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Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System
Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System
Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System
Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System
Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System
Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System
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Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System


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  • 1. Journal of Autism and Developmental Disorders, Vol. 32, No. 3, June 2002 (© 2002)Brief ReportsBrief Report: Increasing Communication Skills for anElementary-Aged Student with Autism Using the PictureExchange Communication SystemTamara R. Kravits,1 Debra M. Kamps,1,4 Katie Kemmerer,2 and Jessica Potucek3 The purpose of this study was to examine the effects of the Picture Exchange Communication System (PECS) on the spontaneous communication skills of a 6-year-old girl with autism across her home and school environments. The effects of the PECS were also examined for social interaction. Results indicated increases in spontaneous language (i.e., requests and com- ments) including use of the icons and verbalizations across those settings in which PECS was implemented. Intelligible verbalizations increased in two of three settings, and changes in peer social interaction were noted in one of the two school settings. KEY WORDS: Picture Exchange Communication System; augmentative communication; peer training.INTRODUCTION sembles a more naturalistic approach to teaching in that communication is child initiated rather than controlled Augmentative communication systems (AACs) by adult verbal cues. The PECS was developed tohave been shown to be a successful language inter- (1) provide an effective AAC for nonverbal children,vention for many nonverbal children (e.g., Reichle & while simultaneously minimizing the prompt depen-Sigafoos, 1991; Shafer, 1993; Zangari, Lloyd, & dency by teaching children to spontaneously initiateVicker, 1994). Unfortunately, instructional strategies their wants/needs through an exchange of a picture forusing AAC systems may rely on the overuse of verbal the corresponding item /activity, and (2) to provide ver-and/or physical prompts such as “What do you want?” bal models of language with use of the picture exchangeor “Point to what you want.” As a result, some children to encourage oral language. In addition, PECS combinesbecome prompt dependent and lack spontaneity in their previously researched procedures into the teaching pro-communication (Mirenda & Dattilo, 1987). tocol to encourage child initiation/motivation including A promising instructional intervention with AAC (a) child choice and preference (e.g., Dyer, 1989;is the Picture Exchange Communication System (PECS) Koegel, O’Dell, & Koegel, 1987), (b) time delay (e.g.,developed by Bondy and Frost (1994), which addresses Charlop, Schreibman, & Thibodeau, 1985; Halle, 1982),these concerns. PECS is structured in a way that re- (c) environmental arrangement (e.g., Carta, Sainato, & Greenwood, 1988), and (d) differential reinforcement1 University of Kansas, Juniper Gardens Children’s Project, Kansas (e.g., Koegel et al., 1987; Reichle & Sigafoos, 1991). City, Kansas 66101. In descriptive reports, Bondy and Frost (1994)2 Autism Training Center, University of Louisville, Louisville, Ken- noted improved communication for children with tucky. autism using the PECS as well as increases in sponta-3 Project S.A.I.L., 10401 Holmes Road, Suite 440, Kansas City, Mis- neous language acquisition; however, few empirical souri 64131.4 Correspondence should be addressed to Debra M. Kamps, Juniper demonstrations have been reported. In a second de- Gardens Children’s Project, 650 Minnesota Ave., 2nd Floor, Kansas scriptive study with 31 preschoolers with disabilities, City, Kansas 66101; e-mail: the use of PECS showed increased spontaneous use of 225 0162-3257/02/0600-0225/0 © 2002 Plenum Publishing Corporation
  • 2. 226 Kravits, Kamps, Kemmerer, and Potucekicons and generalization to novel school settings Measurement(Schwartz, Garfinkle, & Bauer, 1998). Verbalizationsincreased for talkers but not for nonverbal children The frequency of spontaneous language includingin the study. The purpose of the current study was to requests (i.e., words or approximations asking for items(a) evaluate the effectiveness of teaching PECS on the or help), comments (i.e., labeling or describing items,spontaneous communication of an elementary-aged situations), or expansions (adding new elements to pre-child with autism, (b) determine feasibility of use by vious utterances) was selected as the target behaviorthe mother, classroom teachers, and peers across home (dependent variable) to be treated with the PECS.and school environments, and (c) note effects in con- Requests and comments were counted only if theyjunction with social skills training for social interaction occurred without prompting (i.e., no instruction, ques-behaviors. tion within 5 seconds prior). Data were collected by the experimenters for lan- guage behaviors that occurred within 10-minute sam-METHOD ple periods. When the student communicated, the observer recorded what the student communicated, theParticipant, Settings, Materials mode (e.g., verbal, symbol, sign), the function (e.g., Molly was a 6-year-old girl with a diagnosis of request, comment), and to whom (i.e., adult or peer) theautism. She was integrated, with the assistance of a para- student was communicating. Repeated verbalizationsprofessional, in a half-day kindergarten program in the were recorded as one communicative episode, endingpublic school. In addition, she received 30–60 minutes after a 5-second pause.of special education services per day from the learning Social interaction data were collected in 5-minutecenter teacher and language therapist. Molly’s score on intervals using a laptop computer programmed with thethe Vineland indicated a 2 years 8 months performance Multi Option Observation System for Experimentallevel. Scores on the Wechsler Preschool and Primary Studies (MOOSES) developed by Tapp, Wehby, andScale of Intelligence (WPPSI-R) were within the 27th Ellis (1992). This system was used to code the dura-percentile for verbal behavior and the 1st percentile for tion of interaction between Molly and her peers or theadaptive behavior. Her developmental age was 2–2.5 adults in her environment. Once an interaction (i.e., ini-years on the Psychoeducational Profile-Revised (PEP- tiation followed by a response within 5 seconds) wasR). When prompted, Molly communicated using 1- to observed, it was keyed in and continuously recorded2-word utterances (e.g., “Want cookie”), but her speech until the observer keyed the end of the interaction; seewas difficult to understand, and her frequency of initi- prior reports for program description (Kamps, Potucek,ations was very low. She also used gestures and eye con- Gonzalez-Lopez, Kravits, & Kemmerer, 1997).tact to communicate, but she initiated and used more Language samples and social interaction data wereverbalizations at home with her mother than with teach- collected at least once every session across all settingsers or peers at school. Thus, the PECS was chosen to (i.e., two times a week in journal time and centers, twoprovide Molly with an effective communication system or three times a week at home).across settings and to increase her spontaneous initia- Interobserver agreement was collected for eachtions and interactions with others in her environment. language variable for 11% of the observation sessions. Settings for the study included leisure and snack The mean percentage of agreement for content of thetime in Molly’s home and play periods with peers dur- verbalizations was 93% in baseline and 91% in inter-ing journal (writing/coloring in notebooks followed by vention; 97% in baseline for mode (icon versus sign ver-play) and center activities (free play) at school. All set- sus verbal) and 96% in intervention; and 89% intings were similar to free time with play with others as baseline for function (i.e., spontaneous request versusa primary activity and the inclusion of peers at school. comment) and 86% in intervention. Reliability wasMaterials consisted of food (e.g., popcorn, candy, soda, computed on an item-by-item basis, with the numbercookies), toys (e.g., Casio piano, Koosh Balls, Slinkys, of agreements divided by the number of agreementsmarkers, Silly Putty), and games (e.g., Don’t Break the plus disagreements. Reliability for social interactionIce). Graphic symbols/icons (line drawings) of items data for 14% of the MOOSES files was computed me-were taken from the Mayer-Johnson Picture Commu- chanically using software that matched the files of thenication Symbols (1990) or were hand drawn (2 2- primary and second observers with the mean agreementinch black and white). at 86%.
  • 3. PECS 227Design and Procedures Phase I, Physically-Assisted Exchange, consisted of teaching Molly to initiate a communicative exchange A multiple baseline design across settings (Baer, by giving her a picture of a desired item/activity to theWolf, & Risley, 1968) was used to document treatment trainer. Training consisted of placing the item slightlyeffectiveness. The experimental conditions included out of her reach. When she reached for the item, atwo baseline conditions and two treatment phases that prompter (seated behind Molly) assisted her usingoccurred during play activities at home and school. “hand over hand” to pick up the picture and hand it to the trainer. If she did not reach within 3–4 seconds, theBaseline (A1) trainer prompted from behind. The receiving trainer Molly was observed while in play situations across held out her hand serving as a cue. Once the pictureall settings before teaching using the PECS. Reinforcer touched the hand of the receiving trainer, the trainerassessment was also conducted once before beginning stated “Oh, you want _____,” and the requested itembaseline. Then in baseline, sessions included a variety was given to the student. Delays were increased to pro-of available materials, including those noted as pre- mote spontaneity and discrimination. The criterion forferred items from the reinforcer assessment. These were Phase I consisted of Molly exchanging the pictures in-available without contingent requests during the play dependently without the prompter’s assistance andtime. Data were collected on the frequency of Molly’s without the open hand cue from the trainer for 80% ofspontaneous language and social interaction across the teaching period trials (typically 5–10 each session,4 weeks in all settings (i.e., home, centers, and journal with 17 trials in the initial session to teach picking uptime). Verbalizations to Molly were typical to the set- the icon and the exchange). Phase II, Expanding Spon-tings (i.e., directions for the activity, some questions taneity, consisted of three steps: the introduction of theregarding her needs, general commenting). The school communication board (pictures attached with Velcro),activities were more independent play with occasional an increase in the distance of the receiving trainer andadult interactions, whereas the mother engaged in more Molly, and an increase in the distance of the board fromchatting during the leisure activities with general com- Molly. Again, 80% correct, independent requesting wasmenting and some contingent questioning (e.g., “What the criterion. Phase III, Discrimination of Pictures,do you want?”). consisted of discrimination between multiple pictures on the communication board, correspondence checksBaseline (A2) (use of icons to force correct discriminations based upon preferences), and picture size reduction (initial During the second baseline condition, the com- size 2 2 inches, then 1 1 inches). Phases I–IIImunication board with symbols was introduced across were taught to criterion in the home setting, and thenall environments, but Molly was not prompted to use treatment was implemented in classroom Data were collected under the same conditions as All sessions consisted of both teaching periods andthose described in the A1 condition across 1 week at play periods. The procedures of the PECS were taughthome, 12 weeks during centers, and 17 weeks during during the teaching periods (5–10 trials, approximatelyjournal time. 5 minutes) immediately followed by the free play pe- riods (15–20 minutes), during which a choice of itemsTreatment (B) and activities was available for play contingent on re- The PECS was implemented during play activities questing using the PECS (the same materials as avail-across all settings following procedures as outlined in able in baseline, with new items assessed periodically).the manual (Frost & Bondy, 1994). The PECS is an Peers at school also received brief training in use of theAAC system that uses a variety of behavioral tech- PECS with Molly. Data were collected under the sameniques to teach children to communicate. These tech- conditions as those described in the A1 and A2 condi-niques are incorporated into six teaching phases that tions, during the play periods after training. Note thattarget different components of communication (i.e., initially during PECS training in the home, reinforcerspontaneous requesting, discriminating, building sen- assessment was conducted before training and thosetence structure, responding to questions). Phases I–III materials were used in training. When free play began,as outlined in the training protocol were conducted in however, the mother chose an activity that typicallythis study, including reinforcer assessment at the be- was not an activity from those determined as reinforcersginning of each training session (Frost & Bondy, 1994). based on assessment. Although preferred items from
  • 4. 228 Kravits, Kamps, Kemmerer, and Potucekthe assessment were still available, the mother directedMolly to use the item she selected, rather than allow-ing Molly to choose her activity. Thus, beginning withthe 13th session of the home intervention phase, Mollywas allowed to choose (with the icon initiation) whichitems to use during free play. A total of 71 trials overfive training periods was required to reach criterion forPhases I–III at home, 41 trials over eight sessions wererequired in centers, and 15 trials over five sessions wererequired in journal time. Once criteria for the phaseswere reached, reinforcer assessment and a minimum offive training trials continued at the beginning of ses-sions; however, the time for training became muchshorter over time as Molly mastered initiations withPECS.Social Intervention with the PECS (C) During this condition, the PECS was used in com-bination with social skills training to increase the du-ration of Molly’s interaction with her peers. Molly’speers were instructed on how to keep her engaged dur-ing game playing situations (games were used in placeof free choice activities). Peer training was conductedfor four sessions, followed by peer practice (i.e., a fewminutes of models and reminders) conducted beforeeach play/leisure period. Social skills included sharingmaterials, taking turns, asking and answering questions,and extending the play interactions. Training includeddefining the skill, modeling, and practice trials with thepeers and Molly. Data were collected under the sameconditions as described. Fig. 1. Total frequency of spontaneous icon-based language and icon-plus verbals (i.e., requests, comments, and expansions) across settings.RESULTS AND DISCUSSION As displayed in Figure 1, the total frequency of curred in all settings, with 38 learned icons andspontaneous language using icons or icons plus ver- 4–8 icons used during 10-minute intervention sessions.bals per 10-minute session increased during settings Intelligible verbalizations also showed increases in twowhen the PECS treatment conditions were imple- of three settings, home and journal time, with a rangemented. Effects were consistent across home and school of 15–16 at home and 5–8 at school. Thus, spontaneousand when PECS was used by the mother, teachers, and language, which often included icon use but also in-peers. No use of icons was demonstrated during base- cluded some verbal language without the icons, in-line (although icons were present), and with the PECS creased with the intervention. At home, Molly averagedinstructional protocol, Molly demonstrated successful 8–9 initiations during play in baseline (all verbal) anduse of the augmentative system. An increase in initia- 18 during PECS (icons and verbals). During school cen-tions at home was noted when materials from the rein- ters, Molly averaged 3–5 initiations in baseline, withforcer assessment and training were also available increases to 11 during the intervention. During journalduring free play, indicating choice as a critical aspect time, similar effects were noted with a mean of 4 –7to increasing spontaneity within PECS. initiations in baseline and 14 during intervention. These Table I. presents mean data by condition for use findings indicate that increased spontaneous languageof icons, as well as spontaneous verbalizations and du- included both increased verbalizations and icon use inration of social interaction. Reliable use of icons oc- two settings. The t tests indicated significantly more
  • 5. PECS 229 Table I. Means of Behaviors by Session tively). These increases reflect increased contact with a small number of peers rather than increases in the A1 A2 B C number of peers contacted.Mean frequency of icon use Home 0 0 5.2 4 Centers 0 0 4.4 6.5 SUMMARY Journal time 0 0.8 7.8 7.6Mean frequency of intelligible verbalizations This study provided an empirical demonstration of Home 9.6 5.8 15.5 16 the effectiveness of PECS in increasing spontaneous Centers 2.5 5.3 7.2 5.8 Journal time 6.0 3.8 6.5 8.3 communication skills for a young child with autism.Mean frequency of initiations = icon verbalizations or These findings are consistent with descriptive reportsicons verbalizations or verbalizations alone (e.g., Bondy & Frost, 1994; Schwartz et al., 1998) and Home 9.9 8.0 17.4 19.0 experimental reports documenting specific strategies Centers 2.5 5.2 11.2 11.0 such as the use of child preference/choice and time Journal time 7.7 4.3 14.2 14.3Mean duration of social interaction with peers delay tactics in language intervention (e.g., Dyer, 1989;(300 seconds total time) Halle, 1982; Koegel et al., 1987). Findings expand prior Home 38 0 16 54 studies by including an older child (kindergarten age) Centers 71 31 54 173 and by including the home as an intervention setting. Journal time 60 26 146 183 Experimenters also noted that Molly’s use of the sys- tem helped her become a much more spontaneous per- son using the icons in home and school activities. The duration of Molly’s peer interactions increased in jour-initiations (df 1, F 114.9, p .01) and verbal- nal time, and the frequency increased in both, from 0izations (df 1, F 30.1, p .01) during interven- to 2 in baseline to 7 in centers and 13 in journal timetion sessions over baseline sessions. Observations also using the PECS, clear documentation for the social va-indicated, however, that Molly did not significantly in- lidity of the system in school. Before the PECS, ob-crease the range of spoken vocabulary during inter- served communication was nonverbal, more passivevention. For younger children, it has been reported that (e.g., gestures, smiles), and primarily directed towardif verbal language begins, it generally occurs after ap- the adults. It is unclear, however, what social effectsproximately a year in the PECS program (Bondy, Hoff- were from PECS alone versus PECS plus the socialman, & Glassberg, 1999). Thus, this case was not a skills booster sessions. Limitations thus include thereliable one for study of the PECS in regards to verbal confound of the social skills enhancement, a confoundlanguage acquisition due to (a) prior verbal language to PECS alone as an intervention, and no generaliza-by Molly as exhibited in baseline and (b) length of the tion or follow-up probes. Future research with PECSintervention. should include (a) implementation with multiple par- The duration of social interaction with peers (see ticipants and those with varying levels of functioning,Table I) was also monitored to note treatment effects. (b) long-term study of PECS with completion of theMinimal changes were noted at home for interaction training protocol (advancement through all six trainingtime with use of the PECS, but this is likely an effect phases) and use of PECS across longer periods of theof opportunity as Molly’s brother was the only “peer” school day, and (c) alternative social interventions inavailable at home, with an occasional friend from combination with the At school, however, increases were only notedwith PECS intervention in one of two settings ( journal REFERENCEStime), with increases in the duration to 146 secondsover baseline levels of 26–60. Differential effects may Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some dimensionshave been due to peer proximity in the two settings with of applied behavior analysis. Journal of Applied Behavior Analy-children seated on the floor 1–2 feet apart in journal sis, 1, 91– 97. Bondy, A., & Frost, L. (1994). The Picture Exchange Communica-time play and at tables (3–4 feet apart) during center tion System. Focus on Autistic Behavior, 9, 1– A few follow-up sessions were conducted using Bondy, A., Hoffman, A., & Glassberg, W. (January, 1999). The Pic-PECS and social skills training with peers in centers ture Exchange Communication System Training, Kansas City, MO.and journal time (C), with probes indicating additional Carta, J., Sainato, D., & Greenwood, C. (1988). Advances in the eco-increases in both settings (means 173, 183, respec- logical assessment of classroom instruction for young children
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