ERIC ED564578: What Works for You? Using Teacher Feedback to Inform Adaptations of Pivotal Response Training for Classroom Use

2012·0.5 MB·English

by  ERIC

HindawiPublishingCorporation
AutismResearchandTreatment
Volume2012,ArticleID709861,11pages
doi:10.1155/2012/709861
Research Article
What Works for You? Using Teacher Feedback to Inform
Adaptations of Pivotal Response Training for Classroom Use
AubynC.Stahmer,1,2JessicaSuhrheinrich,1,2SarahReed,1,2andLauraSchreibman2
1ChildandAdolescentServicesResearchCenter,AutismDiscoveryInstitute,RadyChildren’sHospitalSanDiego,
3020Children’sWay,SanDiego,CA92123,USA
2DepartmentofPsychology,UniversityofCalifornia,SanDiego,9500GilmanDrive,LaJolla,CA92093-0109,USA
CorrespondenceshouldbeaddressedtoAubynC.Stahmer,[email protected]
Received8June2012;Accepted8October2012
AcademicEditor:BryanKing
Copyright©2012AubynC.Stahmeretal. This is an open access article distributed under the Creative Commons Attribution
License,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperly
cited.
Severalevidence-basedpractices(EBPs)havebeenidentifiedasefficaciousfortheeducationofstudentswithautismspectrum
disorders (ASD). However, effectiveness research has rarely been conducted in schools and teachers express skepticism about
theclinicalutilityofEBPsfortheclassroom.InnovativemethodsareneededtooptimallyadaptEBPsforcommunityuse.This
studyutilizesqualitativemethodstoidentifyperceivedbenefitsandbarriersofclassroomimplementationofaspecificEBPfor
ASD,PivotalResponseTraining(PRT).Teachers’perspectivesonthecomponentsofPRT,useofPRTasaclassroomintervention
strategy,andbarrierstotheuseofPRTwereidentifiedthroughguideddiscussion.TeachersfoundPRTvaluable;however,theyalso
foundsomecomponentschallenging.Specificteacherrecommendationsforadaptationandresourcedevelopmentarediscussed.
This process of obtaining qualitative feedback from frontline practitioners provides a generalizable model for researchers to
collaboratewithteacherstooptimallypromoteEBPsforclassroomuse.
1.Introduction are indicative of poor translation of information from
researchtoeducationalsettings.
Oneareaofgrowingconcernforbothresearchersandeduca- Researchers and educators alike often are frustrated by
torsisprovidingeducationalservicestochildrenwithautism the gap between research and practice [6–8]. There are
spectrumdisorders(ASD).ServingstudentswithASDposes concerns on both sides regarding the utility of EBPs devel-
achallengetopublicschoolsbecauseveryfewcomprehensive oped in research settings for use in educational environ-
interventionshavebeenrigorouslyandsystematicallytested ments. Researchers question whether educators attempt-
in school settings, as opposed to highly controlled research ing to replicate research models adequately assess fidelity
settings [1, 2]. Despite the limited data on the effectiveness of implementation (the degree to which the intervention is
ofspecificevidence-basedpractices(EBPs)inschools,many used as specified) or replicate all aspects of the program
teachers report supporting and using such practices [3]. [9].Conversely,educatorsoftenfeelthatpracticesdeveloped
However, they also state that they typically modify EBPs by researchers do not capture the richness and complexity
for use in the classroom by combining and adapting EBPs of the children in their programs or the environments in
from various training protocols to fit their own teaching whichtheywork[3,10].Itisimperativethatthisresearch-to-
preferences and the needs of individual students [4]. While practicegapbeclosedthrougheffectivetranslationofEBPs
it is possible that these informal adaptations based on intoeducationalsettingstoimprovethequalityofavailable
teachers’ judgment may not change the effectiveness of the servicesforchildrenwithASD.
intervention,researchinotherareassuggeststhatthepositive Innovativemodelsofinterventionadaptationandimple-
outcomes demonstrated in research settings may not be mentation may provide a more effective response to the
maintained when programs are modified [5]. These issues disconnectbetweenresearchandpractice.Suchmodelsshift
2 AutismResearchandTreatment
fromthetraditional,unidirectionalattemptstomoveinfor- one-to-one settings [29]. However, PRT was developed for
mation from research into practice settings toward a more use by clinicians and parents and has been tested primarily
reciprocal,interactiveeffortbetweenresearchersandpracti- inindividualsessionswithoneadultandonechild.Special
tioners[6,11,12].Toensurethatbestpracticesareportable educationteachersoftenteachinthecontextofsmallgroup
tousualcaresettings,researchersmustgainapreciseunder- activities and may not have the opportunity to work one-
standing of the perspectives of community stakeholders on-onewithstudentsduringthemajorityoftheschoolday.
regarding the benefits and barriers of specific practices Therefore,thereisaneedtoadaptPRTtobetterfitclassroom
and work directly with stakeholders, such as teachers, to settings.
adaptinterventions[13–15].Thistypeofcollaborationwill Thisstudyispartofalargerprogramdesignedtotrans-
provide researchers a base from which to shape EBPs in a latePRTintoclassrooms.Thecollaborativemodeloftrans-
waythatmakesthemfeasibleforuseincommunitysettings. lationincludesobtainingfeedbackfromteachers,observing
Information gained from teachers can then be scientifically teachers’useofPRTintheclassroom,testingrecommended
tested to ensure ongoing effectiveness of the intervention adaptationsbasedonobservationandfeedbackfindings,and
given recommended adaptations. Alternatively, if adapta- testingthemodifiedprogram.Thefirststepintheprocessof
tionscompromiseeffectivenessoralterchildoutcomes,new understandinghowPRTmayneedtobeadaptedforeffective
trainingmethodsoradditionalmaterialsmaybedeveloped useintheclassroomisgatheringinformationfromteachers
tobettersupportteachers’abilitytoimplementtheoriginal regardingtheirviewsonnecessaryadaptations.
interventionwithfidelity. The purpose of this study was to work collaboratively
One EBP for students with ASD that can be used in with teachers to obtain their feedback on the benefits and
classrooms is Pivotal Response Training (PRT). PRT is a barriers of using PRT in their programs as well as their
naturalisticbehavioralintervention,basedontheprinciples recommendationsforpotentialmodifications.Weusedfocus
ofappliedbehavioranalysis,whichissoundlysupportedin groups to gather teachers’ input in order to obtain insight
thescientificliterature[8,16–18].Arecentreviewconducted intohowtoincreasetheusabilityofPRTinappliedsettings.
by the National Professional Development Center on ASD The process of gathering information from frontline stake-
listed PRT as one of 24 EBPs with evidence of efficacy for holders represents the first step in collaboration between
teachingstudentswithASD[19].PRTisamulticomponent teachers and researchers to effectively move EBPs for ASD
interventionshowntobeefficaciousforimprovingcommu- intotheclassroom.
nication, play, academic skills, and social interaction. It is
basedonaseriesofstudiesidentifyingimportanttreatment 2.Method
componentsanddemonstratingtheireffectonchildbehav-
ior. The “pivotal” responses trained in PRT are motivation, Afocusgroupapproachwaschosentoobtainanunderstand-
initiation, and responsivity to multiple cues (i.e., increasing ingofthewaysinwhichclassroomteachersimplementand
breadth of attention). Specific elements include gaining modify existing PRT protocol. Focus groups are character-
attention, presenting clear and appropriate instructions, izedbytheuseofparticipantswhohaveaspecificexperience
interspersing maintenance tasks, sharing control (including with or opinions about the topic and the exploration of
following the child’s choice and taking turns), requiring subjectiveexperiencesofparticipantsinrelationtopredeter-
thechildtorespondtomultiplecues,providingcontingent minedresearchquestions[30,31].
consequences, ensuring a direct relationship between the
child’sresponse,andthereinforcerandreinforcingattempts. 2.1.Participants. Focusgroupswereconductedwiththirteen
There is some evidence for the efficacy of PRT when teachers serving children with ASD, aged three to eight, in
implementedbyclassroomteachers[20–23]andparaprofes- SanDiegoCounty,whotaughtatleastonestudentwithASD
sionalstaff[24].However,thesestudieshavebeenrelatively in their classrooms at the time of invitation. Invitations to
small efficacy studies and therefore effectiveness of PRT is participate in focus groups were made through phone calls
unknownwhenitisimplementedbyteacherswhohavenot ande-mailsto60teachersservingthetargetpopulationwho
beentrainedinthecontextofaresearchprotocol.Research hadpreviouslyexpressedgeneralinterestinparticipatingin
examining usual care in the Southern California region research studies. Interested teachers were asked to describe
indicatesthatmorethanseventypercentof80teacherssur- their knowledge and experience with PRT. Twenty of the
veyedreportedusingPRTorsomevariationofPRTintheir teacherswhowereinitiallycontactedwerenolongerworking
classrooms. However, the majority reported adapting the in the district or were no longer teaching special education
interventionbyusingonlycertainpartsormixingPRTwith at the time of contact. Of the 40 remaining teachers, 10
other strategies (Stahmer, unpublished data; [25]). Some did not respond. Seven declined participation citing time
educationalprogramsreportusingPRTincombinationwith constraints. Of the 23 teachers who expressed interest in
otherinterventions[26–28],whichmayalsoaffecttreatment participating, eight could not participate due to scheduling
integrityandeffectiveness. conflictsandtwodidnotrespondtoschedulingphonecalls.
Several factors make PRT an excellent intervention for The remaining 13 were divided into three separate groups
translationintoschoolsettings.BecausePRTwasdeveloped (based on self-report): (1) PRT Trained and Using (PRT-
foruseinthenaturalenvironment,classroomsareanappro- USE), teachers trained in PRT and currently using PRT
priatesettingforPRTimplementation,andthereisevidence (n = 5); (2) PRT Trained and Not Using (PRT-NO USE),
indicatingteacherscanlearntocorrectlyimplementPRTin teacherstrainedinPRTbutnotcurrentlyusingPRT(n=3);
AutismResearchandTreatment 3
(3)NotPRTTrained(NOTTRAINED),teachersnottrained thesettingandactivitiesinwhichPRTmightbeused,andthe
in PRT (n = 5). All teachers who participated in the PRT- generalbenefitsandbarrierstotheuseofthesetechniquesin
USEfocusgroupreportedeitherreceivingonthejobtraining theclassroom.Toensurethatallparticipantsprovidedinput,
(n = 3) or attending a PRT training workshop (n = 2). the moderator asked different participants to begin each
Training was provided by a supervisor (n = 3), classroom discussionandtoprovideinputthroughoutthediscussion.
consultant (n = 1), or outside consultant (n = 1). In Next,themoderatoraskedparticipantstoreviewalistof
the PRT-NO USE group, one teacher reported attending a thespecificcomponentsofPRTanddiscussthebenefitsand
workshop, one reported receiving on the job training, and barriersofeachcomponent,easeofuseofeachcomponent,
one reported attending a workshop and receiving on the and whether they liked each component for classroom use.
job training from a district autism consultant. None of the TeachersintheNOTTRAINEDgroupwereaskedtodiscuss
teachers in the NO TRAINING group reported receiving whethertheyusedanysimilarstrategiesintheirclassrooms.
PRTtrainingofanykind.Consistentwiththedemographics At the end of each group, participants were thanked and
of teachers serving students with ASD in San Diego, all given$20ascompensationfortheirparticipation.
participants were women. Of the 13 participating teachers,
12 (92%) were Caucasian, and 1 (8%) was Asian/Pacific 2.4. Data Analysis. Data analysis was guided by grounded
Islander. Participants ranged in age from 28 to 65 years theory(i.e.,theoryderivedfromdataandthenillustratedby
(M = 40.9,SD = 11.7).All13participantshadaBachelor’s characteristicexamplesofdata;[34]).First,audiorecordings
degree and 10 had Master’s degrees. Teachers’ years of of focus group discussions were transcribed by student
experience working with children with ASD ranged from 1 research assistants, blind to the purpose of the project, and
to 34 years (M = 13.1, SD = 10.1). Teachers worked in reviewedbytheresearchteamforaccuracy.Thetranscripts
13 different schools, and classrooms included autism-only, were then independently coded by three of the project
cross-categorical,severeandmild/moderatedesignations. investigators at a general level in order to condense the
dataintoanalyzableunits.Theconstantcomparativemethod
2.2. Data Collection. An interview guide was developed [34]wasthenusedtoidentifyfiveprimarythemes.Themes
to examine participants’ perspectives on the use of PRT wereidentifiedbycomparingcodesassignedtosegmentsof
techniques in the classroom (see the Appendix for sample textandidentifyingcharacteristicssharedamongcodesand
questions). Questions for the guide were generated based characteristicsthatdistinguishedbetweencodes.Segmentsof
onthestudygoalsandpilotdiscussionabouttheirprogram transcriptsrangingfromaphrasetoseveralparagraphswere
methods with an advisory board of teachers and adminis- assignedcodesbasedonapriori(i.e.,basedonquestionsin
trators serving children with ASD (see Section 2.4). Digital theinterviewguide)oremergentthemes.Disagreementsin
audio recordings were made using a Conference Grabber assignment or description of codes were resolved through
microphoneandalaptopcomputerwithAudacityrecording discussion and enhanced definition of codes. The final list
software. of codes consisted of a list of themes, issues, accounts of
behaviors,andresponsestothepresentationsofthevignette.
2.3.Procedure. Focusgroupstookplaceatacentrallocation Thetranscriptswereassessedforcodingagreementbetween
for all participants. Each group lasted no more than two theauthorsusingaproceduresupportedbyotherqualitative
hours. Informed consent was gathered at the start of the studies[35,36].Toexaminereliability,thenumberofcoded
group, and participants completed a background question- statements on which the coders agreed was divided by the
naire, which included demographics, teaching experience, number of agreements plus disagreements and multiplied
andtraining/experiencewithPRT. by 100. For all coded statements, the coders agreed 85%
Themoderatorforallthreegroupsfollowedtheinterview (range=85-86%) of the time, indicating good reliability
guide.Afterintroductions,themoderatoraskedparticipants in qualitative research [35]. Disagreements were resolved
to provide an overview of their programs. Teachers in the throughconsensus.Disagreementstypicallyarosewhenone
NOTRAININGgroupwereprovidedwithabriefoverview codermissedaninstanceofatopic,typicallywhenateacher
of PRT and each PRT component. Consistent with a well- spoke about the principle of a PRT component generally
established format in focus group methodology [32, 33], (ratherthannamingthecomponentitself).
the next phase of the discussion used a vignette (see the Themeswerecomparedacrossgroupstolookfortrends.
Appendix for an excerpt of the vignette). A short vignette A peer debriefing method [37] was used to provide some
describingthehypotheticalcasehistoryofaschoolagechild content validation. Results were presented to an advisory
withASDwasintroducedtofacilitatediscussionamongthe boardofteachersandadministratorsfamiliarwithPRTwho
teachersthroughexposuretouniformstimuliandtoprovide provided feedback regarding interpretation of the teachers’
a basis for the quantification and comparison of responses comments.
withinandacrossthefocusgroups.Allparticipantsreceived
the same vignette. Participants were asked to read the 3.Results
vignette then decide what type of intervention they would
recommendifsuchastudentcametotheirprogramandhow Primary themes across the groups were identified as (a)
PRT might (or might not) be used. Subsequent questions the benefits of PRT; (b) barriers to use of PRT; (c) spe-
focused on how participants would use PRT techniques or cific training issues; (d) recommendations for specific PRT
other strategies with the child described in the vignette, components; (e) areas in need of empirical validation and
4 AutismResearchandTreatment
adaptation. Themes were very similar across the three 3.3.SpecificTrainingIssues. Teachersinbothtrainedgroups
groups;therefore,datawerecollapsed.Representativequotes reported that the lack of a clear and comprehensive PRT
fromvariouscategoriesareprovidedasdescriptiveexamples manual, or specific methods for using PRT in a classroom,
ofthedata. made it difficult to train paraprofessionals (e.g., classroom
assistants)intheintervention.
3.1.BenefitsofPRT. TeachersconsistentlyreportedthatPRT
“If you teach them [paraprofessionals] to do a
madesensetothemandfitwellwiththeirconceptsofwhat
certainpiece,likeinterspersingmaintenancetasks,
constitutesgoodteachingforstudentswithASD.
theygettheone,butifyoutrytodomorethanone
“Youhaveitemsavailablethatyouknowhe’sgoing itgetsalittleconfusingandtheyarenotsurewhat
towantsohe’smorelikelytoaskforit.Hegetsit tofocuson.”
andsoheisreinforcedforthedesiredbehaviorof
Teachers reported that certain prerequisite skills were
requesting.It’sgoodteaching.”
needed to understand the foundation and goals of PRT.
TheyfeltthatPRTcouldbeusedsuccessfullyandappro- Specifically, they felt that paraprofessionals needed a basic
priatelywithstudentswhohadavarietyofdisabilities,mak- understandingoftheunderlyingprinciplesofABAinorder
ingiteasytoimplementinclassroomsservingchildrenwith tounderstandhowandwhentousePRTwithstudents.
variedneeds.
“My hang up is really training. Last year when
“A lot of these are things all kids need, not just I did train I wanted to make sure they [para-
childrenwithautism.” professionals] were doing it correctly. I felt like it
washarderforthemtograspunlesstheyhadthat
They found the components to be natural to use and ABA background. So I needed to make sure they
consistent with good teaching practices. Teachers reported understood the basics of ABA before going on to
that PRT increased generalization of children’s skills and PRT,otherwiseitwasjustconfusing.”
foundthatparentsviewedPRTpositively.
Teachersstatedthattheyneededawaytobreakdownthe
“Idohaveahardtimegettingchildrentogener- components of PRT so they could teach paraprofessionals
alize, so I like having PRT because it helps that one or two components at a time rather than all at once.
changeoverandithelpstobridgethegap.” In addition, understanding how to explain the program
in broadly accessible terms and having a simple way to
3.2. Barriers to the Use of PRT. Teachers reported some communicatethemethodandsupportingresearchtoparents
significantbarrierstotheuseofPRTintheirclassrooms.In wasimportanttothem.
general,teachersfounditeasiertousemorestructuredpro-
“I’vegotafewparentsI’vetalkedtothatlovePRT,
grams,suchasDiscreteTrialTeachingorTEACCHmethods,
theythinkthatit’sjustwonderful,andtheywant
duetoeaseofdatacollectionandclarityoftheprocedures.
Teachersreportedthatitwasdifficulttosimultaneouslytake todoitathome.Iwonderifitmightbesomething
wecouldoffertoparents...iftheyunderstandhow
dataandimplementPRTcorrectly.Whilesometeachersfelt
touseitandhowitcanhelptheirchildren.”
thatPRTwasverynatural,othersfoundthattherequirement
tofollowaspecificsequenceofcomponentswastoocontrol-
ling.Incontrast,someteachersfeltalackofstructureinPRT 3.4. Recommendations Regarding Specific PRT Components.
whichmadeitdifficulttokeeptheoverallteachingsequence Teachers reported common perspectives on many of the
andcomponentsclear. individual components of PRT. The list of the components
(withbriefdescriptions)andteachers’commentsforeachare
“Becauseitreallyislooselystructured...Ialways summarizedinTable1.
feellikeIamlearning.Idonotfeellikeanexpert
in any way. It gets a little confusing with all the
3.4.1. Gaining Attention. There was clear consensus that
pieces.”
gainingstudents’attentionwasimportant,buteasytoforget.
Teachers reported difficulty using PRT (or strategies
“If we are trying to promote language and play
similar to the PRT components) in group settings with
it[theinstruction] should be clear,andthechild
multiplestudents.
mustbeattendinginordertogiveanappropriate
“Isthereawaytodevelopthistouseinagroup?As response.”
opposedtohavingitbesoone-on-one?Istherea
Teachers expressed concerns that maintaining student
waythatyoucouldusePRTwithagroupofthree
attention(especiallyforstudentswithASD)inagroupwas
kids,fourkids,fivekids,sowecoulddoit?” not a realistic goal and that it was especially difficult for
Inaddition,someteachersreporteddifficultywithimple- classroomassistants.
mentationbecausePRTwasnottiedtoaspecificcurriculum,
whichmadeitdifficulttodeterminewhatgoalstotargetor 3.4.2. Presenting Clear Opportunities/Instructions. Teachers
howtofollowachild’sindividualeducationplan(IEP). indicated that using clear instructions was consistent with
AutismResearchandTreatment 5
Table1:SummaryofPRTcomponentsandfocusgroupfeedback.
PRTcomponent/areaofneed Definition Focusgroupfeedback
(i)Important,buteasytoforget
Teachermusthavethestudent’sattention (ii)Difficulttoensureallstudentsareattendingina
Gainsattention
beforepresentinganopportunity. group
(iii)CanbedifficultwithASDstudentsingeneral
Thequestion/opportunitymustbeclearand
Clearopportunity/instruction (i)Easytoimplementconsistently
appropriatetothetask.
Tasksthatareeasy(maintenance)mustbe (i)Difficulttoidentifyforeachstudent
Maintenancetasks interspersedwithmoredifficulttasks (ii)Minimizesfrustration
(acquisition). (iii)Difficulttotrainparaprofessionals
(i)Importantformaintainingstudentmotivation
Theteachershouldfollowthestudent’s
(ii)Difficulttoaddresssomegoalswithstudent-chosen
Childchoice(sharedcontrol) choiceoftasks,toalargeextent,and/or
materials
providechoiceswithintasks.
(iii)Notappropriateinallclassroomsettings/activities
Teachershouldmodelappropriatebehavior (i)Difficulttoimplement,especiallyingroupsettings
Turntaking(sharedcontrol) inthecontextofagive-and-takeinteraction (ii)Difficultinnonplay-basedactivities
withthestudent. (iii)Sometimesnotappropriate
(i)Challengingtoconsistentlyhavemultiplecue
Someinstructionsshouldinvolvecuesthat materialsavailable
includemultiplecomponents(twoormore (ii)Descriptionofmultiplecuesinthemanualis
Multiplecues
aspectsoftheenvironment,stimuli,or confusing
activity). (iii)Maynotbeappropriateforchildrenwithminimal
language
(i)Partofgeneralgoodteaching
Reinforcementmustbecontingentonthe
Contingentconsequence (ii)Challengingwhenthebehavioriscorrectbutnotat
child’sbehavior.
anappropriatetime
(i)Highlyeffective
(ii)Somechildrenonlyworkforediblesortangible
Reinforcementshouldbenaturaland
Directreinforcement reinforcers
directlyrelatedtothedesiredbehavior.
(iii)Canbedifficulttofindforeveryskill,especially
academics
Goal-directedattemptstorespondmustbe
Reinforcementofattempts (i)Usefulstrategyforkeepingmotivationhigh
reinforced.
(i)Bettertrainingmaterials/manualneeded
(ii)PrerequisiteknowledgeofABAnecessary
Training — (iii)Breakdownofcomponentsforparaprofessionals
needed
(iv)Specifictechniquesforworkingingroupsneeded
(i)HowtointegratePRTwithotherstrategies
(ii)Individualizingforeachstudent
Resources — (iii)HowtousePRTwithIEPgoals/curriculums
(iv)Datacollectionsystem
(v)Information/handoutsforparents
theirteachingstrategies,andeasytoimplementconsistently. “OneofthethingsIfindfrustratingisinterspers-
Theyfeltthatusingsimplerlanguageandclearinstructions ingthemaintenancetasks.Ihavetoremindmyself
couldbedifficultforparaprofessionals. sometimes—youdonotalwayshavetoexpectthis
level—wait, remember to let them be successful
“I think using clear instructions is one of the thistime....Thetwogirls[paraprofessionals]who
mostimportant[components]ifyou’regoingtoget workintheclassroomwithmedonotunderstand
comprehensionatall.” that.Theyarealwayslookingforthatonecorrect
response...andthentheywonderwhyweseesome
3.4.3.InterspersingMaintenanceTasks. Teachersreportedlik- of the behaviors that we see. So I think that it is
ingtheuseofmaintenancetaskstokeepstudent’sfrustration really important to remember that you’ve got to
low but also indicated that this was a particularly difficult vary it [the task] and let them be successful and
componenttocommunicatetoclassroomstaff. putthosemaintenancetasksinthere.”
6 AutismResearchandTreatment
3.4.4.UsingSharedControl(FollowingtheChild’sChoiceand wasdifficultformanyskillstaughtintheclassroomandfor
TakingTurns). Teachersdiscussedthenecessityofincluding childrenwhopreferredediblereinforcers.
childchoiceaswaytoimprovestudents’motivationtopar-
“I basically let them choose their own reinforcer
ticipate. However, they felt that it was often unrealistic to
but there are times when I basically have to say,
allowchildrentoconsistentlychooseactivitiesinthecontext
“No, you are not working for that reinforcer.” I
of the classroom and particularly during group activities.
Teachers found it difficult to take turns with the learning know it is against everything we are supposed to
bedoingbutIhavekidsthateatnothingbutcandy
materials,particularlywhentheactivitywasnotplaybased.
andIdonotknowwhattodoaboutit.”
Theirtypicalteachingpracticesmayinvolveamoredidactic
approach, or modeling an activity or lesson and then
subsequentlyallowingthechildtocompletetheactivity. 3.4.8. Reinforcing Attempts. Teachers in all groups agreed
thatreinforcementofgoal-directedattemptswasimportant
“There are times when it’s appropriate for the formaximizingstudentmotivation.
childtomakechoicesandtaketurns,andthereare
times when it is not, because that is the way the
3.5. Areas in Need of Empirical Validation and Adaptation.
world is: There are times when you get to choose
Teacherswereaskedspecificallyaboutrecommendationsfor
andtimesyoudonot.”
adaptingPRTforuseinclassroomenvironments.Inparticu-
lar,theyreportedaneedforstrategiesthatwouldallowthem
3.4.5. Requiring Response to Multiple Cues. Incorporating to use PRT in the context of their existing classroom struc-
multiple cues or conditional discriminations (i.e., discrim- ture.Theyalsowantedtoseespecifictechniquesforimple-
inations requiring response to two or more elements of a mentingPRTingroupsettingsofthreeormorestudents.
compound stimulus to make an appropriate response) is a
“Myclassroomisnotreallysetuptostructureitfor
componentofPRTthathasbeenshowntohelpbroadening
one particular child. It’s not feasible with fifteen,
attention in children with autism [38–40]. For example, a
student who is coloring may be offered a box of crayons twentyotherkidsinthere.”
and markers in different colors and instructed, “Choose a
Teachersreportedusingseveralotherteachingstrategies
greencrayon.”Thisinstructionrequiresthatthechildchoose thateithertheyfeltwereeffectiveorthattheyweremandated
something that is both green (not another color) and a
tousebytheirdistrict.Therefore,theyfeltitwasimportant
crayon (not a marker) in order to make the appropriate
toknowhowtointegratePRTwithinthesestrategies.
response. Teachers reported that the use of multiple cues
wasparticularlyconfusinganddifficulttoimplementinthe “There are five or six [interventions] I am sup-
classroomduetothetimeittooktoarrangetheenvironment posedtobeimplementinginmyprogrambutitis
andmaterialstoutilizethesetypesofinstructions. understoodthatweshouldbetakingpiecesofeach
andincorporatingthemaswebestseefit.”
“For me it’s too hard to have enough materials
available in my classroom for each student and Teachers wanted information on how to individualize
everygoaltoalwaysbeworkingonmultiplecues.” PRTfortheirstudents.Becausespecialeducationclassrooms
focusonattainmentofIEPgoalsforeachstudent,theyalso
In addition, teachers had concerns regarding the use of requestedinformationonhowtousePRTtotargetstudents’
this component with students who they felt did not have IEP goals. Teachers reported that parents and schools are
thelanguageorcognitivecapacitytounderstandconditional becoming“datadriven”andaskedforbetterdatacollection
discriminations. systemsspecifictoPRTthatwouldallowthemtoeasilytrack
andsharestudentprogress.
3.4.6. Providing Contingent Consequences. Teachers agreed
“There is not a way to talk about child progress
that contingent feedback is important and part of good
(withPRT).It’snotverymeasurable,andsomuch
teachingingeneral.However,theyreportedthatitcouldbe
ofwhatwedoisdatadriven.”
difficult if a child exhibits a correct behavior at a time or
placethatdidnotallowthemtorewardthebehavior(e.g.,a In summary, teachers from focus groups representing
childwithlimitedverbalskillsspontaneouslyinterruptsthe three separate populations (PRT-USE; PRT-NOT USE and
teacherreadingastoryandrequestsbubbles). NOTTRAINED)hadsimilaropinionsonthespecificcom-
ponentsofPRTandhowtheinterventionmaybeimproved
“Any response to a child’s behavior must be con- foruseintheclassroom.
tingent.Butifitiscircletimeandheveryappro-
priately and correctly requests to go outside, the
4.Discussion
answeris“no”,it’snottimetogooutside.”
Theresultsofthisstudyprovidepreliminarydataonteacher
3.4.7.UtilizingDirectReinforcement. Teachersreportedthat perspectives about how PRT may be adapted and supple-
direct reinforcement was an effective strategy in general. mented to best fit classroom needs for students with ASD
However,theyindicatedthattheuseofdirectreinforcement (see Table 2). There are several key findings that may lead
AutismResearchandTreatment 7
Table2:Summaryofrecommendedadaptationsbasedonteachers’perspectivesandqualityofclassroomimplementation.
Teacherjudgments Possibleadaptation
PRTcomponent/area
Importance Easeofimplementation
Noadaptationnecessary;manualto
Gainsattention High Med includestrategiesformaintaining
attention
Clearopportunity/instruction High High Noadaptationnecessary
Noadaptationnecessary;Training
Maintenancetasks High Low resourcesandmethodfor
identificationneeded
Noadaptationnecessary;resourcesfor
Childchoice
High Med addressingvariedgoalswithstudents’
(sharedcontrol)
chosenitemsacrosssettings/activities
Turntaking
Low Low Additionalresearchneeded
(sharedcontrol)
Multiplecues Low Low Additionalresearchneeded
Noadaptationnecessary;additional
Contingentconsequence High Med resourcesandtrainingneededasstep
isbackedbyextensiveresearch
Directreinforcement High Low Additionalresearchneeded
Reinforcementofattempts High High Noadaptationnecessary
Training High Low Trainingmaterialsneeded
Resources High N/A Parentresourcesneeded
Resources High N/A Datacollectionresourcesneeded
toalterationstoPRTthatallowformoreeffectiveclassroom 4.1. Additional Resources and Training. Additional or more
implementation. Teachers reported valuing certain PRT intensivetraininginPRTingeneralmaybehelpful;however,
components as important for student learning. Some of training does not appear sufficient to overcome implemen-
thevaluedcomponentstheyfoundrelativelyeasytoimple- tationbarriersinthisgroupofteachers.Someteacherswho
ment (e.g., presenting clear opportunities and reinforcing were trained in PRT were no longer using the intervention
attempts), while others they found difficult (e.g., gaining at all and a majority reported adapting the intervention.
attention, following the child’s choice, utilizing contingent, Therefore, adaptation and/or focused training based on
and direct reinforcement), particularly in group settings. teacherfeedbackarelikelynecessary.
The components that teachers value and report no trouble Providing contingent and direct consequences are two
implementing likely do not require adaptation, while more componentsofPRTthatteachersfindimportantbutreport
focused training may be needed to ensure appropriate asdifficulttoimplementconsistently.Thenextsteptoward
implementationintheareasthatarerecognizedasimportant effectivetranslationofthesecomponentsmaybegenerating
but perceived as difficult. There are also some components classroom-specific additional resources and strategies for
teachers did not appear to value highly and also reported implementation, so that teachers may more readily relate
as difficult, such as taking turns and requiring a response theirtrainingonthesecomponentstotheday-to-dayimple-
to multiple cues. These components may require future mentationofthestrategyintheirprograms.Resourcesmay
researchtotesttheeffectivenessofadaptations,and/orteach- includeinformationonwhyprovidingcontingentanddirect
ersmayneedadditionaleducationregardingthenecessityof consequences is important (based on supporting research)
thesecomponentsforstudentlearning. and how teachers can improve their use of contingent and
These results are likely applicable to other naturalistic direct consequences in the classroom context (with real-
behavior methodologies using similar intervention compo- world examples, classroom scenarios, activity suggestions,
nents, including Incidental Teaching [41, 42], mand-model andtroubleshooting).Inaddition,creativemethodsofdevel-
[43], time delay [44], and Milieu Teaching [45]. Although oping direct reinforcers that can be easily provided to mul-
thesespecifictechniquesweredevelopedindifferentlabora- tiplestudentsintheclassroom,forexample,throughtoken
tories, the approaches are similar in that they share many systems,maybeexploredforeffectiveness.Similarly,teachers
basic components. Examining teacher use of a variety of reporteddifficultyprovidingchoicestostudents.Highlight-
naturalisticstrategiesmayleadtoricherdataregardingsubtle ing creative examples of providing choices within teacher-
differences in components and delivery strategies that may directed group learning contexts may decrease concerns
enhanceorinhibitclassroomimplementation. regardingthiscomponentandperceptionofitsdifficulty.
8 AutismResearchandTreatment
Findings also indicated several areas of need for addi- developingchildrendonotconsistentlyrespondtomultiple
tional resources that are not related to the specific com- cuesuntil36monthsofage[51].Becausetheageofreliable
ponents of PRT. Teachers requested materials and strate- ASDdiagnosishascontinuedtodrop[52],itislikelythatstu-
gies for training paraprofessionals, communicating with dentsreceivingservicesintoday’sclassroomsaretooyoung
parents, collecting student data, and monitoring student tobereliablyexpectedtorespondtoconditionaldiscrimina-
progress. Although not specific to PRT protocol, these tions.Inaddition,themajorityofstudiesonoverselectivity
concerns provide intervention developers with important andASDwereconductedtwentytothirtyyearsago[53].It
information regardingthetypesofresourcesteachersneed. is likely that children receiving services for ASD today are
Development and testing of training materials for teachers distinctfromthepopulationsusedinolderstudies.Thelack
and staff, parent information, and data collection materials of current research on overselectivity and ASD leaves open
thatfitthecontextoftheclassroomandschoolenvironment the question of whether conditional discriminations are a
are essential for the sustainability of interventions in the difficultyforstudentstoday,andthuswhetherteachersneed
community. Responding to these specific teacher needs is a to specifically teach this skill. An examination of the extent
criticalstepineffectivetranslationofEBPs. towhichtoday’schildrenwithASDstrugglewithconditional
discriminationsmayhelptoshaperecommendationsforthe
4.2. Additional Research. Teachers reported particular diffi- use(oromission)ofthisPRTcomponentintheclassroom.
cultywithandlackofvaluefortheturntakingcomponent.
Thissuggestsaneedforadditionalresearchonthiscompo- 4.3. Limitations. There are several limitations to these data
nentaspartofthetranslationprocess.Nextstepsmayinvolve that must be acknowledged. First, these data consist of
evaluating how modifications to the component affect teacherreportsofhowtheyusePRTintheclassroom.Obser-
overallefficacyofPRTonchildbehaviorandoutcome.First, vational data of teacher use of PRT and fidelity of imple-
the specific factors that make this component difficult for mentationwerenotobtainedfromtheseteachers.Werelied
teacherstoimplementshouldbeoutlined.Forexample,the on teacher report of training as it was obtained in this
turntakingcomponentofPRTrequiresthattheteacherboth community sample and do not have details regarding the
model a behavior (typically language or play) and present qualityoftrainingorlevelofimplementationofPRTbythese
a contingent opportunity to respond to the student in the teachers. It is possible that teachers may differ in their ease
sameinteraction.Thismaybedifficultforteachersbecause of use of PRT depending upon their level of training and
they typically demonstrate new skills for students in an competencyinthemodel[54].However,itislikelythatthe
instructionalmanneratthebeginningofaninteraction,but typeoftrainingreportedbyparticipatingteachersrepresents
donotmodelnewskillsbytakingturnswithstudentsonce typical levels of training in EBPs in public educational
an activity has begun (e.g., they may do the first problem settings. In addition, a recent study examining teacher use
of a math worksheet on the whiteboard as an example, but ofPRTin21classroomsintwodifferentcitiessupportsthe
thenstudentsworkindependentlytocompletetheremaining idea that teachers do not consistently use turn taking or
problems).Empirically identifying how providing an initial multiple cues and are best able to implement antecedent
demonstration (rather than modeling in the context of a strategies such as providing a clear cue with fidelity [55].
turn) affects student learning would inform the process of Second, data were obtained from a small group of teachers
possible modification of turn taking for future classroom in Southern California classrooms who represent only a
use. Additionally, unlike other individual components of subset of teachers contacted. Most teachers were Caucasian
PRT, turn taking has not been studied in isolation to and almost had advanced degrees, which likely does not
determine its influence on child behavior within the larger reflectthedemographicsofthemajorityofteachers.Specific
framework of the intervention. This stands in contrast to benefitsandbarrierstotheuseofPRTmaybedifferentacross
other components, such as utilizing contingent and direct thecountryandshouldbeexploredinfutureresearch.
reinforcement[46,47],interspersingmaintenancetasks[48,
49],andreinforcingattemptsatcorrectresponding[49,50], 4.4. Conclusions. Overall, the results of this investigation
which have all been experimentally examined individually. indicate that teachers perceive PRT as an intervention that
Teachers’ reported difficulty with this component and the is useful and practical for classroom use. Teachers valued
current lack of explicit empirical support make turn taking many of the individual components of PRT, as well as the
an excellent component for experimental examination and naturalisticbehavioralprinciplesthatprovideitstheoretical
potential modification in order to make PRT optimally foundation.Consistentteacherfeedbackacrossfocusgroups
usableforclassroomteachers. indicates areas for possible adaptation and further study.
A second component for which teachers expressed Components the teachers value but report to be difficult
difficultyandlackofvalueisthemultiplecuescomponent. are likely to require additional training rather than radical
Teachersindicatedthatthedescriptionofthecomponentwas adaptation. This perception of implementation difficulty
difficulttounderstandandexpressedconcernthatthemulti- may reflect teacher’s lack of confidence in implement-
plecuescomponentmaynotbedevelopmentallyappropriate ing these strategies. This may not be specific to PRT but
foralloftheirstudentswithASD. may reflect a general dearth of intensive training in autism
Areviewoftheliteratureindicatesarelationshipbetween interventions in general.However, forthecomponents that
developmental level and overselectivity (i.e., responding teachers report both not valuing and not using, additional
to simultaneous multiple cues) and reveals that typically research may be needed to identify possible modifications
AutismResearchandTreatment 9
anddeterminetherelativeimportanceofthesecomponents PresentationofStrategiesUsedinPRT
for the effectiveness of PRT. Closer empirical examination
(2)Pleasereviewthespecificstrategiesthatareused
of these components may benefit not only translation of
inPRT.Pleasetellusifyouuseanyofthesestrategies
PRT to classrooms but may also be important to PRT as a
inyourprogram.
whole.Thesefindingsareusefulindeterminingnextstepsfor
researchersinterestedinsystematicadaptationofPRTforthe
(a) Would you use any of these strategies with
classroomaswellasclinicians,suchasteachers,whoprovide
thechildinthevignette?
frontlineservicestochildrenwithASD.
Overall,thisresearchmayserveasamodelfortheprocess (b) Would you adapt any of the strategies or
of adapting EBPs for clinical settings more generally. A techniques for this child? That is, how might
phasedapproach,inwhich(1)teacherfeedbackissolicited, your use of the particular technique for this
(2) specific adaptations are studied empirically in the childbedifferentfromwhatthe“manual”says?
laboratory, and then (3) appropriate adaptations are tested
(c) In what settings might you use these tech-
in the field, may assist with effective translation of EBPs
niques(ifatall)?
intothecommunity.Itisclearthatunidirectionalmodelsof
translatingEBPsforclinicaluseareinsufficientandineffec-
(3) Please tell us about techniques you really like to
tive. Providing the opportunity for an interactive exchange
use in your classroom (both those listed as part of
of information between researchers and teachers is a likely
first step toward effective translation of EBPs. Additionally, PRT and those not listed). Why do you like them?
Howhaveyoufoundthemhelpfulinyourprogram?
the process of gathering information about what works in
educationalsettingsshouldimprovethequalityofresources (4) Please tell us about any of the listed PRT strate-
resultingfromsystematicscientificadaptation.Amodelfor gies/techniques you DO NOT like. Why do not you
facilitating the widespread delivery of high-quality, EBPs to likethem?
students with ASD is a necessary and crucial step toward
effectivetreatmentofthedisorderthatwarrantstheattention (5) Please tell us about any techniques (PRT based
or otherwise) that you have tried and discontinued.
ofresearchersandteachersalike.Usingqualitativemethods
Whatpromptedyoutodiscontinuethetechnique(s)?
to integrate teachers’ opinions and values into the research
processmayenhancedissemination. (6)Whatwouldyouliketosaytoresearchersabout
howtobesthelpschoolteachersuseevidence-based
Appendix strategiesinclassroomprograms?
SampleFocusGroupQuestions
Acknowledgments
Vignette Excerpt. Alexander is a 4-year-old diagnosed with
The authors would like to thank the participating teachers
autistic disorder and mild developmental delay. He is using
fortheirclearandhonestfeedback.Thisworkwassupported
single words and pointing to communicate his needs. He
by the Institute for Education Sciences, Special Education
asksforbubblesandavarietyofotheritems.Heisrepeating
ResearchandDevelopmentalCenters(R324B070027).
wordshehearswithin3-4wordsentencesandhasaspeaking
vocabularyofatleast40words;however,heusuallyuses1-
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