to 4 months following training using standardised tests, questionnaires and
behaviour coded directly from video recordings. Results: Overall, children’s communication skills,
namely functional utterances, increased following training. Parents’ fidelity in implementing PRT
techniques also improved after training, and generally these changes were maintained at follow-up.
A moderate to strong relationship was found between parents’ increased ability to implement PRT
techniques and improvement in the children’s communication skills. Conclusion: Our findings suggest
that brief parent training in PRT promises to provide an immediate, cost-effective intervention that could
be adopted widely. Keywords: Autism, pivotal response treatment, parent training, communication.

Evidence has demonstrated that outcomes for chil- problematic when confronted with long waiting lists
dren with autism spectrum disorder (hereafter for service. It is therefore critical to determine
referred to as autism) are substantially improved with whether briefer parent training has a positive impact
early intensive behavioural intervention (EIBI; e.g., on child and parent outcomes. To date, only three
National Autism Center, 2009; National Research studies have addressed this question (Baker-Eric-
Council, 2001; Rogers & Vismara, 2008). However, zen, Stahmer, & Burns, 2007; Stahmer & Gist, 2001;
currently for many children access to EIBI is either Vismara, Colombi, & Rogers, 2009).
precluded or delayed beyond the recommended age One non-random assignment group design study
(e.g., Majnemer, Shevell, Rosenbaum, & Abra- (N = 22) demonstrated that some parents are able to
hamowicz, 2002) due to long waiting lists. Training learn the techniques of pivotal response treatment
parents in evidence-based intervention techniques is (PRT) after 12 weekly one-hour individual sessions
generally considered an efficient method of expand- (Stahmer & Gist, 2001). PRT focuses on increasing
ing the availability of intervention services to children the child’s motivation to communicate, using the
with autism. Additional advantages of parent training principles of applied behaviour analysis in play and
are the potential for increased maintenance and other natural daily-life settings (R.L. Koegel et al.,
generalisation of child skills, and increased parental 1989; R.L. Koegel & L.K. Koegel, 2006). Parents who
self-efficacy (e.g., Bryson et al., 2007). participated in both the parent training sessions and
There is some evidence for the effectiveness of a parent support group (n = 11) were more likely to
training programmes for parents of children with master the strategies than parents who completed
autism (e.g., Aldred, Green, & Adams, 2004; Drew et the training sessions alone (8/11 versus 4/11
al., 2002; McConachie, Randle, Hammal, & Le parents met the fidelity criterion, respectively). Par-
Couteur, 2005), although the results of a recent RCT ents who mastered the PRT techniques reported
show minimal effects on symptoms of autism and significantly larger increases in their children’s
moderate effects on child communication (Green et vocabularies. Also, the number of words children
al., 2010). These programmes vary in orientation, used (coded from video) increased from pre- to post-
although most focus on enhancing the children’s intervention, regardless of parental skill level. While
ability to communicate. Currently, parent training these results are promising, no follow-up data were
programmes for children with autism are relatively collected and child outcomes were based largely on
intensive (25 to 180 hours of training), which is parent-report measures.
Additional support for 12 weekly, one-hour indi-
vidual parent training sessions in PRT comes from a
Conflict of interest statement: No conflicts declared. large-scale (N = 158) community-based study in
 2010 The Authors. Journal of Child Psychology and Psychiatry
 2010 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
1322 Jamesie Coolican, Isabel M. Smith, and Susan E. Bryson

which significant improvements were found in par-

Method
ent-reported adaptive skills immediately following
training (Baker-Ericzen et al., 2007). Unfortunately, Participants
the researchers did not evaluate other child out-
Participants were eight families of children newly diag-
comes or parents’ fidelity of implementation, and nosed with autism, recruited through an eligibility list
there was no follow-up evaluation. for a publicly funded EIBI Programme. One parent of
More recently, Vismara and colleagues (2009) each child participated in the study (5 mothers and 3
used a multiple baseline design (N = 8) to evaluate fathers). Inclusion criteria were that families had a child
12 one-hour weekly sessions of parent training in the aged 2–5 years diagnosed with autism, lived within
Early Start Denver Model. This model of intervention 30 km of the IWK Health Centre, and that parents had a
incorporates PRT and other techniques from the minimum Grade 8 education. Families were excluded
Denver Model, which focuses on teaching imitation, from the study if the child was already receiving some
non-verbal communication and pragmatics. Parent form of applied behavioural analysis treatment; and if
the child had a major sensory, motor or neurological
fidelity increased with training, with most parents
impairment/disorder (e.g., uncorrected visual or hear-
(87.5%) meeting the fidelity criterion after 6 hours of
ing loss, or physically incapacitating brain damage).
training. In addition, children’s spontaneous func- Only one family was excluded, specifically because they
tional utterances, imitation skills, and engagement lived too far from the study site.
improved following 12 hours of training and were All children were diagnosed with autism by an inde-
maintained at the 3-month follow-up. Furthermore, pendent developmental pediatrician and psychologist
the largest gains in children’s spontaneous func- with expertise in autism using DSM-IV-TR (APA, 2000).
tional utterances occurred once parents demon- Seven of the eight children met criteria for autism on
strated the ability to implement the strategies with the Autism Diagnostic Observation Schedule (ADOS;
fidelity. This study’s results raise the question of Lord et al., 1999) and the Autism Diagnostic Interview –
whether parents are able to acquire the intervention Revised (ADI-R; Lord et al., 1994). Child 2’s ADI-R
scores fell below the cut-off (4 and 3 points below the
skills with 6 hours of training and have a positive
cut-off for reciprocal social interaction and communi-
impact on their children’s outcomes.
cation, respectively); however, his ADOS scores were
The present study was designed to examine the above the autism cut-off, and he was given a clinical
efficacy of brief (6-hour) training in PRT for parents diagnosis of autism. Table 1 summarises the children’s
of young children with autism. Eight families of characteristics at baseline. Prior to training, children’s
preschoolers with autism, who were waiting to word use ranged from one-word approximations (e.g.,
access a more intensive intervention programme, ‘mmm’ for ‘more’) to short phrases. All families spoke
participated in 6 hours of training in PRT. The main English as their primary language and were of middle to
question was whether child gains would occur in upper-middle socioeconomic status (Hollingshead
multiple domains of behaviour, notably in commu- Index; Miller, 1983). Parent education ranged from
nication and disruptive behaviour, post-training and partial high school to graduate degree. All but two
families (Child 1 and 2) had completed the Hanen ‘More
at follow-up. Secondarily, the study examined
than Words’ programme (Sussman, 1999) within 1 to
whether brief training in PRT would be sufficient for
2 months prior to beginning the study. This is a train-
parents to learn how to implement the strategies ing programme designed to help parents promote
with fidelity, and whether parent training would be communication and social skills in their children,
associated with improvements in their perceived self- consisting of eight 2.5-hour group sessions and three
efficacy. Finally, we examined whether gains in home visits. The programme is publicly funded in this
parent fidelity were associated with gains in child province, and was facilitated by two speech-language
communication. pathologists.

Table 1 Child characteristics at baseline

Cognitive ability PLS ACa PLS ECb

Child Age (yrs; mo) Sex (percentile, test) Age-equivalent Age-equivalent

1 4;8 M 1st, DASc 3;10 2;11

2 3;3 M 2nd, WPSSI-IIId 2;7 2;9
3 3;8 M <1st, Bayley-IIIe 1;3 1;5
4 3;9 M 9th, Bayley-III 2;7 2;3
5 4;3 M 16th, Bayley-III 2;5 1;10
6 2;4 F <1st, Bayley-III 0;7 1;3
7 4;4 M <1st, Bayley-III 1;6 2;0
8 4;1 M <1st, Bayley-III 2;1 1;11
a
Preschool Language Scale 4th Edition (Zimmerman et al., 2002), Auditory Comprehension; bPreschool Language Scale 4th Edition,
Expressive Communication; cDifferential Ability Scales (Elliot, 1990); dWeschler Preschool and Primary Scale of Intelligence, 3rd
Edition (Wechsler, 2002); eBayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III; Bayley, 2005).

 2010 The Authors

Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.
 Parent training in PRT 1323

Study design Disruptive behaviour. Disruptive behaviour was

assessed by coding its occurrence or non-occurrence
A non-concurrent multiple (across-participants) base-
during each 15-second interval of a 10-minute video
line design was used. Participants remained in the
segment. Disruptive behaviour was operationally
baseline (pre-training) phase for 3 to 7 weeks. The
defined as (a) vocal (e.g., screaming, whining or crying);
effects of the intervention were evaluated at both the
(b) physical (e.g., hitting, kicking, throwing, pushing);
end of the 2-week training period (post-training) and 2
or (c) oral (e.g., biting, spitting).
to 4 months following training (follow-up).

Parent outcome measures

Parent education procedures, settings and materials
Fidelity of PRT implementation. A continuous
Parent training sessions. Parents received three 1-minute interval coding system was used (ten 1-min-
separate 2-hour training sessions over 2 consecutive ute intervals) to code fidelity of PRT implementation.
weeks, for a total of 6 hours of individual training in PRT Each interval was coded as either correct or incorrect
techniques. Prior to the first session, parents were pro- for each of the following 5 techniques: Clear Opportu-
vided with ‘How to teach pivotal behaviours to children nities, Child Choice, Contingent, Natural Rewards, and
with autism: A training manual’ (R.L. Koegel et al., 1989). Rewards Attempts (for definitions, adapted from R.L.
The first two parent training sessions were conducted at Koegel et al., 2002, see Supplementary Appendix C).
our clinical lab and the third session was conducted in The fidelity of implementation score was the average
family homes in order to promote generalisation of par- percentage of intervals, across all five strategies, during
ents’ PRT skills. During the first session, parents were which parents demonstrated appropriate use of the
introduced to basic PRT principles, and the trainer techniques. Following Stahmer and Gist (2001), the
modelled the techniques with the child. For the remain- criterion for fidelity of implementation was 75%.
der of the session, parents implemented PRT techniques
with their child, while receiving feedback from the trai- Self-efficacy. Parental self-efficacy was measured
ner. PRT was taught in the context of play with the child. using the Parental Self-Efficacy Scale, which is a
The second and third sessions consisted mainly of in vivo domain-specific measure of parents’ perceived self-
feedback for the parents, as well as problem solving on efficacy related to their child’s challenging behaviour
issues that had arisen since the previous session. (Hastings & Brown, 2002). This parent-report ques-
tionnaire consists of five items, each rated on a 7-point
Cameras. Two Sony Handycam DVD camcorders scale; the total score was used.
with surround sound microphones were used to collect
the video probes. Satisfaction. Parents completed a questionnaire
assessing their satisfaction with the training, created
for the purpose of the current study.
Child outcome measures
Communication. Two methods, functional verbal Data collection procedures
utterances and type of utterance, were used to measure
changes in child communication. Following R.L. Koegel, Fifteen-minute video-recorded probes were collected
Symon, and L.K. Koegel (2002), the presence or absence during pre-training, post-training and at follow-up. In
of functional verbal utterances (FVUs; for details, see each phase, a research assistant video-recorded the
Supplementary Appendix A) was coded from each parent interacting with his/her child during typical play
15-second interval of a 10-minute video recording, and with toys at the family’s home. Four to five video probes
the percentage of intervals with FVUs served as the were collected on separate days during the pre-training
dependent variable. phase (ranged from 3 to 7 weeks), and 3–5 probes were
As the second communicative outcome measure, collected on separate days during each of the post-
5-minute video segments were coded for whether child training and follow-up phases. The first 10 minutes of
utterances were appropriate (i.e., functional and direc- each probe were coded for the outcome measures, and
ted) or inappropriate (e.g., stereotypic, echolalic or data were averaged across the video probes in each
incomprehensible) and the degree to which they were phase.
prompted (i.e., model prompted, indirectly prompted, or Parents completed the parental self-efficacy ques-
child initiated) using an incidence scoring form (see tionnaire at all three time points (pre- and post-training
Supplementary Appendix B for definitions). Overall and at follow-up) and the Parent Satisfaction Ques-
responsivity was calculated as the percentage of times tionnaire after completing the training. Before training
the child responded appropriately, following either a and at follow-up, the children completed a standardised
model prompt or an indirect prompt. language assessment (PPVT-III and/or PLS-4).

Language. Two standardised measures were used to Inter-observer reliability

determine whether expressive and receptive language
improved at follow-up. The Preschool Language Scale, The primary coder for each outcome measure was blind
4th Edition (PLS-4; Zimmerman, Steiner, & Pond, 2002) to treatment phase. In order to establish inter-observer
and the Peabody Picture Vocabulary Test, 3rd Edition agreement on each of the measures coded from video
(PPVT-III; Dunn & Dunn, 1997) are individually recordings, an independent coder coded 30% of the
administered tests of language. videos, including an equal number of randomly selected
 2010 The Authors
Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.
1324 Jamesie Coolican, Isabel M. Smith, and Susan E. Bryson

pre-training, post-training, and follow-up videos from over, the group gains in FVUs observed post-training
different children. For videos coded for the occurrence were maintained at follow-up (Z = ).92, p > .05,
versus non-occurrence of behaviours, inter-observer d = .14).
reliability was calculated using both inter-observer
agreement per interval and kappa coefficients (Cohen, Nature of child utterances. The percentage of times
1960). Intra-class correlations were calculated for
the children responded appropriately (Responsivity)
interval/ratio measures.
Overall, inter-observer reliability was good for all
increased significantly following training (Z = )2.52,
measures coded from videos. The mean inter-observer p > .05, d = .85; see Table 2), and was maintained at
agreement was 86%, with kappa of .85 for FVUs; 97%, follow-up (Z = ).56, p > .05, d = .25). The percentage
with kappa of .97 for disruptive behaviour; and 80%, of responses that were preceded by a model prompt
with kappa of .79 for fidelity of implementation. With did not differ from pre- to post-training, or from post-
regard to utterance type, intra-class correlations were training to follow-up (Z = )1.12, d = ).42 and
excellent (model prompted: .79; indirectly prompted: Z = ).14, d = .14, p > .05, respectively). However,
.96; initiations: .91; inappropriate responses: .88; no there was a significant increase in the percentage of
response: .98). responses that were indirectly prompted (Z = )2.24,
p < .05, d = .91), which was maintained at follow-up
(Z = ).14, p > .05, d = ).18). The percentage of
Analyses
initiations did not change significantly following
Both visual inspection and statistical analyses were training (Z = .0, p > .05, d = .04) or from post-train-
used to evaluate the data. For child FVUs and parent ing to follow-up (Z = ).28, p > .05, d = ).11). Simi-
fidelity of implementation, individual data were dis- larly, the percentages of inappropriate responses did
played graphically and inspected for changes in level not change across the three phases (Z = ).56,
upon introduction of the training (as recommended by d = .11 and Z = ).84, d = .30, p > .05, for pre- to
Kazdin, 1982). The Wilcoxon matched-pairs signed-
post-training and post-training to follow-up,
ranks test (Sheskin, 2007; Wilcoxon, 1945) was used to
respectively). There was a significant decrease in the
determine whether, overall, a statistically significant
change occurred after training (i.e., pre-training to percentage of no responses following training
post-training), and whether gains were maintained at (Z = )2.24, p < .05, d = .73), which was maintained
follow-up (i.e., post-training to follow-up). In order to at follow-up (Z = ).14, p > .05, d = .16).
determine the magnitude of the changes, effect sizes
were also calculated (Cohen, 1992). Spearman’s corre- Standardised language measures. Overall, there
lations were used to assess the relationship between was no significant difference in age-equivalent scores
changes in parent fidelity and changes in child between pre-training and follow-up (4 to 6 months)
communication (i.e., FVUs and responsivity) from on the Auditory Comprehension (AC) scale of the
pre-training to post-training and follow-up. PLS-4 (Z = ).34, p > .05, d = .05, n = 8). However,
there was a trend towards higher age-equivalent
scores at follow-up compared to pre-training on the
Results Expressive Communication (EC) scale of the PLS-4
(Z = )1.83, p = .07, d = .34, n = 8). In two children,
Child outcomes
large age equivalence gains were made on the PLS-4:
Functional verbal utterances. Figure 1 provides 13 and 12 months (Child 2), and 3 and 7 months
data on the percentage of intervals with FVUs during (Child 6), for AC and EC respectively.
parent–child interactions. As shown there, all eight Overall, there was no significant difference in age-
children demonstrated an increase in FVUs after equivalent scores between pre-training and follow-
training, although gains were minimal for Child 1 up on the PPVT-III (Z = )1.60, p = .11, d = 1.16,
and Child 6 (mean increase of 9.0% and 4.5%, n = 5). Individual PPVT-III scores indicated that
respectively). Between post-training and follow-up, single-word receptive vocabulary increased at a rate
Children 1, 5, and 6 made gains in FVUs (mean greater than expected following training for 3 of the 5
increase of 8.3%, 11.2%, and 25.7%, respectively). children who were able to complete the test: over the
Three children (3, 4, and 7) demonstrated a slight 4- to 6-month period of the study, age equivalence
decrease in FVUs between post-training and follow- increased by 7 months (Child 1), 23 months (Child
up (mean decrease of 4.5%, 5.7%, and 9.0%, 2), and 12 months (Child 4).
respectively), while Children 2 and 8 displayed a
larger decrease in FVUs from post-training to follow- Disruptive behaviour. With two exceptions (Chil-
up (mean decrease of 29.4% and 20.0%, respec- dren 1 and 6), there was minimal disruptive behav-
tively). No general patterns, based on initial language iour during the video-recording sessions (i.e.,
level, were observed across the three treatment average of less than 10% of intervals), regardless of
phases. treatment phase. Child 1 displayed disruptive
Overall, the children’s FVUs increased following behaviour during the pre-training phase, which
training (Wilcoxon (Z) = )2.52, p < .05, d = 1.00; decreased immediately following training (mean
mean change = 25.84%, range = 4.5–58%). More- decrease of 10%) and was maintained at the
 2010 The Authors
Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.
 Percentage of Intervals with FVUs (solid line) and Implementing PRT Techniques (dash line) Parent training in PRT 1325

100 Pre-training Post-training Follow-up

90 Pre-training Post-training Follow-up 100
80 90
70 80
Fidelity Fidelity
60 70
FVU 60 FVU
50

Percentage of Intervals with FVUs (solid line) and Implementing PRT Techniques (dash line)
40 50
30 40
20 Child 6 30 Child 5
10 20
0 10
1 2 3 1 2 3 4 5 6 7 8 1 2 3 4 5 6 0
1 2 3 4 1 2 3 1 2 3

100
90 100
80 90
70 Fidelity 80 Fidelity
60 FVU 70 FVU
50 60
40 50
30 40
Child 7
20 30 Child 1
10 20
0 10
1 2 3 1 2 3 4 5 6 1 2 3 0
Week 1 2 3 4 5 1 2 3 4 5 6 1 2 3 4 5

Pre-training Post-training Follow-up 100

100 90
90 80
80 70
70 Fidelity 60
Fidelity
60 50
FVU FVU
50 40
Percentage of Intervals with FVUs (solid line) and Implementing PRT Techniques (dash line)

40 30
30 Child 4 20 Child 8
20 10
10 0
0 1 2 3 4 5 6 7 1 2 1 2 3 4
1 2 3 4 1 2 3 4 5 6 1 2 3 Week

100
90
80
70 Fidelity
60 FVU
50
40
30
Child 2
20
10
0
1 2 3 4 1 2 3 4 5 6 1 2 3

100
90
80
70
60 Fidelity
50 FVU
40
30
20 Child 3
10
0
1 2 3 4 1 2 3 4 5 1 2 3 4
Week

Figure 1 Percentages of intervals during which children produced functional verbal utterances (FVUs) and parents
implemented PRT techniques during each video probe, by week of participation in the study. Three to five video
probes were taken during each phase (i.e., pre-training, post-training, and follow-up). The order of presentation is
based on the length (i.e., 3 to 7 weeks) of the pre-training phase

3.5-month follow-up (mean increase of 2%). Child 6 p > .05, d = .17) or between post-training and follow-
also displayed some disruptive behaviour, which up phases (Z = )1.18, p > .05, d = .08).
decreased slightly by the follow-up phase (mean
decrease of 5.5% from pre-training to follow-up). Qualitative notes. Parents universally reported
Overall, no change was seen in disruptive behaviour positive changes in child communication. The par-
between pre- and post-training phases (Z = ).73, ents of Child 3 noted that he ‘seems to be initiating
 2010 The Authors
Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.
1326 Jamesie Coolican, Isabel M. Smith, and Susan E. Bryson

Table 2 Mean responsivity (number of appropriate responses were at least one SD below the mean of a clinical
by number of language opportunities) across the three treat- sample; Hastings & Brown, 2002), scores increased
ment phases
to within the average range by follow-up (M = 13.0
Child Pre- training Post- training Follow-up and 20.0, for pre- training and follow-up, respec-
tively). Overall, there was no significant difference in
1 130/224 181/239 135/148
parental self-efficacy scores between pre- and post-
58.04% 75.76% 91.22%
2 107/134 182/206 81/91 training (Z = ).42, p > .05, d = .32; n = 6), or be-
79.85% 88.35% 89.01% tween post-training and follow-up (Z = ).95, p > .05,
3 8/66 133/169 90/112 d = .06; n = 6).
12.12% 78.70% 80.36%
4 130/193 163/213 106/174
Parent satisfaction. Overall, parents found the
67.36% 76.53% 60.92%
5 65/135 88/144 137/165 whole training experience to be very helpful (M = 9/
48.15% 61.11% 83.03% 10). They rated the training sessions as being very
6 18/73 26/101 65/99 helpful (M = 8.7/10) and the training manual as
24.66% 25.74% 65.66% fairly helpful (M = 7.1/10). Parents rated the training
7 25/108 90/129 39/65
in PRT as being more helpful in increasing their
23.15% 69.77% 60.00%
8 128/184 91/101 74/106 child’s language (M = 7.6/10) than decreasing dis-
86.49% 90.10% 69.81% ruptive behaviour (M = 5.2/10). All of the parents’
Mean 49.98% (27.75) 70.75% (20.44) 75.00% (12.48) qualitative comments were very positive. For exam-
ple, one parent stated ‘I found the training very
helpful. It made me feel much more confident in
more … saying words first without any prompting’. what I’m doing.’ Another parent said ‘I’m amazed at
Child 6’s parent noted that ‘she started using a lot of how little effort on our part can create such a big
words without prompting. She’s saying new words change for our child so far.’
every day’. Child 7’s parent reported that ‘he
understands more’. Time implementing PRT. Overall, parents reported
spending .5 to 2 hours a day implementing PRT
with their children, with a range of 4 to 10 hours a
Parent outcome measures
week. Note, however, that parents reported that it
Fidelity of PRT implementation. Figure 1 shows was difficult to estimate the amount of time
that during the pre-training phase, none of the par- they spent doing PRT, because they were incorpo-
ents met the criterion for fidelity (i.e., implementa- rating the techniques into routines throughout the
tion of the PRT techniques during a minimum of 75% day.
of the intervals). However, 5 of 8 parents (62.5%; 4
mothers) met the criterion for fidelity during the
post-training phase. Four of these parents (50%; 3
mothers) continued to meet the fidelity criterion at
Follow-up minus Pre-training FVUs and Responsivity

80 FVU
follow-up.
Responsivity
More specifically, all parents demonstrated in- 70
creased skill levels after training, with Parents 1, 2,
60
4, 6, and 7 meeting the criterion for fidelity post-
training. Three parents (Parents 1, 2, and 5) con- 50
tinued to make at least slight gains at follow-up 40
(mean increase of 11.2%, 3.0%, and 14.8%, respec-
tively). The other five parents (Parents 3, 4, 6, 7, and 30
8) displayed either no change or a slight decrease in 20
fidelity between post-training and follow-up (mean
decrease of .6%. 4.4%, 6.7%, 1.5%, and 4.0%, 10
respectively). 0
Overall, parents’ fidelity of implementing PRT 0 10 20 30 40 50
–10
techniques improved significantly after training
(Z = )2.25, p < .05, d = 2.09; mean change = –20
27.16%, range = 12.0–44.4%), and this gain Fidelity Follow-up minus Pre-training
was maintained at follow-up (Z = .0, p > .05,
Figure 2 Relationship between change from pre-train-
d = .13). ing to follow-up in mean percentage of intervals during
which parents implemented PRT techniques (fidelity),
Self-efficacy. In general, parents demonstrated and change in mean percentage of intervals during
high levels of perceived self-efficacy pre-training. which the child produced (a) functional verbal utter-
However, for the two parents with lower pre-training ances (FVUs; triangles) and (b) appropriate child
levels of self-efficacy (Parents 4 and 5, whose scores responses (responsivity; squares)
 2010 The Authors
Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.
 Parent training in PRT 1327

sick for one month during the follow-up period,

Relationship between parent fidelity and child
which might account for the decrease in FVUs. For
communication
Child 2, there were fewer language opportunities
No significant correlation was found (rs = .12, (i.e., times when the parent creates an opportunity
p > .05) between changes in parent fidelity and child for the child to communicate) during follow-up
FVUs from pre-training to post-training. However, compared to the post-training phase (91 vs. 206,
parent fidelity and child FVUs were moderately cor- respectively, as coded from videos). Providing fewer
related from pre-training to follow-up (rs = .50, language opportunities likely has a major impact on
p < .05), indicating that as the fidelity of parents’ the percentage of FVUs, as the children were mak-
implementation of PRT skills increased, child FVUs ing few initiations (i.e., < 22% of their utterances)
also increased (see Figure 2). Similarly, there was no and communicating primarily when a language
relationship between changes in parent fidelity and opportunity was provided by their parents. There-
changes in child responsivity from pre- to post- fore, decreases in FVUs for Children 2 and 8 may
training (rs = ).05, p > .05). However, there was a not represent ‘true’ decreases in communication
strong correlation between pre-training and follow- skills. Conversely, it is important to note that
up (rs = .88, p < .05), indicating that the degree to increases in communication did not appear to be
which parent PRT skills improved was related to the attributable to increases in the number of language
extent to which child responsivity increased (see opportunities provided.
Figure 2). The communication changes reported here were
explored further by examining the nature of child
utterances. After training and at follow-up, the chil-
dren were more likely to provide an appropriate
Discussion
response to their parents’ prompts (responsivity),
The present study is the first to systematically eval- instead of responding inappropriately or not at all.
uate the efficacy of brief (6-hour) training in PRT for This pre- to post-training change in more appropri-
parents of young children with autism. This was ate responding (20.9%) parallels that obtained fol-
accomplished using a non-concurrent multiple lowing a 20-hour group parent training programme
baseline (across-participants) design with eight (21.0%; Openden, 2005), and again in our study was
families. The eight preschoolers (1 girl) were all maintained at follow-up. When looking specifically at
diagnosed with autism and ranged in cognitive and the degree to which the children were prompted to
language ability from mildly to severely impaired, respond, there were no overall changes in model-
with the majority of children falling in the severe prompted responses, initiations, or inappropriate
range (e.g., with little or no expressive language). responses. However, child responses to indirect
In terms of communication, the overall frequency prompts, which are higher-level than those modelled
of child FVUs increased after training and was directly, increased after training and were main-
maintained at the 2- to 4-month follow-up. This tained at follow-up. Some studies have demon-
finding is consistent with previous studies that have strated increases in child initiations when they are
shown increases in children’s communication fol- targeted (e.g., L.K. Koegel, Camarata, Valdez-
lowing parent training in PRT (e.g., Laski, Charlop, & Menchaca, & R.L. Koegel, 1998; L.K. Koegel, Carter,
Schreibman, 1988; R.L. Koegel et al., 2002; Open- & R.L. Koegel, 2003). However, these studies exam-
den, 2005). Notable, however, is that despite only ined treatment delivered by clinicians, not parents.
6 hours of training, our average increase in FVUs Laski and colleagues (1988) found an increase in
from pre- to post-training (25.8%) is comparable to spontaneity for 4/8 children following 5 to 9 sessions
that reported by Openden (2005) following 20 hours of parent training in the natural language paradigm
of group parent training (18.5%). (an earlier version of PRT). Owing to the brevity of the
In the present study, gains in FVUs following training in the current study, initiations were not
training were maintained at follow-up, although this specifically targeted. Thus, it was not surprising that
varied across the children with autism. Unlike the verbal initiations did not show significant change.
other children, Child 6, a very young and cognitively Some parents did report informally that their child
delayed child, made minimal gains from pre- to was initiating more (primarily requests) following
post-training (a short time); however, her gains at training.
follow-up were large. This finding raises the possi- With regard to standardised test performance,
bility that very young (under 36 months) cognitively two of the 8 children on the PLS-4, and 3 out of the
delayed children may take longer to respond to 5 children testable on the PPVT-III, demonstrated
treatment than older preschoolers or preschoolers age equivalence increases equal to or greater than
at a more advanced developmental level. Among the expected over a 4- to 6-month period (the dura-
remaining children, two (Children 1 and 5) contin- tion of the intervention). In addition, there was a
ued to make gains at follow-up, while the others trend toward an increase in expressive language,
(particularly Children 2 and 8) did not maintain which future studies might replicate with larger
their post-training gains at follow-up. Child 8 was numbers.
 2010 The Authors
Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.
1328 Jamesie Coolican, Isabel M. Smith, and Susan E. Bryson

In the present study, increases in communication self-efficacy throughout the study (which might also
were not mirrored by decreases in disruptive have been elevated by their prior participation in
behaviour. This was likely due to floor effects, as the parent training). For the two parents who had rela-
majority of children displayed minimal levels of dis- tively low parental self-efficacy prior to training (both
ruptive behaviour throughout the study. For the two of whom had completed prior parent training), self-
children who did demonstrate higher levels of dis- efficacy did increase considerably following training.
ruptive behaviour prior to training, this decreased This suggests that brief parent training in PRT may
either immediately after training or by follow-up. increase parental self-efficacy for parents who have
Looking specifically at parent outcomes, the low self-efficacy from the outset. The lack of change
results from this study indicate that parents’ ability in parental self-efficacy for those remaining could be
to implement PRT techniques increased after brief due to several factors, including a ceiling effect or the
training and was maintained 2 to 4 months following use of a questionnaire which focused specifically on
training. On average, parents’ fidelity of implemen- parents’ perceptions of their ability to handle their
tation score increased by 27% following only 6 hours child’s behaviour problems, which was not the focus
of training. Prior to training, none of the parents met of the intervention (and possibly less of an issue in
the criterion for fidelity of implementation (>75%). this sample).
However, following 6 hours of training, this criterion Parents reported that the whole training experi-
was met by 5 and 4 of 8 parents at post-training and ence was very helpful, particularly in increasing their
follow-up, respectively. Although pre-training fidelity child’s language. The training sessions, which
scores may have been elevated for parents who included in vivo feedback, were considered to be
completed the More than Words parent training more helpful than the manual, which was reported
programme (which incorporates child choice, one of as being fairly helpful. Critical here in planning
five main PRT techniques), the two parents (of Chil- future training programmes is that parents per-
dren 1 and 2) who did not were not distinguishable ceived the training package, particularly the indi-
on the basis of their PRT fidelity data. However, we vidual sessions, as being highly beneficial. In
acknowledge that it is unknown whether PRT train- addition, it will be important for future research to
ing was enhanced by the parents’ previous More measure parent satisfaction at follow-up as well as
than Words experience. immediately after training.
In comparison, Stahmer and Gist (2001) reported Of the studies that have assessed parent fidelity of
that only 4 of 11 parents who completed 12 hours of implementation, this is one of the few to investigate
PRT training without a support group mastered the the relationship between changes in parents’ skills
techniques. Thus, even though the parents in our and child outcomes. We provide evidence for a rela-
study received less training (6 vs. 12 hours), more tionship between the extent to which parent skill
demonstrated mastery of the techniques post-train- level increased and the magnitude of improvement in
ing (62% vs. 36%). It is unclear why these findings child communication following training. This find-
are discrepant, as the characteristics of the partici- ing, evident on two measures at follow-up, is critical,
pants in the two studies are similar. One difference is as it highlights the importance of focusing on fidelity
that the training provided in the present study was of treatment when providing an intervention or
more concentrated (i.e., 6 hours over 2 weeks vs. evaluating its impact on children’s skill develop-
12 hours over 12 weeks), which may have enhanced ment.
parent learning. Other potential contributing factors The present multiple-baseline (across-partici-
include the prior completion of the More than Words pants) design controls for temporal or developmental
programme by most parents in the current study, effects between pre- and post-training; however, the
and cross-study differences in training style. pre-training phase (3 to 7 weeks) was shorter than
We also note that both mothers (n = 5) and fathers the follow-up phase (2 to 4 months). Therefore,
(n = 3) participated in the present study. Four out of development could have contributed to changes
5 mothers (80%) compared to 1 out of 3 fathers (33%) between the post-training and follow-up phases.
met the criterion for fidelity of PRT implementation A further limitation is that the design does not allow
post-training. In related work, Seung, Ashwell, comparison of brief parent training in PRT to another
Elder, and Valcante (2006; N = 8) reported no intervention. Now, with positive preliminary find-
difference between mothers and fathers in the ings, a randomised clinical trial (RCT) would provide
acquisition of two skills for promoting their child’s stronger evidence for the efficacy of brief parent
social reciprocity. Unfortunately, the interesting training in PRT. An RCT would also provide an
issue of possible sex differences in training uptake opportunity to assess the generalizability of our
remains outstanding, as the small samples in both findings, which are based on only 8 parent–child
studies preclude any conclusions. dyads. Most parents who volunteered to participate
While parents’ ability to implement the PRT tech- in this study were of middle to upper-middle socio-
niques increased, there was no overall increase in economic status, had previously participated in a
parental self-efficacy following training. However, parent training programme (i.e., More than Words),
most of the parents had high levels of parental and displayed some skill in PRT techniques prior to
 2010 The Authors
Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.
 Parent training in PRT 1329

training. Therefore, the results may not generalise to Appendix C. Fidelity of implementation opera-
other families with preschoolers with autism. How- tional definitions (Word document)
ever, 8 is considered a large sample for a single- This material is available as part of the online
subject design. Moreover, the pattern of changes in article from:
both parent and child behaviour, although modest, http://onlinelibrary.wiley.com/doi/abs/10.1111/j.
was fairly consistent across all 8 parent–child dyads, 1469-7610.2010.02326.x
and the compelling relationships between parents’ Please note: Blackwell Publishing are not respon-
fidelity of treatment and child gains, both strengthen sible for the content or functionality of any supple-
the conclusions drawn from the study. mentary materials supplied by the authors. Any
Finally, the present findings may have implica- queries (other than missing material) should be
tions for clinical practice. In the face of long waiting directed to the corresponding author for the article.
lists and delays in treatment services, providing
parents with early brief training focused on
enhancing their children’s communication may Acknowledgements
improve the children’s prognosis. We consider these
This research was supported by a grant from the
results of parent-implemented PRT to be promising.
IWK Health Centre, and by doctoral scholarships
However, the small effects evident in a recent RCT
awarded to J.C. from Autism Speaks and the Aut-
study investigating another parent training pro-
ism Research Training Program (funded by CIHR
gramme are sobering (Green et al., 2010). Future
and Autism Speaks). J.C. completed this research
research will help to determine what type and
as part of her doctoral requirements under the
intensity of parent training is required to optimise
supervision of S.B. We thank Julie Longard, Marie
treatment effects. We are particularly optimistic that
McIntosh, Tania Moss, Sara Chapell and Nicole
training might enhance parents’ confidence and self-
Latimer for coding videos and for videotaping fami-
efficacy in supporting their children’s development.
lies. In addition, we thank Patrick McGrath for his
Our parent training programme was not resource or
contributions to this study. Thank you to the Aut-
time intensive. It might therefore be feasible for
ism Team at the IWK Health Centre and, in partic-
families living in both rural and urban areas, and for
ular, Theresa Milligan, for assistance in
various professionals who are involved in the care
recruitment. We are also grateful to all the children
and education of children with autism.
and parents who generously gave their time to
contribute to this research.
Supplementary material
The following supplementary material is available for Correspondence to
this article:
Jamesie Coolican, Autism Research Centre, IWK
Appendix A. Functional verbal utterance opera-
Health Centre, PO Box 9700, Halifax, NS B3K 6R8,
tional definition;
Canada; Tel: 902-470-7275; Fax: 902-470-7457;
Appendix B. Definitions for the nature of child
Email: jamesie.coolican@iwk.nshealth.ca
utterances;

Key points

• Training parents in pivotal response treatment/training (PRT) has been shown to increase communication
in children with autism.
• To date, most studies have evaluated 25 hours of training, although preliminary evidence suggests that
less intensive training may still be effective.
• The current study demonstrates that after brief (6-hour) parent training, child communication and parent
skills increased, and generally were maintained 2 to 4 months following training.
• Improvements in parents’ ability to implement PRT techniques were associated with improvements in
child communication.
• Brief parent training promises to provide an immediate cost-effective intervention that could be adopted
widely.

effectiveness. Journal of Child Psychology and Psychia-

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 2010 The Authors

Journal of Child Psychology and Psychiatry  2010 Association for Child and Adolescent Mental Health.