The Star Treatment

Fifty years ago the “treatment” of people on the autism spectrum was barbaric. Electric shocks, confinement, LSD and more were in vogue at various points in the past. Today, however, ongoing research has led to a revolution in treatments. One of the most successful, Pivotal Response Treatment (PRT), was developed at the UC Santa Barbara Koegel Autism Center.

Created by Robert and Lynn Koegel, PRT is an intervention based on Applied Behavior Analysis. A comprehensive approach to treating autism, PRT targets multiple areas of child development with motivational strategies that produce demonstrable improvements in social, communication and academic skills.

“The treatment used to be so awful for kids with autism,” said Lynn Koegel, clinical director of the Koegel Autism Center. “In fact, when I started, almost every single child with autism was institutionalized by adolescence, and sometimes even in the preschool years. And now, it’s just so rare. None of the kids are institutionalized, and almost all of them get to stay at home for as long as they need to.”

In recognition of their 30 years of work, the Association of Behavior Analysis honored the Koegels for their “enduring programmatic contributions in behavior analysis” at its 42^nd annual convention in Chicago. In their acceptance speech before more than 3,000 people in the audience, the Koegels gave a 10-minute presentation on the evolution of autism treatment and the challenges remaining. They also showed a video of a time when children were tied to their beds and treated with electric shock.

“We talked about how far we’ve come, but how far we have to go because there are so many areas that are still needing research in autism and treatment for autism, family stress, diversity and all kinds of things,” Lynn Koegel noted. “Nobody really knew what to do with the kids, so they developed these treatments that were pretty inhumane and for the most part ineffective. That seems like a long time ago, but in the scheme of things it’s really a short time that we’ve been able to have effective interventions.”

The Koegel Autism Center continues to research and develop treatments for autism. One of its newer initiatives is treating adults, an overlooked segment of those with autism. Many, Koegel said, have trouble finding and keeping jobs, and living independently. “There aren’t really any interventions for adults, and most of them end up living at home their whole life because they’re not independent enough to live out in the community,” Lynn Koegel said. “We’ve published several articles showing that we can successfully work on some of these pre-job skills and some of these social job skills that are helpful for adults and even college students, and that it really helps reduce their anxiety and their depression and helps them get out there and meet friends and be in the community.”

The center also pioneered treatment for a much younger set: infants. In the past, most interventions didn’t begin until children were diagnosed with autism, usually at age 4 or 5. “We started looking and seeing, maybe if we could intervene really early in life we could head off the downward spiraling trajectory and get them on a better developmental trajectory very early on,” Koegel said. “We’ve been focusing on some of the prelinguistic skills, which are mostly social, and engagement, and being interested in people rather than objects, responding to their names and showing more eye contact, smiling more at their parents and things like that.

“And it looks like this early stuff is really time- and cost-effective because the parents can be trained to do it and it’s not like they’re really that far behind when they’re 4 months old,” Koegel continued. “We were thinking that maybe if we could get them really young before they’re even supposed to talk we could get them more fully engaged and maybe that would help their communication. It looks like we’ve been able to get them more social.”

One of the keys in PRT, Koegel said, is its focus on motivational strategies. Children play a big role in determining tasks, which shifts the activity from drudgery to enjoyable. “In the past, the intervention wasn’t much fun for them so they’d spend most of their time trying to get out of the session or avoid the session,” Koegel said. “You had a lot of disruptive behavior and problem behaviors, but now, with our treatment it’s fun for them, so they’re more likely to want to engage in the intervention and not even realize they’re learning. If you don’t realize you’re learning that’s a huge accomplishment.”