The Picture Exchange Communication System (PECS): A Promising Method for Improving Communication Skills of Learners with Autism Spectrum Disorders

Children and youth with autism spectrum disorders (ASD) and other developmental delays frequently experience deficits in functional communication. Identifying and using suitable communication enhancement and augmentative and alternative communication supports is essential to achievement of positive outcomes for these learners. This article discusses the use of the Picture Exchange Communication System (PECS), a commonly used and utilitarian AAC system for children and youth who lack sufficient functional communication skills. Particular attention is given to practitioners’ use of this promising tool. The Picture Exchange Communication System (PECS; Frost & Bondy, 1994, 2002) is an icon-based form of augmentative and alternative communication (AAC). While the system is appropriate for use with a variety of individuals with communication deficits and disorders, it has most commonly been used with children with autism spectrum disorders (ASD; Magiati & Howlin, 2003; Tincani, Crozier, & Alazetta, 2006). PECS was developed in 1986 by Bondy and Frost and is currently marketed and hosted by Pyramid Educational Consultants, Inc. Since its development, PECS has received considerable attention in peerreviewed literature and has generally been shown to be relatively useful promising practice in promoting functional communication in individuals with moderate to severe disabilities (Flippin, Reszak, & Watson, 2010). Description of PECS Materials One attractive feature of PECS is that it requires relatively few materials, all of which can be created or obtained at relatively low cost (Ogletree, Oren, & Fischer, 2007). As the name implies, a key feature of PECS is the picture cards, which contain pictures, also referred to as icons, that represent objects (e.g., ball, computer, cookie), people (e.g., Mom, Dad), or activities (e.g., hug, draw). The icons can be made using a computer graphics program or actual photographs and should be fastened with Velcro® on the back. This will allow the icons to be stored on a Velcro® communication picture board or book, from which the child will be able to select the icons of appropriate or desired items, people, or activities. Additionally, PECS materials include several sentence stems (e.g., “I HEAR,” “I SEE,” “I WANT”), which can be combined with icons to form phrases and sentences in later stages of training and should also be affixed to the communication picture board or book with Velcro®. PECS’ format has several advantages (Ogletree et. al, 2007; Yoder & Stone, 2006). Because PECS requires few materials, the system can easily travel with the child to multiple locations, thus increasing the potential for training and generalization across multiple settings. Also, icons can easily be created to correspond to items in the user’s environment, allowing for specific tailoring to his or Correspondence concerning this article should be addressed to Jennifer Ganz: Texas A&M University, Department of Educational Psychology, 4225 TAMU, College Station, TX 77843-4225. Email: [email protected] Education and Training in Autism and Developmental Disabilities, 2012, 47(2), 176–186 © Division on Autism and Developmental Disabilities 176 / Education and Training in Autism and Developmental Disabilities-June 2012 her settings or preferences. Finally, the “lowtech” nature of the PECS materials eliminates the issues of technological failure and greatly reduces the probability and cost of the materials being damaged or lost. Credentials and Training for PECS Trainers Official PECS training workshops are offered by Pyramid Educational Consultants, Inc. (http://www.pecsusa.com/training.php), including basic and advanced levels. Basic training is designed for individuals seeking certification as a “PECS Certified Implementer,” allowing them to implement the PECS intervention with an assured level of competency. Within two years of attending a basic PECS workshop, the prospective implementer must submit evidence of competency in the areas of: (a) implementation of PECS in each of the six phases, (b) error correction, (c) implementation of PECS during functional activities, (d) writing PECS instructional lessons for clients, (e) data collection within the phases of PECS, and (f) writing summaries of PECS implementation. Practitioners must also pass a written exam covering accurate PECS practice. After passing the exam and demonstrating competency in all six areas, individuals are granted certification, renewable every three years. Advanced PECS implementers may chose to pursue PECS supervisor training through Pyramid Educational Consultants, Inc. (http:// www.pecsusa.com/training.php). According to the company, this training is reserved for experienced implementers who have not only shown knowledge and skills in implementing PECS properly in all six phases but have also demonstrated the ability to critique PECS instructors in a positive and constructive manner. Individuals who qualify as PECS supervisors may not offer PECS training workshops or other formal training but may advise and critique co-workers who have undergone basic PECS implementation training on best implementation practices for PECS and may offer basic information on PECS to other professionals. Suitability for PECS PECS is designed for people who lack an effective system of functional communication (Frost & Bondy, 2002). It is typically not needed or used by individuals who have high verbal functioning, such as those with Asperger syndrome or high functioning autism (Simpson & Myles, 2011). While people with higher functioning variants of ASD, such as Asperger syndrome, have communication and language difficulties, such as understanding metaphors or figures of speech, or have difficulties mastering the social aspects of communication, their communication deficits are usually not severe enough to require PECS or other AAC systems and are most effectively addressed through other types of intervention (Wetherby & Prizant, 2005). Assessing suitability. Pyramid Educational Consultants, Inc. does not publish an official measure to assess suitability for PECS but broadly states that the system may be useful for individuals who (a) lack a method of functional communication that allows them to adequately express their needs and wants, (b) have trouble making their communication understood by others, (c) have a functional communication system that is not adequate in its ability to convey needs and wants, or (d) lack a communication system that allows spontaneous expressive communication across a variety of settings (http://www.pecsusa.com). It is clear that relatively little is known about student characteristics that make them the best candidates for PECS. However, a recent review of PECS methodology and outcomes by Flippin and colleagues (2010) suggested that children who have relatively poor joint attention (e.g., have difficulty sharing interest in an object with another person) and relatively strong interest and tendencies to search out and explore a variety of objects in their environment but relatively limited motor imitation skills have the best outcomes relative to PECS use. Additionally, existing measures that assess functional communication may be useful when determining an individual’s suitability for PECS. These supplemental measures can either be part of a formal, structured evaluation or informal assessments, such as parentor proxy-report checklists. Informal evaluation measures may include the Assessment of Social and Communication Skills for Children with Autism (Quill, Bracken, & Fair, 2000) or Verbal Behavior Milestones Assessment and Placement Program (VB–MAPP; Sundberg, 2008). Examples Picture Exchange Communication System / 177 of more formal, complex assessment include the Test of Early Language Development (Hresko, Reid, & Hammill, 1999) and the Brigance Diagnostic Inventory of Early Development (Brigance, 2004). The primary purpose of these measures in relation to PECS is to determine if the child in question would benefit from an AAC system to improve functional communication and should be interpreted with professional judgment, combining assessment results with observation (Flippin et al., 2010; Ogletree, 2008; Ogletree et al., 2007; Yoder & Stone, 2006). As the name implies, PECS is a visual form of AAC. The visual nature of PECS may be beneficial when working with children with ASD, as there is some evidence that people on the autism spectrum may be highly visual learners (Schopler, Mesibov & Hearsey, 1995). Accordingly, visually-based AAC systems are often seen as the most effective and preferred choice when working with individuals with ASD (Mirenda, 2001; National Research Council, 2001). PECS symbols are both concrete and static in nature, appealing to the common preference of individuals with ASD for consistent, explicit objects and ideas (Heflin & Alaimo, 2007; Ogletree, 2008). Most icons have a one-to-one correspondence with an object, person, or activity, thus reducing confusion common to many forms of communication wherein abstract interpretations and variable meanings exist. Furthermore, the icons themselves are consistent in appearance and meaning, further reducing linguistic ambiguity and allowing for recognition instead of recall (Heflin & Alaimo). Considerations regarding multiple disabilities. While the visual nature of PECS presents several advantages relative to use with individuals with ASD, the visual focus of PECS may make it a poor choice for people with both ASD and blindness or severe low vision, unless modifications are made (Lund & Troha, 2008). PECS has been used effectively with a blind clinician through the addition of Braille tags to the picture cards (Charlop, Malmberg, & Berquist, 2008). Of course such a modification with a blind or low vision PECS-user would require that the user read and comprehend Braille. Lund and Troha (2008) investigated the use of PECS with three adolescents with both autism and severe visual impairment or blindness. Tactile symbols were used as an accommodation, and verbal prompts, which are not typically used in PECS training, were applied if the communication partner deemed them necessary. All three participants showed varying degrees of increased functional communication with PECS over the course of the intervention. Only one of the participants was able to show proficiency—defined as correct independent response rate of 80% or higher in two separate trials—at each of the first three stages of PECS. Lund and Troha speculated that this may be due to the time-limited nature of the study—each participant received only 30 sessions of PECS—and noted that the participants’ rates of improvement were similar to those seen in children without co-occurring visual impairment. It appears the use of tactile symbols may be an effective way to modify PECS for use by those with co-occurring ASD and severe visual impairments. PECS also requires some degree of proficient motor functioning (Bondy & Frost, 1994; Frost & Bondy, 1994). The user must be able to pick up, carry, and hand the icon cards as needed. In later stages of training, the user must be able to align icons and sentence stems closely enough to demonstrate their association (e.g., show that the “I SEE” sentence string and the “ball” icon are connected). If necessary, modifications, such as creating larger or thicker icons and sentence stems, can be made to increase the ease of use for children with limited fine and gross motor function due to physical impairments or muscle weakness (Bondy & Frost). PECS may be a viable alternative for individuals who lack the fine motor coordination necessary for sign language or typing-based AAC systems (Ogletree & Oren, 2006). The highly visual nature of PECS also makes it good choice for individuals with ASD and co-occurring hearing impairment or Deafness (Tincani, 2004). Furthermore, PECS attempts to model natural language development through the use of icons and thus does not assume or require the capacity for expressive spoken language (Bondy & Frost, 2001). Additionally, PECS can be used in conjunction with American Sign Language or another signing system or spoken language, depending on the needs, abilities, and preferences of 178 / Education and Training in Autism and Developmental Disabilities-June 2012 the user and his or her support system (Tincani). Considerations for English Language Learners. Relatively little research has been conducted regarding special education and AAC for children who are also English Language Learners (ELL; Simpson & Ganz, in press). However, current recommendations for the general population of ELL students hold that education should involve both English and the child’s first or familial language, if possible, with a preferred emphasis on the language spoken at home (Donovan & Cross, 2002). PECS may be a particularly useful AAC system to use with this population, as the visual nature of the icons transcends language barriers (Simpson & Ganz, in press). Thus, a child from a Spanish-language home who has been trained in PECS could use the same set of icons with his or her English-speaking teacher at school and with his or her parents at home. Words and phrases may be translated into both languages, perhaps allowing the child to use one set at home and another set at school. If verbal prompts are used, the prompts could be given in both languages until the user is able to respond appropriately to prompts in both languages. Alternately, the parents or teacher may decide to pursue training in only one language for the sake of simplicity (Simpson & Ganz). Given both the lack of literature on this topic and the highly personal nature of linguistic identity, the decision of what language or languages to use for verbal prompts or icons should be mutually decided by the parents and trainers prior to the start of PECS training. Use of PECS with adolescents. A vast majority of the existent studies of PECS have focused on young children, as they are more likely to lack an established AAC system and be receiving intensive intervention services (Lancioni et al., 2007). However, older children and adolescents who lack adequate functional communication skills, whether verbal or with another form of ACC, may still benefit from PECS training (Simpson & Ganz, in press). Functional communication is vital in increasing an individual’s ability to live independently, and a lack of functional communication skills may increase the rate of challenging behaviors, thus impacting the individual’s ability to gain and maintain employment and participate in other independent living tasks (Koegel, Koegel, Shoshan, & McNerney, 1999; Prizant, Wetherby, & Rydell, 2000). Thus, PECS would have high social validity if it could increase functional communication in a way that decreased problem behaviors and increased capacity for independent living. The handful of studies (Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002; Ganz, Sigafoos, Simpson, & Cook, 2008; Lund & Troha, 2008; Tincani et al., 2006) that have examined the use of PECS in older children and adolescents have shown promising results, although two of these studies (Ganz, Sigafoos, et al., 2008; Lund & Troha, 2008) made substantial modification to the standard PECS training procedures. Further research is necessary in order to better understand the utility and limitations of PECS in this population. Theoretical Grounding of PECS and Implications for Practice PECS utilizes a behavioral training system, based on the theories of B. F. Skinner and colleagues (e.g., Skinner, 1957) and of applied behavioral analysis (Baer, Wolf & Risley, 1968; Cooper, Heron, & Heward, 2007). Unlike some other communication instructional programs for people with ASD, however, PECS relies primarily on direct reinforcement, similar to the direct reinforcement that occurs during typical language development (Frost & Bondy, 1994). For example, if a child gives his or her communicative partner a “ball” icon, he or she is then given access to a ball, thus strengthening the association between the icon and the corresponding, reinforcing object. This differs from other communication training techniques where the user may be rewarded with a third, unrelated item (e.g., the therapist says, “touch ball,” and the student touches the “ball” picture and is a given a cookie as a reward; DeBoer, 2007). The use of direct reinforcement leads to clearer associations between icons and objects or actions and mimics the naturally occurring reinforcement of verbal speech in typicallydeveloping children (Bondy & Frost, 2001). For this reason, it is important that a child’s preferred reinforcers, such as certain types of toys or specific foods, are identified prior to the start of PECS training and that correPicture Exchange Communication System / 179 sponding icons are created. Reinforcers can be identified through simply observing the user in his or her environment (Bondy & Frost) or through systematic recording and comparison of the user’s responses to several potential reinforcers (Frost & Bondy, 1994). Phases of PECS Training Bondy and Frost (2001) conceptualized PECS training as occurring in six phases, with the opportunity for additional training. Each phase becomes increasingly complex and demands greater expressive and/or receptive communication skills from the user. For this reason, it is recommended that the phases be completed in order, and that the next phase should be tackled only when the user achieves an adequate ratio of correct responses during two or more separate trials or days. This ratio can be set by the treatment team, although 80% minimum accuracy rates are commonly used in the literature (e.g., Lund & Troha, 2008; Bondy & Frost, 1994). The six phases of PECS training are generally designed to correspond to typical communication development. The descriptions below are provided for informational purposes and are not intended to replace formal PECS training. Phase 1: Initial Communication Training The first phase of PECS teaches the user that icons can be used as communication tools (Frost & Bondy, 1994, 2002). In this phase, the user is shown a preferred reinforcer by a communication partner; most students instinctively try to reach for the reinforcer. When this happens, a second instructor, the prompter, places the appropriate icon in the user’s hand and guides the learner’s hand to the communication partner’s hand. When the user drops the icon into the communicative partner’s open hand, the user should immediately be allowed to have access to the reinforcer for a brief period of time. If verbal communication is also being modeled, the communicative partner can name the reinforcer as the user releases the icon into his or her hand. In order to prevent satiation, the reinforcer should be promptly and gently taken away from the user after a few seconds (Frost & Bondy, 1994, 2002). The process should then be repeated until the user consistently and independently hands the communication partner the icon in order to receive access to the reinforcer, as determined by the pre-set correct response ratio. The prompter’s guidance and assistance in picking up the icon and reaching towards the communication should fade over trials, and the communication partner’s open handed prompt may change to a close-handed one as the user demonstrates an understanding of the association between giving the communication partner the icon and access to the reinforcer. This process should be repeated with other icons, in various settings, and with various communicative partners in order to build the user’s vocabulary in anticipation for the item and icon discrimination training that occurs in phase three and to promote skill generalization. Phase 2: Retrieval and Delivery of Icons In phase two, the child is taught to independently retrieve icons and deliver them to a communication partner who is not immediately available (Frost & Bondy, 1994, 2002). For example, in this stage, a child may be taught to retrieve an icon placed a few feet away from him or her and then deliver it to a communication partner in an adjacent room in order to gain access to the desired item, as represented by the icon. Frost and Bondy (2002) hold that this type of training encourages spontaneous communication by demonstrating to the child that communication that requires effort on the part of the child can still lead to the desired results. Additionally, phase two may be used to teach a child the important of persistence when communicating wants or needs. For example, the learner may have to learn to give an item to a communication partner who initially has his or her back turned. These skills can be conceptualized as analogous to a speaking child learning that he or she must increase the volume of his or her voice when trying to speak with someone who is a greater distance away (Frost & Bondy, 2002). The amount of effort and persistence required of the learner should be gradually increased throughout phase two. This is also the phase in which a child should start learn180 / Education and Training in Autism and Developmental Disabilities-June 2012 ing to retrieve icons for desired objects from his or her communication book or board. Phase 3: Icon and Item Discrimination In phase three, the child learns that presenting his or her communication partner with different icons will result in different consequences and thus learns to discriminate between icons and to select the icon for a desired object from a group of other icon choices (Frost & Bondy, 1994, 2002). This phase begins with presenting the child with two icons based on the results of the pretreatment preference assessment. One icon should represent a highly desired item while the other icon should represent a much less desired item. If the child picks the less desired icon, he or she should be given that item by the communication partner, and, when the child shows disinterest in it, a follow-up teaching procedure that demonstrates or prompts choosing the icon for the desired item should occur. If the child does indeed initially present his or her communication partner with the icon of the desired item, this should be reinforced with both access to said item and social reinforcement of the selection, such as verbal praise (Bondy & Frost, 2001). After the child has mastered discrimination between the more desired and the less desired item, he or she should then be given a choice between two icons representing items of equally high desirability that are both in the child’s immediate environment (Frost & Bondy, 1994, 2002). After he or she exchanges an icon, the communication partner should prompt the child to “take it,” being sure to use a pronoun instead of naming the item. If the child attempts to access the item corresponding with the icon he or she selected, he or she should then be granted brief access to the item. If the child attempts to access another item, however, the communication partner should block him or her from obtaining access to any item except the one represented by the previously selected icon, then use an error correction procedure. Once the child has mastered this level of discrimination with two icons, the number of icons and items presented should be increased, until the child can discriminate between five or six icons of appropriately equivalent desirability and even look through multiple pages of the communication book in order to locate a particular icon (Bondy & Frost, 2001).