Case Reports and Shorter Communications

Functional Communication and Other Concomitant Behavior Change Following 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 children with language delays, including those with autism, functional language. A feature 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.

he Picture Exchange Communication System (PECS) is widely used to teach functional language to children with language delays, including those with autism, yet there are relatively few studies documenting its efficacy (CharlopChristy, 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, a behaviour class deemed by some to be pivotal (Koegel, Carter, & Koegel, 2003), leading to broader behaviour change and generalisation. Reported collateral behaviour changes include the acquisition of verbal language. Schwarts, Garfinkel and Bauer (1998) demonstrated that PECS was acquired successfully by a number of children with various developmental disabilities, and reported generalisation of PECS use to untrained settings and concomitant effects on untrained language functions. Some of the children in that study, including children with autism, also acquired verbal language. Charlop-Christy et al. (2002) in a study in which three children with autism were taught functional communication using PECS, have also demonstrated collateral behaviour change, including the acquisition of verbal language, but they did not report requests and other initiations separately. Finally, Frea,
Address for correspondence: Angelika Anderson, Faculty of Education, Monash University, Clayton VIC 3800, Australia. E-mail: Angelika.Anderson@education.monash.edu.au
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Arnold and Vittimberga (2001) report concomitant behaviour change (reduction in aggression and increase in choice-making behaviour) following PECS training. While all these studies report some generalisation results, all data was collected either in early intervention centres, clinics, or integrated preschools. None of the studies were carried out in the home, nor did they report generalisation data collected in home settings. The current investigation provides additional empirical data on the effectiveness of PECS training with children with autism in a childs home. The explicit focus of this study was on concomitant change in behaviours not directly targeted by the intervention. Our hypothesis was that following PECS training there would be beneficial 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 nontargeted behaviours (play, television viewing and verbal initiations other than mands). The study was conducted in the childs home and all reported language related data was collected in a nontraining generalisation setting (free-play following instruction).

Participant
The participant was a 6-year-old Samoan boy (pseudonym Todd), diagnosed as autistic at 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 this study 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 displayed some echolalic speech. This consisted mainly of jingles and lines from TV commercials and Todds favourite DVD shows. Todd spent much of his time engaged in repetitive tapping/drumming of a pair of identical objects and/or watching television, to the extent 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 in this home were open plan, with only partial separation of the kitchen and living room spaces. Training sessions were conducted at the kitchen table, and the freeplay (generalisation) sessions occurred in the living room. Sessions were conducted between the hours of 4 pm and 6 pm for no longer than 1 hour each. 174

Intervention
The materials used were the PECS communications folder containing from 25 to 30 symbols, a video camera, table, chairs for Todd, the trainer and, in step 1, for the helper, and an array of toys (details from authors on request). The communication folder was a green A5 folder containing three pages that had three stripes of Velcro per page, placed horizontally. This was the same for the inside front and back covers. On the front of the folder were four stripes of Velcro, three were placed horizontally and one was placed vertically. One horizontal stripe
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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 sentence strip 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 picture cards. 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 outcome data was obtained in a no-treatment generalisation condition immediately following the 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 3 involved training skills necessary for intervention (compliance training); and Phase 4 was the PECS training phase. During all phases other than Phase 1 (which was entirely free-play) the sessions consisted of 30 minutes of instructional time followed by 30 minutes of free-play. During the free-play time the researcher was present and available, but did not provide any instruction. The child was free to engage in 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 in the childs home, an open-plan living space with siblings and parents present at times, necessitated a degree of compliance by the child to allow any interactions with the researcher to occur. The requests (turn off the television, come to the table, sit down, and play) were presented at least 5 consecutive times without providing any consequences for compliance or noncompliance. Criterion (compliance within 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 needed before PECS training could occur. During this phase Todd was taught to comply with the following 3-step request sequence using a forward chaining procedure: (1) TV off now (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; CharlopChristy et al., 2002), up to Step 4 sentence strip. This included a reinforcement assessment, initial physical exchange of pictures of preferred items, generalising the use of PECS by working at and away from the workstation, increasing the array of choices offered at a time, and encouraging independent use of PECS to mand.
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Step 1. The physical exchange included assessment of reinforcers (finding out what the child preferred in food, activity and objects/toys), fully assisted picture exchange for 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 for the exchange, and fading of open handed cue (used to prompt a response). Step 2. Expanding spontaneity included attaching a preferred item picture to a communication board (using Velcro) and then increasing the distance between trainer and student and the distance between student and board, so that the learner had to come and nag the adult with his mands. Step 3. Picture discrimination included (1) discrimination training, (2) correspondence checks, (3) reduction of picture-card size. Step 4. Sentence structure: (1) stationary I want picture child put together a sentence 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 I want picture child made sentence strip with I want plus desired item. The trainer was no longer seated at the workstation but away from the child, so that the child was required to get out of his seat and go to the trainer, and get her attention to place the sentence strip in the trainers hand; (3) Referents not in sight the learner was able to construct the sentence strip I want plus desired item manding for things not offered 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. By the 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 randomly. Todd learned to initiate communication in the first three phases of PECS by choosing his reinforcer and matching picture card, and giving it to his communicative partner. In the fourth phase of PECS Todd was able to initiate communication by putting his sentence strip together (I want plus whatever his choice was) and then take the strip with his constructed sentence and give this to his communicative 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 only verbal language with or without the use of PECS was recorded.

System of Observation
176 All sessions were videotaped. For each session a 10-minute segment of free-play was analysed, 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 Agreements + Disagreements
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The mean agreement for these sessions was 96%.

Dependent variables
Three behaviour classes were monitored throughout the study: language, play, and television watching.

Operational Definitions Language. Language was defined as verbalisations by Todd that could be understood by most people, including those who did not know him well. Subcategories of language that were specifically recorded were mands, initiations, and new words used. 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 person present, with or without the use of PECS, that was not a mand and not a response to another persons verbal or nonverbal initiation. New words. These were recognisable words spoken by Todd that had not previously been recorded. These were recorded and added to a cumulative word list.

Play Interactive manipulation of an instrument (toys, game, equipment) in the way it was designed to be used (i.e., building with blocks, pushing a car around, playing playstation), or interactive contact with another person (specifically tickling). Play was scored from the moment Todd made appropriate contact with a toy until disengaged, defined as noncontact with all toys for 5 seconds or more. Cumulative duration 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 seconds continuously without interruptions exceeding 30 seconds. A cumulative duration was recorded, in minutes, using the counter on the video.

Results
Figure 1 displays the number of mands, verbal initiations and a cumulative count of new words spoken by Todd across all phases in the free-play (generalisation) setting. No mands were observed in the phases preceding PECS training, whereupon manding occurred on 12 of 17 days (range 022, mean = 4.2). Similarly, no instances of verbal 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 and again on 1 occasion on each of the final 2 days of this phase. These were spontaneous 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, mean level = 6.1). The cumulative record of new words spoken shows that Todd was observed to say a single new word in baseline 1 and 16 words on the first day of compliance training. These 16 words were a single phrase of echolalic speech of a
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FIGURE 1

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Number of mands, initiations and the cumulative record of new words for a 6-year-old boy with autism during baseline, compliance training and PECS training in a generalisation setting.

jingle from a TV show. No other new words were recorded until the first day of PECS training. However following the start of PECS training new words were observed on 15 of the 17 days, and Todds observed spoken vocabulary expanded to 89 words.
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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.

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. TV watc 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 a reduction in the time Todd spent watching TV (range 065%, mean = 28%), and during 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 time Todd engaged in play behaviour. Zero levels of play were observed in both baseline phases, with some play being recorded on two of the four observed sessions during compliance training (mean = 26%). A further change was observed during PECS training with Todd engaging in play on 14 of the 17 days (range 0100%, mean = 45%).

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Discussion
These results confirm previous findings that PECS is acquired easily by a child with developmental disabilities (Charlop-Christy et al., 2002; Frea et al., 2001;
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Schwartz et al., 1998), and support previous findings that PECS acquisition is associated with concomitant behaviour change, including the acquisition of verbal 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, functionally different verbal initiations, as well as a reduction in television watching and an increase in play. The observed collateral behaviour change or generalisation adds strength to the argument that PECS targets pivotal behaviours. This study also demonstrated that PECS training can be successfully implemented entirely in a natural environment (here, the childs home), and that the positive changes generalise to a nontreatment setting. Some limitations of the current study are noted. The focus was entirely on the effects of PECS training on concomitant behaviour change. Consequently, data of the actual effectiveness of the PECs training in the training setting were not collected. Furthermore, carrying out this study entirely in the natural environment, with no attempts to control this environment (e.g., other family members were present at times, the TV set was not removed or locked) meant that some initial compliance training was necessary to increase Todds accessibility to instruction/interaction. The compliance training is a possible confound, and it is possible that at least some observed concomitant behaviour change was the result of the compliance training alone. However, the television set was always available in the free-play time period, and the child could have switched it on at any time in this condition. This illustrates part of the challenge of working entirely in natural settings. Further exploration of behaviour changes as a result of targeting pivotal behaviours, particularly with children with autism, in natural 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 augmentative 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 evaluation 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-initiations 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 communication skills for an elementary-aged student with autism using the picture exchange communication system. Journal of Autism & Developmental Disorders, 32(3), 225230. Liddle, K. (2001). Implementing the Picture Exchange Communication System (PECS). International Journal of Language & Communication Disorders, 36(Suppl), 391395.
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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: Western Psychological Services. Schwartz, I.S., Garfinkle, A.N., & Bauer, J. (1998). The picture exchange communication system Communicative outcomes for young children with disabilities. Topics in Early Childhood Special Education, 18(3), 144159.

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