A 10-year-old nonverbal Greek boy, C.Z., who had beendiagnos.docx

A 10-year-old nonverbal Greek boy, C.Z., who had been
diagnosed with both bilateral sensorineural profound hear-
ing loss and autism, was taught to use the Picture Exchange
Communication System (PECS), with some modifications and
extensions, over a 4-month intensive intervention period. C.Z.’s
original communication and behavioral status as well as the
PECS application process are presented, along with the
communicative, language, and psychosocial outcomes follow-
ing the intervention program. Follow-up data were collected
6 months post.
Little research has focused on the coexistence of hearingloss
and autism in children (Gillberg & Steffenburg,1993; Gordon,
1991; Jure, Rapin, & Tuchman, 1991).
Epidemiological studies reveal higher comorbidity rates than
would be expected in the general population (Gordon; Jure
et al.). As Konstantareas and Homatidis (1987) reported, au-
ditory peculiarities and abnormalities in children with autism
have often been noted, yet no systematic and reliable data have
been collected on the frequency of hearing loss or peripheral
ear problems in this population. Generally, hearing problems
are reported more frequently in people with neurological and
developmental disorders than in those without such diagnoses
(van Schrojenstein Lantman-de Valk, 1997). Autism has also
been reported to occur more often in children with viral-
related diseases known to affect hearing, such as congenital ru-
bella (Chess, 1971) and congenital cytomegalovirus infection
(Stubbs, Ash, & Williams,1984).
The prevalence of autism is 30–40 cases in 100,000 (i.e.,
0.3%–0.4%; Rutter, 2005) while the prevalence of hearing loss
in the general population under 45 years of age is 4% (Nadol,

1993) and 2% of newborn infants experience bilateral hearing
loss with 0.7% in the moderate to profound range (Conn-
Wesson et al., 2000). Based on these studies, it can be con-
cluded that the incidence of hearing loss in children with
autism, as well as the incidence of autism in children with hear-
ing loss, is greater than the one found in typically developing
populations. Jure et al. (1991) found that 61 out of 1,150 chil-
dren with hearing impairments met the criteria for a diagnosis
of autism, or 5.3% of the population of individuals with hear-
ing impairments. In another Swedish study, Rosenhall, Nor-
din, Sandstrom, Ahlsen, and Gillberg (1999) reported on au-
diological examinations of 199 children with autism; 7.9% of
them were found to exhibit mild to moderate hearing loss, and
3.5% had severe or profound hearing losses.
Despite the high comorbidity of autism and hearing loss,
few studies have used complete audiometrical battery tests
(i.e., combined measures of pure tone audiometry and tym-
panometry) to assess the hearing status of children with autism
(Smith, Miller, Stewart, Walter, & McConnell, 1988). The
small number of studies may be explained by the observation
that hearing assessment is very difficult in cases of combined
autism and hearing impairment, as it is in all children with mul-
tiple disabilities (Jure et al., 1991). On one hand, no in-depth
hearing examinations are carried out on individuals who pre-
sent behaviors associated with severe autism (Hayes & Gor-
don, 1977). On the other hand, in many combined cases the
diagnosis of hearing loss comes much earlier than the diagno-
sis of autism (Roper, Arnold, & Monteiro, 2003). Roper et al.
concluded that the characteristics of autism in deaf children re-
semble those observed for hearing children. Nevertheless,
when both conditions occur, the communicative and language
problems are even more severe than with either of the two dis-
orders in isolation (Rosenhall et al., 1999).

Although many specialized intervention methods are be-
ing used with varying degrees of effectiveness for individuals
with autism or hearing loss, no research is available regarding
therapy in combined cases. As Jure et al. (1991) state, there
are no school programs specifically designed for children with
autism and hearing impairment. They suggested that the ideal
solution for these children would be placement in a special
class of a school for the hard-of-hearing, where a behavioral
intervention program would be combined with sign language
training.
Alternatively, a promising avenue for communication train-
ing in the case of children with autism and hearing impairment
may be combining a nonverbal, alternative communication ap-
proach with the principles of behavioral analysis. Alternative
augmentative communication systems have commonly been
used to promote the communication skills of nonverbal chil-
FOCUS ON AUTISM AND OTHER DEVELOPMENTAL
DISABILITIES
VOLUME 22, NUMBER 1, SPRING 2007
PAGES 23–32
The Application of PECS in a
Deaf Child With Autism:
A Case Study
Georgia A. Malandraki and Areti Okalidou
DISABILITIES
24

dren with autism. The American Speech–Language–Hearing
Association (1989) defines alternative augmentative commu-
nication as an area of clinical practice that attempts to com-
pensate (temporarily or permanently) for the disability of
people with severe expressive communication disorders. The
communication challenge is to assist verbal and nonverbal chil-
dren with autism in developing functional communication and
spontaneous (oral or sign) language use (Carr, Binkoff, Kolo-
ginsky & Eddy, 1978; Charlop, Shreibman & Thibodeau,
1985; Lovaas, 1977) Most importantly, the acquisition of
functional communication is considered a primary prognostic
factor for long-term communication outcomes (Bondy &
Frost, 1994).
A method that targets functional communication via non-
verbal means is the Picture Exchange Communication System
(PECS) developed by Frost and Bondy (1994) in the Dela-
ware Autistic Program. PECS applies principles of applied be-
havior analysis to a system of alternative and augmentative
communication that focuses on self-initiated communicative
behavior (Bondy & Frost, 1998). Although initially designed
for young children with autism, PECS has been applied with
success to people with other developmental disorders (Liddle,
2001) and across the age range, up to age 26 (Chambers &
Rehfeldt, 2003). The basic idea of PECS is to provide indi-
viduals who have limited communication abilities with a sys-
tem via which they can interact with others, making their needs
and desires known (Frost & Bondy, 1994, 1998). PECS users
learn to approach a communicative partner and exchange, with
him or her, the picture of a desired item for the item itself. By
doing this, they learn to initiate spontaneous communication
within a social context and to participate in the cause–effect
act of communication (Frost & Bondy, 1994, 1998), an act
that is fundamental to the whole communication process.
Although there are limited reports on the efficacy of

PECS, its few documented implementations in individuals
with autism spectrum disorders and other developmental dis-
abilities have resulted in very encouraging communicative and
social outcomes (Ganz & Simpson, 2004; Kravits, Kamps,
Kemmerer, & Potucek, 2002; Liddle, 2001). Bondy and Frost
(1994) indicated that 85 children with autism acquired func-
tional communication via PECS. Bondy and Peterson (1990)
reported that 59% of children with autism who used PECS for
more than 1 year managed to acquire oral language as their
sole means of communication. Finnegan and colleagues
(1987) indicated that the use of PECS resulted in decreases in
problem behaviors and increases in appropriate social
behaviors.
Furthermore, Charlop-Christy, Carpenter, Le, LeBlanc, and
Kellet (2002) provided empirical evidence for the positive out-
comes obtained by PECS in the acquisition of speech and com-
municative-social behaviors and in the reduction of problem
behaviors.
The clinical case reported in the present study concerns a
child with multiple disabilities diagnosed with both autism and
profound hearing loss. Because the child had never worn hear-
ing aids and was nonverbal, PECS was chosen as the alterna-
tive augmentative communication system for this child’s com-
munication training. The present study constitutes the first
documented trial of the application of PECS in a combined
case of autism and profound hearing loss, and also one of the
few documented incidences of PECS application in Greece. It
occurred within the framework of the child’s communication
intervention program at school. The goal of the intervention
was to establish functional communication for the child, who
could not communicate his needs or feelings with verbal or
nonverbal language. The goal of the study was to assess the ef-
ficacy of PECS as a communication method for this school-
age, nonverbal child with autism and hearing impairment.

Method
Participant
The study was approved by the Research Committee of the
Technological and Educational Institute of Patras and by the
National Foundation of Deaf and Hard of Hearing Individu-
als of Southwestern Greece. Written consent was given by the
participant’s parents. The participant, C.Z., was a 10-year-old
Greek boy who had been diagnosed with both congenital pro-
found hearing loss and autism.
A complete battery of audiological assessments (i.e., pure-
tone audiometry, tympanometry, and auditory brainstem re-
sponse [ABR]) was performed at the Department of Audi-
ology and Neuro-Otology at a children’s hospital in Athens.
Audiological results established the diagnosis of profound bi-
lateral sensorineural hearing loss at the age of 2 and 6 years.
At age 10, the diagnosis of autism was made by a psychologist
at C.Z.’s school, based on the criteria in the Diagnostic and
Statistical Manual of Mental Disorders (4th ed.; American Psy-
chiatric Association, 1994). C.Z. had been enrolled for 3 years
as a boarding student at a national school for children who are
deaf and hard of hearing. He attended school regularly. The
school followed the total communication method for deaf
education, and C.Z. was instructed via Greek Sign Language,
finger-spelling, and written language. Throughout school
hours he had been receiving in-class instruction support by a
paraprofessional who served as his tutor. C.Z.’s hearing status
was monitored annually by the audiological center affiliated
with the school. During his third year in school he was evalu-
ated by the school’s psychologist, who conducted a couple of
follow-up visits to monitor C.Z.’s behavioral status. An IQ as-
sessment was not administered due to the lack of nonverbal
standardized tests in this area in Greece. For three semesters,

C.Z. had received speech and language therapy from three stu-
dent clinicians completing supervised practica. At that time his
speech and language therapy were focused on increasing lip-
reading skills, without any signs of progress. His family history
revealed that C.Z.’s parents were both deaf and communicated
with each other through the Greek Sign Language. However,
his 19-year-old sister was hearing and typically functioning.
25
Study Design
The study was composed of four phases:
1. an informal assessment;
2. the main intervention program (4 months), which was
highly intensive and allowed acquisition of PECS up to
6th phase;
3. the maintenance intervention program (4 months), which
was less intensive, conducted by a single new trainer, and
consisted of two sessions per week of 30 to 45 minutes
each; and
4. the follow-up, which was a 2-hour informal observation
by the main trainer that took place 6 months following
cessation of the main intervention program.
Data were collected only for the main intervention program
and are reported in this article.

Prior to the onset of training, communication skills were
informally assessed via teacher and caregiver interviews and
records review, in addition to direct observation and elicited
responses. Data pertaining to the child’s communication pro-
file before and after the intervention program were recorded.
Also, gross observations on the behavioral and social patterns
before and after the intervention were obtained. Following the
establishment of baselines regarding the child’s communica-
tive and psychosocial behaviors during the 1-week observation
and the 3-day assessment period, PECS training began. Dur-
ing Phases 1, 2, and 3, PECS training was highly structured,
consisting of 3 to 5 sessions weekly, each of 30 to 45 minutes
duration. Subsequently, during Phases 4 and 5, PECS training
became more intensive, but sessions were not structured. For
1.5 months the trainers spent 8 to 10 hours daily in C.Z.’s en-
vironment in order for him to apply the communication sys-
tem in his daily living. Thus, the training staff participated in
C.Z.’s daily activities, identified teachable moments, and used
incidental teaching to stimulate communicative interactions.
The following steps were taken to foster generalization:
(a) change of trainers, (b) change of environment (therapy
rooms), (c) remote placement of the communication book,
and (d) expansion of therapy time to consecutive whole-day
sessions in C.Z.’s living environment.
Settings
The settings in which the different phases of PECS were im-
plemented included almost all of the common places of the
boarding house, a speech therapy room, and C.Z.’s classroom
at school. In the first phases of PECS, the therapy room used
was a 10-foot by 16-foot room with one table and three chairs.
Two of the chairs (for the child and the second trainer) were
placed next to each other, and the third chair (for the main
trainer) faced them from across the table. In subsequent phases
of the program, sessions were held in a variety of places rep-

resenting the actual living environments of the child, namely,
the common room, the playroom, the dining room, the bed-
room, and the study room of the boarding house, as well as a
few other bigger classrooms at the school. The bigger class-
rooms enabled an increase in distance between the child, the
trainers, and PECS materials, which was a program require-
ment in advanced phases of PECS.
Trainers
None of the trainers had previous experience with PECS. The
main trainer was a senior undergraduate student in the De-
partment of Speech and Language Therapy of a local univer-
sity (and one of the authors of the study), and the second
trainer was a kindergarten teacher. The main trainer studied
the PECS Training Manual (Frost & Bondy, 1994) and was
supervised by a certified speech–language pathologist familiar
with its implementation. The main trainer trained the second
trainer via three 30-minute sessions of direct instruction and
additional on-site observation. Subsequently, six additional
trainers (five of C.Z.’s caregivers at the boarding house, plus
his school teacher) were individually trained by the main
trainer before participating in the advanced phases of the pro-
gram. Each one had a 30-minute session of direct instruction
with the trainer, and the entire procedure of each phase was
explained during some demonstrative training sessions. Dur-
ing each phase the additional trainers were also asked to come
into the therapy room to observe the main trainer (on-site
observation). Finally, after the acquisition of PECS (main in-
tervention program), an additional trainer carried on a main-
tenance program and received in-service training for 2 weeks,
which included (a) three 30-minute sessions of direct instruc-
tion and inspection of videotaped sessions, (b) on-site obser-
vation, and (c) hands-on supervised training.

Materials
Before the intervention, trainers devoted a few days preparing
and constructing the necessary materials (i.e., the pictures and
the cards). These were constructed according to the require-
ments of PECS (Frost & Bondy, 1994). The initial cards used
were black-and-white pictures with drawings composed of
thick black lines. Pictures were designed by hand by a semi-
professional designer, then scanned and processed by the re-
searchers with the software program Graphic Converter. All
pictures were the same size (10 centimeters by 5 centimeters).
C.Z. was familiar with almost all of the pictures chosen. Fig-
ure 1 shows an example of the PECS pictures used.
Starting with the second phase, a communication book
was introduced. This was a three-ring binder where all pic-
tures, and subsequently word cards, were attached. Velcro was
used to attach the pictures, the word-cards, a sentence strip,
and cards with the phrases “I want” and “This is” in Greek.
The picture cards were replaced by word cards of the same size,
written in lower case letters. In subsequent phases these word
cards were reduced to approximately half the original size.
DISABILITIES
26
During the fourth phase, 66 small cards (2.5 centimeters
square) were added to C.Z.’s communication book and orga-
nized into six categories. Table 1 presents the items included
in each category during this phase.
Informal Assessment

Descriptions of Behavior. Information on C.Z.’s be-
havior patterns and psychosocial condition was gathered via
teacher reports and direct observation for 7 consecutive days,
6 hours per day. During direct observation, all of C.Z.’s dis-
crete behaviors were recorded in a notebook. The following
behaviors were noted:
• Establishing fleeting eye contact when addressed by his
teachers or caregivers for less than 5 seconds per
occurrence.
• Stereotypical movements of clapping and hand-flapping
conducted without a specific aim while standing, walking,
or sitting on his favorite chair. The frequency of these
movements was 30 per hour.
• Stereotypically walking back and forth the width of the
main corridor to the kitchen without a specific aim, three
times or more per half hour for 3.5 hours per day.
• Insistence on sitting specifically and exclusively on a
particular chair, located in a secluded area of the children’s
playroom, where he would not allow anyone else to sit.
• Not responding to requests by caregivers to enter and play
in the children’s playroom.
Communication Skills. A questionnaire administered to
teachers and caregivers indicated that C.Z. rarely communi-
cated interactively. When he wanted something edible he com-
municated by
• going toward the thing he wanted (the most frequent be-
havior pattern);

• leading (taking an adult’s hand and guiding him or her to
the desired item);
• using the sign for “come,” when he invited someone to
do something for him or to give him something, without
indicating anything else and without making eye contact;
or
• screaming or moving his head (rare).
With respect to language comprehension, C.Z. was able to
follow two one-step commands (“sit down” and “stand up”),
which were given by the trainer using a hand gesture. He
did not respond to his name auditorily, in writing, visuo-
auditorily, or by finger-spelling. With respect to written lan-
guage skills, C.Z. had a relatively sizable rote vocabulary, as he
received formal instruction via a tutor-aided literacy program.
When cued by modeling the type of task, he was able to read,
copy, and write almost 150 words (mostly nouns), indepen-
dently (30+) or with prompting (i.e., after the trainer had writ-
ten the first letter or two). His reading ability was assessed by
prompting him to match written words to pictures or actual
objects. Upon picture presentation he could finger-spell 31
words without prompting and nearly 150 words with minimal
prompting (i.e., after the trainer had finger-spelled the first one
or two letters). The 31 words were: (a) eye, hair, mouth, nose,
ears, leg, hands, and neck (body parts); (b) red, black, blue,
white, green, purple, brown, light blue, yellow, and orange (col-
ors); (c) cat, horse, goat, chicken, bird, and dog (animals); and
(d) orange, apple, lemon, strawberry, banana, and pear (fruit).
Reportedly, he had never used these written words for com-
munication and was observed only once to exhibit sponta-
neous writing: When 8 years old, he wrote the correct date of
that particular day on the blackboard in his classroom. In sum,
C.Z. did not communicate functionally with other people,
hearing or deaf, by using oral or sign language, even though

FIGURE 1. Progression of card presentation during PECS
training. The top figure indicates the initial type of card, the
middle figure the type of card including the picture and the
written word, and the bottom figure the card with just the
written word on it.
27
he had been exposed to signing both at school and at the
boarding house for 3 years and at home since birth. Further-
more, his writing and finger-spelling skills remained unex-
plored with respect to functional communication as he only
used them upon request or during formal learning tasks dic-
tated in class by his tutor. Evidently, C.Z. was not motivated
to communicate with others, nor was he directly taught how
to communicate. Therefore, the goal of the intervention was
to establish functional communication. For that purpose, the
researchers chose PECS, with a few adaptations made because
C.Z. had a profound hearing loss.
Intervention Program
Assessment of Reinforcers. Prior to the actual inter-
vention, an assessment of potential reinforcers was performed
to identify the items C.Z. found the most desirable. Three ses-
sions were devoted to the task of identifying toys and edibles.
The procedure strictly followed the principles and guidelines
of the PECS Training Manual (Frost & Bondy, 1994) by in-
terviewing others who knew the child, observing the child in
the natural environment, and conducting a formal reinforce-
ment assessment using a multiple-without-replacement assess-

ment procedure (DeLeon, Iwata, & Roscoe, 1997). For the
category of toys, a total of eight items were chosen, in order
of C.Z.’s preference: car, Playmobil©, truck, Play-Doh©, col-
ored pencils, magic markers, teddy bear, and ball. C.Z. was
hesitant to reach for edibles. He did not choose anything dur-
ing two sessions, most likely because he had been chastised by
his caregivers in the past for grabbing food. In view of this ap-
parent difficulty, C.Z.’s caregivers were asked to provide their
opinions regarding his favorite edibles. A total of nine edibles
were chosen: banana, cookie, chocolate, potato chips, apple,
pear, Coca-Cola©, orange juice, and water.
PECS Modifications
Training followed the guidelines described in the treatment
protocol of the PECS Training Manual (Frost & Bondy,
1994). Except for the seventh (additional) phase, which was
not targeted due to time limitations, PECS phases were ap-
plied with some extensions and modifications (reported in
Table 2) tailored to C.Z.’s hearing loss and writing ability.
Data Collection and Reliability
During the first three stages of PECS, data were recorded by
two trainers using assessment forms adapted from the PECS
Training Manual (Frost & Bondy, 1994). Initially, the main
trainer independently collected data while the second trainer
served as an observer. Then, at regular intervals (i.e., every 10
trials), the second trainer was asked to score over the relevant
part at the assessment forms. Only responses receiving verifi-
cation by the second trainer were considered valid. Fewer than
five disagreements occurred in this decision process, and in-
terobserver agreement was 96.5%. In subsequent phases, the
main trainer continued to be responsible for collecting data,
and the second-trainer scoring procedure was followed by each

of C.Z.’s caregivers (whoever was on duty at the time). Train-
ing of caregivers took place at the third stage of the fourth
phase.
The criterion for the trainers to move to the next PECS
step was that C.Z. exhibited at least 80% success in perform-
ing each session’s trials independently. The number of trials
per scheduled session varied from 17 to 45, depending on the
tasks used at each stage.
Results
Before the application of PECS, C.Z. had a limited, nonfunc-
tional communication profile. After the intervention he
achieved
a much higher communication level, which was completely
functional in social contexts. Table 3 provides the number of
sessions required for mastery at each of the stages.
As shown in Table 3, the first phase (teaching the physi-
cally assisted exchange) with its extension (written cards in-
stead of pictures) for both categories lasted 9 sessions, the
second phase (expanding spontaneity) lasted 11 sessions, the
third phase (simultaneous discrimination of pictures) lasted 3
sessions, the fourth phase (building sentence structure) lasted
20 sessions, the fifth phase (responding to “What do you
want?”) lasted 16 sessions, and the sixth phase (commenting
in response to a question) lasted 4 sessions.
TABLE 1
Cards Created for Phase 4
Category Written words: Items
Edibles Chips, crescent rolls, chocolate,
cookie, orange juice, Coca-Cola,

water, apple, banana, pear, bread,
orange, milk, yogurt
Toys Ball, car, truck, Playmobil, puzzle,
teddy bear
Basic needs Sleep, food, toilet
School things Pencil, eraser, pencil sharpener,
notebook, book, bag
Things for arts and crafts Colored pencils (10 words, one for
each color, e.g., green pencil),
magic markers (10 words, one for
each color, e.g., yellow marker),
scissors, glue, Play-Doh, yarn of all
colors
Useful items Glass, plate, spoon, fork, straw
DISABILITIES
28
In Phase 4 (sentence structure), the first stage (placing
a selected card next to the “I want” card) and second stage
(moving both the “I want” card and the target card, and hand-
ing the strip over) were acquired in 3 sessions, but the third
stage (use of a sentence strip to request far-remote items),
which in essence constitutes the spontaneous use of the PECS
program, was acquired in 20 days. The spontaneous use of the
communication book was a very difficult task that needed sev-
eral hours of training each day. Phase 5 began before Phase 4

was completely finished. Phase 5 was acquired 1 day before
Phase 4. Table 4 presents descriptions of communicative be-
haviors before and after intervention.
During generalization of Phases 4 and 5, C.Z. started to
use some of the signs the trainers had shown him with the
cards. In particular, the first signs he made were for water, toi-
let, food, and pencil, which he gestured during the time he
was matching the cards on the sentence strip prior to handing
them to the trainers. An unexpected outcome was the onset
of vocalizations. C.Z. vocalized during the generalization of
Phases 4 and 5, at exactly the moment he was choosing the
TABLE 2
PECS Modifications and Additions for Training a Child With
Autism and Deafness
Intervention goals Changes of PECS training Analytic
description of PECS changes
To facilitate functional use
of writing
To facilitate focus on
alternative sensory
channels (vision and
touch)
To effect multimodal
communication mode
To effect spontaneous use
of PECS
To accelerate acquisition

of spontaneous use
of PECS
Note. PECS = Picture Exchange Communication System (Frost
& Bondy, 1994).
Modification: Gradual replacement
of pictures by written words
(Phase 1)
Modification: Replacement of all
verbal praises, reassurances, and
prompts by a multi-nonverbal
communication mode
Addition: Multimodal communica-
tion responses by the trainers
(onset at Phase 4)
Addition: Multimodal communica-
tion initiations by the trainers
(Phases 5 and 6)
Addition: Dramatic increase of in-
tervention time (onset at the
third stage of Phase 4)
Modification: Preceding the third
stage of Phase 4 (spontaneous
requesting via PECS) by Phase 5
(responding to the question
“What do you want?”)
At first, pictures were presented alone; then they were presented
with written words underneath them; finally, they were com-
pletely replaced by written words. The implementation of this

extension occurred early on because during his evaluation C.Z.
had shown increased facility with the recognition of many writ-
ten words.
Throughout PECS training, all verbal praises, reassurances, and
prompts were given via nonverbal means, namely, by simulta-
neous usage of Greek Sign Language, intense facial expres-
sions, and intense clapping, as well as praise touch (such as
shoulder patting).
During and after Phase 4, the trainers’ responses following
C.Z.’s
returning the sentence strip to them involved more than verbal-
ization of the sentence. They simultaneously expressed the
sentence via Sign Language and with concurrent emphatic ar-
ticulation while holding the strip very close to their mouths to
facilitate lip-reading.
In Phases 5 and 6, written question forms replaced the verbal
questions, “What do you want?” and “What is this?” The train-
ers also expressed these questions in Sign Language and with
emphatic articulation while holding the strip very close to their
mouths to facilitate lip-reading.
The third stage of Phase 4 is a crucial stage because it targets
spontaneous use of the communication book in everyday life.
For the acquisition of this stage, the trainers decided to spend
approximately 8 hrs per day at the boarding house. The spe-
cific goals were to introduce the whole program in C.Z.’s every-
day life and to instruct his caregivers in the use and
functionality of the PECS program.
Due to time restrictions related to the contracting institution
providing the speech therapy program, the order of Phase 4
(Stage 3) and Phase 5 was reversed in hope of enhancing com-
pletion of the PECS program within the assigned time frame. It

was hypothesized that an earlier introduction of Phase 5 would
facilitate the acquisition of Stage 3 of Phase 4. Hence, the
trainers decided to begin the application of Phase 5 after
Stage 3 of Phase 4 was introduced but before it was acquired,
that is, before C.Z. learned to express his needs spontaneously
via the sentence strip “I want ___ .”
29
cards to put them on the sentence strip. These vocalizations
seemed like an effort to read each word aloud. Until then no
similar vocalizations had been observed, although he had been
able to recognize the words for 2 years prior to the study.
The acquisition of a communication system was found to
have a positive impact on C.Z.’s psychosocial functioning.
Table 5 presents descriptions of psychosocial behaviors before
and after intervention.
Another observed outcome was the change of other chil-
dren’s behavior toward C.Z. According to his caregivers, the
other children had always treated C.Z. very positively (even
protectively), but after the application of PECS their behavior
became even more positive. In particular, they began to play
with him more and often hugged and kissed him. Many times
they tried to be his trainers, with great success, by taking the
card with the written question “What do you want?” and ask-
ing him in the same way his trainers did.
Moreover, a positive psychosocial outcome of the PECS
intervention was the observed change toward his mother.
Prior to PECS, C.Z. had never expressed any anticipation of

her arrival to take him home. Even when he did not see her
for a long period of time, he reacted almost indifferently. For
the first time, a few weeks before the intervention was com-
pleted, he exhibited new behaviors toward his mother when
she came to take him home. At first he eagerly anticipated her
arrival; then, when his mother came, he quickly grabbed his
bag and ran toward her. He was smiling, and his mother re-
ported that was the first time she had seen him so happy. She
assured the trainers that his general behavior at home had im-
proved as well.
Maintenance Program and
Follow-Up Observation
During the 4-month maintenance program, C.Z.’s communi-
cation book was available at all times and in all settings. Ac-
cording to the additional trainers’ reports, during this period
C.Z. continued to exhibit spontaneous usage of PECS, both
to request and to comment.
Six months after the main intervention period, a 2-hour
observation was arranged at the boarding house. The recorded
behaviors suggested that the intervention continued to be ef-
fective. Specifically, the trainers recorded the following: (a)
C.Z.
spontaneously requested five items by using his communica-
tion book; (b) he spontaneously requested toilet and water
through Greek Sign Language; (c) he understood two orders
that were given to him through Greek Sign Language (“wash
your hands” and “bring your bag”); and (d) he responded cor-
TABLE 3
Stages and Number of Sessions for PECS Acquisition
PECS phases Stage Sessions

Phase 1: Teaching the physically assisted exchange Exchange
pictures for toys 4
Exchange written words for toys 2
Exchange pictures for edibles 1
Exchange written words for edibles 2
Phase 2: Expanding spontaneity Remove card from
communication board 2
Increase distance between book and trainer 2
Increase distance between child and book 4
New communication partners 3
Phase 3: Simultaneous discrimination of pictures Exchange via
picture discrimination 1
Correspondence checks 1
Use of small cards 1
Phase 4: Building sentence structure Placing card in the “I want
___ ” sentence frame 1
Constructing and delivering the sentence “I want + card” to
trainer 2
Requesting remote, nonvisible objects 17a
Phase 5: Responding to “What do you want?”b Asking the child
with zero-delayed pointing prompt 0.5
Asking the child with delayed pointing prompt 0.5
Asking without pointing prompt 15a
Phase 6: Commenting in response to a question Placing card in
the “This is ___ ” sentence framec 3
Two-question discrimination 1
& Bondy, 1994).
aAll-day sessions. bPhase 5 was introduced prior to Stage 3 of

Phase 4. Following onset of the Stage 3 of Phase 4, C.Z.
requested 15 items either as a response
to the question or spontaneously. c The question “What do you
see?” and the three-question discrimination stage were not used
due to time limitations of the
intervention program at the school.
DISABILITIES
30
rectly to alternating written questions, “What do you want?”
and “What is this?”
Furthermore, his caregivers commented that he used many
more Greek Sign Language signs to communicate. He often
smiled and was very affectionate with his trainers. He exhib-
ited fewer stereotypical movements with hands. Most of the
time he sat on the couches with other children; only once did
he go toward his favorite chair, but did not sit on it.
Discussion
The primary goal of this study was to establish a functional
communication system for a 10-year-old boy with profound
hearing loss and autism, who was unable to communicate
functionally using verbal or nonverbal language. The commu-
nicative results described above show that this goal was met
with adequate success. With 4 months of intensive interven-
tion, C.Z. learned to use a functional communication tool (the
PECS communication book) spontaneously.
Interestingly, the training period for PECS acquisition in

this case was longer than for 3 hearing children with autism
who were 3–8, 5–9, and 12 years old, all of whom acquired
the six phases in 11 to 12 sessions (Charlop-Christy et al.,
2002). This difference might be attributed to C.Z.’s multiple
disabilities. However, C.Z.’s training period is similar to that
reported for a 3-year-old boy with autism (Bondy & Frost,
1994). Hence, it seems that the pace for PECS acquisition de-
pends on factors other than age or the presence of multiple
disabilities. Because longitudinal data on C.Z.’s progress are
lacking, one can only speculate that younger children would
reach higher levels of language than older children. Nonethe-
less the remarkable finding is that, overall, within one-third of
a year, C.Z. achieved satisfactory command of PECS for com-
munication purposes.
Additionally, the entire intervention led to very positive
changes in C.Z.’s psychosocial development, elements which
were not targeted by the intervention program. During the
final phases of PECS, he started to socialize (i.e., play and in-
teract with his peers) and ceased having an obsession for sit-
ting on the isolated chair. This significant change may be
attributed to increased communication skills, which play a crit-
ical role in the development of socialization skills. Another
outcome was the reduction of behaviors characteristic of
autism, as C.Z. reduced the frequency of stereotypical move-
TABLE 4
Communication Behaviors Before and
After PECS Intervention
Before After
Going toward the things
he wanted

Guiding someone to the
things he wanted (lead-
ing) without looking at
the communication
partner
Making a come sign with
his hand without look-
ing at the communica-
tion partner
Rarely screaming or mov-
ing his head
No responding to
questions
& Bondy,
1994).
Spontaneously exchanging the sen-
tence strip (with a complete
three-word written sentence) for a
particular item or skill (i.e., sponta-
neously initiating communication)
Interacting with a communication
partner in order to ask for some-
thing and usually establishing eye
contact before going to his com-
munication book
Simultaneously beginning to use
signs from Greek Sign Language

and almost always looking at his
communication partners
No screaming, no head moves
Responding to questions “What do
you want?” and “What is this?”
TABLE 5
Psychosocial Profile of C.Z. Before and After
PECS Intervention
Before After
Rare eye contact lasting fewer
than 5 seconds with train-
ers and other communica-
tion partners
Many stereotypical move-
ments, especially clapping
and flapping hands
A stereotypical walk from the
width of the main corridor
to the kitchen, approxi-
mately six times per hour
A severe obsession with sit-
ting on a particular isolated
chair, on which he did not
let anyone else sit
Almost complete indifference
in the presence of other

people (except for rare
cases); flat affect
Refusal to enter and play in
the children’s playroom
& Bondy,
1994).
Established eye contact for more
than 15 seconds with trainers
and other communicative part-
ners during interactions
Reduction of all stereotypical
movements
Stereotypical walk occurred only
three or four times per day at
most
Rarely sat on “his” chair any
more; instead, preferred to sit
on the common-room couches
with the other children, and
surprisingly, showed indiffer-
ence when someone else sat
on his chair
Became expressive with others
and had body contact with
them much more often; devel-
oped a positive affect, having a
smiling face and many times
hugging others spontaneously

Entered playroom daily, thus be-
ginning to interact with other
children during play
31
ments. Bondy and Frost (1998), Finnegan et al. (1987), and
Charlop-Christy et al. (2002) have documented the positive
contribution of PECS to the alleviation of behavior manage-
ment problems in individuals with autism. Increases in social
behaviors and decreases in aberrant and stereotypical behav-
iors mirror the findings of a Natural Aided Language inter-
vention case study of an adolescent with autism (Cafiero, 2001).
Several complementary explanations can be posited for the
behavioral and social outcomes of PECS as used with C.Z.
First, after the intervention C.Z. could make his desires and
needs known; this newly acquired communication ability may
have reduced frustration and concomitant aberrant behaviors.
Alternatively, C.Z.’s communication competency may have
brought about a global behavioral change in his living and
learning environment, which in turn may have had a positive
impact on his behavior. Both adults (teachers, tutors, care-
givers) and other children were able to interact with C.Z. via
PECS. Hence, “his change” may have brought about “their
change,” facilitating more change on C.Z.’s part, and so on.
Such chaining of positive changes may have been conducive to
interactions triggered by C.Z.’s newly acquired communica-
tion ability. Pertaining to language skills, he started acquiring
some Greek Sign Language concepts for the first time in his
life, and 6 months later this ability had expanded. This acqui-

sition can be compared to the acquisition of verbal language
concepts by hearing children with autism after the application
of PECS (Bondy & Frost, 2001). Like many of those children,
who begin to speak and express themselves in their language
by connecting the verbal word with the picture, C.Z. began
to “speak” in his language, Greek Sign Language, by con-
necting each sign with the written word. Thus in the case of
C.Z., PECS may have functioned as the means to acquire sign
language.
Moreover, the fact that C.Z. began to make vocalizations
that he had never made before leads to the conclusion that the
particular intervention program, although it does not directly
target verbal language, encourages its acquisition. It should be
noted that onset of vocalizations is rare in the case of a 10-
year-old deaf child, especially for those with multiple disabili-
ties. Nevertheless, vocalization is an expected outcome when
PECS is used (Bondy & Frost, 1994; Bondy & Frost, 1998;
Charlop-Christy et al., 2002; Ganz & Simpson, 2004). This
newly acquired behavior was concomitant with PECS usage.
Interestingly, C.Z.’s communication development encom-
passed both language and speech areas in a rudimentary way,
despite his nonverbal orientation.
The anecdotally reported array of unexpected positive
changes—increases in social interactions, increases in vocali-
zations, decreases in aberrant behaviors, emergence of sign
language, and changes in peer responses and positive affect—
resembles the “Pygmalion effect” (Rosenthal & Jacobson,
1992), according to which students perform better simply be-
cause they are expected to do so. C.Z.’s communication
change may have reinforced the staff ’s attitudes and expecta-
tions toward C.Z., thereby increasing their interactions; the
latter change may then have been incorporated into peer atti-
tudes toward C.Z. These changes deserve systematic future

study to document PECS outcomes. An alternative interpre-
tation is that C.Z.’s progress may not be attributed to PECS
per se but to the intensiveness of the intervention, since the
particular intervention that C.Z. received was more intensive
than any of the other previous services.
One limitation of this study includes the scoring of C.Z.’s
attempts in each session, which was conducted by both train-
ers in unison and not independently. Anecdotally, all staff
members of his boarding school who had known him for
3 years commented on his skill acquisition and verified that it
was a dramatic change. Another limitation was that the data
on his behavioral and social patterns collected at the beginning
and end of the intervention were merely descriptive. This pit-
fall occurred because the original focus of this study was the
change of C.Z.’s communication profile. More quantifiable
and continuous data on behavioral and social patterns within
the intervention period might have given insight on how and
when his behavior began changing. Finally, data on fidelity of
the PECS implementation were not collected across the vari-
ous trainers. It is possible that variations of implementation
may have enhanced or inhibited C.Z.’s acquisition of func-
tional spontaneous communication.
This study confirms the effectiveness of the Picture Ex-
change Communication System, with a few adaptations, in the
case of combined autism and profound hearing loss. It also re-
ports the impact of communication on C.Z.’s social life and
confirms the PECS creators’ findings that their system encour-
ages the emergence of both speech and language production.
Because this study reports only a single case, it is imperative
that more research be conducted with individuals with autism
and hearing impairment to validate the finding that PECS can
facilitate the development of communication in children with
multiple disabilities, even at older ages.

ABOUT THE AUTHORS
Georgia A. Malandraki, MA, is a PhD candidate in speech–
language
pathology at the University of Illinois at Urbana-Champaign.
Her cur-
rent interests include developing diagnostic and therapeutic
procedures
for individuals with swallowing and voice disorders, as well as
studying
the neural correlates of swallowing and voice in normal and
disordered
populations. Areti Okalidou, PhD, is an assistant professor of
speech–
language pathology at Macedonia University. Her current
interests in-
clude speech and communication development of children with
hearing
loss and other developmental disabilities, speech and
communication
following cochlear implantation, detection of children with
commu-
nicative impairments and intervention. Address: Areti Okalidou,
De-
partment of Educational and Social Policy, University of
Macedonia,
156 Egnatia Str., PO Box 1591, Salonika 540 06, Greece; e-
mail:
[email protected]
AUTHORS’ NOTES
1. We would like to thank Helen Drosinou, Louisa Voniati,
Anna Ser-
petsidaki, the Dean, the teachers, and all the staff members of
the

DISABILITIES
32
boarding school for their kind assistance and dedication that
they ex-
hibited in C.Z.’s intervention program.
2. Authors are listed alphabetically.
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