Pivotal Response Treatment for Children with Autism Spectrum Disorders… · 2017-08-26 · REVIEW PAPER Pivotal Response Treatment for Children with Autism Spectrum Disorders: A

REVIEW PAPER

Pivotal Response Treatment for Children with AutismSpectrum Disorders: A Systematic Review

Rianne Verschuur & Robert Didden & Russell Lang &

Jeff Sigafoos & Bibi Huskens

Received: 11 September 2013 /Accepted: 24 September 2013 /Published online: 26 October 2013# Springer Science+Business Media New York 2013

Abstract Intervention studies evaluating pivotal responsetreatment (PRT) were systematically identified and analyzed.Forty-three studies were summarized in terms of (a) participantcharacteristics, (b) dependent variables, (c) intervention proce-dures, (d) intervention outcomes, and (e) certainty of evidence.The majority of the reviewed studies (56.4 %) had seriousmethodological limitations. However, the reviewed studies thatprovided conclusive or preponderant evidence (43.6 %) indi-cated that PRT results in increases in self-initiations and collat-eral improvements in communication and language, play skills,affect and reductions in maladaptive behavior for a number ofchildren. Furthermore, the reviewed studies suggested that themajority of caregivers and staff members were able to imple-ment PRT techniques, but evidence for collateral improve-ments in caregivers' and staff members' behaviors remainssparse. Implications for future research are discussed.

Keywords Autism spectrum disorders . Pivotal responsetreatment . Children . Systematic review

The term autism spectrum disorder (ASD) refers to a class ofpervasive developmental disorders characterized by impair-ments in social interaction, deficits in speech/language andcommunication development, and restricted, repetitive, and ste-reotyped behaviors (American Psychiatric Association 2013).The number of children diagnosed with ASD has increased inrecent years (Baird et al. 2006; Baron-Cohen et al. 2009;Fombonne 2009) and this increase is associated with growingdemands for effective educational services (Kogan et al. 2008).There is thus an increasing need for effective and cost efficienteducational interventions for children with ASD.

Currently, there are numerous intervention methods thatclaim to be effective for educating children with ASD, includ-ing various medications, speech/language therapy, assistivetechnology interventions, sensory integration therapy, musictherapy, visual schedules, gentle teaching, holding therapy,special diets, and vitamin supplements (e.g., Goin-Kochelet al. 2007; Green et al. 2006; Hess et al. 2008; Howlin 2005;Simpson 2005). There is insufficient evidence to support theuse of most of these interventions (e.g., Howlin 2005; Langet al. 2012; Mulloy et al. 2010; Simpson 2005; Simpson andKeen 2011). However, a large body of research has demon-strated positive effects from interventions based on the princi-ples of applied behavior analysis (ABA), especially for teach-ing functional skills and reducing problem behavior in childrenwith ASD (e.g., Matson et al. 1996; Matson and Smith 2008;National Research Council [NRC] 2001; Smith et al. 2007;Vismara and Rogers 2010).

ABA-based approaches often involve teaching single re-sponses in a structured one-to-one teaching paradigm(Duker et al. 2004). This approach, sometimes referred to asdiscrete-trial training (DTT), has been associated with gains inintellectual functioning, language, and social skills of childrenwithASD andwith reductions in problem behavior (e.g., Eldeviket al. 2009; Lovaas 1987; Peters-Scheffer et al. 2011; Smith2001; Vismara and Rogers 2010). However, the DTT approach

R. Verschuur (*) :R. DiddenBehavioural Science Institute, Radboud University Nijmegen,P.O. Box 9104( 6500 HE Nijmegen, The Netherlandse-mail: [email protected]

R. Verschuur :B. HuskensDr Leo Kannerhuis, P.O. Box 62( 6865 ZH Doorwerth,The Netherlands

R. LangClinic for Autism Research Evaluation and Support, Texas StateUniversity—San Marcos, 601 University Dr, San Marcos,TX 78666, USA

J. SigafoosSchool of Educational Psychology and Pedagogy, VictoriaUniversity ofWellington, P.O. Box 17-310, Karori 6147(Wellington,New Zealand

Rev J Autism Dev Disord (2014) 1:34–61DOI 10.1007/s40489-013-0008-z

also has some potential disadvantages. First, it has been noted tobe relatively time-consuming and costly (Koegel et al. 2003b,1999c; Smith 2001; Vismara and Rogers 2010). Second, stimu-lus and response generalizationmay not occur,without additionalgeneralization programming (Lovaas et al. 1973; Smith 2001;Steege et al. 2007; Stokes and Baer 1977; Vismara andRogers 2010).

To address these potential limitations of DDT, more natural-istic interventions have been developed (Allen and Cowan2008). The latter approaches are generally considered to benaturalistic in the sense that they (a) are typically conducted ina variety of natural settings, (b) tend to be more loosely struc-tured than interventions following a DTT format, (c) involve theuse of a variety of motivational strategies, such as following thechild's lead, (d) incorporate a variety of stimuli, prompts, andnatural reinforcers, and (e) target clusters of responses rather thanteaching skills involving a single response (Allan and Cowan2008; Delprato 2001; Koegel et al. 1987a, 1999c). Naturalisticapproaches typically include a package of teaching proceduresthat are often referred to as involving (a) incidental teaching (e.g.,McGee et al. 1983, 1985), (b)milieu teaching (e.g., Hancock andKaiser 2006), (c) the Natural Language Paradigm, or (d) PivotalResponse Treatment (e.g., Koegel et al. 1987b; Koegel andKoegel 2006).

Pivotal Response Treatment (PRT), which evolved from theNatural Language Paradigm (NLP), is described as a compre-hensive naturalistic intervention model based on ABA. PRTaims to teach pivotal behaviors to children with ASD in orderto achieve generalized improvements in their functioning(Koegel et al. 2006). Pivotal behaviors are described as behav-iors that, when targeted, lead to collateral improvements inother—often untargeted—aspects of functioning. Pivotal re-sponses are conceptually related to behavioral cusps. Rosales-Ruiz and Baer (1997) describe behavioral cusps as behaviors inwhich changes have far-reaching consequences, because thosebehavior changes expose the individual to new reinforcers,contingencies, and environments. The concepts of pivotal re-sponses and behavioral cusps are similar in that they both aimto facilitate further development by prioritizing target behaviorsthat lead to widespread behavior change.

So far, research has focused on four aspects of functioningthat appear to be pivotal: (a) motivation, (b) self-initiations, (c)responding to multiple cues, and (d) self-management(Koegel et al. 1999a, c, 2001). Motivational procedures areincorporated to teach pivotal behaviors and include: (a) fol-lowing the child's lead and offering choices, (b) gaining thechild's attention, (c) providing clear opportunities to respond,including shared control and turn taking, (d) varying tasks andinterspersing maintenance and acquisition tasks, (e) usingcontingent and natural reinforcement, and (f) reinforcing at-tempts at target skills (e.g., Dunlap and Koegel 1980; Koegelet al. 1999a, c, 1987a; Koegel and Koegel 2006; Koegel et al.2001, 1988). A critical feature of PRT is implementation of the

intervention in the child's natural environment to promotegeneralization (Stokes and Baer 1977). Family involvement,in the form of teaching parents and other caregivers to imple-ment the motivational procedures, is also emphasized (Koegeland Koegel 2006).

The extent to which PRT can be considered to be anevidence-based practice has been examined. For example,Simpson (2005) evaluated 33 treatments for children withASD and concluded that PRT is a scientifically based practicefor the education of children with autism. In 2009, the NationalAutismCenter (NAC) also concluded that PRT is an establishedintervention. Another synthesis of research on PRT concludedthat PRTeffectively improved social and emotional behaviors ofyoung children with ASD (Masiello 2003). A comparativereview, involving studies that compared naturalistic interven-tions (including NLP and PRT) with DTT, concluded thatnaturalistic interventions were more effective in teaching lan-guage to young children with ASD (Delprato 2001).

Surprisingly, none of these reviews addressed the claim thatPRT leads to improvements in untargeted behaviors via thetargeting of pivotal behaviors. Thus, it remains unclear as towhether pivotal behaviors are in fact pivotal (Koegel et al. 2001).It is also unclear whether the research on PRT supports thetheoretical model of PRT. Furthermore, none of the previousreviews referenced above systematically considered caregiver orstaff variables that might impact on PRT implementation (e.g.,the extent to which parents can learn to use the techniques andthe effects on parental affect or stress). This is a limitationbecause such variables could influence PRT's effectiveness(Koegel and Koegel 2006; Schreibman et al. 1991; Steiner2011). In recent years, a large number of studies on the effec-tiveness of PRT have been conducted, which have not yet beenincluded in previous systematic reviews. Given the limitations ofprevious reviews and the recent growth in the number of PRTstudies, a systematic review on PRT was considered importantand timely.

The purpose of this systematic review was to analyze theresearch on PRT in order to (a) document the range of skillsthat have been targeted for improvement with PRT, (b) assessthe success of PRT for improving the skills of children withASD (i.e., pivotal skills and untargeted skills), (c) assess thesuccess of PRT for improving the skills of caregivers and staff,(d) evaluate the certainty of evidence arising from these stud-ies, (e) identify limitations of the existing evidence base, and(f) suggest directions for future research.

Method

Search Procedures

To identify studies for inclusion in this review, we searchedfive electronic databases: Education Resources Information

Rev J Autism Dev Disord (2014) 1:34–61 35

Center (ERIC), Linguistics and Language Behavior Abstracts,Medline, PubMed, and PsychINFO. Publication year was notrestricted, but searches were limited to peer-reviewed studies.Within each database, the following parenthetical terms wereentered as free text into the keywords field (PRT or pivotalresponse treatment or pivotal response training or pivotalresponse therapy or pivotal response intervention or pivotalresponse teaching or pivotal response or NLP or naturallanguage paradigm) and combined with autis* or ASD orpervasive developmental disorder or PDD-NOS or Asperger.

The abstracts of the studies returned from the electronicdatabase searches were reviewed to determine if the studymet the inclusion criteria (see Inclusion and ExclusionCriteria). In addition, following the database searches, handsearches—covering December 2012 to June 2013—wereconducted on the journals that had published at least twostudies identified for the review from the electronic databasesearches. Finally, the reference lists of the studies meeting theinclusion criteria were reviewed to identify additional studiesfor inclusion. Searches of databases, journals, and referencelists occurred from February to June 2013. A total of 441abstracts were screened for inclusion (see Reliability ofSearch and Coding Procedures).

Inclusion and Exclusion Criteria

To be included in this review, studies had to meet the follow-ing predetermined criteria. First, at least one of the participantshad to have been diagnosed with Autistic Disorder, Asperger'sDisorder, or Pervasive Developmental Disorder NotOtherwise Specified. Second, the study had to have includedan empirical evaluation of either PRTor NLP. In order to meetthis criterion, the study had to involve implementation of atleast one antecedent motivational technique (i.e., followingthe child's lead, getting the child's attention, providing a clearopportunity for responding, or interspersing maintenance andacquisition tasks) and one consequent motivational technique(i.e., contingent and natural reinforcement or reinforcement ofattempts) and the study had to refer to the intervention as PRTor NLP or explicitly state the specific motivational techniquesthat were implemented (Koegel and Koegel 2006; Koegelet al. 2010c, 1987b). Third, the study has to have been writtenin English, Dutch, or German (i.e., languages understood bythe authors of this review). Studies were excluded if themotivational techniques of PRT and NLP were implemented,but the intervention evaluated was not referred to as PRT orNLP. For example, Hancock and Kaiser (2002) examined theeffects of Enhanced Milieu Teaching (EMT) for developingsocial communication skills of preschool children with ASD.The milieu teaching procedures included following the child'slead and giving the child access to requested objects (i.e.,natural reinforcement). The approach thus shared some ofthe motivational techniques associated with PRT and NLP.

However, the Hancock and Kaiser study was excluded becauseit did not specifically evaluate either PRT or NLP and becauseEMT includes additional intervention components not com-monly considered inherent to PRT. Studies were also excludedif the motivational techniques of PRTor NLP were implement-ed, but the purpose of the study was not to evaluate PRT orNLP. For example Sherer and Schreibman (2005) investigatedwhether a behavioral profile predicted children's response toPRT. Although PRTwas implemented, the purpose of the studywas not to evaluate PRT. The study was therefore excluded.Ultimately, 43 studies met the inclusion criteria.

Data Extraction

Included studies were summarized in terms of (a) participantcharacteristics (i.e., characteristics of the children with ASDand characteristics of parents or staff that implemented PRT),(b) dependent variables, (c) intervention procedures, (d) inter-vention outcomes, including measures on follow-up, general-ization and, social validity, and (e) certainty of evidence.Various procedural aspects were also noted, including methodof data-collection, implementer, experimental design, inter-observer agreement, and treatment fidelity.

Intervention outcomes of PRT were first summarized asreported by the study's authors. Further, intervention outcomesof PRT were classified as positive, mixed, or negative (e.g.,Lang et al. 2012; Machalicek et al. 2008; Palmen et al. 2012).Results were classified as positive in single-case design studiesif visual analysis of graphed data revealed that all participantsimproved on all dependent variables. In studies using a groupdesign, results were classified as positive if the PRT groupmade statistically significant improvements on all dependentvariables. Results were classified as mixed in single-case de-sign studies if some, but not all participants or dependentvariables improved. In studies using a group design, resultswere classified as mixed if the PRT group statistically signifi-cant improved on some, but not all dependent variables.Results were classified as negative in single-case studies ifnone of the participants improved on any dependent variable.In studies using a group design, results were classified asnegative if the PRT group did not make statistically significantimprovements on any dependent variable.

Certainty of evidence was evaluated for each study byconsidering several methodological characteristics (e.g., re-search design) in order to provide an overview of the qualityof evidence of research on PRT (Schlosser and Sigafoos 2007).The certainty of evidence for each study was rated as either“suggestive”, “preponderant” or “conclusive”, using the clas-sification system as described by Lang et al. (2012), Palmenet al. (2012), Ramdoss et al. (2011) and Ramdoss et al. (2012).The lowest level of certainty was suggestive evidence. Studiesclassified as “suggestive” did not evaluate the intervention withan experimental design (e.g., AB-design or intervention-only

36 Rev J Autism Dev Disord (2014) 1:34–61

design). The second level was preponderant evidence. Studiesclassified as ‘preponderant’ had the following qualities: (a) thestudy used an experimental design (e.g., group design withrandom assignment, ABAB-design or multiple baseline de-sign), (b) adequate inter-observer agreement and treatmentfidelity were reported (i.e., measured during at least 20 % ofthe sessions with at least 80 % agreement and fidelity), (c)operational definitions for dependent variables were providedand (d) sufficient details for replication of intervention proce-dures were provided. However, studies at the preponderantlevel were limited in their ability to control for alternativeexplanations for treatment outcomes. For example, if two co-inciding interventions (e.g., PRT and DTT) were targeting thesame dependent variable and no design feature controlled forthe effect of DTT, the study was classified as “preponderant”.The highest level was conclusive evidence. Studies classifiedas “conclusive” contained all the attributes of the preponderantlevel, but the study's design also provided at least some controlfor alternative explanations for treatment outcomes (e.g., agroup design with appropriate randomization and blinding ora concurrent multiple baseline design).

Reliability of Search and Coding Procedures

The first and last author of this review independently conductedthe database search to check agreement. The reliability of thedatabase search was determined by calculating the percentageof articles identified by both authors out of the total number ofidentified articles (99 % initial agreement on the databasesearch). A total of 436 articles were identified during the initialdatabase search. The first and last author then independentlyscreened the abstracts of the 436 articles for possible inclusion.The resulting lists of abstracts were compared across co-authors. Agreement as to whether a study should be consideredfor inclusion was 90 % (i.e., agreement was obtained on 393 ofthe 436 studies). A total of 136 studies were further screened forpossible inclusion in this review applying the inclusion andexclusion criteria. Agreement as to whether a study should beincluded or excluded was obtained on 114 of the 136 studies(i.e., agreement was 84 %). The disputed articles were thendiscussed by the co-authors until 100 % agreement wasachieved. Next, hand searches, covering December 2012 toJune 2013 were conducted for journals that published at leasttwo included studies. This journal search identified one addi-tional study for inclusion. Finally, the reference lists of theincluded studies were searched and another four studies wereidentified for inclusion. Agreement on the inclusion of thestudies identified via hand searches and reference list searcheswas 100 %. Ultimately, 43 studies were included in this review.

After the list of included studies was agreed upon, the firstauthor extracted information to develop an initial summary ofthe 43 included studies. In cases where two studies presentedresults from the same group of participants, the data from both

studies were consolidated into one summary (e.g., Pierce andSchreibman 1997a, b). A total of 39 summaries were devel-oped. To ensure the accuracy of these summaries and tocalculate inter-coder agreement on the extraction of data, thelast author used a checklist containing five questions: (a) Isthis an accurate description of the participants? (b) Is this anaccurate description of the dependent variables? (c) Is this anaccurate description of the intervention procedures? (d) Is thisan accurate description of the intervention outcomes? and, (e)Is this an accurate description of the certainty of evidence?There were 195 items on which there could be agreement ofdisagreement (i.e., 39 studies with five items per study). Initialagreement was obtained on 184 items (94 %). If a summarywas considered inaccurate, the co-authors discussed the studyand the summary and made changes. This process was con-tinued until consensus was achieved.

Results

Table 1 summarizes each of the included studies in terms of(a) participant characteristics, (b) dependent variables, (c)intervention procedures, (d) intervention outcomes, and (e)certainty of evidence.

Participant Characteristics

In 37 of the summarized studies, data on child characteristicswere reported. A total of 420 children participated in thesestudies. The sample size of participants ranged from 2 to 158with 14 studies involving more than 6 children. Of the 420children, 298 (71.0 %) were male, 65 (15.4 %) were female andthe sex of 57 children (13.6 %) was not reported. Childrenranged in age from 1;0 to 12;7 years; months (M=4;7 years).Themajority of the children (n =221; 52.6%) were identified ashaving ASD, but a specific diagnosis was not stated. One-hundred eighty-one children were diagnosed with autism(43.1 %), six with PDD-NOS (1.4 %) and two withAsperger's syndrome (0.5 %). Ten children (2.4 %) did not havea formal diagnosis of ASD, but met the cutoff score for an ASDon the Autism Diagnostic Observation Schedule or AutismDiagnostic Interview—Revised. In addition to ASD, one childalso had developmental delays and mental retardation.

Nine studies reported data on caregiver characteristics. Atotal number of 121 caregivers participated in these studies. Ofthe 121 caregivers, 22 (18.2 %) were male, 75 (62.0 %) werefemale and the sex of 24 caregivers (19.8 %) was not reported.The caregivers were mainly the children's parents, but threestudies also included a grandparent or one-to-one intervention-ist (Koegel et al. 2002; Randolph et al. 2011; Symon 2005).Caregiver education level was reported in six studies andranged from high school to a graduate degree.


Tab

le1

Summaryof

included

studies

Citatio

nParticipantcharacteristics

Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

Baker-Ericzén

etal.

(2007)

Children:

N=158(83%

male,17

%female);M

age=

49.36months;

with

autistic

disorderor

PDD-N

OS;

with

variousethnicbackgrounds

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:adaptiv

efunctio

ning

(VinelandAdaptiveBehavior

Scales;V

ABS)

Interventio

n:12-w

eekparent

educationprogram

(121-h

individualsessions),consistin

gof

amanual,teaching

ofPR

Ttechniques,com

pletingteaching

activ

ities,discussingstrategies

and

weeklyhomeassignments.

PRTtechniques:child

'schoice;clear

opportunities

andshared

control;

interspersalof

maintenance

and

acquisition

tasks;natural

reinforcem

ent;reinforcem

ento

fattempts.

Implem

enter:

PRT-trainedtherapists

(i.e.,master's

leveld

evelopmental

specialistsor

doctorallevelclin

ical

psychologist)(parenttraining),

parents(PRT)

Children:

positiv

eAdaptivefunctio

ning:statisticallysign.

improvem

ento

ntheABCandeach

subdomainof

theVABS;

nostatistically

sign.differences

betweenboys

andgirlsor

ethnic

backgrounds;statistically

sign.

difference

betweenagegroups

atpretestand

posttest(children≤

3yearswerelessim

paired

atpretest

andshow

edmostimprovem

entat

posttest),butimprovem

entw

asstatistically

sign.for

allage

groups;

FU:N

R.G

en:N

R.S

V:N

R

Suggestiv

e:pre-experimentald

esign

(pretest-postdesign,with

outcontrol

group);IOAandTFwereNR;

operationald

efinition

ofdependent

variable;insufficientd

etailson

interventionprocedures

(i.e.,parent

training);lim

itedcontrolfor

alternativeoutcom

esdueto

pre-

experimentald

esign

Bernard-O

pitzetal.

(2004)

Children:

N=8(genderNR);aged

28–

44months;7child

renmetcutoff

scoreforautism

onADI-R;2

groups,m

atched

onage,ADI-R,

PL-A

DOSandSy

mbolic

Play

Test

(SPT

)

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:autism

symptom

s(PL-A

DOS);sym

bolic

play

(SPT

);compliance;attendingbehavior;

communication(observatio

n)

Interventio

n:6

hof

training

perweek

during

5weeks

forbehavioral

(DTT)andplay

(NLP)

condition;

10hof

therapyby

parentsper

weekduring

both

conditions

PRTtechniques:child'schoice;natural

reinforcem

ent

Implem

enter:

psychology

(honors)

graduate(behavioralo

rplay);

parent

(both);coordinator

(pre-and

post-interventionsessions)

Children:

mixed

(playcondition)

Autismsymptom

s:reduced

communicationandinteraction

scores

for7child

ren,reducedplay

scores

for5child

renandreduced

stereotypedbehavior

scores

for7

child

renafterboth

conditions(play

condition

separately

was

NR)

Symbolic

play:increase

for5child

ren

afterboth

conditions

Com

munication:

increase

forall4

verbalchild

renacross

communicationpartnersafterboth

conditions

Com

pliance:

increase

for2child

ren

with

coordinatorsandfor4child

ren

with

parents(play)

Attendingbehavior:increase

for1

child

with

coordinatorsandfor5

child

renwith

parents(play)

FU:N

R.G

en:Y

es:N

R.S

V:Y

es

Suggestiv

e:quasi-experimentald

esign

(i.e.,counterbalancedcrossover

design,w

ithtoosm

alln

umberof

pre-

andpost-interventiondata

points);IO

Awas

inadequatefor

attendingbehavior

andTFwas

NR,

however,interventionconditions

werevalid

ated;n

ooperational

definitions

somedependent

variables(i.e.,compliance,

attendingbehavior

and

communication);insufficientdetails

oninterventio

nprocedures

(i.e.,

contento

fsessions);lim

itedcontrol

foralternativeexplanations

dueto

quasi-experimentald

esign

Coolican

etal.(2010)

Children:

N=8(7

males,1

female);

aged

2;4–4;8years;with

autism

Parents:N=8(3

fathers,5mothers);

middleto

upper-middle

socioeconomicclass

Child

behavior:

Pivotalb

ehaviors:typeof

utterance

(observatio

nof

initiations)

Other

behaviors:functio

nalv

erbal

utterances

(observatio

n);typeof

utterances

(observatio

nof

appropriate/inappropriate,

utterances,degreeto

which

utterances

wereprom

pted

andno

response);disruptiv

ebehavior

Interventio

n:32-hindividualPR

Ttraining

sessions,consistingof

amanual,instruction,modeling,

practiceandin

vivo

feedback

PRTtechniques:clearopportunities;

child

'schoice;contin

gent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Children:

mixed

Initiations:no

statisticallysign.change

Functionalverbalu

tterances:

statistically

sign.increase,but

minim

algainsfor2child

ren;

maintainedduring

FU,but

(slig

ht)

decreasesfor5child

ren

Type

ofutterances:statistically

sign.

increase

inappropriateutterances

andindirectly

prom

pted

responses

Preponderant:trueexperimentaldesign

(i.e.,non-concurrent

multip

lebaselin

edesign

acrossparticipants);

adequateIO

AandTF(PRT)for5

parents,butT

F(parenttraining)was

NR;o

peratio

nald

efinitionsof

dependentv

ariables;sufficient

details

oninterventio

nprocedures;

limitedcontrolalternative

explanations

dueto

non-concurrent


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

(observation);expressiveand

receptivelanguage

(Preschool

LanguageScale4thedition,P

LS-4;

PeabodyPictureVocabularyTest

3rdedition,P

PVT-3.

Parentb

ehavior:

fidelityof

PRT

implem

entatio

n(observatio

n);

parentalself-efficacy(ParentalS

elf-

EfficacyScale)

Implem

enter:

parents(PRT)andNR

forparent

training

anddecrease

inno

responses,

maintainedduring

FU;n

ostatistically

sign.changein

model

prom

pted

andinappropriate

responses

Disruptivebehavior:no

statistically

sign.decreaseduetolowlevelof

disruptivebehavior

duringbaseline

Expressivelanguage:no

statistically

sign.increaseon

Expressive

Com

munication(EC)of

PLS-4,but

largegainsfor2child

ren

Receptivelanguage:no

statistically

sign.increaseon

Audito

ryCom

prehension

(AC),butlarge

gainsfor2child

ren;

nostatistically

sign.increaseon

PPVT-3,but

increase

insinglewordreceptive

vocabulary

for3children

Parents:mixed

Fidelity

ofimplem

entatio

n:sign.

increase

infidelityof

implem

entatio

n,maintainedduring

FU;5

parentsmetcriterion

post-

training

Parentalself-efficacy:

nostatistically

sign.increase

FU:Y

es.G

en:N

R.S

V:Y

es

multip

lebaselin

edesign

(i.e.,

limitedcontrolfor

history)

Gianoum

isetal.(2012)

Children:

N=6(3

males,3

females);

aged

3–4years;with

ASD

Staff:N=3(3

females);preschool

teacherassistants;experience:

1–2years

Child

behavior:

Pivotalb

ehaviors:N

ROther

behaviors:appropriate

vocalization(observatio

n);

maladaptiv

ebehavior

(observatio

n)Staffb

ehavior:

performingastim

ulus

preference

assessment(SP

A;

observation);conductingaNLP

teaching

session(observatio

n)

Interventio

n:NLPbehavioralskills

groupstafftraining,consistingof

instruction,rehearsal,modelingand

feedback

plus

4–510-m

inindividualsessions

PRTtechniques:child

'schoice;clear

opportunities;immediateand

contingent

reinforcem

ent;natural

reinforcem

ent

Implem

enter:

experimenter(staff

training)andstaff(N

LP)

Children:

mixed

Appropriatevocalization:

increase

for

4child

ren

Maladaptivebehavior:decrease

for4

child

ren

Staff:positiv

ePerform

ingSPA:increase

forall3staff

ConductingNLP

:increase

forall3

staff

FU:N

R.G

en:Y

es(generalizationof

staff's

skillsto

anotherchild

);SV

:Yes

Conclusive:true

experimentald

esign

(i.e.,multip

lebaselin

edesign

across

staff;startingpointsof

intervention

werestaggered);adequateIO

Aand

TF(stafftraining);operational

definitio

nsof

dependentv

ariables;

sufficient

details

oninterventio

nprocedures;control

foralternative

explanations

Gilletetal.(2007)

Children:

N=3(3

males);aged

4–5years;with

autism

Parents:N=3(3

females);aged

34–38years;educationlevel:high

school—Ph

D

Child

behaviors:

Pivotalb

ehaviors:spontaneous

vocalizations

(observatio

n)Other

behaviors:

prom

pted

vocalizations;m

eanlength

ofutterance(M

LU);appropriateplay;

inappropriateplay

(observatio

n)Parentb

ehaviors:NLP

implem

entatio

n(observatio

n)

Interventio

n:Parent

training:trainingsessions

consistin

gof

instruction,video

model,practice,im

mediate/delayed

feedback

until

3setsof

10NLP

trialswereconductedwith

90%

correctimplem

entatio

nforeach

component

and2setsof

10NLP

trialswerescored

at90

%accuracy

Children:

mixed

Spontaneousvocalizations:increase

for2

child

renandslightincrease

for

1child

Prompted

vocalizations:increase

for1

child

MLU

:increase

for2child

ren

Appropriateplay:increase

for2

child

ren



multip

lebaselin

edesign

across

dyads);

adequateIO

AandTF(N

LP

implem

entatio

n),T

F(parent

training)was

NR,how

ever,parent

training

was

successfully

replicated

with

3parents(i.e.,all3

met

criterion

forfidelityof

implem

entatio

n),suggestingTF


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

NLPim

plem

entatio

n:3–610-m

insessions

1–2tim

esaweek(num

ber

ofweeks

NR),consistin

gof

PRT

techniques

andmodelingof

appropriatevocalizations

andplay

PRTtechniques:child

'schoice;clear

opportunities

(turntaking);

immediateandcontingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts(loose

shaping)

Implem

enter:

psychologist(parent

training),parents(N

LP)

Inappropriateplay:decrease

for1

child

;noplay

decreasedfor2

child

ren

Parents:positiv

eNLPimplem

entation:

all3

parents

reachedcriterion

levelinminim

umnumberof

sessions,w

hich

was

maintainedduring

NLP

implem

entatio

nFU

:NR.G

en:Y

es(for

1child

,tohome

situation).S

V:Y

es

(parenttraining)

was

adequate;

operationald

efinition

ofdependent

variables;sufficient

details

oninterventio

nprocedures;lim

ited

controlalternativeexplanations

due

tonon-concurrent

multip

lebaselin

edesign

(i.e.,lim

itedcontrolfor

history)

Harperetal.(2008)

Children:

N=2(2

males);aged

8;6and

9;1years;with

autism

Peers:N=6(2

males,4

females);aged

8–9years;with

outd

isabilities

Child

behaviors:

Pivotalb

ehaviors:g

aining

attention

(observation;

N=1);initiatio

nsto

play

(observatio

n;N=1)

Other

behaviors:turn

taking

(observation;

N=2)

Peerbehaviors:

NR

Interventio

n:Peer

training:7

20-m

intraining

sessions

consistin

gof

strategy

instruction,visualtraining

cards,

cuecards,modeling,role-play,

reinforcem

ent,assessmento

funderstandingandgeneralizationto

playground

PRTinterventio

n:20-m

inmorning

recess

period

on7consecutivedays

involving2peersperchild

implem

entingPR

Ttechniques

and

narrativeplay

PRTtechniques:child

'sattention;clear

opportunities

(i.e.,turn

taking);task

variation;reinforcem

entofattempts

Implem

enter:

study'sfirstauthor(peer

training),peers(PRTinterventio

n)

Children:

positiv

eGaining

attention:

increase

for

participant1

,maintainedduring

generalization

Initiations

ofplay:slight

increase

for

participant2

,maintainedduring

generalization

Turn

taking:increase

forparticipant1

andslightincrease

forparticipant2

,maintainedduring

generalization

FU:N

R.G

en:Y

es(tobaselin

econdition).SV

:NR

Suggestive:quasi-experimentald

esign

(i.e.,multip

lebaselin

edesign

across

2child

ren);adequateIO

Aand

TF(except

for1peer

scoringbelow

criterion

onnarratingplay);

operationaldefinitionsof

dependent


details

oninterventio

nprocedures;lim

ited

controlfor

alternativeexplanations

dueto

quasi-experimentald

esign

Huskens

etal.(2012)

Children:

N=5(4

males,1

female);

aged

10;3–12;4years;4with

PDD-

NOSand1with

Asperger's

disorder

Staff:N=5(5

female);d

irectcarestaff

ofdaytreatm

entfacility;

experience:8

months –7years

Child

behavior:

Pivotalb

ehaviors:child

initiations

follo

wingalearning

opportunity

andspontaneouschild

initiations

(observation)

Other

behaviors:NR

Staffb

ehavior:

creatin

glearning

opportunities

(observatio

n)

Interventio

n:28-hPR

Tgrouptraining

days

consistingof

instruction,video

models,assignmentsandrole-play;

315-m

inindividualvideofeedback

sessions

PRTtechniques:follo

wchild

;clear

opportunity;immediateand

contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

psychologist(staff

training),staff(PRT)

Children:

mixed

Child

initiations

follo

wingalearning

opportunity:sign.increasefor2

child

renfrom

baselin

eto

post-

instruction(TAUnovlap=1resp.

0.82),for1child

from

video

feedback

toFU(TAUnovlap=1)

Spontaneouschild

initiations:sign.

increase

for1child

from

post-

instructionto

feedback

(TAUnovlap=1)

Staff:mixed

Creatinglearning

opportunities:sign.

increase

for3staffmem

bersfrom

baselin

eto

post-instructio

n(overall

TAUnovlap=0.85)andfor1staff

mem

berfrom

post-instructio

nto

videofeedback

(overallTA

Unovlap=

Conclusive:true

experimentald

esign

(i.e.,multip

lebaselin

edesign

across

dyads;startin

gpointo

finterventio

n(video

feedback)werestaggered);

adequateIO

AandTF(video

feedback);operationaldefinitionsof

dependentv

ariables;sufficient

details

oninterventio

nprocedures;

controlfor



Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

0.11);sign.decreasefor1staff

mem

berduring

FU

FU:Y

es.G

en:N

R.S

V:Y

esKoegeletal.(1998a)

Children:

N=3(2

males,1

female);

aged

3.75–5.42years;with

autism

(N=2)

andwith

developm

ental

delays,m

entalretardatio

nand

autism

(N=1)

Child

behaviors:

Pivotalb

ehaviors:n

umberof

spontaneouslyaskedquestions

(observation)

Other

behaviors:numberof

new

stim

ulus

itemslabeledcorrectly

(observation)

Interventio

n:30-m

insessions,

consistin

gof

PRTtechniques,

prom

pting,tim

edelayandfading

(from

preferredto

neutralitems;

from

opaque

bagto

visibleitems)

PRTtechniques:child

'schoice;clear

opportunities;taskvariationand

interspersalof

maintenance

and

acquisition

tasks;natural

reinforcem

ent

Implem

enter:

clinicianandchild

'smother(generalization)

Children:

positiv

eSpontaneouslyaskedquestio

ns:

increase

forall3

child

renduring

interventio

n;somedecrease

during

fading,but

child

rencontinuedto

spontaneouslyaskquestio

nsCorrectlylabelednewstimulus

items:

increase

forall3

child

ren

FU:N

R.G

en:Y

es(acrossstim

uli,

settingsandpeople).SV

:NR


(i.e.,multip

lebaselin

edesign

across

participants;startingpointsof

interventio

nwerestaggered);

adequateIO

A,T

Fwas

NR,despite

multicomponent

interventio

n;operationaldefinitionsof

dependent


details

oninterventio

nprocedures;control

for


Koegeletal.(2003a,b)

Children:

N=2(2

males);aged

6;3and

4;4years;with

autism

Child

behaviors:

Pivotalb

ehaviors:n

umberof

productio

nsof

self-initiatedquery

(observation)

Other

behaviors:numberof

occurrencesof

targeted

morphem

e;percentage

correctp

roductions

oftargetmorphem

e;MLU;

generalized

useof

child

-initiated

query;

totaln

umberof

verbs;

diversity

ofverbs(observation)

Interventio

n:230-m

insessions

aweek,consistin

gof

PRTtechniques

andprom

pting

PRTtechniques:child

'schoice;clear

opportunities;naturalreinforcem

ent

Implem

enter:

interventio

nist

Children:

positiv

e(for

reported

outcom

es)

Num

berof

productions

ofqueryand

occurrencesoftargeted

morphem

e:NR

Percentagecorrectp

roductions

oftargeted

morphem

e:increase

for

both

child

ren

MLU

:increase

forboth

child

ren

Generalized

useof

child

-initia

ted

query:

increase

forboth

child

ren

Totaln

umberof

verbs:

increase

for

both

child

ren

Diversityof

verbs:

increase

forboth

child

ren

FU:N

R.G

en:Y

es(acrossverbsand

settings).S

V:N

R


esign

(i.e.,multip

lebaselin

edesign

across

only

2children);adequateIO

A,but

TFwas

NR;n

ooperational

definitio

nsof

somedependent

variables(i.e.,MLU,generalized

useof

child

-initiatedqueryand

diversity

ofverbs);insufficient

details

oninterventio

nprocedures

(i.e.,duratio

nof

interventio

n,prom

pting);lim

itedcontrolfor


dueto

quasi-experimentald

esign

Koegeletal.(2010a)

Children:

N=3(3

males);aged

3;2–

4;8years;with

autism

Child

behavior:

Pivotalb

ehaviors:p

ercentageof

unprom

pted

‘where’questions

(observatio

nof

socialinitiations)

Other

behaviors:numberof

correct

individually

targeted

prepositions/

ordinalm

arkers(observatio

n)

Interventio

n:twiceweekly60-m

insessions,including

hiding

ofdesired

items,prom

pting,reinforcem

ent

andprom

ptfading

PRTtechniques:child

's;clear

opportunities;contin

gent

reinforcem

ent;natural

reinforcem

ent

Implem

enter:

clinician

Children:

positiv

eUnprompted

wherequestions:increase

inunprom

pted

where

questio

nsfor

all3

child

ren;

generalizationto

homesetting

Prepositio

ns/ordinalmarkers:increase

inlanguage

structures

forall3

child

ren

FU:N

R.G

en:Y

es(generalizationto

homesetting).SV

:NR


(multip

lebaselin

edesign

across


interventio

nwerestaggered);

adequateIO

A,but

TFwas

NR;


dependent


details

oninterventio

nprocedures;control

for


Koegeletal.(1999b)

Children(phase

2):N

=4(genderN

R);

aged

2;7–3;11

years;with

autism

Child

behaviors(phase

2):

Pivotalb

ehaviors:n

umberof

spontaneousinitiations

(observation)

Other

behaviors:language

age

(Brown'sstages

ofdevelopm

ent),

pragmaticratin

gs(9-point

Likert

ratin

gscale),adaptivefunctio

ning

Interventio

n:60-m

in1-to-1

sessions

twiceweeklyduring

anaverageof

2;6years,consistin

gof

PRT

techniques,promptingandfading

PRTtechniques:child

'schoice;clear

opportunities;taskvariation;natural

reinforcem

ent

Implem

enter:

clinician

Children:

positiv

eSpontaneousinitiations:increase

for

all4

child

ren

Language

age:

change

was

NR

Pragm

aticratin

gs:increase

forall4

child

rento

appropriatepragmatic

behavior

Suggestiv

e:pre-experimentald

esign

(i.e.,pretest–posttestdesign,

with

outcontrol

group);adequate

IOAformostd

ependent

variables

(i.e.,onlyIO

Aforp

ragm

aticratin

gswas

79%),butT

Fwas

NR;


dependent


details

on


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

(VABS),socialand

community

functio

ning

(records

from

school

filesetc.)

Adaptivefunctio

ning:increase

forall4

child

rento

levelclose

tocalendar

age

Social/com

munity

functio

ning:regular

education,(above)averagegrades,

socialcircleswith

typically

developing

peersoutsideschool,

extracurricularactiv

ities

andno

diagnosisof

autism

post-

interventio

nforall4

child

ren

FU:N

R.G

en:N

R.S

V:N

R

interventio

nprocedures;n

ocontrol


dueto

pre-experimentald

esign

Koegeletal.(2012)

Children:

N=3(2

males,1

female);

aged

5–6years;2with

autismand1

with

Asperger's

disorder

Child

behavior:

Pivotalb

ehaviors:u

nprompted

peer-

directed

initiations

(observatio

n)Other

behaviors:socialengagement

(observatio

n);affect(observation)

Interventio

n:weekly10-m

insessions

consistin

gof

facilitated

socialplay

with

outinitiatio

nstraining

for2

child

ren(promptingpeers;

encouragem

ento

fplay;p

rompting

responsesto

peers;game

supervision)

and/or

facilitated

social

play

with

initiations

training

forall

3child

ren(promptinginitiations

andresponsesto

peers)

PRTtechniques:child

'schoice;task

variation;

naturalreinforcement

Implem

enter:

(under)graduate

university

studentsin

psychology

Children:

positiv

eUnprompted

peer-directedinitiations:

increase

forall3

child

ren;

large

effect(d=1.1resp.1.2resp.1.2)

Social

engagement:increase

forall3

child

ren;

largeeffect(d=2.5resp.

4.9resp.1.2)

Affect:increase

forall3

child

ren;large

effect(d=4.2resp.4.0resp.4.3)

FU:Y

es(for

1participant).G

en:Y

es(generalizationto

no-interventionist

condition);SV

:NR



multip

lebaselin

edesign

across

child

ren;

startin

gpointsof

interventio

nwere

staggered);adequateIO

AandTF;


dependent


details

oninterventio

nprocedures;lim

ited

controlfor


dueto

non-concurrent

multip

lebaselin

edesign

(i.e.,lim

itedcontrol

forhistory)

Koegeletal.(2010b)

Children:

N=4(3

males,1

female);

aged

4;3–7;8years;with

autism

Child

behavior:

Pivotalb

ehaviors:interest(5-point

Likertratingscale)

Other

behaviors:latency(tobegina

task),rate(productivity

)and

disruptiv

ebehavior

(observatio

n)

Interventio

n:sessions

includinga

writin

g(N

=4)

ormath(N

=2)

activ

ityandPR

Ttechniques

PRTtechniques:child

'schoice;task

variationandinterspersalof

easy

anddifficulttasks;contingent

reinforcem

ent;natural

reinforcem

ent

Implem

enter:

NR

Children:

positiv

eInterest:increase

forall4

child

renand

during

both

tasks,maintained

during

post-intervention

Latency:

decrease

forall4child

renand

during

both

tasks,maintained

during

post-intervention

Rate:

increase

forall4

childrenand

during

both

tasks,maintained

during

post-intervention

Disruptivebehavior:decrease

forall4

child

renandduring

both

tasks,

maintainedduring

post-intervention

FU:N

R.G

en:N

R.S

V:N

R

Suggestiv

e:true

experimentald

esign

(non-concurrentm

ultip

lebaselin

edesign

across

participantsand

behaviors;startin

gpointsof

interventio

nwerestaggered);

adequateIO

A,but

TFwas

NR;


dependent

variables;insufficient

details

oninterventio

nprocedures;lim

ited

controlfor


dueto

non-concurrent

multip

lebaselin

edesign

(i.e.,lim

itedcontrol

forhistory)

Koegeletal.(1996)

Children:

N=17

(10males,7

females);

aged

3–9;

with

autism;in2groups:

PRT(N

=7)

andIndividualTarget

Behavior(IBT;

N=10);groups

similarwith

regard

toageand

adaptiv

efunctio

ning

Parents:N

andgenderwereNR;w

ide

rangeof

socioeconomiclevels

Child

behavior:NR

Parentb

ehavior:

interactionalpatterns

(6-point

Likertratingscales

for

happiness,interest,stressleveland

communicationstyle)

Interventio

n:manualized

procedures,

(video)modeling,practiceand

feedback

until

criterion

of80

%correctimplem

entatio

nwas

metfor

both

conditions.ITB:p

resent

discretetrialsandclearinstructions,

selectfunctio

nalreinforcers,present

reinforcersonly

aftercorrect

response

anduseshapingand

prom

pting.PR

T:P

RTtechniques

Parents(PRTonly):positiv

eInteractionalp

atterns:

increase

from

neutraltopositiv

eratin

gon

all4

scales;statistically

sign.greater

increase

onall4

scales

inPR

Tcondition

FU:N

R.G

en:N

R.S

V:N

R

Suggestiv

e:pre-experimentald

esign

(pretest–posttestdesign

for2

interventio

nswith

outcontrol

group);adequateIO

AandTF

(intervention)

was

NR,but

parent

training

continueduntil

criterion

was

met,suggestingadequateTF

(intervention),T

F(parenttraining)

was

NR;o

peratio

nald

efinitionsof

dependentv

ariables;insufficient

details

oninterventio

nprocedures


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

PRTtechniques:child

'schoice;

interspersalof

maintenance

and

acquisition

tasks;natural

reinforcem

ent;reinforcem

ent

ofattempts;multip

lecues

Implem

enter:

therapists(parent

training),parents(PRTor

ITB)

(i.e.,duratio

nandintensity

ofinterventio

nwereNR);lim

ited

controlfor


dueto

pre-experimentald

esign

Koegeletal.(1998b)

Children:

N=5(4

males,1

female);

aged

3;8–7;6years;with

autism

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:percentage

correct

productionof

targetsounds

during

conversatio

n(observatio

n);o

verall

intelligibility(6-point

Likertrating

scale)

Interventio

n:Analoguecondition:2

45-m

insessions

aweekuntil

80%

criterion

level

was

metforeach

step

(targetsound

prom

pted,targetsound

spontaneous,wordprom

pted,w

ord

spontaneous,sentence),including

modeling,prom

pting,

reinforcem

entand

shaping

Naturalistic

condition:2

45-m

insessions

aweekto

teachtarget

soundin

words,including

PRT

techniques

andmodelingof

target

sound

PRTtechniques:child

'schoice;clear

opportunities;reinforcemento

fattempts

Implem

enter:

clinician

Children:

mixed

Percentagecorrectp

roductionof

targetsounds

during

conversatio

n:increase

tohigh

levelo

fcorrectly

produced

targetsounds

innaturalistic

condition

forall5

child

ren,lowlevelsof

correctly

produced

targetsounds

inanalogue

condition

forall5

child

ren

Overallintelligibility:

1-to

2-point

improvem

entfor

4of

5children

from

pre-

toposttest(naturalistic

condition

separately

was

NR)

FU:N

R.G

en:Y

es(acrosssettings).

SV:N

R


(i.e.,ABAdesign

with

counterbalancedordero

fconditions

across

participants,including

baselin

emeasurespriorto

each

condition:A

BACABor

ACABAC,

B=analogue

andC=naturalistic);

IOAwas

adequateforproductio

nof

targetsounds,but

notfor

intelligibility,adequateTF;


dependent


details

oninterventio

nprocedures;lim

ited

controlfor


(i.e.,interactioneffects)

Koegeletal.(1992)

Children:

N=3(2

males,1

female);

aged

3;4–4;6years;with

autism

Clinician:

NR

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:disruptiv

ebehavior;

individuallanguage

targets

(observation)

Clin

icianbehaviors:

instruction

pertaining

task-related

and

disruptiv

ebehavior;p

resentationof

reinforcem

ent(observation)

Interventio

n:1–

310-m

insessions

on1dayaweekduring

3monthsin

eitheranalogue

condition

(consistingof

instruction,

prom

pting,shapingand

reinforcem

ent)or

NLPcondition

(consistingof

PRTtechniques

and

modelingof

targetresponse)

PRTtechniques:child

'schoice;task

variation;

naturalreinforcement;

reinforcem

ento

fattempts

Implem

enter:

clinician(advanced

doctoralstudent)

Children:

positiv

eDisruptivebehavior:less

disruptiv

ebehavior

during

NLPforall3

child

ren

Individual

language

targets:

more

correcttargetlanguagebehavior

during

NLP

Clin

ician:

mixed

Task-related:moretask-related

instructionduring

NLP

Disruptivebehavior:less

instruction

pertaining

disruptiv

ebehavior

during

NLP

Reinforcement:slightly

less

reinforcem

entd

uringNLP

FU:N

R.G

en:Y

es(toparents);S

V:N

R


esign

(i.e.,repeated

reversalsdesign

with

2conditions(analogueandNLP)

with

orderof

conditionsand

numberof

sessions

varied

across

andwith

insubjects,w

ithout

baselin

econdition);adequateIO

AandTF;

operationald

efinitionsof

dependentv

ariables;sufficient

details

oninterventio

nprocedures;

controlfor


dueto

quasi-experimentald

esign

Koegeletal.(1987b)

Children:

N=2(genderNR);aged

4;5

and5;8years;with

autism

Children:

Pivotalb

ehaviors:spontaneous

speech

(observation)

Other

behaviors:im

mediateand

deferred

imitativ

eutterances

(observation)

Interventio

n:2-hNLPsessions

consistin

gof

PRTtechniques

and

modelingof

targetresponse

PRTtechniques:child

'schoice;task

variation;


reinforcem

ento

fattempts

Implem

enter:

clinician

Children:

positiv

eIm

itativeutterances:increase

inim

mediateanddeferred

imitativ

eutterances

forboth

child

ren;

increase

inim

mediateim

itativ

eutterances

ingeneralizationsetting

Spontaneousspeech:increase

forboth

child

ren;

slight

increase

forboth

child

renin

generalizationsetting


esign

(i.e.,multip

lebaselin

edesign

across

2child

renandanalogue

teaching

during

baselin

e);IOAinadequatein

generalizationsettingsandTFwas

NR;o

peratio

nald

efinitionsof

dependentv


details

oninterventio

nprocedures

(i.e.,treatm

entd

uration);lim

ited


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

FU:Y

es(for

1child

).Gen:Y

es(across

settings).S

V:N

Rcontrolfor


dueto

quasi-experimentald

esign

Koegeletal.(2002)

Children:

N=5(2

males,3

females);

aged

3;10–5;7

years;with

ASD

Parents:N=9(5

mothers,3

fathers,1

grandm

other);8

parentshadpost-high

schooleducationdegrees

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:functio

nalv

erbal

responses(observatio

n)Parentb

ehaviors:fidelityof

PRT

implem

entatio

n(observatio

n);

parentalaffect(observatio

n)

Interventio

n:5consecutive5-hparent

training

days,consistingof

amanual,modelingandfeedback

toteachPR

Ttechniques

PRTtechniques:child

'schoice;clear


interspersalof

maintenance

and

acquisition

tasks;im

mediateand

contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

parent

educator

(i.e.,

advanced

doctoralstudent)and

parents(PRT)

Children:

positiv

eFunctionalverbalresponse:

increase

forall5child

ren,maintainedduring

FUParents:positiv

eFidelity

ofimplem

entatio

n:increase

forallp

arents,m

aintainedduring

FUParentala

ffect:increase

topositiv

eaffectlevelduringinterventio

nfor4

parents,maintainedduring

FU;

increase

topositiv

eleveld

uringFU

for1parent

FU:Y

es.G

en:Y

es(tohomesituation).

SV:N

R


(non-concurrentm

ultip

lebaselin

edesign

across

child

ren);IOAwas

adequateformostd

ependent

variablesformostchildren,TF

(PRT)was

adequate,T

F(parent

education)

was

NR,how

ever,

parent

educationwas

successfully

replicated

with

3parents(i.e.,all3

metcriterion

forfidelity),

suggestin

gTF(parenteducatio

n)was

adequate;o

peratio

nal

definitio

nsof

dependentv

ariables;

sufficient

details

oninterventio

nprocedures;lim

itedcontrolfor


dueto

non-

concurrent

multip

lebaselin

edesign

(i.e.,lim

itedcontrolfor

history)

Kuhnetal.(2008)

Children:

N=2(2

males);aged

7and

8years;with

autism

Peers:N=5(4

males,1

female);aged

6–8years;3with

specificlearning

disabilities,1with

mild

mental

retardationand1with

adevelopm

entaldisability;divided

in2peergroups

(AandB)

Child

behaviors:

Pivotalb

ehaviors:initiatio

ns(observation)

Other

behaviors:responsesto

peer

prom

pts(observation);rateof

responsesto

prom

pts(observatio

n)Peerbehaviors:

interaction

opportunities

(observatio

n)

Interventio

n:Peer

training:8

20-m

intraining,

consistin

gof

pictureprom

pts,

modeling,role-playandfeedback

Generalization(PRTim

plem

entatio

n):

3–410-m

insessions

includingplay

with

targetchild

andfading

ofpictureprom

pts,usingPR

Ttechniques,extendedconversatio

nandnarrativeplay

PRTtechniques:child

'sattention;

child'schoice;clear

opportunities

(i.e.,turn

taking);reinforcem

ento

fattempts

Implem

enter:

investigators(peer

training),peers(PRT

implem

entation)

Children:

mixed

Initiations:increase

forboth

child

ren

with

peergroupAandfor1child

with

peergroupB

Responses:increaseforboth

child

ren

with

peergroupA;slig

htincrease

forboth

child

renwith

peergroupB

Rateof

responses:

increase

forboth

child

renwith

peergroupAandfor1

child

with

peergroupB

Peers:positiv

eInteractionopportunities:increase

for

both

peergroups

with

both

child

ren

FU:N

R.G

en:Y

es(tobaselin

econdition).SV

:NR


esign

(i.e.,multip

lebaselin

edesign

across

2peergroups);adequateIO

Aand

TF;

nooperationald

efinition

ofsomedependentv

ariables

(i.e.,

interactionopportunities);sufficient

details

oninterventio

nprocedures;

limitedcontrolfor

alterativ

eexplanations

dueto

quasi-

experimentald

esign

Laski

etal.(1988)

Children:

N=8(7

males,1

female);

aged

5–9;6years;with

autism;4

nonverbaland

4echolalic

speech

Com

parisonchildren:

N=6(gender

NR);aged

2;2–9;8;

matched

onchronologicaland

mentalage

Siblings:N=3(genderNR);aged

2;8–

3;10

years

Parents:NR

Child

behaviors:

Pivotalb

ehaviors:child

vocalizations

(observationof

spontaneous

speech)

Other

behaviors:child

vocalizations

(observatio

nof

imitatio

nsand

answ

ers);echolalia(observatio

n)Parentb

ehaviors:parent

verbalizations

(observatio

n)

Interventio

n:5–915-m

inindividual

NLPparent

training

sessions

consistin

gof

instruction,modeling,

invivo

training

andfeedback,until

criterion

was

met;1

5-min

NLP

sessions

with

child

athome,4tim

esaweek

PRTtechniques:clearopportunities

(i.e.,shared

controland

turntaking);

task

variationandmultip

leexem

plars;naturalreinforcement;

reinforcem

ento

fattempts

Children:

mixed

Child

vocalizations:increase

incombinedvocalizations

inbothplay

setting

andbreakroom

forall8

child

ren;

increase

inim

itatio

nsfor

all8

child

ren,in

answ

ersfor4

child

renandslight

increasesin

spontaneousspeech

for4child

ren;

nochange

incomparisonchild

ren;

increase

inim

itatio

nsand

spontaneousspeech

for1sibling

andansw

ersfor2siblings

Conclusive:true

experimentald

esign

(i.e.,multip

lebaselin

edesign

across

child

ren;

startin

gpointsof

interventio

nwerestaggered);

adequateIO

AandTF;

operational

definitio

nsof

dependentv

ariables;

sufficient

details

oninterventio

nprocedures;control

foralternative

explanations


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

Implem

enter:

therapist(parent

training);parents(N

LP)

Echolalia:no

echolalia

for4children;

slightdecrease

for3

childreninplay

setting;n

ochange

inbreakroom

Parents:mixed

Parentverbalizations:increase

inplay

setting

forall8

parents;increase

inbreakroom

for7parents;increase

with

siblings

FU:N

R.G

en:Y

es(acrosssettingsand

child

ren).S

V:N

RLy

donetal.(2011)

Children:

N=5(5

males);aged

3;10–

6;1years;with

autistic

disorder

Child

behavior:

Pivotalb

ehaviors:N

ROtherbehaviors:duratio

nofinteraction

with

toys

(observatio

n);n

umberof

play

actio

ns(observatio

n);n

umber

ofplay

verbalizations

(observatio

n)

Interventio

n:Video

modeling:10–158-minsessions

conductedtwicedaily,consistingof

watchingthevideomodeltwiceand

4-min

play

PRT:2030-m

insessions,consistingof

PRTtechniques

andmodelingof

symbolic

play

PRTtechniques:child

'schoice;clear

opportunities

(i.e.,turn

taking);task


maintenance

andacquisition

tasks;


reinforcem

ento

fattempts

Implem

enter:

experimenter

Children:

mixed

Durationof

interactionwith

toys:no

statistically

sign.increaseforVM

andPR

TNum

berof

play

actio

ns:statistically

sign.increaseforVM

andPR

Tin

training

setting;statistically

sign.

increase

PRTin

generalization

setting,but

notfor

VM;n

ostatisticallysign.differencebetween

VM

andPR

Tintraining

setting,but

statistically

sign.differencein

generalizationsetting,favoringPR

TNum

berof

verbalizations:no

statistically

sign.increaseforVM

andPR

Tin

training

setting

and

generalizationsetting;n

ostatisticallysign.differencebetween

VM

andPR

Tintraining

setting

and

generalizationsetting

FU:Y

es.G

en:Y

es.S

V:N

R


esign

(i.e.,counterbalanceddesign

with

random

assignmenttosequence

ofconditions,buttoo

smalln

umberof

baselineandfollow-upprobes

after

each

condition);adequateIO

A,but

TFwas

NR;o

peratio

nald

efinitions

ofdependentv

ariables;sufficient

details

oninterventio

nprocedures;

limitedcontrolfor

alternative

explanations

dueto

quasi-

experimentald

esign

Minjarezetal.(2011,

2013)

Children:

N=17

(17males);aged

2;5–

6;7years;16

with

autistic

disorder,

1with

PDD-N

OS

Parents:N=24

(9fathers,15

mothers

of17

families)

Child

behavior:

Pivotalb

ehaviors:N

ROther

behaviors:functio

nalv

erbal

utterances

(observatio

n)Parentb

ehavior:

fidelityof

PRT

implem

entatio

n(observatio

n);

parentalstress

(Parentin

gStress

Index/Sh

ortF

orm:totalstress,

parentaldistress,parent–child

dysfunctionalinteractio

nand

difficultchild);em

powerment

(Fam

ilyEmpowermentS

cale:

family,servicesandcommunity

level)

Interventio

n:10-w

eekPRTgroup

training

(1090-m

ingroupsessions,

150-m

inindividualsession)

consistin

gof

manuals,lectures,

exercises,videomodelsandvideo

feedback;p

arentsweretaught

in3

groups

PRTtechniques:child

'sattention;clear

opportunities

andshared

control;

child'schoice;taskvariationand

interspersalof

maintenance

and

acquisition

tasks;im

mediateand

contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

licensedpsychologist

(parenttraining),parents(PRT)

Children:

positiv

eFunctionalverbalu

tterances:

statistically

sign.increasein

functio

nalv

erbalu

tterances

Parents:mixed

Fidelity

ofPRTimplem

entatio

n:statistically

sign.improvem

entin

fidelityof

PRTim

plem

entatio

nParentalstress:

statistically

sign.

decrease

intotalstressandparent–

child

dysfunctionalinteractio

n;no

statistically

sign.decreasein

parentaldistress

anddifficultchild

Empowerment:statistically

sign.

increase

atalllevels

FU:N

R.G

en:N

R.S

V:N

R

Suggestiv

e:pre-experimentald

esign


with

outcontrol

group);adequate

IOAandTF(PRTim

plem

entatio

n),

butT

F(parenttraining)

was

NR;


dependent


details

oninterventio

nprocedures;lim

ited

controlfor


dueto

pre-experimentald

esign

Nefdt

etal.(2010)

Children:

N=27

(92.6%

male,7.4%

female);M

age(treatmentg

roup,

Child

behaviors:

Pivotalb

ehaviors:N

RInterventio

n:self-directedlearning

program

(SDLP)

consistin

gof

anChildren:

positiv

ePreponderant

:trueexperimental

design

(pretest–posttestcontrol


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

TG)=

38.92months,M

age

(waitlistcontrolg

roup,W

CG)=

38.43months;with

ASD

;with

ASD

;nostatistically

sign.

differencesbetweenTG(N

=13)

andWCG(N

=14)atpretest

Parents:N=27

(12%

male,88

%female);educatio

nlevel:graduate

degree

(15%),college

degree

(51%),somecollege

(29%)and

high

school

(4%);no

statistically

sign.differencebetweenTGand

WCGatpretest

Other

behaviors:functio

nalv

erbal

utterances

(observatio

n)Parentb

ehaviors:fidelityof

PRT

implem

entatio

n(observatio

n);

language

opportunities

(observatio

n);parentconfidence(6-

pointL

ikertratingscale)

interactive66-m

inDVDanda

manual.DVDconsistedof

instructionin

ABAandPR

Ttechniques,video

models,multip

lechoice

testsandinteractivelearning

tasks

PRTtechniques:child

'schoice;clear


contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

parents(PRT)

Functionalverbalu

tterances:

significantd

ifferencebetweenTG

andWCGatposttest:T

Gincreased

functio

nalv

erbalu

tterances

follo

wingSD

LP

Parents:positiv

eFidelity

ofimplem

entatio

n:significant

difference

betweenTGandWCGat

posttest:T

Gim

plem

entedPR

Tfollo

wingSD

LP

Language

opportunities:significant

difference

betweenTGandWCGat

posttest:T

Gprovided

more

language

opportunities

follo

wing

SDLP

Parentconfid

ence:significant

difference

betweenTGandWCGat

posttest:T

Gwas

moreconfident

during

interactions

follo

wingSD

LP

FU:N

R.G

en:N

R.S

V:Y

es

groupdesign,w

ithrandom

group

assignmentand

nosign.difference

betweengroups

atpretest(i.e.,

random

ized

clinicaltrial));adequate

IOA,T

F(SDLP)

was

NR,how

ever,

achecklistw

asused

toensureall

parentsview

edDVDin

similar

manner;no

operationald

efinitions

ofsomedependentv

ariables

(i.e.,

functio

nalv

erbalu

tterances

and

parentconfidence);sufficientdetails

oninterventio

nprocedures;control


Pierce

andSchreibm

an(1995)

Children:

N=2(2

males);aged

10years;with

autism

Peers:N=2(2

males),aged

10years

Child

behaviors:

Pivotalb

ehaviors:initiatio

ns(observation)

Other

behaviors:maintaining

interactions

(observatio

n);joint

attentionbehaviors(i.e.,

nonengagem

ent,onlooking,

object

engagement,supportedjoint

attentionandcoordinatedjoint

attention;

observation);language

use(observatio

n);socialb

ehavior

(Walker–McC

onnelS

caleof

Social

Com

petence)

Interventio

n:430-m

insessions

consistin

gof

amanual,modeling

androle-play;

10-m

insessions

consistin

gof

practiceandfeedback

until

criterion

of80

%correct

implem

entatio

nwas

met,including

PRTtechniques,m

odelingof

appropriatesocialbehavior

and

narrativeplay

PRTtechniques:child

'sattention;

child'schoice;clear

opportunities

(i.e.,encourageandextend

conversatio

n;turn

taking);task

variation;

multip

lecues;

reinforcem

ento

fattempts

Implem

enter:

therapist(peer

training),

peers(PRT)

Children:

mixed


forboth

child

ren,

maintainedduring

FUMaintaining

interactions:increase

for

both

child

ren,maintainedduring

FUJointa

ttentionbehaviors:

increase

insupportedandcoordinatedjoint

attention

Language

use:

increase

innumberof

words

forboth

children;

increase

insentence

length

for1child

Social

behavior:increase

inpeer-

preferredsocialbehavior

forboth

child

ren;

increase

inteacher-

preferredsocialbehavior

for1child

FU:Y

es.G

en:Y

es(acrosstoys

and

settingsforboth

childrenandpeers

for1child

).SV

:NR

Suggestive:

quasi-experimentald

esign

(i.e.,multip

lebaselin

edesign

across

2child

ren);adequateIO

AandTF

(PRT)was

NR,how

ever,post-PR

Tphaseonlystartedafteratleast80

%correctimplem

entatio

n,TF(peer

training)was

notreported;


dependent


details

oninterventio

nprocedures;lim

ited

controlfor


dueto

quasi-experimentald

esign

Pierce

andSchreibm

an(1997a,b)

Children:

N=2(2

males);aged

7–8years;with

autism

Peers:N=8(genderNR);aged

7–9years

Child

behaviors:

Pivotalb

ehaviors:initiatio

ns(observation)

Other

behaviors:maintaining

interactions;languageuse;play

(observation)

Interventio

n:430-m

insessions

consistin

gof

amanual,modeling

androle-play,10-m

insessions

consistin

gof

practiceandfeedback

until

criterion

of80

%correct

implem

entatio

nwas

met,including

PRTtechniques,m

odelingof

appropriatesocialbehavior

and

narrativeplay

PRTtechniques:child

'sattention;

child'schoice;clear

opportunities

Children:

mixed


forboth

child

ren

Maintaining

interactions:increase

for

both

child

renacross

peers

Language

use:

increase

forboth

child

reninfrequencyandquality

oflanguage

Play:

nochange

innumberof

toys

played

with

persession,butrange

oftoys

increasedacross

sessions


(i.e.,multip

lebaselin

edesign

across

peers,replicated

across

2child

ren;

startin

gpointsof

interventio

nwere

staggeredacross

peers);adequate

IOA,T

F(PRT)was

NR,how

ever,

post-PRTphaseonly

startedafterat

least8

0%

correctimplem

entatio

n,suggestin

gTF(PRT)was

adequate,

TF(peertraining)was

NR;


dependent


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

(i.e.,encourageandextend

conversatio

n;turn

taking);task

variation;

multip

lecues;

reinforcem

ento

fattempts

Implem

enter:

therapist(peer

training),

peers(PRT)

FU:Y

es.G

en:Y

es(acrosspeers,toys

andsettings).S

V:N

Rvariables;sufficient

details

oninterventio

nprocedures;lim

ited

controlfor


dueto

unstablebaselin

es

Randolphetal.(2011)

Children:

N=3(2

males,1

female);

aged

3–7years;with

autism

Caregives:N=3(1

male,2females);1

in-hom

ecareprovider,1

biological

father

and1grandm

other;with

out

college

degrees

Child

behavior:

Pivotalb

ehaviors:social

communicationbehavior

(observationof

frequencyof

communicativeinitiations)

Otherbehaviors:socialcommunication

behavior

(observatio

nof

frequency

ofcommunicativeresponses)and

play

behavior

(observatio

n),

adaptivefunctio

ning

(Vineland-II)

Parentb

ehavior:

fidelityof

PRT

implem

entatio

n(observatio

n)

Interventio

n:10

individualPR

Ttraining

sessions

(130-m

inand945

to55-m

insessions),consistingof

instruction,modeling,guided

practice,independentp

racticeand

feedback

PRTtechniques:child

'sattention;clear

opportunities

(i.e.,shared

control);

multip

lecues;immediateand

contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

therapist(caregiver

training),caregivers(PRT)

Children:

mixed

Social

communicationbehaviors:

increase

intotalresponse

percentage

from

baselin

etotraining

forall3

child

ren,increase

from

training

toFUfor2child

ren;

increase

infrequencyof

communicativeinitiations

and

responsesfor2child

ren

Playbehavior:decrease

invaried

play

for2child

ren;

increase

inappropriateplay

forall3

child

ren,1

child

maintainedincrease

during

FUAdaptivefunctioning:no

meaningful

differencesforall3

child

ren

Parents:mixed

Fidelity

ofPRTimplem

entatio

n:increase

inlevelo

ffidelityforall3

caregiversduring

training;2

caregiversmaintainedcriterion

leveld

uringFU

FU:Y

es.G

en:N

R.S

V:Y

es

Conclusive:true

experimentald

esign

(i.e.,multip

lebaselin

edesign

across


interventio

nwerestaggered);

adequateIO

AandTF(caregiver

training);operationald

efinitionsof

dependentv

ariables;sufficient

details

oninterventio

nprocedures;

controlfor


Robinson(2011)

Children(focal):N=4(4

males);aged

3–8years;with

autism

Children(generalization):N=4(3

males,1

female);aged3–10

years;

3with

autism

and1with

Dow

nsyndrome

Staff:N=4(4

females),

paraprofessionalsateducational

institu

tions;experience3months–

17years

Child

behavior:

Pivotalb

ehaviors:N

ROtherbehaviors:individualtarget

social-com

municativebehaviors

(observation);child

affect(6-point

Likertratingscales)

Staffb

ehavior:

fidelityof

implem

entatio

n(observatio

n);level

ofinvolvem

ent(observation);

duratio

nof

training

program

(observation)

Interventio

n:315-m

insessions

includingmodelingand15-m

insessions

involvingvideofeedback

until

80%

fidelityof

implem

entatio

nwas

achieved

PRTtechniques:child

'schoice;clear

opportunities

andshared

control;

contingent

reinforcem

ent;natural

reinforcem

ent

Implem

enter:

author

(stafftraining),

paraprofessionals(PRT)

Children:

mixed

Targetsocial-com

municative

behaviors:

increase

intarget

behaviorsforall4

child

ren;

target

behaviorsgeneralized

andwere

maintainedduring

FUChild

affect:increase

inaffectacross

phases

toapositiv

elevelfor

1child

Staff:positiv

eFidelity

ofimplem

entatio

n:increase

infidelityof

implem

entatio

n,which

generalized

across

studentsand

activ

ities

andwas

maintained

during

FULevelo

finvolvement:decrease

inhovering

anduninvolved

from

baselin

etotreatm

entand

increase

inmonito

ring

andim

plem

entin

g,which

generalized

across

students

andactiv

ities

andwas

maintained

during

FU

Conclusive:true

experimentald

esign

(i.e.,multip

lebaselin

edesign

across


interventio

nwerestaggered);

adequateIO

AandTF(PRT

implem

entatio

n),T

F(stafftraining)

was

NR,how

ever,stafftraining

was

successfully

replicated

with

3staff

mem

bers(i.e.,all3

metcriterion

for

fidelityof

implem

entatio

n),

suggestin

gTF(stafftraining)was

adequate;o

peratio

nald

efinitionsof

dependentv

ariables;sufficient

details

oninterventio

nprocedures;

controlfor



Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

Durationof

program:meantim

erequired

tomeetcriterion

was

91.25min

(range:6

0–115min)

FU:Y

es.G

en:Y

es(generalization

across

activ

ities

andstudents).SV

:Yes

Schreibm

anetal.(1991)

Children:

N=19

(genderNR);aged

2;8–12;7

years;with

autism

Parents:N

=19

(2fathers,17

mothers);

Mage=

37;1

years

Raters:N=120(genderNR);

undergraduatestudents

Child

behaviors:

NR

Parentb

ehaviors:affect(6-point

Likertratingscales

forenthusiasm

,interestandhappiness)

Interventio

n:parent

training,

consistin

gof

manuals,video

modelingandfeedback

for

IndividualTargetBehavior

(repeatedtrials,prompting,shaping

andreinforcem

ent)and/or

PRT

(PRTtechniques)

PRTtechniques:child

'schoice;clear

opportunities

(i.e.,turn

taking);

multip

lecues;interspersalo

fmaintenance

andacquisition

tasks;


reinforcem

ento

fattempts

Implem

enter:

therapist(parent

training);parents(ITBand/or

PRT)

Parents:positiv

eAffect:morepositiv

eaffecton

all

scales

andoveralld

uringPR

Tcondition

FU:N

R.G

en:N

R.S

V:N

R

Suggestiv

e:pre-experimentald

esign

(posttestonlydesign);IO

Awas

NR,

butT

Fwas

adequate;o

peratio

nal

definitio

nof

dependentv

ariable;

insufficient

details

onintervention

procedures

(i.e.,treatm

entd

uration

andintensity

);no

controlfor


dueto

pre-

experimentald

esign

Seiverlin

getal.(2010)

Children:

N=3(2

males,1

female);

aged

40–49months;with

ASD

Staff:N=3(1

male,2females);2

teacherassistantsand1staff

training

coordinator;experience:

NR

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:proportio

nof

opportunities

with

correctv

ocal

responding

foreach

of3vocal

chaining

links

across

5items

(observation)

Staffb

ehaviors:NLPstaffbehavior

(observationof

room

setupand

performingNLPprocedures)

Interventio

n:3–430-m

inNLPstaff

training

sessions

consistin

gof

behavioralskillstraining

(i.e.,

feedback,instructio

ns,rehearsal,

modelingandassessment)and

generalcasetraining

(i.e.,useof

scriptsto

simulatechild

behavior)

PRTtechniques:child

'schoice;clear


contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

experimenter(staff

training)andstaff(N

LP)

Children:

mixed

Proportionof

opportunities

with

correctvocalresponding

foreachof

3vocalchaininglin

ksacross

5items:

increase

for2child

ren;

complexity

ofvocalchains

increasedforthese2child

ren

Staff:positiv

eNLPstaffb

ehavior:

increase

tocriterion

of90

%forallstaffwith

in3–4sessions,m

aintainedduring

post-training

FU:N

R.G

en:N

R.S

V:Y

es

Conclusive:true

experimentald

esign

(i.e.,multip

lebaselin

edesign

across

dyads;startin

gpointsof

interventio

nwerestaggered);

adequateIO

AandTF(staff

training);operationald

efinitionsof

dependentv

ariables;sufficient

details

oninterventio

nprocedures;

controlfor


Smith

etal.(2010)

(including

program

descriptionof

Byrson

etal.2007)

Children:

N=45

(33males,12

females);M

calendar

age=

50months;with

autism

Parents:NR

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:expressive

and

receptivelanguage

(PLS-4,PP

VT-3

andreceptivelanguage

subscaleof

theMerrill–

Palm

er-Revised);

communication(Vineland-II:

receptiveandexpressive

communication);cognitiv

eability

(Merrill–

Palm

er-Revised);adaptiv

ebehavior

(Vineland-II);autism

symptom

s(SocialR

esponsiveness

Scale);b

ehavioralp

roblem

s(Child

BehaviorChecklist,ages

11/2–5)

Interventio

n:Cohort1

:56-hgroupworkshopdays

forparentsandstaffincluding

instruction,guided

practice,

feedback

andsm

allg

roup

discussions;one-to-one

interventio

nistim

plem

entedPR

Tforchild

15haweekduring

12months;parentsim

plem

ented

PRTduring

daily

routines

Cohort2

:1-w

eekin

vivo

parent

training

(group

workshopor

individual);one-to-one

interventio

nistim

plem

entedPR

Tforchild

15haweekduring

Children:

mixed

Resultsarereported

separately

for

lower

(<50)andhigher

(>50)IQ

groups

Expressivelanguage:statisticallysign.

increase

after6and12

monthsfor

lower

IQ(η

p2=0.45)andhigherIQ

(ηp2=0.76);greatergain

forhigher

IQgroup

Receptivelanguage:statistically

sign.

increase

after6and12

monthsfor

lower

IQ(η

p2=0.40)andhigherIQ

(ηp2=0.60);greatergain

forhigher

IQgroup

Suggestiv

e:pre-experimentald

esign


with

outcontrol

groupand(quasi)

random

selection);IOAandTF

(parent/stafftraining)wereNR,but

TF(PRTim

plem

entatio

n)was

adequate;o

peratio

nald

efinitionsof

dependentv


details

oninterventio

nprocedures

(i.e.,parent

training

cohort2);

limitedcontrolfor

alternative

explanations

dueto

pre-

experimentald

esign


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

Parentb

ehaviors:parentalstress

(Parentin

gStressIndex/Sh

ortForm)

6months,10

haweekduring

3monthsand5–6haweekduring

3months;parentsim

plem

ented

PRTduring

daily

routines

PRTtechniques:child

'schoice;clear

opportunities;interspersalo

fmaintenance

andacquisition

tasks;


reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

consultantsof

Koegel

Autism

Center(parenttraining

cohort1),localclinicians

(parent

training

cohort2),interventionists

andparents(PRT)

Expressivecommunication:

statistically

sign.increaseafter6or

12monthsforlow

erIQ

(ηp2=0.57)

andafter6and12

monthsfor

higher

IQ(η

p2=0.73)

Receptivecommunication:

statistically

sign.increaseafter12

monthsfor

lowerIQ

(ηp2=0.43)and

after6

and

12monthsforhigher

IQ(η

p2=

0.73)

Adaptivebehavior:modestg

rowth

inadaptiv

ebehavior

(sub

domains

and

ABCof

Vineland-II)after6and

12monthsforlower

IQandhigher

IQ(η

p2=0.27)

Cognitiveabilities:

statistically

sign.

increase

after6and12

monthsfor

both

groups

(ηp2=0.61);greater

gainsinfirst6

monthsforh

igherIQ

Behavioralproblem

s:statisticallysign.

decrease

after6or

12monthsfor

both

groups

(ηp2=0.31)

Autismsymptom

s:statistically

sign.

decrease

after6and12

monthsfor

higher

IQ(η

p2=0.33),butn

otfor

lower

IQParents:NR

FU:N

R.G

en:N

R.S

V:N

RStahmer(1995);S

tahm

eretal.(2006)

Children:

N=7(7

males);aged

4;3–

7;2years;with

autism

Typicald

evelopingchild

ren:

N=7

(genderNR);M

age=

3;2years;

matched

onexpressive

language

Child

behaviors:

Pivotalb

ehaviors:initiatio

ns(observation)

Other

behaviors:play

behavior

(observatio

nof

symbolic

play,

complexity

andcreativ

ity);

language

(PPVT-R,E

OWPV

Tand

MacArthurCDI);responses

toother's

initiations

(observatio

n);

play

ability

(6-point

Likertrating

scales

forchild'soverallplayability,

creativ

ity,enjoyment,social

interactionandplay

complexity

)

Interventio

n:1-hPR

Tsessions

(sym

bolic

play

training,S

PT)3

times

weekly,preceded

orfollowed

by1-hPR

Tsessions

(language

training,L

T)3tim

esweeklyfor

8weeks

consistin

gof

PRT

techniques

targetingsymbolic

play

orlanguage

andmodelingof

symbolic

play

PRTtechniques:child

'schoice;clear

opportunities

(i.e.,turn

taking);task


maintenance

andacquisition

tasks;


reinforcem

ento

fattempts

Implem

enter:

therapist(PR

T),parents

andpeer

(generalization)

Children:

mixed

Initiations:no

substantialchanges

for

allchildren

Playbehavior:increase

insymbolic

play

andplay

complexity

forall

child

renafterSP

T,to

similarlevel

aslanguage-m

atched

controls;

change

increativ

itywas

NR;slig

htdecreaseofplay

skillsduring

FUfor

5child

ren;

noincreasesafter

language

training

(control

condition);

Language:change

onlanguage

measureswas

NR

Responses

toother'sinitiations:

increase

inpositiv

eresponsesforall

child

ren

Playability:groupdata:statistically

sign.increaseon

each

scale,but

typically

developing

child

renwere

ratedsign.higherboth

pre-

and

Suggestiv

e:true

experimentald

esign

(multip

lebaselin

edesign

across

child

renplus

controlconditio

n(i.e.,

language

training)toassesswhether

symbolic

play

training

was

necessaryto

increase

symbolic

play

orwhether

language

training

was

sufficient);IO

Awas

notadequate

foralldependentvariables(i.e.,play

complexity

andinitiations)andTF

was

NR;n

ooperationald

efinitions

ofsomedependentv

ariables

(creativity,initiatio

nsandresponses

toother's

initiations);insufficient

details

oninterventio

nprocedures

(i.e.,language

training);controlfor



Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

post-training;

individualdata:

(slight)increase

for4children

FU:Y

es.G

en:Y

es(playbehavior;

across

toys

andpersonsfor6

child

ren).S

V:N

RStahmer

andGist(2001)

Children:

N=22

(genderNR);with

ASD

;in2groups:p

arenteducatio

n+supportg

roup

(Mage=

35months);p

arenteducatio

nonly

(Mage=

35.6

months)

Parents:N=22

(fam

ilies,genderNR);

middle-to-highsocioeconomiclevel

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:vocabulary

(observatio

n;MacArthurCDI)

Parentb

ehaviors:useof

PRT

techniques

(observatio

n)

Interventio

n:12

weekly1-hindividual

parent

educationsessions,

consistin

gof

amanualand

training

inPR

Ttechniques

forboth

groups;

12weekly1-hsupportg

roup

meetin

gs,consistingof

inform

ation

onASD

,group

processand

build

ingrelatio

nships

forsupport

forparent

education+support

group

PRTtechniques:child

'schoice

and

shared

control;clearopportunity;

interspersalof

maintenance

and

acquisition

tasks;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

parent

educator

(parent

training),parents(PRT)

Children:

positiv

eVocabulary:MacArthurCDI:

statistically

sign.increasein

words

learnedforchild

renwhose

parents

metcriteriaforP

RTuse;statistically

sign.differencebetweengroups

inwords

produced

andunderstood,

favoring

child

renwhose

parents

metcriteriaforPR

Tuse,no

difference

betweengroups

incommunicativegestures;

observation:

statistically

sign.

increase

innumberof

words

used

forallchildren

Parents:mixed

PRTuse:

increase

formajority

ofparents;statistically

sign.better

performance

ofparentsin

parent

education+supportg

roup

(i.e.,8

parentsmetcriterion

of75

%correct

usevs.4

parentsinparenteducation

only

group)

FU:N

R.G

en:N

R.S

V:N

R

Suggestiv

e:true

experimentald

esign

(i.e.,pretest–posttestcontrolg

roup

design);adequateIO

A,but

TF

(parenttraining)

was

NR;n

ooperationaldefinitionsof

dependent

variables(i.e.,vocabulary);

insufficient

details

onintervention

procedures

(i.e.,componentsparent

training);lim

itedcontrolfor

alternativeexplanationdueto

norandom

assignmenttogroups

Steineretal.(2013)

Children:

N=2(genderNR);aged

12months;no

form

aldiagnosisof

ASD

,but

moderate/severe

concern

onADOS-T.

One

participantw

ithlittle/noconcernon

ADOS-Twas

inthestudy,butw

asom

itted

from

this

analysis

Parents:NR

Child

behavior:

Pivotalb

ehaviors:N

ROther

behaviors:functio

nal


n);

cognitive

functio

ning

(Mullen

Scales

ofEarly

Learning);

diagnosticim

pression

(ADOS)

Parentb

ehavior:

fidelityof

implem

entatio

nof

PRT

(observation)

Interventio

n:10-w

eekPRTparent

training

(101-hsessions:8

clinic

and2homesessions)consistingof

manuals,instructio

n,liv

emodeling,

guided

practiceandfeedback

PRTtechniques:clearopportunity

;child

'schoice;interspersalo

fmaintenance

andacquisition

tasks;


reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

clinician(parenttraining

andPRT);parents(PRT)

Children:

mixed

Functionalcom

munication:

increase

forboth

children,maintainedpost-

treatm

ent

Cognitivefunctio

ning:increase

for1

child

Diagnostic

impression:decrease

inseverity

ofASD

symptom

sto

non-

significantlevelfor1child

Parents:positiv

eFidelity

ofimplem

entatio

nof

PRT:

increase

forboth

child

ren,

maintainedpost-treatment

FU:N

R.G

en:N

R.S

V:Y

es


esign

(i.e.,multip

lebaselin

edesign

across

child

ren,buttoo

smalln

umberof

baselin

eprobes);adequateIO

A,but

TF(PRTim

plem

entatio

n)was

not

adequateforallp

arentspost-

treatm

entand

TF(parenttraining)

was

NR;o

peratio

nald

efinitionsof

dependentv

ariables;sufficient

details

oninterventio

nprocedures;

limitedcontrolfor

alternative

explanations

dueto

quasi-

experimentald

esign

Suhrheinrich

(2011)

Children:

N=NR(genderNR);aged

3–8years;with

autism

Staff:N=20

(20females);teachersin

specialeducatio

nsettings;10

self-

selected,10district-selected);

experience:M

(self-selected)=

6;7years,M

(district-selected)=

5;6years;groups

differed

inhours

Child

behavior:NR

Staffb

ehavior:

fidelityof

PRT

implem

entatio

n(observatio

n)

Interventio

n:6-hgroupworkshop

training

inPR

T,consistin

gof

amanual,instruction,videomodel,

practiceandfeedback

plus

coaching

sessions,consistingof

video

feedback

andmodeling(self-

selected:1

–4coaching

sessions

Staff:positiv

eFidelity

ofimplem

entatio

n:increase

innumberof

PRTcomponents

implem

ented;

15%

ofteacher

masteredallP

RTcomponentsat

post-training,30

%after1

coaching

sessionand40

%after2coaching

sessions;o

ncompletionof

Suggestiv

e:pre-experimentald

esign

(i.e.,pretest–posttestdesign

with

out

controlg

roup);IO

Awas

not

adequateforallo

bservatio

ncategories

(i.e.,turn

taking)andTF

(stafftraining)was

NR;o

peratio

nal

definitio

nsof

dependentv

ariables;

sufficient

details

oninterventio

n


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

readingeducationalliterature

favoring

self-selectedteachers

until

criterion

was

met;d

istrict-

selected:3

coaching

sessions)

PRTtechniques:child

attention;

clear

opportunities

andturn

taking;

child'schoice;contin

gent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

teachers(PRT)andNR

forteachertraining

coaching,1

00%

ofself-selected

teachersmasteredallP

RT

componentsvs.1

0%

ofdistrict-

selected

teachers

FU:N

R.G

en:N

R.S

V:N

R

procedures;lim

itedcontrolfor


dueto

pre-

experimentald

esign

Suhrheinrich

etal.

(2007)

Staff:N=10

(10females);teachersin

earlyinterventio

nclassroomsin

publicschools(N

=4)

and

specialized

programs(N

=6);

teaching

experience:1

–16years

Staffb

ehaviors:fidelityof

PRT

implem

entatio

n(observatio

n)Interventio

n:Stafftraining:low

level(manualand

modeling,N=2),m

oderatelevel

(manual,instructionandmodeling,

N=2),h

ighlevel(manual,

instruction,modelingandfeedback,

N=6)

PRTim

plem

entatio

n:210-m

inone-to-

onesessions

and210-m

ingroup

sessions

inacounterbalancedorder

PRTtechniques:child

'sattention;child

choice's;clear

opportunities

and

turn

taking;contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

teachers(PRT)andNR

forstafftraining

Staff:mixed

Fidelity

ofimplem

entatio

n:on

group

levelm

astery

criteriaweremetfor

allcom

ponents,except

forturn

taking;levelof

training

hadeffect

onPR

Tuseduring

one-to-one

sessions,but

varied

byPR

Ttechnique;levelo

ftraining

hadno

effecton

PRTuseduring

group

sessions;lessexperiencedteachers

metfidelitycriterion

inone-to-one

sessions,but

notingroupsessions

andmoreexperiencedteachersdid

notm

eetfidelity

criterion

inboth

conditions,butp

erform

edbetter

during

groupsessions

FU:N

R.G

en:N

R.S

V:N

R

Suggestive:

pre-experimentald

esign

(i.e.,posttestonly

design);IO

Aand

TF(stafftraining)wereNR,but

TF

(PRTim

plem

entatio

n)was

adequateexcept

forturn

taking;

operationald

efinition

ofdependent

variable;insufficientd

etailson

interventio

nprocedures

(i.e.,staff

training);lim

itedcontrolfor


dueto

pre-

experimentald

esign

Symon

(2005)

Children:

N=3(3

males);aged

2;10–

5;4years;with

autism

Primarycaregivers:N=3

(3mothers);with

atleastcollege

degree

Significant

caregivers:N=3

(1male,2genderNR);1fatherand

2one-to-one

interventio

nists

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:functio

nalv

erbal

utterances;appropriatebehaviors

(observation)

Primary/significant

caregiver

behaviors:

fidelityof

implem

entatio

n(observatio

n)

Interventio

n:5consecutive5-hparent

training

days,consistingof

manuals,m

odelingandfeedback

toteachPR

Ttechniques;significant

caregivertraining

ranged

from

3–25

handconsistedof

videomodels,

modeling,feedback

and/or

manuals

PRTtechniques:child

'schoice;clear


interspersalof

maintenance

and

acquisition

tasks;im

mediateand

contingent

reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

clinician(parent

education);p

rimarycaregivers

(PRT;

significantcaregiver

training);significantcaregivers

(PRT)

Children:

positiv

eFunctionalverbalu

tterances

and

appropriatebehaviors:

increase

for

all3

child

ren

Primaryandsignificant

caregivers:

positiv

eFidelity

ofimplem

entatio

n:increase

tocriterion

level(80

%)during

interventio

nforall3

prim

ary

caregivers,m

aintainedduring

FU;

increase

forall3

significant

caregivers

FU:Y

es;G

en:Y

es(tohomesituation).

SV:N

R



multip

lebaselin

edesign

acrossparticipants);

adequateIO

AandTF(PRT),TF

(parenteducatio

nandsignificant

caregivertraining)wereNR,

however,parenteducationand

significantcaregiver

training

were

both

successfully

replicated

with

3caregivers(i.e.,allcaregiversmet

criterion

forfidelityof

implem

entatio

n),suggestingthat

TFwas

adequate;o

peratio

nal

definitio

nsof

dependentv

ariables;

sufficient

details

oninterventio

nprocedures;lim

itedcontrolfor


dueto

non-

concurrent

multip

lebaselin

edesign

(i.e.,lim

itedcontrolfor

history)

Thorp

etal.(1995)

Children:

N=3(3

males);aged

5;4–

9;9years;with

autism

Child

behaviors:

Pivotalb

ehaviors:initiatio

ns(observation)

Interventio

n:16-h

socio-dram

aticplay

training

during

which

thechild

was

encouraged

todevelopaplay

Children:

mixed


for2child

ren.

Language:no

change

onPP

VT-R


(i.e.,multip

lebaselin

eprobedesign

across

child

ren;

startin

gpointsof


Tab

le1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

Other

behaviors:language

(PPT

V-R,

EOWPV

T-R),play

skills(play

historyinterviewandobservationof

role-playing,m

ake-believe

transformations

andpersistence);

positiv

eandnegativ

eresponses

(observation);v

erbal


nof

spontaneousspeech,other

speech

andinappropriatespeech)

them

e,adopta

roleappropriateto

thisthem

eandtoassign

aroletothe

experimenter,consistin

gof

PRT

techniques

andmodelingof

appropriatesocio-dram

aticplay

PRTtechniques:child

'schoice;clear

opportunities

(i.e.,turn

taking);task


maintenance

andacquisition

tasks;


reinforcem

ento

fattempts

Implem

enter:

experimenter(PRT),

parent

(generalization)

andincrease

onEOWPV

T-Rforall

3child

ren

Playskills:increase

inrole-play,make-

believe

transformations

and

persistenceforall3

child

ren;

increase

inim

aginaryplay

athome

forall3

child

renandin

play/social

behavior

with

siblings

for2

child

ren

Responses:increase

inpositiv

eresponsesanddecrease

innegativ

eresponsesforall3

child

ren

Verbal

communication:

increase

inspontaneousspeech

forall3

child

ren;

decrease

ininappropriate

speech

for2child

ren;

otherspeech

was

NR

FU:Y

es.G

en:Y

es(acrosstoys

and

settings).S

V:N

R

interventio

nwerestaggered);

adequateIO

AandTFwas

NR,

despite

multicomponent

interventio

n;operationald

efinitions

ofdependentv

ariables;sufficient

details

oninterventio

nprocedures;

controlfor


VismaraandLy

ons

(2007)

Children:

N=3(3

males);aged

26–

38months;with

autism

Child

behaviors:

Pivotalb

ehaviors:N

ROther

behaviors:numberof

joint

attentioninitiations;contin

gencies

tojointattentioninitiations

(observation);affectd

uringchild

-caregiverinteraction(6-point

Likert

ratin

gscale)

Interventio

n:221/2-hsessions

aweek

for12

weeks;eachsession:

1h

modelingby

principalinvestig

ator

and11/2hguided

practicefor

parentsplus

feedback

PerseverativeInterest(PI)condition:4

21/2-hsessions,using

PIstim

uli

(i.e.,letterandnumbertoys)

Non-perseverativ

eInterest(N

P)condition:4

21/2-hsessions

for2

childrenand821/2-hsessions

for1

child,using

NPstim

uli

Alternatingcondition:1

621/2-h

sessions

for2

childrenand12

21/2-

hsessions

for1child

;eachsession

halfPI

andhalfNPin

rotatedorder

PRTtechniques:child

'schoice;task


maintenance

andacquisition

tasks;


reinforcem

ent;natural

reinforcem

ent;reinforcem

ento

fattempts

Implem

enter:

principalinvestig

ator

(parenttrainingandPR

T);parents

(PRT)

Children:

mixed

Num

berof

jointa

ttentioninitiations:

immediateincreaseforall3children

during

PIcondition;low

levelforall

3child

renduring

NPcondition;

increase

forboth

PIandNPstim

uli

forall3

child

renduring

alternating

condition,suggestinggeneralization

toNPstim

uli

Contin

genciesto

jointa

ttention:

gains

injointattentions

initiations

werea

collateralresulto

fPIstim

uliand

PRTandnota

resultof

contingent

prom

ptingor

reinforcem

ent

Affectduring

child

-caregiver

interaction:

increase

topositiv

eaffectforall3

child

renduring

PI

condition;n

egative(N

=2)

orneutral(N=1)

affectduring

NP

condition;p

ositive

affectforPI

stim

ulifor

all3

child

renandforNP

stim

ulifor

1child

during

alternating

condition,2

child

renincreasedto

positiv

eaffectduring

final2

–3sessions

FU:N

R.G

en:Y

es(toNPstim

uli).S

V:

NR


esign

(i.e.,baselin

e,follo

wed

bycounterbalancedphasereversalof

PIandNPconditions,however,no

return

tobaselin

econdition,

alternatingtreatm

entconditio

nin

finalp

hase);adequateIO

AandTF;


dependent


details

oninterventio

nprocedures;lim

ited

controlfor


dueto

quasi-experimentald

esign

Voosetal.(2013)

Children:

N=2(1

male,1female);

aged

5;5and5;1years;1with

autistic

disorder

and1with

PDD-

NOS

Child

behavior:

Pivotalb

ehaviors:N

ROther

behaviors:ASD

symptom

s(A

DOS);adaptiveskills(Vineland-

II);pragmaticskills(pragm

atic

Interventio

n:individualPRTsessions

with

child

andPR

Tparent

training

for8–10

hperweekduring

4months

PRTtechniques:NR

Children:

mixed

ASD

symptom

s:decrease

for1child

Adaptiveskills:

increase

onsome,but

notallsubdomains

forboth

child

ren

Suggestiv

e:pre-experimentald

esign

(i.e.,case

series

design);IO

Aand

TFwereNR;d

ependent

variables

notfully

operationally

defined;

insufficient

details

onintervention


In six studies data on staff member characteristics werereported. A total number of 45 staff members participated inthese studies. Of the 45 staff members, 1 (2.2%) was male and44 (97.8 %) were female. Staff members' years' of experienceworking in this field was reported in five studies and rangedfrom 3 months to 17 years. Staff members worked in aneducational (n =40; 88.9 %) or clinical (n =5; 11.1 %) setting.

Four studies reported data on peer characteristics. A totalnumber of 21 peers participated in these studies. Of the 21peers, 8 (38.1 %) were male, 5 (23.8 %) were female and thesex of 8 peers (38.1 %) was not reported. Peers were mostoften typically developing children, but five peers were diag-nosed with a specific learning disability, mental retardation ora developmental disability (Kuhn et al. 2008).

Dependent Variables

In 35 studies, child behaviors were targeted. Of these 35studies, 18 studies targeted a pivotal skill. Seventeen studiestargeted self-initiations (e.g., Koegel et al. 2012) and one studytargeted motivation (Koegel et al. 2010b). Across studies, avariety of untargeted skills or collateral changes were mea-sured. Thirty-one studies evaluated the effects of PRT on com-munication and language skills, such as functional verbal ut-terances (e.g., Minjarez et al. 2011), receptive and expressivelanguage (e.g., Coolican et al. 2010), responding to others (e.g.,Kuhn et al. 2008) and maintaining interactions (e.g., Pierce andSchreibman 1997a). Six studies evaluated collateral changes inplay skills as a result of PRT (Gillet and LeBlanc 2007; Lydonet al. 2011; Randolph et al. 2011; Stahmer 1995; Pierce andSchreibman 1997b; Thorp et al. 1995). For example, Lydonet al. measured the duration of interaction with toys and thenumber of play actions and verbalizations. Five studies evalu-ated the effects of PRT on adaptive functioning (e.g., Baker-Ericzén et al. 2007; Koegel et al. 1999b; Randolph et al. 2011;Smith et al. 2010; Voos et al. 2013), using the VinelandAdaptive Behavior Scales (Sparrow et al. 1984, 2005). Fivestudies evaluated collateral changes in maladaptive behavior asa result of PRT (Coolican et al. 2010; Gianoumis et al. 2012;Koegel et al. 1992, 2010b; Smith et al. 2010). For example,Gianoumis et al. measured the percentage of trials with mal-adaptive behaviors (e.g., screaming, crying, and hitting) andSmith et al. used the Child Behavior Checklist (Achenbach andRescorla 2000) to measure problem behavior. Four studiesevaluated the effects of PRT on autism symptoms (Bernard-Opitz et al. 2004; Smith et al. 2010; Steiner et al. 2013; Vooset al. 2013). For example, Smith et al. used the SocialResponsiveness Scale (Constantino and Gruber 2005) to iden-tify changes in autism symptoms. Three studies evaluatedcollateral changes in affect as a result of PRTusing rating scales(Koegel et al. 2012; Robinson 2011; Vismara and Lyons 2007).Two studies evaluated collateral changes in cognitive function-ing as result of PRT (Smith et al. 2010; Steiner et al. 2013),T

able1

(contin

ued)

Citatio


Dependent

variables

Interventio

nprocedures

Interventio

noutcom

esCertainty

ofevidence

profile

oftheCELF-4);

communicationbehaviors

(observatio

n);faceprocessing

(eye

tracking);neuralresponse

(fMRI)

Implem

enter:

clinician(parenttraining

andPRT)

Pragm

aticskills:

increase

forboth

child

ren

Com

municationbehaviors:

increase

onsome,butnotallcom

munication

behaviorsforboth

child

ren

Faceprocessing:im

provem

ent

towards

moretypicalface

processing

pattern

for1child

Neuralresponse:

increasedactiv

ation

in3–4brainregionsutilizedby

typically

developing

child

renfor

both

child

ren

FU:N

R.G

en:N

R;S

V:N

R

procedures;n

ocontrolfor


dueto

pre-

experimentald

esign

Ntotalnum

berof

participantsin

study,PDD-NOSpervasivedevelopm

entaldisordernoto

therwisespecified,NRnotreported,FU

follo

w-up,Gen

generalization,SV

socialvalid

ity,IOAinter-observer

agreem

ent,TFtreatm

entfidelity


using the Mullen Scales of Early Learning or the Merrill–Palmer-Revised Scales of Development (Mullen 1995; Roidand Sampers 2004). Two studies evaluated the effects of PRTon academic functioning (Koegel et al. 2010b, 1999b). Forexample, Koegel et al. (2010b) measured the children's pro-ductivity (i.e., rate of assignment units completed) and latency(i.e., number of minutes it took children to begin a task) duringwriting or math activities. Finally, one study evaluated theeffects of PRT on face processing and neural response (Vooset al. 2013) and another study evaluated the effects of PRT onattendance and compliance (Bernard-Opitz et al. 2004).

In 13 studies caregiver behaviors were targeted. Of thesestudies, nine studies evaluated the effects of caregiver trainingon caregivers' fidelity of implementation of PRT or NLP(Coolican et al. 2010; Gillet and LeBlanc 2007; Koegel et al.2002; Minjarez et al. 2013; Nefdt et al. 2010; Randolph et al.2011; Stahmer and Gist 2001; Steiner et al. 2013; Symon2005). Additionally, two studies evaluated collateral changesin parental stress as a result of PRT (Minjarez et al. 2013; Smithet al. 2010), using the Parenting Stress Index/Short Form(Abidin 1995). Two studies evaluated the effects of PRT onparental affect using rating scales (Koegel et al. 2002;Schreibman et al. 1991). Two studies evaluated collateralchanges in self-efficacy as result of PRT (Coolican et al.2010; Nefdt et al. 2010) and one studymeasured empowerment(Minjarez et al. 2013). Finally, one study evaluated the effectsof PRT on interactional patterns (Koegel et al. 1996) andanother study evaluated the effects of PRT on parentverbalizations (Laski et al. 1988).

Staff behaviors were targeted in seven studies. Of thesestudies, six studies evaluated the effects of staff training onstaff members' fidelity of implementation of PRT or NLP(Gianoumis et al. 2012; Huskens et al. 2012; Robinson 2011;Seiverling et al. 2010; Suhrheinrich 2011; Suhrheinrich et al.2007). Additionally, Gianoumis et al. (2012) evaluated theeffect of staff training on staff members' ability to conduct astimulus preference assessment. Robinson (2011) measured theduration of staff training and staff members' level of involve-ment and Koegel et al. (1992) evaluated the instruction andreinforcement provided by a clinician. Kuhn et al. (2008)measured effects of peer training on the number of interactionopportunities created by peers.

Intervention Procedures

PRTwas implemented in 25 studies and NLP in seven studies.In two studies, other interventions were implemented; howev-er, these interventions included PRT techniques. Specifically,Koegel et al. (2012) used facilitated social play training andThorp et al. (1995) implemented socio-dramatic play training.Five studies did not indicate whether PRT or NLP was imple-mented, but these studies explicitly stated that the specific

motivational techniques inherent to PRT were implemented(Koegel et al. 1998a, 2003a, 2010a, b, 1998b).

In 26 studies caregivers, staff members or peers were taughtto implement PRT or NLP. The total duration of their trainingranged from 66 min to 60 h. In six studies training continueduntil a mastery criterion was met (e.g., Gillet and LeBlanc2007). Two studies did not report the duration of training(Schreibman et al. 1991; Suhrheinrich et al. 2007). Caregivers,staff members, or peers were taught individually in 15 studiesand in a group in seven studies. Three studies combined groupand individual training (e.g., Huskens et al. 2012). In one study,the training format was not reported (Suhrheinrich et al. 2007).The training was implemented by a clinician (i.e., psychologistor therapist) in 16 studies and by an experimenter in six studies.Nedft et al. (2010) used a self-directed learning program to teachparents to implement PRT consisting of an interactive DVD.Three studies did not report who implemented training.Caregiver, staff, or peer training involved a variety of instruc-tional strategies. In 14 studies, a manual was incorporated (e.g.,Minjarez et al. 2011) and 15 studies reported to use didacticinstruction (e.g., Coolican et al. 2010). Eight studies incorporat-ed video modeling as an instructional strategy and 16 studiesincorporated in vivo modeling. Nineteen studies reported to usesome form of practice, such as assignments (e.g., Minjarez et al.2011), role-play (e.g., Pierce and Schreibman 1995) and guidedpractice (e.g., Randolph et al. 2011). Video feedbackwas used infour studies and in vivo feedback in 18 studies. Several studiesincorporated additional instructional strategies, such as smallgroup discussions (Smith et al. 2010), assessments (e.g.,Seiverling et al. 2010), picture prompts (e.g., Harper et al.2008) and reinforcement (Kuhn et al. 2008). Stahmer and Gist(2001) investigated the addition of a parent information supportgroup to PRT parent training.

In 23 studies, the PRTor NLP intervention was implement-ed by caregivers, staff members or peers. In ten studies, aclinician implemented the intervention and in two studies anexperimenter. In three studies, the intervention was imple-mented by a parent as well as a clinician. One study did notreport the implementer (Koegel et al. 2010b). Across studies avariety of PRT techniques were used. In 35 studies followingthe child's choice was incorporated. Nine studies incorporatedgetting the child's attention. In 29 studies, providing clearopportunities for responding was used. Twenty-four studiesused task variation and interspersal of maintenance and acqui-sition tasks. Natural reinforcement was incorporated in 33studies. Of these studies, 18 studies also incorporated contin-gent reinforcement and 15 studies did not report whethercontingent reinforcement was used. In 29 studies, reinforce-ment of attempts at target behaviors was used. Two studiesincorporated all seven PRT techniques (Minjarez et al. 2011;Suhrheinrich 2011). Several studies incorporated additionalintervention strategies, such as multiple cues (e.g., Pierce andSchreibman 1997b), modeling of target response (Stahmer


1995), prompting (e.g., Koegel et al. 2012), prompt fading(e.g., Koegel et al. 2010a), time delay (Koegel et al. 1998a),and narrative play (e.g., Harper et al. 2008).

Intervention Outcomes

Of the 35 studies targeting child behaviors, 15 studies(42.9 %) reported positive outcomes and 20 studies (57.1 %)reported mixed outcomes. Of the 13 studies targeting caregiv-er behaviors, 7 studies (53.8 %) reported positive outcomesand 5 studies (38.5 %) reported mixed outcomes. One studydid not report intervention outcomes concerning caregivers(Smith et al. 2010). Of the seven studies targeting staff behav-ior, four studies (57.1 %) reported positive outcomes and threestudies (42.9 %) reported mixed outcomes. The studytargeting peer behaviors reported positive outcomes. Noneof the included studies reported negative outcomes.

Thirteen of the 39 studies (33.3 %) included data onfollow-up. The length of the period between interventionand follow-up ranged from 2 weeks to 11 months.Generalization of intervention outcomes was measured in 22studies (56.4 %). Generalization was measured across stimuliin eight studies (e.g., Thorp et al. 1995), across persons ineight studies (e.g., Robinson 2011), across conditions in threestudies (e.g., Koegel et al. 2012) and across settings in 13studies (e.g., Symon 2005). In ten studies (25.6 %) measuresof social validity were conducted. All studies used a question-naire to measure social validity (e.g., Huskens et al. 2012).

Certainty of Evidence

Six studies (15.4 %) were classified as providing a conclusivelevel of certainty (Gianoumis et al. 2012; Huskens et al. 2012;Laski et al. 1988; Randolph et al. 2011; Robinson 2011;Seiverling et al. 2010). All six studies reported mixed inter-vention outcomes for children. These studies targeted self-initiations (n =3), communication and language skills (n =5),play skills (n =1), adaptive functioning (n =1), maladaptivebehavior (n =1), and affect (n =1). Adaptive functioning didnot improve and only one child improved on affect, butimprovements on the other targeted skills were reported forthe majority of the children across studies. The two studiestargeting caregiver behaviors also reported mixed interventionoutcomes. These studies targeted fidelity of implementationand parent verbalizations. Of the four studies targeting staffbehavior, three studies reported positive intervention out-comes and one study reported mixed outcomes with regardto fidelity of implementation. One study reported positiveintervention outcomes with regard to level of involvement.

Eleven studies (28.2 %) were rated as providing a prepon-derant level of certainty (Coolican et al. 2010; Gillet andLeBlanc 2007; Koegel et al. 1998a, b, 2010a, 2012, 2002;Nefdt et al. 2010; Pierce and Schreibman 1997a; Symon 2005;

Thorp et al. 1995). Of these studies, seven studies wereclassified as “preponderant”, because they provided limitedcontrol for alternative explanations of intervention outcomes.Specifically, five of these studies did not control for historydue to use of a non-concurrent multiple baseline design (Carr2005). One study did not control for interaction effects due tothe small number of baseline probes between treatment con-ditions (Koegel et al. 1998b) and one study did not control forseveral threats to internal validity due to unstable baselines(Pierce and Schreibman 1997a). Four studies were classifiedas “preponderant”, because treatment fidelity was not reportedor operational definitions for some dependent variables werenot provided, although the study's design controlled for alter-native explanations (e.g., Nefdt et al. 2010). Of the 11 studiesclassified as “preponderant”, six studies reported positiveintervention outcomes for children and five studies reportedmixed intervention outcomes for children. The studiesreporting positive outcomes targeted self-initiations (n =3),communication and language skills (n =6), and affect (n =1).The studies reporting mixed outcomes targeted self-initiations(n =4), communication and language skills (n =5), play skills(n =3), and maladaptive behavior (n =1). Of the five studiesclassified at this level targeting caregiver behaviors, fourstudies reported positive intervention outcomes. These studiestargeted fidelity of implementation (n =4), self-efficacy (n =1), and parental affect (n =1). One study reported mixedintervention outcomes and targeted fidelity of implementationand self-efficacy.

Twenty-two studies (56.4 %) were classified as providing asuggestive level of certainty. Of these studies, 19 studies wereclassified as “suggestive”, because they used a pre-experimental (n =9) or quasi-experimental (n =10) design.For example, Harper et al. (2008) used a multiple baselinedesign across only two participants, but a multiple baselinedesign should include at least three participants to demonstrateexperimental control (Horner et al. 2005). Therefore, the designwas rated as “quasi-experimental” and the study was classifiedas “suggestive”. Three studies used an experimental design, butwere nevertheless classified as “suggestive”, because somedependent variables were not operationally defined, details onintervention procedures were insufficient to enable replication,treatment fidelity was not reported and/or inter-observer agree-ment was not adequate (Koegel et al. 2010b; Stahmer 1995;Stahmer and Gist 2001). Of the 22 studies classified as “sug-gestive” that targeted child behaviors, nine studies reportedpositive intervention outcomes and nine studies reported mixedoutcomes. Three of the five studies that were classified as“suggestive” and targeted caregiver behaviors reported positiveintervention outcomes and two studies reported mixed out-comes. Of the three studies classified as “suggestive” thattargeted staff behaviors, one study reported positive interven-tions outcomes and two studies reported mixed outcomes. Thestudy targeting peer behaviors reported mixed outcomes.


Discussion

This systematic review aimed to evaluate the evidence base ofPRT for improving the skills of children with ASD, caregiversand staff members, to identify limitations of the existingevidence-based, and to suggest directions for future research.A systematic search identified 43 studies, indicating that theeffectiveness of PRT has been extensively investigated. Themajority of these studies were classified as providing a sug-gestive level of evidence. Below, the results of this systematicreview are discussed for children with ASD and caregiversand staff members.

Children with ASD

The results of this systematic review indicate that the majorityof children with ASD that were included in the reviewedstudies were taught to self-initiate through PRT. However,there is yet insufficient evidence to conclude that PRT resultsin improvements in non-targeted pivotal skills, because moti-vation was evaluated in only one study that provided a sug-gestive level of evidence (i.e., Koegel et al. 2010b) andresponding to multiple cues and self-management were notevaluated in any of the included studies. Furthermore, theresults of this systematic review suggest that PRT results incollateral improvements in language and communicationskills (e.g., functional verbal utterances, language, andmaintaining interactions) and play skills for the majority ofchildren with ASD. Moreover, for some children, PRT alsoresulted in changes in affect and reductions of maladaptivebehavior. However, there is insufficient evidence to concludethat adaptive functioning, autism symptoms, cognitive func-tioning, and academic functioning improve as a result of PRT,because none of the studies that were classified as provingconclusive or preponderant evidence reported improvementsin these skills.

The results of this systematic review provide insight intowhat extent research supports the theoretical model of PRT (i.e.,targeting pivotal skills using PRT techniques results in wide-spread improvements in other aspects of functioning). Of thefour skills that are considered to be pivotal, only self-initiationshave been studied in detail. This systematic review indicates thatfor a number of children with ASD, increases in self-initiationsas a result of PRT are accompanied by collateral improvements(i.e., increases in communication and language skills, play skillsand affect and reductions in maladaptive behavior). Thus, theresearch reviewed here does provide some support for thetheoretical model of PRT. However, as motivation, respondingto multiple cues, and self-management were rarely measured inthe studies included in this review, it is not clear whether theseskills improve as a result of PRT, whether improvements inthese skills are accompanied by collateral changes, and thuswhether these skills could be considered pivotal.

It should be noted that motivation itself is difficult to defineoperationally, which could explain why motivation was rarelymeasured. Koegel et al. (2001) defined motivation in terms ofthe effects of improved motivation (i.e., increased responsive-ness to social and environmental stimuli), such as increases inthe number of responses to teaching stimuli, decreases in re-sponse latency, and changes in affect. However, none of thestudies that evaluated these behaviors considered these behav-iors as an effect of improved motivation. There is no clearexplanation for the lack of studies that evaluated responding tomultiple cues. However, some studies implemented “usingmultiple cues” as a PRT technique (e.g., Pierce andSchreibman 1997b), suggesting that this pivotal skill wastargeted, but seemingly not measured. The lack of studies thatevaluated self-management can be explained by the fact that thestudies identified during the database search that involved self-management did not refer to their intervention as PRT or NLPnor did they implement the PRT techniques (e.g., Koegel andFrea 1993; Loftin et al. 2008). It could be considered a limitationof this systematic review that the inclusion criteria did notcomprise studies regarding self-management. However, self-management is also considered a separate intervention thatincorporates specific techniques (e.g., NAC 2009), suggestingthat self-management is not a distinguishing component of PRT.

Although the skills of many children improved as a resultof PRT, it should be noted that a considerable number ofchildren did not improve significantly, as indicated by thelarge number of studies that reported mixed results. Thisvariability in outcomes is not unique to PRT and is consistentwith results of evaluations of behavioral interventions moregenerally (Peters-Scheffer et al. 2011; Reichow 2012).Research on predictors of outcomes from behavioral interven-tions suggests that outcomes are related to children's age (e.g.,Granpeesheh et al. 2009; Perry et al. 2013), language profi-ciency (e.g., Sallows and Graupner 2005), pre-treatment IQ(Perry et al. 2013), severity of autism symptoms (e.g., Ben-Itzchak and Zachor 2011), parental stress (Osborne et al.2008; Strauss et al. 2012), and parental treatment fidelity(Strauss et al. 2012). Research concerning predictors of out-comes of PRT is limited, but a study by Sherer andSchreibman (2005) suggested that response to PRT was pre-dicted by toy contact, approach, and avoidant behaviors, andverbal and nonverbal self-stimulatory behaviors. However, inorder to estimate whether a child is likely to benefit from PRT,additional research is warranted to confirm the influence ofthese potential predictor variables and to identify other pre-dictors of PRT outcomes.

The results of this systematic review further demonstrated alarge variability in the PRT techniques that were implementedacross studies and revealed that only two studies incorporatedall PRT techniques (i.e., Minjarez et al. 2011; Suhrheinrich2011). In particular, “gaining the child's attention and usingcontingent reinforcement” were often not incorporated or not


specifically reported. This could be explained by the fact thatresearchers do often consider these technique as techniques thatare automatically implemented when a clear opportunity torespond or natural reinforcement are provided (e.g., Koegelet al. 2002; Symon 2005). However, when assuming that thestudies that incorporated these techniques also incorporated“gaining the child's attention” respectively “using contingentreinforcement”, the number of studies that incorporated all PRTtechniques only slightly increases to five studies, suggestingthat there is notable variability and/or flexibility regarding thecombination of intervention components that constitute PRT.

Overall, with respect to the effect of PRT on child's behav-ior, we found evidence that supports the effectiveness of PRTand the theoretical model of PRT. However, future researchshould strengthen and extend the existing evidence base andprovide additional support to the theoretical model of PRT.There are several specific directions for future research. First,studies should use true experimental designs to improve thecertainty of evidence. Specifically, researchers should ensurethat single-case designs replicate intervention effects across atleast three participants and that group designs include a con-trol group and randomly assign participants to groups todemonstrate experimental control (Horner et al. 2005; Black1999). Second, pivotal skills should be defined operationallyand measured systematically across studies. Third, futureresearch should rigorously evaluate collateral changes in skillsthat are currently not investigated or investigated withoutusing true experimental designs. Evidence for changes inthese skills would extend the evidence base of PRT andsupport the claim that PRT results in widespread improve-ments in children (Koegel and Koegel 2006). Fourth, futureresearch should investigate which characteristics predict theeffectiveness of PRT. Finally and possibly most important,future research should seek to determine the components thatdefine PRTand distinguish PRT from other interventions (e.g.,EMT), because of the variability in the combination of PRTtechniques across studies and the overlap between PRT andother interventions.

Caregivers and Staff Members

The results of this systematic review suggest that caregiversand staff members can be taught to implement PRT techniqueseffectively using an individualized training approach thatcombines several well-used instructional strategies (e.g.,modeling, guided practice, reinforcement/feedback). Thisfinding is consistent with results of previous reviews oncaregiver and staff training (e.g., Lang et al. 2009; Pattersonet al. 2012; Rispoli et al. 2011). However, the results of thissystematic review also indicate a number of gaps in the currentexisting evidence base. First, the duration of training varied

greatly across studies, indicating that it is unclear how muchtraining caregivers and staff members need to correctly im-plement PRT techniques. Second, as studies incorporated acombination of instructional strategies or demonstrated mixedresults with regard to the effectiveness of a single strategy(Huskens et al. 2012), it is not clear if certain instructionalstrategies are more effective than others to teach PRT tech-niques. Finally, it is not clear whether group training is effec-tive, because the studies that evaluated the effectiveness ofgroup training separately provided a suggestive level of evi-dence (Minjarez et al. 2013; Stahmer and Gist 2001). Toincrease the effectiveness and cost efficiency of caregiverand staff training in PRT, future research should seek todetermine which training format, instructional strategies, andduration of training are most effective and efficient to teachcaregivers and staff members to correctly implement PRTtechniques.

Although most caregivers and staff members were able tocorrectly implement PRT techniques, some caregivers andstaff members within some studies did not meet the criterionfor fidelity of PRT implementation or did not maintain the useof PRT techniques (Coolican et al. 2010; Huskens et al. 2012;Randolph et al. 2011). These mixed results cannot beexplained by training characteristics, because these character-istics did not vary within studies. However, research showsthat fidelity of intervention implementation can be affected bycertain staff characteristics, such as personality, attitude to-wards an intervention and individuals with disabilities, andperceived child–staff member relationship (Durlak and DuPre2008; Peters-Scheffer et al. 2013), but it is not clear whetherthese staff characteristics also predict the fidelity of PRTimplementation. Currently, research regarding the influenceof parent characteristics on treatment fidelity is limited(Randolph et al. 2011). Research demonstrates that parent'slevel of education, family income or socioeconomic status,and parental stress affect children's intervention outcomes(e.g., Osborne et al. 2008; Reyno and McGrath 2006;Strauss et al. 2012), but it is unclear whether these caregivercharacteristics also affect caregivers' fidelity of implementa-tion. Therefore, future research should investigate whethercertain caregiver and staff member characteristics predict thefidelity of PRT implementation.

The results of this systematic review indicate that there islimited evidence for collateral changes in caregivers' affect,verbalizations and self-efficacy, and staff members' level ofinvolvement as a result of PRT. There is yet insufficientevidence to conclude that PRT results in collateral changesin caregivers' stress, empowerment, and interactional patterns.Because the current evidence base is limited, additional re-search regarding collateral changes in caregiver and staffbehavior is warranted.


Conclusion

This systematic review found evidence to support the use ofPRT for increasing self-initiations. Collateral improvementswere found in communication and language, play skills, af-fect, and reductions in maladaptive behavior for a number ofchildren. The overall results of this review provide somesupport for the claimed effectiveness of PRT and for thetheoretical model of PRT. However, the majority of studies(56.4 %) provided only suggestive evidence due to methodo-logical limitations. Also, while this systematic review sug-gests that caregivers and staff members were able to imple-ment PRT techniques, evidence for collateral improvements incaregivers' and staff members' behaviors remains sparse.Future research that uses true experimental designs is neces-sary to strengthen and extend the evidence base for PRT, todetermine child, caregiver, and staff characteristics that predictthe effectiveness of PRT and the fidelity of implementation ofPRT and to determine the components that define PRT anddistinguish PRT from other interventions.

Conflict of interest The authors declare that they have no conflict ofinterest.

References

*Study included in the review

Abidin, R. (1995). The Parenting Stress Index (3rd ed.). Lutz: Psycho-logical Assessment Resources.

Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBApreschool forms and profiles . Burlington: University of Vermont.

Allen, K. D., & Cowan, R. J. (2008). Naturalistic teaching procedures. InJ. K. Luiselli, D. C. Russon, W. P. Christian, & S. M. Wilcynski(Eds.), Effective practices for children with autism: educational andbehavioural support interventions that work (pp. 213–240). NewYork: Oxford University Press.

American Psychiatric Association. (2013). Diagnostic and statisticalmanual of mental disorders (5th ed). Washington, DC: Author.

Baird, G., Simonoff, E., Pickles, A., Chandler, S., Loucas, T., Meldrum,D., & Charman, T. (2006). Prevalence of disorders of the autismspectrum in a population cohort of children in South Thames: theSpecial Needs and Autism Project (SNAP). Lancet, 368 , 210–215.

*Baker-Ericzén, M. J., Stahmer, A. C., & Burns, A. (2007). Childdemographics associated with outcomes in a community-basedpivotal response training program. Journal of Positive Behaviorinterventions, 9 , 52–60.

Baron-Cohen, S., Scot, F. J., Allison, C., Williams, J., Bolton, P., Mat-thews, F. E., & Brayne, C. (2009). Prevalence of autism-spectrumconditions: UK school-based population study. The British Journalof Psychiatry, 194 , 500–509.

Ben-Itzchak, E., & Zachor, D. A. (2011). Who benefits from earlyintervention in autism spectrum disorders? Research in AutismSpectrum Disorders, 5 , 345–350.

*Bernard-Opitz, V., Ing, S., & Kong, T. Y. (2004). Comparison ofbehavioral and natural play interventions for Young children withautism. Autism, 8 , 319–332.

Black, T. R. (1999). Doing quantitative research in the social sciences .London: Sage.

*Bryson, S. E., Koegel, L. K., Koegel, R. L., Openden, D., Smith, I. M.,& Nefdt, N. (2007). Large scale dissemination and communityimplementation of pivotal response treatment: program descriptionand preliminary data. Research & Practice for Persons with SevereDisabilities, 32, 142–153.

Carr, J. E. (2005). Recommendations for reporting multiple-baseline designs across participants. Behavioral Interventions,20 , 219–224.

Constantino, J. N., & Gruber, C. P. (2005). Social responsiveness scale(SRS). Los Angeles: Western Psychological Services.

*Coolican, J., Smith, I. M., & Bryson, S. E. (2010). Brief parent trainingin pivotal response treatment for preschoolers with autism. Journalof Child Psychology and Psychiatry, 51, 1321–1330.

Delprato, D. J. (2001). Comparisons of discrete-trial and normalizedbehavioral language intervention for young children with autism.Journal of Autism and Developmental Disorders, 31, 315–325.

Duker, P., Didden, R., & Sigafoos, J. (2004). One-to-one training: in-structional procedures for learners with developmental disabilities.Austin, TX: Pro-Ed.

Dunlap, G., & Koegel, R. L. (1980). Motivating autistic children throughstimulus variation. Journal of Applied Behavior Analysis, 13, 619–627.

Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: a review ofresearch on the influence of implementation on program outcomesand the factors affecting implementation. American Journal ofCommunity Psychology, 41, 327–350.

Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross,

S. (2009). Meta-analysis of early intensive behavioral intervention

for children with autism. Journal of Clinical Child & Adolescent

Psychology, 38 , 439–450.Fombonne, E. (2009). Epidemiology of pervasive developmental disor-

ders. Pediatric Research, 65 , 591–598.*Gianoumis, S., Seiverling, L., & Sturmey, P. (2012). The effects of

behavioral skills training on correct teacher implementation of nat-ural language paradigm teaching skills and child behavior. Behav-ioral Interventions, 27, 57–74.

*Gillet, J. N., & LeBlanc, L. A. (2007). Parent-implemented naturallanguage paradigm to increase language and play in children withautism. Research in Autism Spectrum Disorders, 1 , 247–255.

Goin-Kochel, R. P., Meyers, B. J., & Mackintosh, V. H. (2007). Parentalreports on the use of treatments and therapies for children withautism spectrum disorders. Research in Autism Spectrum Disorders,1 , 195–209.

Granpeesheh, D., Dixon, D. R., Tarbox, J., Kaplan, A. M., &Wilke, A. E.(2009). The effects of age and treatment intensity on behavioralintervention outcomes for children with autism spectrum disorders.Research in Autism Spectrum Disorders, 3 , 1014–1022.

Green, V. A., Keenan, A. P., Itchon, J., Choi, A., O’Reilly, M., &Sigafoos, J. (2006). Internet survey of treatments used by parentsof childrenwith autism.Research inDevelopmental Disabilities, 27 ,70–84.

Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-implemented Enhanced Milieu Teaching on the social communica-tion of children with autism. Topics in Early Childhood Education,22, 39–54.

Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In R.McCauley & M. Fey (Eds.), Treatment of language disorders inchildren (pp. 203–236). Baltimore: Paul Brookes.


*Harper, C. B., Symon, J. B. G., & Frea, W. D. (2008). Recess is time-in:using peers to improve social skills of children with autism. Journalof Autism and Developmental Disorders, 38, 815–826.

Hess, K. L., Morrier, M. J., Heflin, L. J., & Ivey, M. L. (2008). Autismtreatment survey: services received by children with autism spec-trum disorders in public school classrooms. Journal of Autism andDevelopmental Disorders, 38, 961–971.

Horner, R. H., Carr, E. G., Halle, J., McGee, G., Odom, S., &Wolery, M.(2005). The use of single-subject research to identify evidence-based practice in special education. Exceptional Children, 71 ,165–179.

Howlin, P. (2005). The effectiveness of interventions for children withautism. In W. W. Fleischacker & D. J. Brooks (Eds.),Neurodevelopmental disorders (pp. 101–119). Springer: Wien.

*Huskens, B., Reijers, H., & Didden, R. (2012). Staff training effective inincreasing learning opportunities for school-aged children with au-tism spectrum disorders. Developmental Neurorehabilitation, 15 ,435–447.

Koegel, R. L., & Frea, W. D. (1993). Treatment of social behavior inautism trough the modification of pivotal skills. Journal of AppliedBehavior Analysis, 26, 369–377.

Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments forautism: communication, social, & academic development . Balti-more: Paul H. Brookes.

Koegel, R. L., Dyer, K., & Bell, L. K. (1987a). The influence of child-preferred activities on autistic children's social behavior. Journal ofApplied Behavior Analysis, 20, 243–252.

*Koegel, R. L., O’Dell, M. C., & Koegel, L. K. (1987b). A naturallanguage teaching paradigm for nonverbal autistic children. Journalof Autism and Developmental Disorders, 17, 187–200.

Koegel, R. L., O’Dell, M., & Dunlap, G. (1988). Producing speech use innonverbal autistic children by reinforcing attempts. Journal of Au-tism and Developmental Disorders, 18 , 525–538.

*Koegel, R. L., Koegel, L. K., & Surratt, A. (1992). Language interven-tion and disruptive behavior in preschool children with autism.Journal of Autism and Developmental Disorders, 22, 141–153.

*Koegel, R. L., Bimbela, A., & Schreibman, L. (1996). Collateral effectsof parent training on family interactions. Journal of Autism andDevelopmental Disorders, 26, 347–359.

*Koegel, L. K., Camarata, S. M., Valdez-Menchaca, M., & Koegel, R. L.(1998a). Setting generalization of question-asking by children withautism. American Journal on Mental Retardation, 102 , 346–357.

*Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., & Smith, A. E.(1998b). Increasing speech intelligibility in children with autism.Journal of Autism and Developmental Disorders, 28, 241–251.

Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999a).Pivotal response intervention I: overview of approach. Journal ofthe Association for Persons with Severe Handicaps, 24, 174–185.

*Koegel, L. K., Koegel, R. L., Shoshan, Y., & McNerney, E. K. (1999b).Pivotal response intervention II: preliminary long-term outcomedata. Journal of the Association for Persons with Severe Handicaps,24, 186–198.

Koegel, R. L., Koegel, L. K., & Carter, C. M. (1999c). Pivotal teachinginteractions for children with autism. School Psychology Review,28, 576–594.

Koegel, R. L., Koegel, L. K., & McNerney, E. K. (2001). Pivotal areas inintervention for autism. Journal of Clinical Child & AdolescentPsychology, 30 , 19–32.

*Koegel, R. L., Symon, J. B., & Koegel, L. K. (2002). Parent educationfor families of children with autism living in geographically distantareas. Journal of Positive Behavior Interventions, 4 , 88–103.

*Koegel, L. K., Carter, C.M., &Koegel, R. L. (2003a). Teaching childrenwith autism self-initiations as a pivotal response. Topics in Lan-guage Disorders, 23, 134–145.

Koegel, R. L., Koegel, L. K., & Brookman, L. I. (2003b). Empiricallysupported pivotal response interventions for children with autism. In

A. E. Kazdin & Yale University School of Medicine, & Child StudyCenter (Eds.), Evidence-based psychotherapies for children andadolescents (pp. 341–357). New York: Guilford Press.

Koegel, R. L., Openden, D., Fredeen, R., & Koegel, L. K. (2006). Thebasics of pivotal response treatment. In R. L. Koegel & L. K. Koegel(Eds.), Pivotal response treatments for autism: communication,social, & academic development (pp. 3–30). Baltimore: Paul H.Brookes.

*Koegel, L. K., Koegel, R. L., Green-Hopkins, I., & Barnes, C. C.(2010a). Brief report: question-asking and collateral language ac-quisition in children with autism. Journal of Autism and Develop-mental Disorders, 40, 509–515.

*Koegel, L. K., Singh, A. K., & Koegel, R. L. (2010b). Improvingmotivation for academics in children with autism. Journal of Autismand Developmental Disorders, 40, 1057–1066.

Koegel, R. L., Koegel, L. K., & Camarata, S. M. (2010c). Definitions ofempirically supported treatment. Journal of Autism and Develop-mental Disorders, 40, 516–517.

*Koegel, L. K., Kuriakose, S., Singh, A. K., & Koegel, R. L. (2012).Improving generalization of peer socialization gains in inclusiveschool settings using initiations training. Behavior Modification,36, 361–377.

Kogan, M. D., Strickland, B. B., Blumberg, S. J., Singh, G. K., Perrin, J.M., & van Dyck, P. C. (2008). A national profile of the health careexperiences and family impact of autism spectrum disorder amongchildren in the United States. Pediatrics, 122 , 1149–1158.

*Kuhn, L. R., Bodkin, A. E., Devlin, S. D., & Doggett, R. A. (2008).Using pivotal response training with peers in special education tofacilitate play in two children with autism. Education and Trainingin Developmental Disabilities, 43 , 37–45.

Lang, R., Machalicek, W., Rispoli, M. J., & Regester, A. (2009). Trainingparents to implement communication interventions for children withautism spectrum disorders: a systematic review of training proce-dures. Evidenced Based Communication Assessment and Interven-tion, 3 , 174–190.

Lang, R., O’Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W.,& Giesbers, S. (2012). Sensory integration therapy for autism spec-trum disorders: a systematic review. Research in Autism SpectrumDisorders, 6 , 1004–1018.

*Laski, K. E., Charlop, M. H., & Schreibman, L. (1988). Trainingparents to use the natural language paradigm to increase theirautistic children's speech. Journal of Applied Behavior Anal-ysis, 21 , 391–400.

Loftin, R. L., Odom, S. L., & Lantz, J. F. (2008). Social interaction andrepetitive motor behaviors. Journal of Autism and DevelopmentalDisorders, 38, 1124–1135.

Lovaas, O. I. (1987). Behavioral treatment and normal educational andintellectual functioning in young autistic children. Journal of Con-sulting and Clinical Psychology, 55, 3–9.

Lovaas, O. I., Koegel, R., Simmons, J. Q., & Long, J. S. (1973). Somegeneralization and follow-up measures on autistic children in be-havior therapy. Journal of Applied Behavior Analysis, 6 , 131–165.

*Lydon, H., Healy, O., & Leader, G. (2011). A comparison of videomodeling and pivotal response training to teach pretend play skills tochildren with autism spectrum disorder. Research in Autism Spec-trum Disorders, 5 , 872–884.

Machalicek, W., O’Reilly, M. F., Beretvas, N., Sigafoos, J., Lancioni, G.,Sorrells, A., & Rispoli, M. (2008). A review of school-based in-structional interventions for students with autism spectrum disor-ders. Research in Autism Spectrum Disorders, 2 , 395–416.

Masiello, T. L. (2003). Effectiveness of pivotal response training as abehavioral intervention for young children with autism spectrumdisorders. Winterberry Research Syntheses, 1 , 1–10.

Matson, J. L., & Smith, K. R. (2008). Current status of intensive behav-ioral interventions for young children with autism and PDD-NOS.Research in Autism Spectrum Disorder, 2 , 60–74.


Matson, J. L., Benavidez, D. A., Compton, L. S., Paclawskyj, T., &Baglio, C. (1996). Behavioral treatment of autistic persons: a reviewof research from 1980 to the present. Research in Developmentaldisabilities, 17, 433–465.

McGee, G. G., Krantz, P. J., Mason, D., &McClannahan, L. E. (1983). Amodified incidental teaching procedure for autistic youth: acquisi-tion and generalization of receptive object labels. Journal of AppliedBehavior Analysis, 16, 329–338.

McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1985). The facilita-tive effects of incidental teaching on preposition use by autisticchildren. Journal of Applied Behavior Analysis, 18, 17–31.

*Minjarez, M. B., Williams, S. E., Mercier, E. M., & Hardan, A. Y.(2011). Pivotal response group treatment program for parents ofchildren with autism. Journal of Autism and Developmental Disor-ders, 41, 92–101.

*Minjarez, M. B., Mercier, E. M., Williams, S. E., & Hardan, A. Y.(2013). Impact of pivotal response training group therapy on stressand empowerment in parents of children with autism. Journal ofPositive Behavior Interventions, 15, 71–78.

Mullen, E. (1995).Mullen scales of early learning (AGS Edition) . CirclePines, MN: American Guidance Service Inc.

Mulloy, A., Lang, R., O’Reilly, M., Sigafoos, J., Lancioni, G., & Rispoli,M. (2010). Gluten-free and casein-free diets in the treatment ofautism spectrum disorders: a systematic review. Research in AutismSpectrum Disorders, 4 , 328–339.

National Autism Center (2009). National Standards report . Randolph:National Autism Center.

National Research Council (2001). Educating children with autism .Washington: National Academy Press.

*Nefdt, N., Koegel, R. L., Singer, G., & Gerber, M. (2010). The use of aself-directed learning program to provide introductory training inpivotal response treatment to parent of children with autism. Journalof Positive Behavior Interventions, 12, 23–32.

Osborne, L. A., McHugh, L., Saunders, J., & Reed, P. (2008). Parentingstress reduces the effectiveness of early teaching interventions forautistic spectrum disorders. Journal of Autism and DevelopmentalDisorders, 38, 1092–1103.

Palmen, A., Didden, R., & Lang, R. (2012). A systematic review ofbehavioral intervention research on adaptive skill building in high-functioning young adults with autism spectrum disorder. Researchin Autism Spectrum Disorders, 6 , 602–617.

Patterson, S. Y., Smith, V., & Mirenda, P. (2012). A systematic review oftraining programs for parents of children with autism spectrumdisorders: single subject contributions. Autism, 16, 498–522.

Perry, A., Blacklock, K., & Dunn Geier, J. (2013). The relative impor-tance of age and IQ as predictors of outcomes in intensive behav-ioural intervention. Research in Autism Spectrum Disorders, 7 ,1142–1150.

Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). Ameta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with Autism Spec-trum Disorders. Research in Autism Spectrum Disorders, 5 , 60–69.

Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2013).Therapist characteristics predict discrete trial teaching proceduralfidelity. Intellectual and Developmental Disabilities, 51, 263–272.

*Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviorsin children with autism: effects of peer-implemented pivotal responsetraining. Journal of Applied Behavior Analysis, 28 , 285–295.

*Pierce, K., & Schreibman, L. (1997a). Multiple peer use of pivotalresponse training to increase social behaviors of classmates withautism: results from trained and untrained peers. Journal of AppliedBehavior Analysis, 30, 157–160.

*Pierce, K., & Schreibman, L. (1997b). Using peer trainers to promotesocial behavior in autism: are they effective at enhancing multiplesocial modalities? Focus on Autism and Other Developmental Dis-abilities, 12 , 207–218.

Ramdoss, S., Lang, R., Mulloy, A., Franco, J., O’Reilly, M., Didden, R.,& Lancioni, G. (2011). Use of computer-based interventions to teachcommunication skills to children with autism spectrum disorders: Asystematic review.

Ramdoss, S., Machalicek, W., Rispoli, M., Mulloy, A., Lang, R., &O’Reilly, M. (2012). Computer-based interventions to improve so-cial and emotional skills in individuals with autism spectrum disor-ders: a systematic review. Developmental Neurorehabilitation, 15 ,119–135.

*Randolph, J. K., Stichter, J. P., Schmidt, C. T., O’Connor, K. V., &Schultz, T. P. (2011). Fidelity and effectiveness of PRT implementedby caregivers without college degrees. Focus on Autism and OtherDevelopmental Disabilities, 26 , 230–238.

Reichow, B. (2012). Overview of meta-analyses on early intensive be-havioral intervention for young children with autism spectrum dis-order. Journal of Autism and Developmental Disorders, 42, 512–520.

Reyno, S. M., & McGrath, P. J. (2006). Predictors of parent trainingefficacy for child externalizing behavior problems: a meta-analyticreview. Journal of Child Psychology and Psychiatry, 47 , 99–111.

Rispoli, M., Neely, L., Lang, R., & Ganz, J. (2011). Training paraprofes-sionals to implement interventions for people with autism spectrumdisorders: a systematic review. Developmental Neurorehabilitation,14, 378–388.

*Robinson, S. E. (2011). Teaching paraprofessional of students withautism to implement pivotal response treatment in inclusive schoolsettings using a brief video feedback training package. Focus onAutism and Other Developmental Disabilities, 26 , 105–118.

Roid, G., & Sampers, J. (2004). Merrill–Palmer-revised scales of devel-opment . Wood Dale: Stoelting.

Rosales-Ruiz, J., & Baer, D. M. (1997). Behavioral cusps: a develop-mental and pragmatic concept for behavior analysis. Journal ofApplied Behavior Analysis, 30, 533–544.

Sallows, G. O., & Graupner, T. D. (2005). Intensive behavioral treatmentfor children with autism: four year outcome and predictors. Ameri-can Journal on Mental Retardation, 110 , 417–438.

Schlosser, R., & Sigafoos, J. (2007). Editorial: moving evidence-basedpractice forward. Evidence-Based Communication Assessment andIntervention, 1 , 1–3.

*Schreibman, L., Kaneko, W. M., & Koegel, R. L. (1991). Positive affectof parents of autistic children: a comparison across two teachingtechniques. Behavior Therapy, 22, 479–490.

*Seiverling, L., Pantelides, M., Ruiz, H. H., & Sturmey, P. (2010). Theeffect of behavioral skills training with general-case training on staffchaining of child vocalizations within natural language paradigm.Behavioral Interventions, 25, 53–75.

Sherer, M. R., & Schreibman, L. (2005). Individual behavioral profilesand predictors of treatment effectiveness for children with autism.Journal of Clinical and Consulting Psychology, 73, 525–538.

Simpson, R. L. (2005). Evidence-based practices and students withautism spectrum disorders. Focus on Autism and Other Develop-mental Disabilities, 20 , 140–149.

Simpson, K., & Keen, D. (2011). Music interventions for children withautism: narrative review of the literature. Journal of autism anddevelopmental disorders, 41, 1507–1514.

Smith, T. (2001). Discrete trial training in the treatment of autism. Focuson Autism and Other Developmental Disabilities, 16, 86–92.

Smith, T., McAdam, D., & Napolitano, D. (2007). Autism and appliedbehavior analysis. In P. Sturmey & A. Fitzer (Eds.), Autism spectrumdisorders: applied behavior analysis, evidence, and practice (pp. 1–29).Austin: Pro-Ed.

*Smith, I. M., Koegel, R. L., Koegel, L. K., Openden, D. A., Fossum, K.L., & Bryson, S. E. (2010). Effectiveness of a novel community-based intervention model for children with autistic spectrum disor-der. American Journal on Intellectual and Developmental Disabil-ities, 115 , 504–523.


Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vinelandadaptive behavior scales . Circle Pines: American GuidanceService.

Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland adaptivebehavior scales (2nd ed.). San Antonio: Psychological Corporation.

*Stahmer, A. C. (1995). Teaching symbolic play skills to children withautism using pivotal response training. Journal of Autism and De-velopmental Disorders, 25, 123–141.

*Stahmer, A. C., & Gist, K. (2001). The effects of an accelerated parenteducation program on technique mastery and child outcome. Jour-nal of Positive Behavior Interventions, 3 , 75–82.

*Stahmer, A. C., Schreibman, L., & Powell, N. P. (2006). Social valida-tion of symbolic play training for children with autism. Journal ofEarly and Intensive Behavior Intervention, 3 , 196–210.

Steege, M.W.,Mace, F. C., Perry, L., & Longenecker, H. (2007). Appliedbehavior analysis: beyond discrete trial teaching. Psychology in theSchools, 44, 91–99.

Steiner, A. M. (2011). A strength-based approach to parent education forchildren with autism. Journal of Positive Behavior Interventions,13, 178–190.

*Steiner, A. M., Gengoux, G. W., Klin, A., & Chawarska, K. (2013).Pivotal response treatment for infants at-risk for autism spectrumdisorders: a pilot study. Journal of Autism and DevelopmentalDisorders, 43, 91–102.

Stokes, T. F., & Baer, D. M. (1977). An implicit technology of general-ization. Journal of Applied Behavior Analysis, 10, 349–367.

Strauss, K., Vicari, S., Valeri, G., D’Elia, L., Arima, S., & Fava, L. (2012).Parent inclusion in early intensive behavioral intervention: the

influence of parental stress, parent treatment fidelity and parent-mediated generalization of behavior targets on child outcomes.Research in Developmental Disabilities, 33, 688–703.

*Suhrheinrich, J. (2011). Training teachers to use pivotal response train-ing with children with autism: coaching as a critical component.Teacher Education and Special Education, 34 , 339–349.

*Suhrheinrich, J., Stahmer, A. C., & Schreibman, L. (2007). A prelimi-nary assessment of teachers' implementation of pivotal responsetraining. Journal of Speech-Language Pathology and Applied Be-havior Analysis, 2 , 8–20.

*Symon, J. B. (2005). Expanding interventions for children with autism:parents as trainers. Journal of Positive Behavior Interventions, 7 ,159–173.

*Thorp, D. M., Stahmer, A. C., & Schreibman, L. (1995). Effects ofsociodramatic play training on children with autism. Journal ofAutism and Developmental Disorders, 25, 265–282.

*Vismara, L. A., & Lyons, G. L. (2007). Using perseverative interests toelicit joint attention behaviors in young children with autism: theo-retical and clinical implications for understanding motivation. Jour-nal of Positive Behavior Interventions, 9 , 214–228.

Vismara, L. A., & Rogers, S. J. (2010). Behavioral treatments in autismspectrum disorder: what do we know? Annual Review of Psycholo-gy, 6 , 447–468.

*Voos, A. C., Pelphrey, K. A., Tirrell, J., Bolling, D. Z., Vander Wyk, B.,Kaiser, M. D., & Ventola, P. (2013). Neural mechanisms of im-provements in social motivation after pivotal response treatment:two case studies. Journal of Autism and Developmental Disorders,43, 1–10.


Documents

Pivotal Response Treatment for Children with Autism Spectrum Disorders… · 2017-08-26 · REVIEW PAPER Pivotal Response Treatment for Children with Autism Spectrum Disorders: A