Pivotal Response Treatment and Autism Ranking: Strong positive evidence

Key Features

Pivotal response treatment (also known as pivotal response training, PRT or the natural language paradigm) is a form of teaching in which the teacher concentrates on changing certain 'pivotal' behaviours, such as motivation and self-management.

Pivotal response treatment is based on the idea that certain aspects of a child's development are considered to be 'pivotal', that is, crucial for the behaviours which depend on them. The pivotal areas are motivation, self-management, self-initiation, and the ability to respond to multiple environmental cues.

In pivotal response treatment the trainer concentrates on changing these pivotal areas in order to change the behaviours which depend on them, such as speech and language, social behaviour, and challenging behaviour.

There are several multi-component programmes (such as the Early Start Denver Model and the Nova Scotia early intensive behaviour intervention) which include pivotal response treatment as a key element.


The trainer aims to ensure the child is motivated throughout the learning process. For example, they may provide the child with choices, such as allowing him or her to decide which toy to play with. The trainer may reinforce learning with naturally occurring rewards, such as by giving him or her a toy if he or she can ask for it, instead of giving him or her a sweet instead. They may also teach new, more difficult tasks between easy tasks that the child has already mastered.


The trainer aims to teach the child individual to be aware of his inappropriate behaviours, to collect information on those behaviors, and to reward himself or to request rewards from others. For example, she may ask him to keep a star chart, which shows when he has done something right. When he gets enough stars, he gets a reward.


The trainer teaches the child to act spontaneously in response to natural cues. For example, she may encourage the child to ask questions about something he can see, such as a favourite toy, in order to get it.

·Multiple environmental cues

The trainer teaches the child to be aware of, and how to respond to, all of the relevant cues in a situation. For example, if the child already responds correctly to the request 'Get your jumper', the trainer can add another cue by saying 'Get your red jumper' or 'Get your jumper from your room'.

·Other key elements

There are a number of other elements which are considered to be important within PRT.

The trainer ensures that the child is paying attention to any instructions. This might be achieved by touching the child lightly on the arm and ensuring that he is looking at and/or listening to the instructor.

The trainer uses short, simple instructions such as 'Get your blue ball' instead of long, confusing instructions such as 'Why don't you get your blue ball so that we can play catch.'

The trainer arranges the child's immediate environment to encourage learning, for example by placing things that the child likes nearby in order to encourage conversation about those things.

19 Dec 2017
Last Review
01 Oct 2016
Next Review
01 Oct 2019