Several evidence-based practices (EBPs) have been identified as efficacious for the education of students with autism spectrum disorders (ASD). However, effectiveness research has rarely been conducted in schools and teachers express skepticism about the clinical utility of EBPs for the classroom. Innovative methods are needed to optimally adapt EBPs for community use. This study utilizes qualitative methods to identify perceived benefits and barriers of classroom implementation of a specific EBP for ASD, Pivotal Response Training (PRT). Teachers' perspectives on the components of PRT, use of PRT as a classroom intervention strategy, and barriers to the use of PRT were identified through guided discussion. Teachers found PRT valuable; however, they also found some components challenging. Specific teacher recommendations for adaptation and resource development are discussed. This process of obtaining qualitative feedback from frontline practitioners provides a generalizable model for researchers to collaborate with teachers to optimally promote EBPs for classroom use.
One area of growing concern for both researchers and educators is providing educational services to children with autism spectrum disorders (ASD). Serving students with ASD poses a challenge to public schools because very few comprehensive interventions have been rigorously and systematically tested in school settings, as opposed to highly controlled research settings [
Researchers and educators alike often are frustrated by the gap between research and practice [
Innovative models of intervention adaptation and implementation may provide a more effective response to the disconnect between research and practice. Such models shift from the traditional, unidirectional attempts to move information from research into practice settings toward a more reciprocal, interactive effort between researchers and practitioners [
One EBP for students with ASD that can be used in classrooms is Pivotal Response Training (PRT). PRT is a naturalistic behavioral intervention, based on the principles of applied behavior analysis, which is soundly supported in the scientific literature [
There is some evidence for the efficacy of PRT when implemented by classroom teachers [
Several factors make PRT an excellent intervention for translation into school settings. Because PRT was developed for use in the natural environment, classrooms are an appropriate setting for PRT implementation, and there is evidence indicating teachers can learn to correctly implement PRT in one-to-one settings [
This study is part of a larger program designed to translate PRT into classrooms. The collaborative model of translation includes obtaining feedback from teachers, observing teachers’ use of PRT in the classroom, testing recommended adaptations based on observation and feedback findings, and testing the modified program. The first step in the process of understanding how PRT may need to be adapted for effective use in the classroom is gathering information from teachers regarding their views on necessary adaptations.
The purpose of this study was to work collaboratively with teachers to obtain their feedback on the benefits and barriers of using PRT in their programs as well as their recommendations for potential modifications. We used focus groups to gather teachers’ input in order to obtain insight into how to increase the usability of PRT in applied settings. The process of gathering information from frontline stakeholders represents the first step in collaboration between teachers and researchers to effectively move EBPs for ASD into the classroom.
A focus group approach was chosen to obtain an understanding of the ways in which classroom teachers implement and modify existing PRT protocol. Focus groups are characterized by the use of participants who have a specific experience with or opinions about the topic and the exploration of subjective experiences of participants in relation to predetermined research questions [
Focus groups were conducted with thirteen teachers serving children with ASD, aged three to eight, in San Diego County, who taught at least one student with ASD in their classrooms at the time of invitation. Invitations to participate in focus groups were made through phone calls and e-mails to 60 teachers serving the target population who had previously expressed general interest in participating in research studies. Interested teachers were asked to describe their knowledge and experience with PRT. Twenty of the teachers who were initially contacted were no longer working in the district or were no longer teaching special education at the time of contact. Of the 40 remaining teachers, 10 did not respond. Seven declined participation citing time constraints. Of the 23 teachers who expressed interest in participating, eight could not participate due to scheduling conflicts and two did not respond to scheduling phone calls. The remaining 13 were divided into three separate groups (based on self-report): (1)
An interview guide was developed to examine participants’ perspectives on the use of PRT techniques in the classroom (see the Appendix for sample questions). Questions for the guide were generated based on the study goals and pilot discussion about their program methods with an advisory board of teachers and administrators serving children with ASD (see Section
Focus groups took place at a central location for all participants. Each group lasted no more than two hours. Informed consent was gathered at the start of the group, and participants completed a background questionnaire, which included demographics, teaching experience, and training/experience with PRT.
The moderator for all three groups followed the interview guide. After introductions, the moderator asked participants to provide an overview of their programs. Teachers in the NO TRAINING group were provided with a brief overview of PRT and each PRT component. Consistent with a well-established format in focus group methodology [
Next, the moderator asked participants to review a list of the specific components of PRT and discuss the benefits and barriers of each component, ease of use of each component, and whether they liked each component for classroom use. Teachers in the NOT TRAINED group were asked to discuss whether they used any similar strategies in their classrooms. At the end of each group, participants were thanked and given $20 as compensation for their participation.
Data analysis was guided by grounded theory (i.e., theory derived from data and then illustrated by characteristic examples of data; [
Themes were compared across groups to look for trends. A peer debriefing method [
Primary themes across the groups were identified as (a) the benefits of PRT; (b) barriers to use of PRT; (c) specific training issues; (d) recommendations for specific PRT components; (e) areas in need of empirical validation and adaptation. Themes were very similar across the three groups; therefore, data were collapsed. Representative quotes from various categories are provided as descriptive examples of the data.
Teachers consistently reported that PRT made sense to them and fit well with their concepts of what constitutes good teaching for students with ASD.
They felt that PRT could be used successfully and appropriately with students who had a variety of disabilities, making it easy to implement in classrooms serving children with varied needs.
They found the components to be natural to use and consistent with good teaching practices. Teachers reported that PRT increased generalization of children’s skills and found that parents viewed PRT positively.
Teachers reported some significant barriers to the use of PRT in their classrooms. In general, teachers found it easier to use more structured programs, such as Discrete Trial Teaching or TEACCH methods, due to ease of data collection and clarity of the procedures. Teachers reported that it was difficult to simultaneously take data and implement PRT correctly. While some teachers felt that PRT was very natural, others found that the requirement to follow a specific sequence of components was too controlling. In contrast, some teachers felt a lack of structure in PRT which made it difficult to keep the overall teaching sequence and components clear.
Teachers reported difficulty using PRT (or strategies similar to the PRT components) in group settings with multiple students.
In addition, some teachers reported difficulty with implementation because PRT was not tied to a specific curriculum, which made it difficult to determine what goals to target or how to follow a child’s individual education plan (IEP).
Teachers in both trained groups reported that the lack of a clear and comprehensive PRT manual, or specific methods for using PRT in a classroom, made it difficult to train paraprofessionals (e.g., classroom assistants) in the intervention.
Teachers reported that certain prerequisite skills were needed to understand the foundation and goals of PRT. Specifically, they felt that paraprofessionals needed a basic understanding of the underlying principles of ABA in order to understand how and when to use PRT with students.
Teachers stated that they needed a way to break down the components of PRT so they could teach paraprofessionals one or two components at a time rather than all at once. In addition, understanding how to explain the program in broadly accessible terms and having a simple way to communicate the method and supporting research to parents was important to them.
Teachers reported common perspectives on many of the individual components of PRT. The list of the components (with brief descriptions) and teachers’ comments for each are summarized in Table
Summary of PRT components and focus group feedback.
PRT component/area of need | Definition | Focus group feedback |
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Gains attention | Teacher must have the student’s attention before presenting an opportunity. | (i) Important, but easy to forget |
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Clear opportunity/instruction | The question/opportunity must be clear and appropriate to the task. | (i) Easy to implement consistently |
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Maintenance tasks | Tasks that are easy (maintenance) must be interspersed with more difficult tasks (acquisition). | (i) Difficult to identify for each student |
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Child choice (shared control) | The teacher should follow the student’s choice of tasks, to a large extent, and/or provide choices within tasks. | (i) Important for maintaining student motivation |
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Turn taking (shared control) | Teacher should model appropriate behavior in the context of a give-and-take interaction with the student. | (i) Difficult to implement, especially in group settings |
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Multiple cues | Some instructions should involve cues that include multiple components (two or more aspects of the environment, stimuli, or activity). | (i) Challenging to consistently have multiple cue materials available |
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Contingent consequence | Reinforcement must be contingent on the child’s behavior. | (i) Part of general good teaching |
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Direct reinforcement | Reinforcement should be natural and directly related to the desired behavior. | (i) Highly effective |
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Reinforcement of attempts | Goal-directed attempts to respond must be reinforced. | (i) Useful strategy for keeping motivation high |
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Training | — | (i) Better training materials/manual needed |
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Resources | — | (i) How to integrate PRT with other strategies |
There was clear consensus that gaining students’ attention was important, but easy to forget.
Teachers expressed concerns that maintaining student attention (especially for students with ASD) in a group was not a realistic goal and that it was especially difficult for classroom assistants.
Teachers indicated that using clear instructions was consistent with their teaching strategies, and easy to implement consistently. They felt that using simpler language and clear instructions could be difficult for paraprofessionals.
Teachers reported liking the use of maintenance tasks to keep student’s frustration low but also indicated that this was a particularly difficult component to communicate to classroom staff.
Teachers discussed the necessity of including child choice as way to improve students’ motivation to participate. However, they felt that it was often unrealistic to allow children to consistently choose activities in the context of the classroom and particularly during group activities. Teachers found it difficult to take turns with the learning materials, particularly when the activity was not play based. Their typical teaching practices may involve a more didactic approach, or modeling an activity or lesson and then subsequently allowing the child to complete the activity.
Incorporating multiple cues or conditional discriminations (i.e., discriminations requiring response to two or more elements of a compound stimulus to make an appropriate response) is a component of PRT that has been shown to help broadening attention in children with autism [
In addition, teachers had concerns regarding the use of this component with students who they felt did not have the language or cognitive capacity to understand conditional discriminations.
Teachers agreed that contingent feedback is important and part of good teaching in general. However, they reported that it could be difficult if a child exhibits a correct behavior at a time or place that did not allow them to reward the behavior (e.g., a child with limited verbal skills spontaneously interrupts the teacher reading a story and requests bubbles).
Teachers reported that direct reinforcement was an effective strategy in general. However, they indicated that the use of direct reinforcement was difficult for many skills taught in the classroom and for children who preferred edible reinforcers.
Teachers in all groups agreed that reinforcement of goal-directed attempts was important for maximizing student motivation.
Teachers were asked specifically about recommendations for adapting PRT for use in classroom environments. In particular, they reported a need for strategies that would allow them to use PRT in the context of their existing classroom structure. They also wanted to see specific techniques for implementing PRT in group settings of three or more students.
Teachers reported using several other teaching strategies that either they felt were effective or that they were mandated to use by their district. Therefore, they felt it was important to know how to integrate PRT within these strategies.
Teachers wanted information on how to individualize PRT for their students. Because special education classrooms focus on attainment of IEP goals for each student, they also requested information on how to use PRT to target students’ IEP goals. Teachers reported that parents and schools are becoming “data driven” and asked for better data collection systems specific to PRT that would allow them to easily track and share student progress.
In summary, teachers from focus groups representing three separate populations (PRT-USE; PRT-NOT USE and NOT TRAINED) had similar opinions on the specific components of PRT and how the intervention may be improved for use in the classroom.
The results of this study provide preliminary data on teacher perspectives about how PRT may be adapted and supplemented to best fit classroom needs for students with ASD (see Table
Summary of recommended adaptations based on teachers’ perspectives and quality of classroom implementation.
PRT component/area | Teacher judgments | Possible adaptation | |
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Importance | Ease of implementation | ||
Gains attention | High | Med | No adaptation necessary; manual to include strategies for maintaining attention |
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Clear opportunity/instruction | High | High | No adaptation necessary |
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Maintenance tasks | High | Low | No adaptation necessary; Training resources and method for identification needed |
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Child choice |
High | Med | No adaptation necessary; resources for addressing varied goals with students’ chosen items across settings/activities |
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Turn taking |
Low | Low | Additional research needed |
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Multiple cues | Low | Low | Additional research needed |
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Contingent consequence | High | Med | No adaptation necessary; additional resources and training needed as step is backed by extensive research |
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Direct reinforcement | High | Low | Additional research needed |
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Reinforcement of attempts | High | High | No adaptation necessary |
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Training | High | Low | Training materials needed |
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Resources | High | N/A | Parent resources needed |
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Resources | High | N/A | Data collection resources needed |
These results are likely applicable to other naturalistic behavior methodologies using similar intervention components, including Incidental Teaching [
Additional or more intensive training in PRT in general may be helpful; however, training does not appear sufficient to overcome implementation barriers in this group of teachers. Some teachers who were trained in PRT were no longer using the intervention at all and a majority reported adapting the intervention. Therefore, adaptation and/or focused training based on teacher feedback are likely necessary.
Providing contingent and direct consequences are two components of PRT that teachers find important but report as difficult to implement consistently. The next step toward effective translation of these components may be generating classroom-specific additional resources and strategies for implementation, so that teachers may more readily relate their training on these components to the day-to-day implementation of the strategy in their programs. Resources may include information on why providing contingent and direct consequences is important (based on supporting research) and how teachers can improve their use of contingent and direct consequences in the classroom context (with real-world examples, classroom scenarios, activity suggestions, and troubleshooting). In addition, creative methods of developing direct reinforcers that can be easily provided to multiple students in the classroom, for example, through token systems, may be explored for effectiveness. Similarly, teachers reported difficulty providing choices to students. Highlighting creative examples of providing choices within teacher-directed group learning contexts may decrease concerns regarding this component and perception of its difficulty.
Findings also indicated several areas of need for additional resources that are not related to the specific components of PRT. Teachers requested materials and strategies for training paraprofessionals, communicating with parents, collecting student data, and monitoring student progress. Although not specific to PRT protocol, these concerns provide intervention developers with important information regarding the types of resources teachers need. Development and testing of training materials for teachers and staff, parent information, and data collection materials that fit the context of the classroom and school environment are essential for the sustainability of interventions in the community. Responding to these specific teacher needs is a critical step in effective translation of EBPs.
Teachers reported particular difficulty with and lack of value for the turn taking component. This suggests a need for additional research on this component as part of the translation process. Next steps may involve evaluating how modifications to the component affect overall efficacy of PRT on child behavior and outcome. First, the specific factors that make this component difficult for teachers to implement should be outlined. For example, the turn taking component of PRT requires that the teacher both model a behavior (typically language or play) and present a contingent opportunity to respond to the student in the same interaction. This may be difficult for teachers because they typically demonstrate new skills for students in an instructional manner at the beginning of an interaction, but do not model new skills by taking turns with students once an activity has begun (e.g., they may do the first problem of a math worksheet on the whiteboard as an example, but then students work independently to complete the remaining problems). Empirically identifying how providing an initial demonstration (rather than modeling in the context of a turn) affects student learning would inform the process of possible modification of turn taking for future classroom use. Additionally, unlike other individual components of PRT, turn taking has not been studied in isolation to determine its influence on child behavior within the larger framework of the intervention. This stands in contrast to other components, such as utilizing contingent and direct reinforcement [
A second component for which teachers expressed difficulty and lack of value is the multiple cues component. Teachers indicated that the description of the component was difficult to understand and expressed concern that the multiple cues component may not be developmentally appropriate for all of their students with ASD.
A review of the literature indicates a relationship between developmental level and overselectivity (i.e., responding to simultaneous multiple cues) and reveals that typically developing children do not consistently respond to multiple cues until 36 months of age [
There are several limitations to these data that must be acknowledged. First, these data consist of teacher reports of how they use PRT in the classroom. Observational data of teacher use of PRT and fidelity of implementation were not obtained from these teachers. We relied on teacher report of training as it was obtained in this community sample and do not have details regarding the quality of training or level of implementation of PRT by these teachers. It is possible that teachers may differ in their ease of use of PRT depending upon their level of training and competency in the model [
Overall, the results of this investigation indicate that teachers perceive PRT as an intervention that is useful and practical for classroom use. Teachers valued many of the individual components of PRT, as well as the naturalistic behavioral principles that provide its theoretical foundation. Consistent teacher feedback across focus groups indicates areas for possible adaptation and further study. Components the teachers value but report to be difficult are likely to require additional training rather than radical adaptation. This perception of implementation difficulty may reflect teacher’s lack of confidence in implementing these strategies. This may not be specific to PRT but may reflect a general dearth of intensive training in autism interventions in general. However, for the components that teachers report both not valuing and not using, additional research may be needed to identify possible modifications and determine the relative importance of these components for the effectiveness of PRT. Closer empirical examination of these components may benefit not only translation of PRT to classrooms but may also be important to PRT as a whole. These findings are useful in determining next steps for researchers interested in systematic adaptation of PRT for the classroom as well as clinicians, such as teachers, who provide frontline services to children with ASD.
Overall, this research may serve as a model for the process of adapting EBPs for clinical settings more generally. A phased approach, in which (1) teacher feedback is solicited, (2) specific adaptations are studied empirically in the laboratory, and then (3) appropriate adaptations are tested in the field, may assist with effective translation of EBPs into the community. It is clear that unidirectional models of translating EBPs for clinical use are insufficient and ineffective. Providing the opportunity for an interactive exchange of information between researchers and teachers is a likely first step toward effective translation of EBPs. Additionally, the process of gathering information about what works in educational settings should improve the quality of resources resulting from systematic scientific adaptation. A model for facilitating the widespread delivery of high-quality, EBPs to students with ASD is a necessary and crucial step toward effective treatment of the disorder that warrants the attention of researchers and teachers alike. Using qualitative methods to integrate teachers’ opinions and values into the research process may enhance dissemination.
Alexander is a 4-year-old diagnosed with autistic disorder and mild developmental delay. He is using single words and pointing to communicate his needs. He asks for bubbles and a variety of other items. He is repeating words he hears within 3-4 word sentences and has a speaking vocabulary of at least 40 words; however, he usually uses 1-2 word phrases when he speaks spontaneously. Alexander is able to follow simple commands without cues such as “sit down”. He can point to a variety of pictures and can identify body parts via pointing. Alexander has difficulty relating to people in his environment. He is a very cautious, shy little boy with difficulty separating from his parents. He enjoys simple toys such as busy boxes and puzzles, and a spinning train. He is not yet engaging in symbolic play on his own but will feed a doll when asked to do so. His preferred activities are somewhat stereotypical in nature. Alexander has been observed to engage in some handflapping, especially when excited. Alexander has difficulty with transitions and changes in plans. He is also somewhat distractible but can complete a task when redirected. He is able to tolerate structured sitting with minimal cues for redirection. (1) What type of program would you set up for this child if he came to your program? (a) What specific techniques or type of technique might you use, if any, with this child? (2) Please review the specific strategies that are used in PRT. Please tell us if you use any of these strategies in your program. (a) Would you use any of these strategies with the child in the vignette? (b) Would you adapt any of the strategies or techniques for this child? That is, how might your use of the particular technique for this child be different from what the “manual” says? (c) In what settings might you use these techniques (if at all)? (3) Please tell us about techniques you really like to use in your classroom (both those listed as part of PRT and those not listed). Why do you like them? How have you found them helpful in your program? (4) Please tell us about any of the listed PRT strategies/techniques you DO NOT like. Why do not you like them? (5) Please tell us about any techniques (PRT based or otherwise) that you have tried and discontinued. What prompted you to discontinue the technique(s)? (6) What would you like to say to researchers about how to best help school teachers use evidence-based strategies in classroom programs?
The authors would like to thank the participating teachers for their clear and honest feedback. This work was supported by the Institute for Education Sciences, Special Education Research and Developmental Centers (R324B070027).