The Purpose Of This Practice-Based Research Synthesis Was To Verify The Effectiveness Of The Picture Exchange Communication System: Intervention Essay, UU, Ireland

The purpose of this practice-based research synthesis was to verify the effectiveness of the Picture Exchange Communication System (PECS) for improving the functional communication skills of individuals with autism spectrum disorders (ASD). The synthesis focused on the degree to which variations in the PECS training are associated with variations in functional communication consequences. In general terms, a practice-based research synthesis differs from more traditional meta-analyses by systematically examining and unpacking the characteristics of practices that are related to differences in outcomes or consequences.

Specifically, this type of analysis focuses more on understanding how the same or similar characteristics exert the same or similar observable effects and not solely on statistical or observation-based relationships between or among these variables. The reader is referred to Dunst et al. (2002) for a detailed explanation of this framework. Individuals diagnosed with ASD share significant deficits in communication (American Psychiatric Association, 2000). In order to address the communication challenges of children with ASD, behavior analysts, speech-language pathologists, and special educators increasingly have turned to augmentative and alternative communication (ACC) (Frea, Arnold, & Vittimberga, 2001).

The Picture Exchange Communication System (PECS) is one of such augmentative communication systems designed to increase functional communication skills and potentially provide a bridge to speech acquisition. The Picture Exchange Communication System has been supported by a small number of case studies and a large body of anecdotal literature. Thus few published experimental studies have specifically investigated the effectiveness of PECS for children with ASD or other developmental disabilities. Furthermore, the majority of the anecdotal literature reviewing the effectiveness of PECS was contributed by its developers, Andy Bondy and Lori Frost. Bondy and Frost’s first published article (1993) on PECS detailed its use with children and adults with developmental disabilities.

Specifically, they described the procedures Correspondence concerning this article should be addressed to Kai-Chien Tien, University of Kansas, 4227 Wimbledon Dr., Lawrence, KS 66047. Education and Training in Developmental Disabilities, 2008, 43(1), Division on Developmental Disabilities Functional Communication Intervention / 61 used to train school-based staff in Peru to use the system over a five-month period.

Although no formal data were collected, the school reported that of the 74 students who received the PECS training, at the end of a 3-month period, 28 were working on mastering Phase I, 28 were working on mastering Phases II, and 18 were working on mastering Phase III of the PECS training protocol. In another study, Bondy and Frost (1994) reported outcomes for 85 noncommunicative preschool children with ASD aged 5 years or younger. While children’s cognitive abilities were not assessed, they were estimated as ranging from near-normal to profoundly disabled. Over 95% learned to use two or more pictures within the exchange format; almost all learned at least one picture within one month of starting the PECS. For the 66 children who used PECS for more than a year, 41 were able to use speech independently, whereas the remaining 25 children were using a combination of pictures or symbols and speech. All children mastered using pictures or symbols to communicate, although not all reached the highest levels of PECS.

Bondy and Frost (1994) also presented anecdotal data from a number of single-case and small-group studies. Most indicated encouraging results in terms of increased spontaneous communication and speech and, in some cases, decreased behavioral problems. The impact of PECS on problem behaviors was also examined in several studies beyond that of Bondy and Frost. For example, PECS was reported as an effective intervention for a 4-year-old with autism to decrease aggressive behavior in a general education preschool classroom (Frea et al., 2001). Dooley, Wilczenski, and Torem (2001) reported a dramatic decrease in problem behaviors and an increase in compliance during transitions following PECS on a 3-year-old boy with a diagnosis of pervasive developmental disorders (PDD). Description of PECS Practice Developed in 1985 by Andrew Bondy and Lori Frost, PECS originally was primarily used for preschool-age children with ASD and other social-communicative disorders who displayed no functional or socially acceptable speech.

The rationale behind PECS is that the exchange of a picture for a reinforcing item parallels the communicative exchange that takes place in typical conversation. The PECS training is based on research and practice in the principles of applied behavior analysis. Thus, distinct teaching strategies, reinforcement strategies, error correction strategies and generalization strategies are essential for teaching each skill. PECS is different from other communication systems in three main ways: (a) it does not require prerequisite skills; (b) it was designed to address the lack of motivation for social reinforcement; and (c) it immediately teaches initiating, instead of teaching responding before initiating (Bondy & Frost, 1994). The PECS training consists of six phases, which will be described in detail in the following.

Phase I–“How” to Communicate. In this phase, the terminal objective is that upon seeing a “highly preferred” item, the child will pick up a picture of the item, reach toward the communicative partner, and release the picture into the trainer’s hand (Frost & Bondy, 2002, pp. 67).

One trainer entices the child with an object that is highly desired. As the child reaches for the desired object, the second trainer, the facilitator, physically assists the child in picking up a picture for the desired object. The first trainer immediately gives the child a reward along with an appropriate comment, such as “Oh, you want M&M!” when he/she receives the picture.

Phase II – Distance and Persistence. In this stage, the exchange continues with attempts to increase the child’s independence. Thus, the terminal objective is that the child goes to his communication book where his picture is stored, pulls the picture off, goes to the trainer, gets the trainer’s attention, and releases the picture into the trainer’s hand (Frost & Bondy, 2002, pp. 93). The child now is encouraged to use greater spontaneity and persistence and to generalize the skill he acquired. The facilitator is still available for as-needed assistance.

Thus, the child learns to remove the picture from a display board for the exchange and must engage in more physical movement than in Phrase I in order to accomplish the exchange. However, child 62 / Education and Training in Developmental Disabilities-March 2008 is still encountering only one symbol on a board at any one time.

Phase III – Picture Discrimination. The terminal object for this phase is that the child requests desired items by going to a communication book, selecting the appropriate pictures from an array, and going to a communication partner and giving him/her the picture (Frost & Bondy, 2002, pp.123). In this stage the child is asked to discriminate between several items on a board, choosing which item he wants, or which activities he wants to try.

The child begins by answering the form of the question “What do you want?” but these are faded quickly so the child will make choices spontaneously as well as in response to a question. As the child becomes more comfortable making discriminations, a third item may be added, and so on.

Phase IV – Sentence Structure. The terminal objective is that the child requests present and non-present items using a multi-word phrase by going to the book, picking up a picture/ symbol of “I want,” putting it on a sentence strip, picking out the picture of what she wants, putting it on the sentence strip, removing the strip from the communication board, and finally approaching the communicative partner and giving the sentence strip to him (Frost & Bondy, 2002, pp.159). Thus, the child is taught to combine the object picture with the carrier phrase “I want” on a sentence strip and to give the strip to the adult or communication partner. The two pictures are attached to a sentence strip and the entire strip is exchanged with the communicative partner in return for the pictured item.

Phase V – Responding to “What do you want?” In this stage, the child learns to respond to the question “What do you want?” by exchanging the sentence strip. Thus, this phase extends the sentence structure begun in Phase IV. Use of the questioning phase is deliberately delayed until this phase because the exchange behavior should be automatic by that point in the programming sequence (Frost & Bondy, 2002, pp. 209). Adjectives and other words may be added to the child’s repertoire to help her further refine her requests.

Phase VI – Commenting. In this final stage, the child learns to respond to the questions “What do you want?” “What do you see?” “What do you have?” This phase makes a fundamental shift in the child’s communication as well as the expected outcome from the teachers or peers. That is, it is designed to introduce the child to commenting behavior, while the previous stages focused on requesting behavior. Through the use of pictures for “I see,” “I hear,” “I smell,” etc., the child is taught to comment on elements of his/her environment. Search Strategy Search Terms Relevant studies were identified by using the keywords “PECS” and “Picture Exchange Communication System.”

The term “autism” was used to further restrict the search. Further, an author search was conducted using “Andy Bondy” and “Lori Frost.” Sources A computer-assisted bibliographic search was conducted. The Psychological Abstracts (PsycINFO), Educational Resources Information Center (ERIC) database, Expanded Academic ASAP, Wilson OmniFile, MEDLINE, Dissertation Abstract Online, Center for International Rehabilitation Research Information and Exchange (CURRIE), and REHABDATA were the primary information databases searched for relevant studies. An online search of the Internet via the Google search engine was also conducted. The reference lists of all acquired sources were also reviewed.

In addition, hand searches were completed for journal articles, book chapters, and books to locate additional studies of PECS that may have been omitted from the bibliographic search findings. Finally, repeated sweeps of various sources were made until no further studies could be located. Selection Criteria Studies were included in the research synthesis if they met all the following criteria:

(a) the focus of the study was to establish the effectiveness of PECS for improving functional communication skills;

(b) the PECS training was described in sufficient detail to ascertain that the intervention applied in a review study Functional Communication Intervention / 63 was the same as the intervention described under Description of the Practice;

(c) individuals involved in the study were diagnosed with ASD;

(d) communication consequences were the major outcome measured; and

(e) articles were written in English. Exclusion criteria. It was necessary to exclude one the study (Cummings & Williams, 2000) that appeared to have met all the inclusion criteria during the initial phase of the search process.

Close inspection of the study revealed that the PECS training was only one component of the treatment so as to warrant its exclusion. Search Results Eleven articles, including 13 studies and 125 participants, met the selection criteria and were included in the research synthesis. Table 1 shows the selected characteristics of the participants. Table 2 lists the research designs used in the studies, dependent measures, and the characteristics of the intervention. Participants The 125 participants who participated in the studies all exhibited limited or no functional communication skills (see Table 1). Ages ranged from one to twelve years old at the baseline assessment.

Participants’ gender was reported in 10 of the studies (77%). The vast majority (65%) of the participants were reported as males (female
36, male
68). Across all the studies, participants’ ethnicity was only reported in three studies (CharlopChristy et al., 2002; Ganz & Simpson, 2004; Tincani, 2004). Participants’ language age was reported in five studies (36%); however, different methods were used for assessment and reporting. Eight studies (57%) did not report participants’ language age, but provide descriptions of their speech abilities (Adkins & Axelrod, 2002; Ganz & Simpson, 2004; Heneker & Page, 2003; Liddle, 2001; Schwartz, Garfinkle, & Bauer, 1998; Tincani, 2004). In the two studies (Charlop-Christy et al., 2002; Jones, 2005) that specifically reported expressive and receptive language ages, the participants’ expressive language ages ranged from 1.2 to 1.8 years, with a mean age of 1.4; the participants’ receptive language ages ranged from 1.8 to 1.9 years, with a mean age of 1.9 years. Participants’ developmental age was reported in three studies (Anderson, 2002; Ganz & Simpson, 2004; Kravits, Kamps, Kemmerer, & Potucek, 2002), but different methods were used for assessment and reporting. One study (Tincani, 2004) reported participants’ standardized intelligence scores on the Developmental Profile-II. Nine studies (64%) did not report any IQ, developmental ages, or other related information on participants; however, one study (Schwartz et al., 1998) indicated that the participants were identified as having cognitive delays. Research Designs Table 2 summarizes the research design employed by the studies included in this synthesis. Twelve studies (92%) used single-participant designs.

One study used a retrospective analysis of archival data to examine pre-/postintervention outcomes (Schwartz et al., 1998). Among the 12 studies employing single-participant designs, four types of research designs were employed. First of all, an AB or a variation of the design was used in four studies (Ganz & Simpson, 2004; Heneker & Page, 2003; Magiati & Howlin, 2003). Second, two studies employed multiple-baseline design across participants (Charlop-Christy et al., 2002; Jones, 2005) while one study used multiple-baseline designed across settings (Kravits et al., 2002). Third, two studies used a changing-criterion design to eliminate the need to withdraw the intervention and include several intervention subphases (Ganz & Simpson; Liddle, 2001). Last, an alternating-treatments design was employed in three studies comparing the effectiveness of PECS and sign language training (Adkins & Axelrod, 2002; Anderson, 2002; Tincani, 2004). Three of the 12 single-participant studies (25%) reported follow-up data after post-treatment (Charlop-Christy et al., 2002; Jones, 2005; Schwartz et al., 1998). Length of time between post-treatment and follow-up ranged from 1 month to 12 months. Two studies conducted by Heneker and Page (2003) reported follow-up results but did not provide data.