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Functional Communication andOther Concomitant Behavior ChangeFollowing PECS Training: A Case Study

Angelika Anderson and Dennis W. Moore

Monash University, Australia

Therese Bourne

IDEA Specialist Services, Auckland, and The University of Auckland, New Zealand

The Picture Exchange Communication System (PECS) is widely used to teach chil-

dren with language delays, including those with autism, functional language. A fea-

ture of PECS is that it incorporates principles deemed by some to be pivotal, leading

to broader behaviour change. In this study, a 6-year-old child with autism was taught

functional language using PECS. Along with measures of language gains, concomitant

changes in nontargeted behaviours (play and TV viewing) following PECS training

were observed. Results show increases in manding, initiations and cumulative word

counts, as well as positive changes in the nontargeted behaviours.

The Picture Exchange Communication System (PECS) is widely used to teachfunctional language to children with language delays, including those withautism, yet there are relatively few studies documenting its efficacy (Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002; Kravits, Kamps, Kemmerer, &Potucek, 2002; Liddle, 2001; Schwartz, Garfinkle, & Bauer, 1998).

A feature of PECS is that it teaches the child to initiate interactions, abehaviour class deemed by some to be pivotal (Koegel, Carter, & Koegel, 2003),leading to broader behaviour change and generalisation. Reported collateralbehaviour changes include the acquisition of verbal language. Schwarts, Garfinkeland Bauer (1998) demonstrated that PECS was acquired successfully by a number ofchildren with various developmental disabilities, and reported generalisation ofPECS use to untrained settings and concomitant effects on untrained languagefunctions. Some of the children in that study, including children with autism, alsoacquired verbal language. Charlop-Christy et al. (2002) in a study in which threechildren with autism were taught functional communication using PECS, have alsodemonstrated collateral behaviour change, including the acquisition of verbal lan-

guage, but they did not report requests and other initiations separately. Finally, Frea,

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Arnold and Vittimberga (2001) report concomitant behaviour change (reduction inaggression and increase in choice-making behaviour) following PECS training.

While all these studies report some generalisation results, all data was collectedeither in early intervention centres, clinics, or integrated preschools. None of thestudies were carried out in the home, nor did they report generalisation data collected

in home settings. The current investigation provides additional empirical data on theeffectiveness of PECS training with children with autism in a childs home. The explicitfocus of this study was on concomitant change in behaviours not directly targeted bythe intervention. Our hypothesis was that following PECS training there would be ben-eficial changes in other behaviours, including increased initiations other than mands,increased play, and decreased levels of stereotypic behaviour (specifically TV viewing).

Method

The aim of the study was to use PECS to teach functional communication to a

6-year-old boy with autism and to monitor concomitant changes in nontargetedbehaviours (play, television viewing and verbal initiations other than mands). Thestudy was conducted in the childs home and all reported language related data wascollected in a nontraining generalisation setting (free-play following instruction).

Participant

The participant was a 6-year-old Samoan boy (pseudonym Todd), diagnosed as autisticat age 3. Todd scored 42 on the Childhood Autism Rating Scale (CARS) (Schopler,Reichler, & Rochen Renner, 1988), rating him severely autistic. At the time of thisstudy Todds receptive language was equivalent to that of a 1-year, 9-month-old as

assessed with the Peabody Picture Vocabulary Test 3rd Edition (Dunn & Dunn,1997). He lived at home with his family and attended the local school. In a previous,unrelated study Todd was reported to have no functional language, though he displayedsome echolalic speech. This consisted mainly of jingles and lines from TV commercialsand Todds favourite DVD shows. Todd spent much of his time engaged in repetitivetapping/drumming of a pair of identical objects and/or watching television, to theextent that he was inaccessible for instruction or other social interactions (Godfrey,Moore, Fletcher-Flinn, Anderson, & Birkin, 2002).

Settings

All training and observations were conducted in Todds home. The living areas inthis home were open plan, with only partial separation of the kitchen and livingroom spaces. Training sessions were conducted at the kitchen table, and the free-play (generalisation) sessions occurred in the living room. Sessions were conductedbetween the hours of 4 pm and 6 pm for no longer than 1 hour each.

Intervention

The materials used were the PECS communications folder containing from 25 to 30symbols, a video camera, table, chairs for Todd, the trainer and, in step 1, for thehelper, and an array of toys (details from authors on request).

The communication folder was a green A5 folder containing three pages thathad three stripes of Velcro per page, placed horizontally. This was the same for thei id f t d b k O th f t f th f ld f t i f V l

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had a removable Velcro (catch) strip/card on it that ran the length of the stripe,and initially included a square with the words I want on it. This was the sentencestrip where Todd would make his sentence of I want and chips, for example.Inside the folder, were 25 to 30 2.5 cm-square colour and black-and-white picturecards. Each of these represented a preferred activity or food, for example, chips,

block (for lego), cup (for drink).

Research Design

An A, B, C, D design was used with a focus on generalisation effects. All outcomedata was obtained in a no-treatment generalisation condition immediately followingthe training.

Procedure

There were four phases in all: Phase 1 was a baseline consisting of observations only

(B 1), Phase 2 was an assessment of readiness for the intervention (B 2), Phase 3involved training skills necessary for intervention (compliance training); and Phase4 was the PECS training phase. During all phases other than Phase 1 (which wasentirely free-play) the sessions consisted of 30 minutes of instructional time fol-lowed by 30 minutes of free-play. During the free-play time the researcher was pre-sent and available, but did not provide any instruction. The child was free to engagein any activity he chose, including watching television.

Phase 1 Baseline 1

This phase was an unobtrusive observation period with no instructional demands or

other communicative initiations from the researcher.

Phase 2 Baseline 2: Readiness Assessment

This phase was designed to assess Todds ability to comply with requests. Working inthe childs home, an open-plan living space with siblings and parents present attimes, necessitated a degree of compliance by the child to allow any interactionswith the researcher to occur. The requests (turn off the television, come to thetable, sit down, and play) were presented at least 5 consecutive times without pro-viding any consequences for compliance or noncompliance. Criterion (compliancewithin 5 seconds of request on five consecutive occasions) was not met.

Phase 3 Compliance Training

Assessments from Phases 1 and 2 indicated that compliance training was neededbefore PECS training could occur. During this phase Todd was taught to comply withthe following 3-step request sequence using a forward chaining procedure: (1) TV offnow (2) Come, sit at the table (3) Lets play (details available from the authors).

Phase 4 Training (PECS)

PECS was implemented as described previously (Bondy & Frost, 1994; Charlop-

Christy et al., 2002), up to Step 4 sentence strip. This included a reinforcementassessment, initial physical exchange of pictures of preferred items, generalising the

f PECS b rking t nd fr m th rk t ti n in r ing th rr f

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Step 1. The physical exchange included assessment of reinforcers (finding out whatthe child preferred in food, activity and objects/toys), fully assisted picture exchangefor pictured item (hand over hand exchange, assisted by a helper, not the trainer)of a picture card to the communicative partner, fading of assistance by the helper forthe exchange, and fading of open handed cue (used to prompt a response).

Step 2. Expanding spontaneity included attaching a preferred item picture to acommunication board (using Velcro) and then increasing the distance betweentrainer and student and the distance between student and board, so that the learnerhad to come and nag the adult with his mands.

Step 3. Picture discrimination included (1) discrimination training, (2) correspon-dence checks, (3) reduction of picture-card size.

Step 4. Sentence structure: (1) stationary I want picture child put together a sen-tence of I want plus desired item on the sentence strip, then gave the sentence strip

to the trainer. The trainer was seated at the workstation at the time; (2) moving Iwant picture child made sentence strip with I want plus desired item. The trainerwas no longer seated at the workstation but away from the child, so that the child wasrequired to get out of his seat and go to the trainer, and get her attention to place thesentence strip in the trainers hand; (3) Referents not in sight the learner was ableto construct the sentence strip I want plus desired item manding for things notoffered as a choice on their communication board, for example, I want the park.

During initial stages of the intervention Todd was given access to three symbols:swing, drink and burger rings. Access to other symbols was gradually increased. Bythe end of the study he had acquired the following PECS vocabulary: I want, swing,

monsters, chocolate, chips, lego, twisties, warehouse, mini-M&Ms, playstation,peaches, bubbles, slinky, play-doh, tickle, car, peaches, koosh ball, apple, banana,chicken, KFC, toilet, television, drive.

As the sessions progressed all choices were arranged throughout the book ran-domly. Todd learned to initiate communication in the first three phases of PECS bychoosing his reinforcer and matching picture card, and giving it to his communica-tive partner. In the fourth phase of PECS Todd was able to initiate communicationby putting his sentence strip together (I want plus whatever his choice was) andthen take the strip with his constructed sentence and give this to his communica-tive partner (trainer). Since Todd exhibited echolalic speech at the start of the

study he was encouraged to voice all mands during the exchange from the outset.During the free-play sessions the PECS materials continued to be available but onlyverbal language with or without the use of PECS was recorded.

System of Observation

All sessions were videotaped. For each session a 10-minute segment of free-play wasanalysed, beginning five minutes after termination of training.

Interobserver Agreement

Interobserver agreement was obtained for all dependent variables in at least 20% of

the sessions in each phase and calculated using the following formula:

Agreements 100


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The mean agreement for these sessions was 96%.

Dependent variables

Three behaviour classes were monitored throughout the study: language, play, andtelevision watching.

Operational Definitions

Language. Language was defined as verbalisations by Todd that could be under-stood by most people, including those who did not know him well. Subcategories oflanguage that were specifically recorded were mands, initiations, and new wordsused. All language measures were monitored using event recording.

Manding. Any occurrence of Todd asking for an activity (e.g., swing), object (e.g.,lego) or place (e.g., garden), using a prefix like I want, Get me, Give me, Get,Give.

Initiations (other than mands). Any verbalisation Todd directed at another personpresent, with or without the use of PECS, that was not a mand and not a responseto another persons verbal or nonverbal initiation.

New words. These were recognisable words spoken by Todd that had not previouslybeen recorded. These were recorded and added to a cumulative word list.

Play

Interactive manipulation of an instrument (toys, game, equipment) in the way itwas designed to be used (i.e., building with blocks, pushing a car around, playing

playstation), or interactive contact with another person (specifically tickling). Playwas scored from the moment Todd made appropriate contact with a toy until disen-gaged, defined as noncontact with all toys for 5 seconds or more. Cumulative dura-tion was recorded, in minutes, using the counter on the video.

Television Watching

This behaviour was defined as looking at the television for longer than 30 secondscontinuously without interruptions exceeding 30 seconds. A cumulative durationwas recorded, in minutes, using the counter on the video.

ResultsFigure 1 displays the number of mands, verbal initiations and a cumulative count ofnew words spoken by Todd across all phases in the free-play (generalisation) setting.No mands were observed in the phases preceding PECS training, whereupon mand-ing occurred on 12 of 17 days (range 022, mean = 4.2). Similarly, no instances ofverbal initiation other than mands were observed during either baseline 1 or 2.Todd was observed to initiate 7 times on the first day of compliance training andagain on 1 occasion on each of the final 2 days of this phase. These were sponta-neous verbalisations and may have been words from his echolalic repertoire.Associated with PECS training was an increase in the number of days on which

verbal initiations occurred and in the rate of initiations each day (range 024, meanlevel = 6.1). The cumulative record of new words spoken shows that Todd was

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Figure 2 displays concomitant changes in the proportion of time Todd engaged in

TV watching and play in the free-play (generalisation) setting across all phases. TVwatc hing was a high probability activity in both baseline 1 and 2 (mean levels 75%and 91% respectively). The introduction of compliance training was associated with areduction in the time Todd spent watching TV (range 065%, mean = 28%), andduring PECS training TV watching occurred on only two of the 17 days (range 042%,mean = 3.8%). An almost reciprocal change was observed in the proportion of timeTodd engaged in play behaviour. Zero levels of play were observed in both baselinephases, with some play being recorded on two of the four observed sessions during com-pliance training (mean = 26%). A further change was observed during PECS trainingwith Todd engaging in play on 14 of the 17 days (range 0100%, mean = 45%).

Discussion

Th lt fi i fi di th t PECS i i d il b hild

FIGURE 2

Time spent watching TV and playing for a 6 year old boy with autism during baseline,

compliance training, and PECS training in a generalisation setting.


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Schwartz et al., 1998), and support previous findings that PECS acquisition isassociated with concomitant behaviour change, including the acquisition ofverbal language (Charlop-Christy et al., 2002; Frea et al., 2001; Schwartz et al.,1998). Teaching the child to mand was associated with an increase in other, func-tionally different verbal initiations, as well as a reduction in television watching

and an increase in play. The observed collateral behaviour change or generalisa-tion adds strength to the argument that PECS targets pivotal behaviours.

This study also demonstrated that PECS training can be successfully imple-mented entirely in a natural environment (here, the childs home), and that thepositive changes generalise to a nontreatment setting.

Some limitations of the current study are noted. The focus was entirely onthe effects of PECS training on concomitant behaviour change. Consequently,data of the actual effectiveness of the PECs training in the training setting werenot collected. Furthermore, carrying out this study entirely in the natural envi-ronment, with no attempts to control this environment (e.g., other family mem-bers were present at times, the TV set was not removed or locked) meant thatsome initial compliance training was necessary to increase Todds accessibility toinstruction/interaction. The compliance training is a possible confound, and itis possible that at least some observed concomitant behaviour change was theresult of the compliance training alone. However, the television set was alwaysavailable in the free-play time period, and the child could have switched it on atany time in this condition. This illustrates part of the challenge of workingentirely in natural settings. Further exploration of behaviour changes as a resultof targeting pivotal behaviours, particularly with children with autism, in natu-ral settings is warranted.

References

Bondy, A.S., & Frost, L.A. (1994). The Picture Exchange Communication System. Focus on

Autistic Behavior, 9(3), 119.

Charlop-Christy, M.H., Carpenter, M., Le, L., LeBlanc, L.A., & Kellet, K. (2002). Using the

picture exchange communication system (PECS) with children with autism: Assessment

of PECS acquisition, speech, socialcommunicative behavior, and problem behavior.

Journal of Applied Behavior Analysis, 35(3), 213231.

Dunn, L.M., & Dunn, L.M. (1997). Peabody Picture Vocabulary Test (3rd ed.). Circle Pines,

MN: American Guidance Service.

Frea, W.D., Arnold, C.L., & Vittimberga, G.L. (2001). A demonstration of the effects of aug-mentative communication on the extreme aggressive behavior of a child with autism

within an integrated preschool setting. Journal of Positive Behavior Interventions, 3(4),

194198.

Godfrey, R., Moore, D.W., Fletcher-Flinn, C., Anderson, A., & Birkin, C. (2002). An evalua-

tion of some programmes for children with autistic spectrum disorder in Auckland: Opportunities,

contingencies, and illusions (Report prepared for The Ministry of Education. Auckland

UniServices Limited). Auckland, New Zealand: The University of Auckland.

Koegel, L.K., Carter, C.M., & Koegel, R.L. (2003). Teaching children with autism self-initia-

tions as a pivotal response. Topics in Language Disorders, 23(2), 134145.

Kravits, T.R., Kamps, D.M., Kemmerer, K., & Potucek, J. (2002). Brief report: Increasing com-

munication skills for an elementary-aged student with autism using the picture exchangecommunication system.Journal of Autism & Developmental Disorders, 32(3), 225230.

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Schopler, E., Reichler, R.J., & Rochen Renner, B. (1988). The childhood autism rating scale(CARS) for diagnostic screening and classification of autism . Los Angelea, CA: WesternPsychological Services.

Schwartz, I.S., Garfinkle, A.N., & Bauer, J. (1998). The picture exchange communicationsystem Communicative outcomes for young children with disabilities. Topics in EarlyChildhood Special Education, 18(3), 144159.


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