Picture Exchange Communication System (PECS)
Abstract 3
Introduction .. 4
Purpose . 6
Literature Review . 7
Synthesis .. 15
Method .. 15
Overview of Design .. 15
Results and Discussion 16
Conclusion 27
References .. 31
Tables 35
Abstract
This project set out to examine the efficacy of a communication system known as the Picture Exchange Communication System (PECS), which is mainly used by individuals with autism. It is estimated that 30 to 40% of children with autism may not develop functional speech (Gerenser, 2009). With that being noted, this project broke down the PECS system in order to understand how each stage worked and why this method seemed to be the most effective among the other systems available to those who are unable to verbally communicate. While researching the efficacy of PECS, I found evidence that supported that with the PECS intervention being the initial communicator, the individual was able to develop some verbalization. After an extensive analysis of research related to the efficacy of the PECS, this project found that the efficacy of the PECS intervention is as varied as the autism spectrum itself. PECS has the ability to promote verbal communication only if the participant is able to complete all six phases of the PECS treatment. Most children treated with PECS were able to learn to communicate vocally during the third and fourth phase of treatment. Based on this information, PECS should be used by professionals as the first method to assist individual with autism. Once PECS has begun, treatment should be continued through all stages in order to enhance verbal communication for the patient.
Keywords: Picture exchange communication system, autism, PECS, augmentative and alternative communication.
Picture Exchange Communication System (PECS)
In 2010, the Centers for Disease Control and Prevention reported that the overall prevalence of a childhood diagnosis of autism spectrum disorder [ASD] is 1 in 68 children (Baio, 2010). Boys are four times more likely than girls to be diagnosed with autistic spectrum disorder (Autism Speaks, 2015). Autistic spectrum disorder is a chronic disorder that affects the psychic-emotional system. The neurodevelopment disorder is characterized by diminished emotional expression; limited, regressed or inability to communicate; repetitive behaviors; and a reduced ability to function in social settings. Autistic spectrum disorder causes a wide spectrum of symptoms including: language and communication limitations, resistance to changes in routines and schedules, preoccupation with repetitive behaviors, and difficulty with social relationships (Slaughter, 2015). Autism Speaks (2015) reported that half of the children who have received some form of an autistic spectrum diagnosis were unable to secure a steady job by the age of 25, and 84% of those diagnosed continue to reside with their parents as adults. Every year, 50,000 children grow out of their school-based autism treatment plans. The National Institute on Deafness and Other Communication Disorders (2010) reported that somewhere between 30-50% of individuals within the spectrum remain limited to minimal verbal skills throughout their lives.
A great deal of research has been done to identify the best method of treating this chronic condition; however, the cause of autistic spectrum disorder is unclear. Researchers are yet to find any genetic markers or biochemical markers that are distinct to the autistic spectrum disorder (Whittaker, 2012). It is most often diagnosed in early childhood when children demonstrate a delay or regression of the ability to communicate and interact socially with their peers. Autistic spectrum disorder often causes a delay in the child’s ability to play imaginatively and function (Slaughter, 2015). The scope of autism’s symptoms affects all of areas of the individual’s life. Often, the autistic behaviors cause the individual to become socially isolated and further reduce their ability to learn social skills.
Children often demonstrate signs of autism by the age of twelve months of age. At this young age, children predisposed to developing autism will avoid eye contact and lack the development of early verbalizations (Rogers and Vismara, 2008). The still-face paradigm research set out to aid in early diagnosis of autistic traits in non-verbal infants. In two segments of two to three minutes each, the parents actively demonstrated a blank facial expression to the non-verbal infants. The non-verbal infants engaged with their parents’ facial expressions in the first segment but became distressed and eventually avoided eye contact. Children who reacted intensely to the still face were at a much higher risk of being later diagnosed with autism than their peers who showed only a minimal reaction to their parent’s blank expression (Cohn, Campbell, and Ross, 1991). By the ages of two to four autistic children will begin to engage in repetitive behaviors (Whittaker, 2012). Among those who are diagnosed, approximately 30 to 40 % of those children are nonverbal (Gerenser, 2009).
One group of researchers (Nah, Young, & Brewer, 2014) evaluated the predictive validity of Autism Detection in Early Childhood (ADEC), a well-established screening tool, and the Childhood Autism Rating Scale (CARS), for long-term outcomes of children with ASD engaged in an early intervention program. They concluded that both screening tools performed similarly in terms of predicting clinical diagnostic outcome and overall adaptive functioning level at an interval of two years following the initial early childhood assessment.
With so many children on the spectrum and nonverbal, how do they communicate? Several tools that are utilized by those that are unable to verbalize their wants and needs are: sign language, computer software, assistive technology devices, and Picture Exchange Communication System (PECS). This project concentrated on the Picture Exchange Communication System (PECS). Andrew S. Bondy and Lori Frost developed the PECS system in 1984 (National Autism Resources, 2015). PECS is known as an augmentative/alternative communication intervention program that was developed to teach functional communication to individuals with limited speech. The Picture Exchange Communication System in now one of the most widely used treatment tools for nonverbal children with autism.
Purpose
This study examined the efficacy of PECS in the treatment of non-verbal individuals with autism. Research focused on the long-term outcomes of PECS. PECS was first developed in the eighties and has been widely used to help autistic nonverbal children learn to communicate. PECS’ six phases are designed to encourage the children to communicate (Codington-Lacerte, 2013). This study examined the effectiveness of PECS when presented to a nonverbal child at an early age. This project broke down and thoroughly explained each phase involved within the PECS intervention to examine the efficacy of this system as well as pursuing answers to the following questions:
Research Question 1: Compared to other types of interventions, how effective is PECS in promoting functional communication for individuals with autism?
Research Question 2: To what extent, or under what conditions, does the intervention promote vocalization or focus on the act of picture exchange?
Research Question 3: What is the success rate for conversational speech among those who begin PECS at a young age?
The study analyzed the effects/outcomes of PECS. The results obtained from this study are to be used to clarify further the most efficient approach when PECS is utilized and to determine what areas are in need of additional research.
Literature Review
This literature review focuses on a brief history of autism, the development of PECS, and the impact that the intervention has had upon nonverbal children with autism. An explanation of each phase is included.
History of Autism
Dr. Leo Kanner introduced the term autism in 1943. He reported on his observations of eleven children who had clinical features that appeared to constitute a unique syndrome, later termed “early infantile autism” (Eisenberg & Kanner, 1956). The pathognomonic disorder that was described in Kanner’s original paper (1943) was characterized as ‘the children’s inability to relate themselves in the ordinary way to people and to situations from the beginning of life’ (p. 566). A distinctive feature that Kanner noted from his observation was the failure to use language for the purpose of communication. Since Kanner’s publication, the term autism has evolved. Autism Speaks (2016) defines autism spectrum disorder (ASD) and autism as general terms for a group of complex disorders of brain development. These disorders are characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication, and repetitive behaviors. As of May 2013, the fifth publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) merged all autism disorders into one diagnosis of ASD. Previous manuals recognized the following disorders as subtypes of autism: autistic disorder, childhood disintegrative disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS) and Asperger syndrome. University of San Diego School of medicine (2016) defined autism as a pervasive developmental disorder involved with an abnormal development and function of the brain. Individuals diagnosed with autism show decreased social communication skills and restricted and/or repetitive patterns of behaviors or interests. Once an autism spectrum disorder diagnosis is established, a treatment or intervention plan is tailored to address the specific needs of the individual. A nonverbal individual diagnosed with autism spectrum disorder who lacked communication skills would benefit from a treatment plan focused on communication and verbalization.
Development of PECS
The Picture Exchange Communication System (PECS) is a training system that was developed to teach nonverbal children with autistic spectrum disorder a quickly acquired, self-initiated functional communication system (Bondy and Frost, 1994, 1998). This method is broken up into six different phases that progress from teaching the individual how to communicate using pictures without verbal prompts to eventually using multipicture sentences. The PECS six phases encourages the individual to progress in his or her communicative abilities. The phase titles and descriptions used for PECS were obtained from Bondy and Frost’ book A Picture’s Worth (2011).
Phase one: Initiating communication. The first step in PECS is to teach the learner to initiate a request. When a powerful incentive is established (e.g. candy, favorite toy), the program can begin. The instructor will provide the child with a picture of the desired item. The child is encouraged to select a picture of an item or activity and hand it to their communication instructor. The instructor responds verbally and then gives the child the item or activity shown in the picture.
Phase two: Expanding the use of pictures. The goal of this phase is to increase the distance from the learner to the instructor, the distance from the child to the pictures, and the number of items the child can request. In this phase, the teacher introduces the communication binder to the child. This binder holds the child’s picture inventory.
Phase three: Choosing the message within PECS. The first two phases concentrated on one picture icon at a time. The difference in this phase is that a distractor picture is introduced. With only one picture to choose from, it can be difficult to establish if the intervention is successful. When discrimination training is introduced, the learner has to select the target picture from a choice of multiple pictures. Error correction strategies are used when the response is incorrect.
Phase four: Introducing sentence structure within PECS. The fourth phase of the PECS is critical to the development of verbal language (Codington-Lacerte, 2013). In this phase, the learner begins using simple sentences structure along with the picture cards to encourage the learner to repeat the phrase verbally. The simple sentences such as “I want” or “I see” are placed on the Velcro strip of the PECS binder followed by the use of a picture card to complete the sentence. Nonverbal autistic children who gain the ability to verbalize, do so during this phase of the PECS.
Phase five: Teaching answering simple questions. The structure of the fifth phase of PECS is different from the other phases. The learner is encouraged to respond to the question “What do you want?” by exchanging the sentence strip.
Phase six: Teaching commenting. Once the learner has successfully replied to “What do you want?”, the instructor can teach the learner how to respond to other simple questions, such as, “What do you see? What do you hear? What do you have?” For this phase to be effective, it should be noted that comments result in social consequences, not receiving the noted item. If the instructor asks: What do you see?” and the child responds “I see car”, the correct response would be “Yes! It is a car! I see car too!” The child would not be handed the item (Harris, 2011).
Impact of PECS
Whittaker (2012) stated that despite advancement in ASD intervention, the prognosis for those who are still non-verbal by five to seven years has remained extremely poor. They are most likely to be diagnosed as having severe autism and developmental disabilities, and to exhibit “challenging” and self-injurious behavior, and to have very poor long-term outcomes, including institutionalization. To coincide with Whittaker’s finding’s, Autism Speaks (2015) reported that over half of the children with autism will wander away or randomly bolt. Additionally, Autism Speaks (2015) explains that severe autism will cost over $2.4 million throughout a child’s lifetime.
According to a study done by Whittaker (2012), at the point when the outcomes of children being treated using PECS splits into the two groups the non-verbal children would best benefit from nonverbal communication acceptance. Whittaker suggested that children over the age of seven who were non-verbal despite early intervention efforts would still benefit from the PECS intervention if the treatment moves towards more of a social communication tool, rather than verbalization tool.
Whittaker (2012) set out to examine why children suffering from the most severe cases of non-verbal Autism are often left out of studies. Whittaker proposed a new speech aversion hypothesis “Aloof, non-verbal young children (<7 years), with severe autism (CARS ⩾37), but without significant dysmorphic features, will show aversive reactions to complex speech (>2–3 words), but not to a silent interlocutor, or one imitating their vocalizations, in proximal encounters” (p. 17). He attributed the trend of exclusion of severe cases of autism from most research studies to a decades old medical tradition where autism was being treated as a single disease rather than a spectrum of disorders. Whitaker discovered that many nonverbal five year olds with autism had higher levels of cognitive function than their communication abilities would suggest.
Benedict (2007) conducted a literature review on the most effective communication interventions available for children with autism. Children suffering from delayed or disordered language are at a greater risk of experiencing behavioral, social and emotional difficulties, but by “identifying the most effective intervention approaches for promoting language acquisition and supporting the development of communication skills in young children with autism is important” (p. ii). Through her research Benedict found it to be beneficial to combine several techniques and strategies rather than only utilizing one specific intervention. By utilizing a combination of interventions it is likely that the child will produce an increase in both language and communication skills. She concluded that not just one intervention could be deemed the most effective over another. For children to successfully increase both language and communication, it is recommended that a combination of strategies must be implemented.
A multifaceted, intense behavior modification approach to treat children with autistic spectrum disorder is seen as the most effective course of treatment. The intense behavior modification treatment may include PECS along with focusing on behavior modification strategies to encourage the children to reduce their disruptive behaviors.
An integrated approach to treatment ensures that the disorder’s symptoms are being addressed systematically as they become evident in day-to-day situations. The use of intensive behavior modification attempts to minimize the disruptive behaviors’ that often cause isolation and social restrictions. Successful behavior modification will reduce the disruptive behaviors associated with autism increasing the patients’ quality of life. Once the disruptive behaviors are addressed treating the academic and communication issues associated with autism becomes easier (Leaf, Taubman, McEachin, Leaf, & Tsuji, 2011).
A study conducted by Leaf, Taubman, McEachin, Leaf, and Tsuji (2011) set out to examine the results of the intensive behavior modification treatment of autistic children and they long-term outcomes. Lovaas first initiated the intensive behavior modification program in 1987. The program uses positive reinforcement techniques and punishment to encourage participants to modify their disruptive behaviors. The early study of the results of intense behavior modification came from a study done by Lovaas of 19 children and a control group (as cited in Leaf et. al.). Nine out of the nineteen children demonstrated average IQ and no longer suffered from autistic spectrum disorder after their treatment. The remaining children treated using intensive behavior modification still scored low to moderately low on the IQ chart and required ongoing specialized education to cope with their autistic symptoms. In the control group, eight children still scored low on the IQ test and required specialized education while the remaining eleven scored extremely low on the IQ tests and demonstrated the same symptoms of autism as they did prior to the research. Many studies have since been conducted proving the intensive behavior modification’s effectiveness in reducing the symptoms of autism. Leaf’s research group came to the conclusion that intensive behavior modification was effective in alleviating the behavioral difficulties that prevented autistic children from being able to learn.
The study conducted by Leaf and colleagues (2011) analyzed the outcomes of 64 participants receiving treatment in four different offices. Of the 64 participants, 25 children were able to meet the criteria to be included in the best outcome Group one, using the more stringent definition similar to that of Lovaas (1987). Twelve of the 25 children who reached the best outcome status returned to regular education and required no further treatment. After the full treatment duration, 45 of the 64 participants receiving the intensive behavior modification treatment met the best outcome status and required minimal additional academic supports. At the beginning of the study, the mean IQ of the study group was 77 after the full course of intensive behavior modification, the mean IQ of the group was 100. The study found that the child’s IQ at intake was a significant predictor to their results. The higher their initial IQ, the more likely their status would significantly improve with treatment. The children’s’ age at initial treatment was not found to contribute to their status improvement. The only correlation found regarding the age of the participants was that children with higher IQ’s were often diagnosed later.
Though communication is only a small part of the intensive behavior modification treatment of autism, it effectively treats the symptoms of autism that impair learning. Early intervention was found to be critical for the prognosis of autistic children. However, Leaf’s research team (2011) came to the conclusion that intensive behavior modification in the first two years of treatment significantly improved the children’s capability for treatment. Children who received treatment that focused on a reduction of problem behaviors and preparation for learning experienced a significant reduction in their autistic limitations. In the first two years of intense behavior modification, the PECS system was used to address the children’s communication limitations. After the first two years of intense behavior modification, the children’s treatment shifted to focus on language development and play therapy. In comparison, children who began their treatment by learning how to communicate showed better results from additional treatment. The remaining 19 children who could not reenter their regular classroom after treatment still showed an improvement in their ability to function and participated in additional treatment programs that focused on their language and communication skills. The researchers observed a trend that children who excelled after only one year of intensive behavior modification were most likely meet the best outcome status.
The organization Autism Speaks (2015) funded a study that reexamined 535 children between the ages of eight and seventeen who had been diagnosed with nonverbal autism prior to their fourth birthday (Wodka, Mathy & Kalb, 2013). By age four, these children were still non-verbal; some could speak a few words but none in this group could say a verb. Most of these children could now speak, contrary to the beliefs of researchers. Of these nonverbal autistic children, 47% later learned to speak fluently, and over 70 % of the children in this group could speak in simple sentences. The researcher found that most of the fluent speakers in this group had above average IQs when assessed using nonverbal testing methods. The children who learned to speak also suffered from lower levels of social impairment. The researchers discovered that the children’s repetitive behaviors did not have any impact on their ability to learn language (Wodka, Mathy & Kalb, 2013).
Summary and Synthesis
The literature review provides a clear understanding of the history of autism, the evolution of the definition, and the term itself. The other area of focus was the overview of the communication tool: Picture Exchange Communication System. In order to understand the contents of the review, it was necessary to provide a breakdown of the six phases that made up the PECS intervention. PECS has been found to be an effective intervention for the treatment of verbal impairment resulting from autism. For this reason, this study analyzes and explains PECS.
Method Overview
The purpose of this integrative project was not to conduct a new study on the efficacy of PECS but to conduct a systematic literature analysis. This literature search utilized the National University Library to gain access to peer-reviewed articles that were relevant to the subject matter. Step one was to establish the keywords that were relevant to the subject. Once keywords were determined: PECS, Effectiveness of PECS, Picture Exchange Communication System, autism, autism spectrum disorder, augmentative and alternative communication, language delay, and Bondy and Frost. Step two was to log into the National University library system and locate the resource section. This section had several different options to choose from. The researcher utilized the options: “A-Z Database List and A-Z Journal List.” Step three was to input keywords, which then produced a list of the online reference systems where the articles, studies, and reviews could be located. Step four was to scan the title and abstract section for relevance to the subject matter. Specific articles that were chosen for this project focused predominately on PECS. Literature reviews and studies that were used within this project were obtained from the following databases: Academic Search Premier, EBSCO, ProQuest Central, Psychology and Behavioral Sciences Collection, and Sage Journals. The resources chosen for this study focused predominately on the issues presented in the research questions (See Table 1 and Table 2).
Results and Discussion
A variety of research has been conducted to determine the effectiveness of PECS in promoting functional communication for individuals with autism, the extent to which PECS intervention promotes vocalization or focus on the act of picture exchange, and the success rate for conversational speech among those who begin PECS at a young age.
The predominate results of the research discussed below reveals that PECS is as varied as autism itself. It has the ability to promote verbal communication only if the participant is able to complete all six phases of the PECS treatment. PECS was an effective intervention that can promote a functional communication system for those individuals with autism spectrum disorder as well as other developmental disabilities. And, PECS training tool is effective in the encouragement of communication.
How effective is PECS in promoting functional communication for individuals with autism?
Flippin, Reszka, and Watson (2010) conducted a study on the effectiveness of this system found evidence that the overall effectiveness of the PECS approach for communication outcomes with children with autistic spectrum disorder is promising although not yet established. Evidence for the effectiveness of the approach on speech outcomes is not as strong. More empirical research should take place in order to examine the gains in speech and communication. This type of research provided a more extensive outlook on whether or not PECS is a precursor to an increase in conversational speech. A meta-analysis of eight single subject experiments conducted by Flippin, Reszka, and Watson came to the recommendation that the fourth phase of the PECS training model should be used as a division point. The group recommended that phase four could be used to encourage verbal development in participants who are responding verbally in their training. After training the majority of the children trained by the PECS model showed only limited gains in their ability to communicate and even more limited advances in their speech development.
Yonder and Stone (2006) examined the outcome of 36 children diagnosed with autism, between the ages of 18-60 months of age. The participants were split into two groups. One group received Responsive Education and Prelinguistic Milieu Teaching [RPMT], and the other group received training using the Picture Exchange Communication System [PECS]. Each treatment was delivered to the participants for a maximum total of twenty-four hours over a sixth-month period. The parents of the participants in both study groups also participated in fifteen hours of training to support their child’s participation in their autism treatment training. Yonder and Stone conducted the study to test the relative efficacy of PECS versus RPMT on spoken communication. Tests were administered at pretreatment, post-treatment, and six-month follow-up periods. Yonder and Stone found that PECS was more successful than RPMT in terms of an increase in the number of non-imitative spoken communication acts and in the number of different non-imitative words used in the post-treatment period. An exploratory analysis revealed that the growth rate of the number of different non-imitative words was faster in the PECS group than in the RPMT group.
Preston and Carter (2009) conducted a study on the efficacy of the PECS system. They found that even though PECS can be an effective system, there is an issue in regards to spontaneity. The child may become dependent on a partner to establish the communication exchange, instead of independently seeking spontaneous communication with an individual. The picture maybe the only reason a child communicates, instead of communicating for social interaction. The study also found that there is no “comprehensive review of empirical literature specifically examining the PECS approach of Frost and Bondy (1994,2002)” (p. 3). Preston and Carter conducted extensive studies: single-subject studies, quasi-experimental group studies, and randomized controlled trials (RCT) studies. They found that without an adequate representation of RCT studies, conclusions were unable to be determined in regards to the PECS interventions, and recommended that further research must be done to exam both effectiveness and efficacy in applied settings. Preston and Carter had an extensive data collection for single-subject studies. Sample size was 15-20 participants in a single-subject study. In total, there were 456 participants separated into 27 studies. The design of this study was a qualitative meta-analysis in order to evaluate and understand how effective PECS is and if speech is increased. The study found that PECS training was the most effective manner of treating nonverbal children with autism. The study also agreed with other researchers that most often children learn to verbalize during the third or fourth phase of PECS. The PECS treatment was best fitted to children with very little communication ability. Preston and Carter concluded that further research needed to be conducted in order to establish if the PECS intervention would be beneficial in terms of increasing the ability to vocalize. The study raised the question of whether or not the PECS intervention encouraged verbalization. The researchers suggested that PECS was initially more effective to model nonverbal communication tactics. Though the six phases of the PECS are intended to progress towards verbal communication after the third phase of the program, most often when children fail to progress from the third or fourth phase of the PECS training, their prognosis is grim. At this point does the PECS training program teach the participants alternative forms of communication (Preston & Carter)?
Tincani and Devis (2011) conducted a meta-analysis study of 16 peer reviewed single-subject participant studies on PECS with percentage of non-overlapping data (PND) as the metric of effect size. The purpose of this study was to examine the efficacy of PECS in establishing functional communication and speech in individuals with autism and other disabilities. The study is composed of 44 participants with PECS as the independent variable and picture exchange and vocalization as dependent variables. Of the 44 participants, data on picture exchange were graphically depicted for 41 participants, whereas data on vocalization were graphically depicted for 12 participants (p. 460). The results from Tincani and Devis’ meta-analysis study indicated that PECS is a functional mechanism that can be trusted when it comes to the promotional of adequate communication to people who are suffering from ASD among other disabilities. Results show little bias when it comes to various aspects that include age, gender among others. According to the analysis of Bondy and Frost (2014), these findings are said to be consistent and reflective of the previous ones that have ideally focused on the revelation that augmentative communication systems are critical when it comes to enhanced communications for those individuals who have autism among other disabilities. The results from phase one to three indicate that communication initiated by the child is enhanced with others, thus helping to nurture future communicative aspects that are critical to their lives. Phase four and five produced inconclusive results, which made it difficult to determine if whether an advancement in communication took place in the child in relation to the advancement in age. Expression labels and intraverbals are some of the aspects for which the study cannot account, thus requiring advanced analysis. It is also indicated in the results that of the 41 participants in the study, 20 did not have autism complications. This indicated that PECS is still effective for the complications that can be said to be beyond autism and that can be essential in other aspects.
The results of Tincani and Devis (2011) assisted in establishing that PECS is an effective mechanism when it comes to facilitating communication for children who have various disabilities, not only autism as it has been widely considered by initial research findings. PECS adds various dimensions on the overall study where it aims at indicating that indeed PECS is a fundamental communication enhancing mechanism among children. The use of six phases in the study is going to indicate that the entire study can be undertaken in an elaborate framework that helps to enhance the quality of the findings that are critical in enhancing future literature (Frost & Bondy, 2014).
Does the intervention promote vocalization or focus on the act of picture exchange?
A series of studies conducted by Tincani, Crozier, and Alazetta (2006) focused on the effects on manding (the request for a desired behavior; term is used in behavioral therapy) and speech development for school-aged children with autism. The purpose of this specific project was to examine two different variables. Each participant was able to “demonstrate an increase in levels of demanding after implementation of PECS” (p. 177), along with an increase in speech as each phase progressed. In study 1, two school-aged children with autism were taught PECS within a delayed multiple baseline design. Study 2 was conducted to confirm a functional relationship between the vocal reinforcement in phase four and increased speech for an additional participant. Results from both investigations provides evidence that “aided communication systems such as PECS are effective in teaching basic communication to non-verbal children with autism” (Mirenda, 2001, p. 183) and also encouraging speech in some users, although speech is not the primary goal of augmentative and alternative communication (AAC) systems.
The overall effect of the PECS training system is intended to be an increased ability to communicate. A study completed by Jurgens, Anderson, and Moore (2009) examined the effects of the PECS as they related to the participants’ overall functional social skills. The research team concluded that the PECS encouraged the learners to initiate and participate in communication, which could lead to their verbal communication development. PECS training encouraged children to communicate in general. As the children participate in the training program their levels of frustration decrease because they can express their needs. The PECS training tool was effective in increasing the children’s ability to make requests, partake in social environments, and begin verbal interactions. The researchers noted that the participants’ ability to use the picture cards to make requests were limited by the availability of the cards. The cards were not always easily available when the children wanted an item and the lack of a communication medium resulted in a frustrated child. The researchers found the PECS system effective but limited in its ability to encourage verbal communication. The research group recommended that children who were beginning to verbalize their communication during the training’s fourth phase be given more vocal communication training to complement the PECS training system. A limitation reported by the researchers was the non-uniformity of the PECS training delivery. They suggested that the link between play and language be studied further to address the correlation. They also recommended the use of the PECS training model as an easily learned form of nonverbal communication to support children suffering from nonverbal autism.
Polles (2010) conducted a study that centered solely on the PECS protocol. The study examined and evaluated the PECS system. It “investigated what linguistic skills children acquire through PECS intervention, ways in which PECS might be extended, and how research on PECS can be improved” (p. 1). Before presenting her evidence on the PECS method, she provides an overview on other communication methods that are commonly used by children with autism. Many children with autism do not develop spoken language; they produce language that comes in several different forms such as irrelevant phrases, echolalia, and stereotyped speech. Early studies attempted to use operant conditioning but found little progress. Sign language was the next intervention that was tested and was determined to be “too complex and abstract for many individuals with autism to learn” (p. 10). Sign language can be effective for some but often times it is not an ideal system. Signing requires a great deal of fine-motor skills, imitation skills, and linear sequencing, with most children with autism have difficulty with.
Augmentative and alternative communication (AAC) includes all forms of communication (other than oral speech) that are used to express thoughts, needs, wants, and ideas (asha.org, 1997). Polles (2010) explains that interventions utilizing the AAC system have “broader focus, teaching children social and communication skills in addition to communicative symbols” (p. 10). PECS is one of the AAC systems, which was created specifically for children with autism. Brody and Frost (1994) claim that their system had several advantages over other interventions such as speech training. This kind of intervention can be effective for some children but is a slow and lengthily process, which can be frustrating for the child. Polles continues to discuss each stage of PECS and how pragmatics, syntax, etc. play a role in PECS.
What is the success rate for conversational speech among those who begin PECS at a young age?
A report published in the International Journal of Language and Communication Disorders examined the long-term outcomes of social-communication skills of children who participated in an earlier autism study (Lerna, Esposito, Conson, & Massagli, 2014). The research team revisited a group of children twelve months after their completion of the PECS training in a previous study. The children who received PECS training and their control group peers were observed during free play interactions. The children who received the PECS training demonstrated increased communication and social skills compared to their control group peers during the follow up examination. The PECS trained group also demonstrated a significant improvement in their ability to cooperatively play with their peers when compared to the control group or their own ability pretreatment. Interestingly, the PECS group did not show any signs of increased verbal language skills or vocabulary in comparison to their control group peers.
Technology has produced a new wave of research. Boesch, Wendt, Subramanian, and Hsu (2013) set out to compare the efficiency of the PECS versus a speech-generating device. The study examined three students over a period of five months. The study was unable to report any major patterns between the children’s’ treatment responses. All three children increasingly communicated throughout their treatment but neither the PECS nor the speech-generating device proved to be effective. Of the three children participating in the study, only one child began to verbally communicate.
New technology has given the PECS a new mobility. Hill and Flores (2014) conducted a study that compared PECS and the software application Proloquo2Go on the iPad™ for treating students with Autism Spectrum Disorder. Software programs, such as Proloquo2Go, may have modernized and condensed the communication tool, but research has shown that the modern applications offer no additional benefits in regards to the treatment of autism. The only additional benefits brought on by the devices are their compact design and easy mobility. The technological versions of the PECS do not demonstrate any significant improvements in treatment efficiency but are less cumbersome than a deck of picture cards. Software such as Proloquo2Go has become common practice in many schools across Canada (Autism Speaks, 2015). The portability of the handheld devices provides teachers with an easier to mobilize version of the traditional cards. The devices also offer the children a more relatable device that has become common classroom teaching aids. Proloquo2Go provides users with text to speech and color picture symbols to facilitate communication. The Hill and Flores study took place over a span of twenty-one days. Students were provided with both a set of picture cards and an iPad™ equipped with Proloquo2Go. The study produced mixed results demonstrating that a low technology intervention is just as effective as modern treatment. However, one student showed a remarkable increase in communication using Proloquo2Go, by the end of the twenty-one days, he was able to use full sentences to make requests. Two of the students also began to verbally repeat the sentences after the Proloquo2Go provided the examples. This is analogous to a teacher’s implementation of the traditional PECS protocol where he or she verbally expressed the prompted communication and asked the child to repeat the sentence. Though further research is required, Hill and Flores recommended that children would best benefit from learning from the traditional PECS model then progressing to the Proloquo2Go on the iPad™.
Technology has increasingly become the favored device amongst young children. More children have access to mobile devices and tablets. An article published by Kristin Rushowy (2012) The Autism Project: iPads ‘speak’ for non-verbal, autistic kids featured a special education school in Toronto Ontario who had received iPads for the students in attendance. Six weeks after acquiring iPads for the classrooms, teachers at Beverley School were absolutely shocked by the transformation. The research conducted at the school has been groundbreaking winning the classrooms two special education teachers the Prime Minister’s Teaching Award. One child, for example could only communicate by screaming and crying prior to the iPad’s arrivals. Six weeks later, the same nonverbal child was able to communicate using the technology; his parents and teachers were impressed by his extensive comprehension abilities that could not be expressed without the technological device. The device allowed him to show his teacher and parents that he understood the difference between yes and no, he knew his numbers, colors and many of his body parts. The children in his classroom who used to be nonverbal began interacting with each other using the technology. For example, the children will walk up to one another and show each other their screens after an accomplishment, at other times children will walk up to watch another child’s screen. The iPads have also managed to capture their attention for more than five minutes a feat their teachers and parents would have thought impossible before they were equipped with their iPads (Rushowy).
The Association for Science in Autism Treatment is a well-respected autism research source used by many professionals in the field of autism treatment and programming. The Association credits the technological device (iPad) for providing individuals with autism the opportunity to communicate (Walkup, 2014). Since the iPad was created in 2010, it has “miracle” device for individuals with autism. The software designed for autism treatment can be used to treat even remote patients and can manipulate the autistic need for uniformity. The research association does not see the device as any more effective than standard intense behavior modification treatment or PECS but its compact design makes the technological treatment path more accessible and provides standardized and uniform treatment. The iPad have proven to be an effective teaching tools for children with autism. Before the iPad’s can reach their full potential as a learning device, however, the autistic child requires behavioral training and PECS training. The association views the technology as a complementary teaching device that requires further research into its potential to aid the autistic community (Walkup).
The Association for Science in Autism Treatment is concerned with the effectiveness of the PECS intervention. The researchers examined multiple studies to examine the effectiveness of PECS as a tool to aid in nonverbal communication and the ability of the PECS to encourage communication (Flippin, Reszka, & Watson, 2010). The Association for Science in Autism Treatments regards the PECS training protocol as an effective manner of teaching nonverbal autistic children an alternative form of communication. The research team concluded, however, that there was no clear evidence that PECS if effective or ineffective in teaching verbal communication skills to participants (Flippin, Reszka, & Watson, 2010).
Conclusion
After an extensive systematic analysis of literature related to the efficacy of the PECS, it can be concluded that PECS is as varied as autism itself. PECS has the ability to promote verbal communication only if the participant is able to complete all six phases of the PECS treatment. Whittaker (2012) stated that if a child cannot learn to verbalize their communication during step three of four of PECS, they are likely to suffer from the most severe forms of autism. Whittaker’s research posed the question about what the next step should be if a child is unable to vocalize their communication despite receiving early intervention using PECS. PECS encourages children to communicate verbally in all phases, but an extensive emphasis is placed of verbal communication starting on phase three of treatment. Leaf and associates (2011) discovered that children who had higher IQs when first diagnosed with autism had better chances of improvement after treatment. The children’s age when they started treatment was not found to contribute to their prognosis.
Inconclusive studies resulted in mixed results, yet have shown the ability of the PECS training model to teach verbal communication. Many of the studies ended with mixed results. Separating the factors that limit the ability of some autistic children in verbal communication have daunted researchers for some time. An area of concern for researchers was why some nonverbal children with autism recover some verbal communication skills others do not. Some children who receive early intervention are able to attend regular classrooms without any major need for further support. Other children are able to live normal lives after early autism intervention and only require minor supports to function; opposed to others are unable to learn to functionally communicate. Additional analysis should be done for those child that rest on the severe side of the spectrum to rule out a dual diagnose or misdiagnosis. However, the design of the PECS training model was intended to provide an alternative form of communication for nonverbal individuals with autism to encourage the participant to want to communicate with their communication partner.
Using the results of Leaf’s research team, PECS can be determined to best as a secondary treatment after initial intensive behavioral modification has already taken its course. With early intervention, children with autism have the opportunity to develop verbal communication skills. These children often require no other intervention or treatment. However, if they still cannot communicate after receiving intensive behavior modification, PECS intervention should be introduced. The children who experienced intensive behavior modification demonstrated less disruptive behaviors that would limit their ability to participate in PECS.
The quantitative synthesis and component analysis conducted by Tincani and Devis (2011) provided evidence that address the proposed research questions within this project. It was evident from their study that PECS was an effective intervention that can promote a functional communication system for those individuals with autism spectrum disorder as well as other developmental disabilities. Though the Ticani and Devis study did not emphasize if the participants were encouraged to vocalize, data was recorded for those participants that used the mand or picture exchange as well as vocalization during training.
Throughout the studies examined, one trend did arise. The PECS training model was best suited for some individuals. The nonverbal children with autism spectrum disorder who had a higher IQ were most likely to become fluent in vocal communication and respond quicker to treatment, whereas others who were administered the same intervention only demonstrated an increase in initiation of conversation via PECS remained nonverbal. Further research is needed in order to determine if these children have experienced a greater quality of life due to PECS training. Regardless of the child’s ability to learn verbal communication skills, the child should be given the opportunity to communicate their needs and wants to teachers and caregivers. It can also be concluded that the PECS training tool is effective in the encouragement of communication. Communication skills are important in order to express wants, needs, interests, etc.; without these skills children diagnosed with autism spectrum disorder are limited in opportunities available to them, if they are reliant on others to figure out or interpret what they are saying. Further research into integrated training tool management programs is required. For example, do PECS impact later treatment programs in nonverbal autistic children? Would starting early autism intervention programs with intense behavior modification increase the child’s response to the PECS training program? What is the ideal sequence of training programs for severe nonverbal autistic children? Extensive research done with multiple groups has yet to discover the route of best treatment that can alleviate the most serious symptoms of the disorder and allow the remaining children to branch off as their treatment needs are being fulfilled. Another area in need of additional examination is reliability of digital versions of the PECS training system. The mobility of the iPad makes the device an ideal tool that can be leveraged for the management of autism training. Another benefit that the iPad offers is the possibility that it can be used to reinforce PECS training after the program had completed. The cost of repeat PECS training is much greater than the cost of the iPad. The iPad may be a motivational device that will encourage the child to continue to communicate once the training is mastered. Further research is needed in order to establish whether digital devices are a potential tool or just a motivator. Technology offers immense potential but lacks empirical evidence to support its use as a treatment tool.
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