The Koegels are the developers of Pivotal Response Treatment® (PRT®), an evidence-based approach to autism that focuses on motivation in core, keystone areas called pivotal areas to produce widespread and rapid treatment gains.

Dr. Robert L. Koegel is the director of the Koegel Autism Center at the University of California, Santa Barbara. Dr. Lynn Kern Koegel is the director of clinical services at the Koegel Autism Center as well as the director of the Eli and Edythe L. Broad Center for Asperger's Research. She has appeared as a special consultant on the ABC show Supernanny, working with a family who has a child with autism.

Q: What exactly is pivotal response treatment?

A: Our main goal in developing PRT has been to speed up the learning process. We want our children to be enthusiastic students and to enjoy the learning process. Children with autism have a lot of challenges and we want them to get on a typical developmental trajectory, so we are in a race against time, and that can only be accomplished if we have cooperative learners. Pivotal Response Treatment focuses on targeting key treatment areas, such as motivation, so that many, many (thousands of) target behaviors change at the same time, without having to work on only one behavior at a time, which is time consuming, and expensive, and laborious.

Q: Why is motivation so important in PRT?

A: Motivation seems to lie at the heart of autism. Autism itself may not be quite as severe as we previously thought. The serious problems may be in large part due to side effects that develop over time. So, interventions, such as PRT, that tap into the students' motivation are especially effective.

Q: Is PRT covered by insurance?

A: Yes. It is an empirically supported ABA treatment that has been proven to improve gains.

Q: Can you give some tips for reducing stress for parents of kids with autism?

A: Sadly, parents of children with autism experience very high levels of stress, and reducing parent stress has been a challenge. There are some areas that we have studied that seem to be helpful.

• First, getting the PRT intervention into daily routines greatly helps reduce parent stress. The intervention for children with autism is time-intensive and busy parents feel guilty and anxious if they don't have a free minute to sit down with their child. However, this can be remedied by incorporating intervention for target goals into everyday life. Then, the PRT intervention can easily be accomplished throughout the day and the child learns how to engage in desired behaviors all day long.
  
  
• We have also studied how professionals can reduce family stress by focusing on the positive. For example, instead of saying "Your child has significant delays in communication," the professional can say, "Your child already says lots of words, so we need to expand on that." Simply focusing on the positive and where we can go when we expand on the child's strengths can reduce stress.
  
  
• Another area that causes stress with parents relates to childcare and their child's communication delays. Parents of children worry when they leave their child with a sitter when their child is unable to tell them how it went with the sitter. Potentially abuse, neglect, or just poor childcare may not be recognized. We try to specially train childcare providers so that parents can leave their child for work, a date night, a work out class, or any relaxing event without having to worry since their child will be in good hands.

Having said that, there haven't been procedures that reduce stress across the board. No doubt that future research will need to focus on supporting the families so that they don't need to stress out day after day. This will undoubtedly require society coming together as a whole and embracing the children and families as a whole so that they are accepted, encouraged, and provided with the best interventions possible so that the children reach their maximal potential.

Q: Are there any diets/supplements/vitamins that can help a child to control their sensory craving needs?

A: Possibly there are some, but at this time the research is not conclusive on that point. We do notice that many children have extremely restricted diets, and focusing on eating right so that the children have a healthy diet is important. The [PRT] Pocket Guide has effective ideas for improving eating habits.

Q: Will early singing in en face engagements help autistic infants?

A: Possibly, but the research in that area is not clear at this time. We have such success with verbal communication (more than 95% of the children start using verbal communication with PRT if intervention starts before age 3), so we usually go straight to prompting verbal expressive communication.

Q: [relates to above question] Has massage and crooning soothing words been of any help in lessening autistic symptoms in toddlers and preschoolers?

A: As far as massage and crooning by itself, it is possible that it might help, but there is minimal research available on this point. However, it is important to remember the concept of motivation in PRT. If your toddler or preschooler loves massage and crooning, we're all for that, but it might be helpful to try to use those interests to create or expand social interaction. Perhaps you could have your child use words to request the crooning or massage. Eventually, this communication could be expanded to create social conversation about the activity. Or, you could practice turn-taking by having the child massage you, too. There are all sorts of possibilities to use PRT with these interests to encourage good communication and social interaction.

Q: What is a good approach for addressing "silly" behaviours in class? My functioning 7 yr old has been having increasing success in making friends but unfortunately, his method has been to become the class clown.

A: The first thing you'll want to do is to make sure that your child's classmates are laughing "with him" and not "at him." If he is getting his classmates' attention in a positive way and isn't disrupting the teaching or learning process I say more power to him! Humor is difficult to teach and if he's figured it out, that's fantastic! On the other hand, if he is engaging in "silly" repetitive behaviors and getting attention in a negative way or a way that isn't age-appropriate, you will need to teach replacement behaviors that serve the same function of getting attention, but are appropriate.

It might be a good idea to observe to see how his classmates are getting their peers' attention if you need ideas, but oftentimes "showing" and "sharing" are great ways to interact with peers. Throw in some extra treats in his lunch to share with his friends. Also, send some pictures, movie stubs, concert tickets, or any other conversation starters with him. In addition to these suggestions we also talk about play dates in our PRT book and how to ensure that they are successful The great news is that your child wants to interact with his peers and wants friends. Your mission will be to get this end goal accomplished in an appropriate way.

Q: [relates to above question] How can I help him understand what's acceptable without discouraging his interest (and success) in building friendships?

A: In all honesty, we don't totally understand friendship ... how it develops, why some people "click off" and why others don't. But, we do know that some things can encourage the friend-making process. In our PRT Pocket Guide, we discuss using mutually reinforcing activities to encourage friendships. There are lots of ways to do this both in and out of school. By focusing on creating appropriate activities using your child's restricted interests you can create a safe and fun environment where your child can excel. Many children with autism actively avoid social interaction because it's just too challenging, but when restricted interests or areas of strength are incorporated into the social event, the children with autism actively and enthusiastically participate.

Q: What do you think about the new 1:88 statistic of children diagnosed with autism/autism spectrum disorder?

A: It means that there are a lot of people in need of help for some types of symptoms they are showing. Whether autism is increasing, or awareness is increasing, or some other reason is causing an increase in numbers, it points to the fact that a very large number of people need help! That's why we continue to need interventions like PRT that are time- and cost-efficient.

	To understand PRT better Watch a before-and-after video clip of PRT in practice, and download this introduction to The PRT Pocket Guide: Pivotal Response Treatment for Autism Spectrum Disorders.

Paula is one of today's most popular and respected experts on autism and inclusive education. Through her work as an independent consultant and the high-energy presentations she gives to professionals across the country, Dr. Kluth helps educators and families create responsive, engaging schooling experiences for students with disabilities and their peers too.

Q: How do families encourage inclusion at their child's school?

A: So many parents want to help their school be and feel more inclusive. Many, however, are at a loss to figure out ways to contribute to this goal. In reality, there are many steps parents can take to encourage inclusion in their schools and in their child's classroom. One big idea would be to run for the school board. This idea seems daunting to many, but can be a VERY effective way to spread an inclusive philosophy. Another idea would be to start or join a parent group focused on advocacy or inclusive education. Families can also join the PTO and be a voice for supporting diverse students. Finally, parents might talk to individual teachers about inclusive education and engage in activities to celebrate National Inclusive Schools Week.

A: It's hard to answer a question like this (or any question about behavior) without being there to observe specific behaviors and to see the classroom. What I can share, however, is that I would typically caution against moving a student into a new placement to wait for a certain set of skills to develop. I have found in so many cases that when we wait for a child to be "ready" for inclusion, we end up waiting a long time. Sometimes, the child never earns his way back into the inclusive setting.

If a student is not successful in an inclusive setting, the answer is usually trying out a wider range of supports. Students with significant movement, communication, and sensory problems will need their teachers to be creative with adaptations and to look at a range of adaptations and accommodations. The struggle some teams may have is that they plan for having "a student with autism" but the problem is that if you know one student with autism, you know just one student with autism. He or she likely needs supports that are different from those required by any other student.

The key will be looking at exactly what types of needs the learner has. Does he run around a lot? He may need more movement breaks. Does he have reliable communication? If not, he needs access to augmentative or alternative communication. Does he struggle to sit down? Then he may need alternative seating.

The bottom line is to realize that any struggles the child has now, he will likely have next year. Instead of waiting for readiness, I would suggest trying to solve the problems in the current environment with changes to the lessons, the strategies, the environment, the personal support, or to the instructional materials.

Q: I can't spend a lot of money, but I am looking for ways to make my 3rd grade classroom more appealing and comfortable for students with autism. Any ideas?

A: What a thoughtful teacher! You are clearly knowledgeable about the needs of students on the spectrum. You are right to assume that these learners will be the most prepared to learn in places where they can relax and feel secure. Ideas for making the classroom more comfortable include providing seating options (e.g., beanbag chairs, rocking chairs, floor pillows, exercise balls); reducing direct light when possible (e.g., using lamp lighting on occasion, shutting lights off certain activities); and minimizing distracting noises (e.g., putting tennis balls on chair and desk legs). You can also create a classroom sensory box to house objects that all students can access when they need a "fidget" or another kind of sensory break.

To keep your remodel inexpensive, ask your school's occupational therapist if he has any materials you can use, go to your PTO and ask for funding to make your classroom more welcoming, or ask local service organizations to work with you. Keep in mind that even a few changes can make a big difference, so don't let a lack of funding stop you from getting started on one or two of these suggestions.

Q: I have a student included in a sixth-grade classroom and he is doing fine academically, but I am not really sure his communication goals are being addressed. How do I both include him and make sure he gets time to work on individual skills?

There are many ways to provide these opportunities. For instance, when students begin the school day, the teacher might "whip" around the room and ask every student to share one thing they learned that day (in five words or less). Or during a math lesson, he might ask students to turn and talk to a partner to compare notes and process the information provided. Still another idea would be to have students work in small groups with assigned roles so that individual learners can practice specific competencies. The encourager gets to practice offering positive comments, while the facilitator has opportunities to work on getting all group members involved in the conversation. Keep in mind that you will need to teach the skills necessary for each of these tasks and assess student performance week to week so any necessary changes can be made the the tasks or to the instruction.

Another way to work on communication is to talk to all staff members about ideas for meeting goals. If a student has a goal of "greeting people appropriately," talk to the music teacher, the physical education teacher, the art teacher, the school secretary, the lunch supervisor, and the custodian about how you want these greetings to look and how they can support the goal by making a personal connection with that particular student each day or week. Or if the student needs work on answering questions, ask staff members to target that goal in their classrooms or lessons.

	See more ideas for a truly inclusive approach Watch the introduction to "You're Going to Love this Kid!" Paula's professional development DVD showcasing effective ways to teach students with autism—and their classmates, with or without a diagnosis of a learning difficulty or exceptionality—in inclusive classrooms.

Dr. Thompson is one of the nation's leading experts on autism. A licensed psychologist who serves as consulting psychologist for the Minnesota Early Autism Project in Maple Grove, he is also a graduate faculty member in the Special Education Program of Department of Educational Psychology at the University of Minnesota and an adjunct professor in the Department of Applied Behavioral Science at the University of Kansas, Lawrence.

Dr. Thompson has received numerous awards, including the Distinguished Research Award, The Arc of the United States; the Academy on Mental Retardation Lifetime Research Award; Don Hake Award of the American Psychological Association; the Edgar A. Doll Award, for contributions to facilitate the transfer of research into practice; and the APA's Ernest R. Hilgard Award and the Impact of Science on Application Award of the Society for Advancement of Behavior Analysis.

Q: At the moment I have a child who is 4 yrs old and is needing toileting support as he is going to school next year. I will highly appreciate if you have some information that staff can use.

A: Toilet training depends on a child's chronological and developmental age and his or her health and physical condition. Generally bladder training can begin when a child goes two or more hours between wetting his diaper and shows signs he is recognizing he is about to urinate, such as holding himself or squirming uncomfortably. It is wise to begin by having the child examined by his pediatrician to determine whether he has any urinary or gastrointestinal issues that may impact on toilet training.

Most of the time bladder training can take place over a week or two with patience and persistence. Bowel training may take longer. I encourage you to consider beginning with the AAP guide to toilet training (The American Academy of Pediatrics Guide to Toilet Training) to know the signs that tje child is ready and for tips such as diet and scheduling. The Potty Journey: Guide to Toilet Training Children with Special Needs, Including Autism and Related Disorders by Judith A. Coucouvanis and Toilet Training for Individuals with Autism or Other Developmental Issues, 2nd Edition, by Maria Wheeler and Carol Stoc Kranowitz have suggestions specifically for children with autism.

If you have tried several times and had difficulty with toilet training it is often helpful to consult a behavior analyst or child psychologist from your school or in the community for advice. Sometimes a single consultation is all you need.

Q: As an Early Intervention Classroom teacher for many years, I am effective with student progress (RTI ideas & other strategies) and with inclusion teachers, paraprofessionals, etc (You're Gonna Love this Kid! mantra)—but my question is: How do I effectively help the families/parents "sign on" to involvement in doing teaching/therapy at home to further benefit their child's progress? They visit the classroom (monthly), I visit the home (sometimes); they can see how things work and are pleased, but just struggle with being in the "therapist-teacher" role. I realize there is a strong connection to their overall readiness in dealing with the entire situation in the beginning, yet if there is something you can offer that may help empower these families "earlier-on," I would gladly work at it! My goal in helping students and families at the "starter level" has always been to improve the quality of life in some way for all involved ... without having families spend a fortune or continuously search for the "single answer" that will bring "normal" to their child and family.

A: Parents are able to participate in various ways in to various degrees in their child's intervention. Some parents, especially single mothers living in distressed financial circumstances, find it difficult to get food on the table, and look after the needs of their other children and don't feel they have the time to devote to specific therapy activities with their child with autism. Sometimes this arises from a misunderstanding of things they can do on their own that won't take a lot of time. Often focusing on one or two periods during the day when simple interventions can be done is a good start.

Other parents begin with the idea that "the experts" will take care of things with their child, such as communication, socialization and other academic training, and assume they either don't know, or may fail if they try to do some of the intervention on their own. I have seen parents sometimes resent the fact that young therapists can achieve changes with their children more quickly than they are able to accomplish, which is understandably discouraging. Reassuring them that it will come easier with time can help. Avoiding a judgmental posture is essential.

Parents who find it difficult to accept the fact their child has a significant disability are often those who have the most difficulty engaging in home therapy because they come face to face with the reality their child may have very significant needs, which they find very disheartening. They are often constantly searching for a diet, vitamin or other biological treatment, and find committing to the daily details of one-to-one therapy extremely difficult. Encouraging them to single out several practical daily problem areas and focusing specifically on them, can help them experience success and be more willing to become involved.

Some parents find it helpful to participate in ACT therapy (Acceptance and Commitment Therapy) which is a form of cognitive behavior therapy which can help overcome obstacles such as acceptance of their child with autism and committing to a plan for his future. Clinical psychologists are increasingly trained in this approach, so a search of the State Psychology Board database may be helpful.

In my experience a minority of parents are able to become very actively involved in most aspects of their children's therapy. That seems daunting to them and easily seems overwhelming. Occasionally parents ask for help with specific issues, like mealtime routines, recreation activities, family outings, etc. and take on new teaching goals on their own, but those are less common in my experience.

Parents are generally doing the best they can. Parents with significant mental health problems of their own may need considerably more support than the average family.

	Learn how to match interventions with individual children Learn how to blend the best of two common autism intervention approaches—discrete trial instruction and naturalistic, incidental teaching—to meet the individual needs of young children with autism in Dr. Thompson's guide Individualized Autism Interventions for Young Children: Blending Discrete Trial and Naturalistic Strategies.

*These answers provided here are for informational purposes only. Observations and recommendations represent the expert opinions of the authors based on their knowledge, experience, and training, but are in no way meant to substitute for the advice of a medical practitioner or other professional. You should consult with a health professional or other specialist if you are interested in more information.