**4. Picture exchange communication system**

For children with autism who have severe speech and language delay, the goal of intervention should focus on developing their functional communication. Teachers and caregivers may enable a child to communicate functionally by selecting to teach those words/forms concepts that are meaningful and relevant to the child's environment; teaching the child to use the words/forms in functional manner, and preparing communication partners in the environment to respond to words/forms used by the child in functional manner. Given the importance communication has as a predictor of future social and educational development and later quality of life, it is imperative that intervention program for children with autism stress on alternative means of communication. These alternatives means consisting of visual icons, symbols and manual signs, capitalize on strong visual processing ability in many children with autism [1]. Picture Exchange Communication System or PECS, as it is commonly known, is an AAC system that primarily uses pictures to teach functional communication skills. Developed at the Delaware Autism Program by Bondy and Frost [15], PECS provides children with communication deficits a method to communicate in social settings. According to the designers of PECS, the rationale for PECS emerged from the failure of traditional techniques such as speech imitations, signing, and picture point systems. These techniques relied only on the teacher to initiate communication and did not enhance children's capacity to initiate social interaction. According to Bondy and Frost, PECS has several advantages over other commu‐ nicative interventions for young children with autism. Speech training is very slow and leaves children no way to communicate in the interval until they can speak some words, if they acquire the ability at all. AACs using speech or sign also require children to have the ability to share a point of focus with an adult and to imitate actions that they see the adult do, both behaviours that children with autism have difficulty with. Finally, according to Bondy and Frost, typically developing children learn language in part because of the associated social rewards for doing so. Their social deficits mean that children with autism are generally not sensitive to such social rewards. Thus, they have little incentive to learn language. The protocol used in PECS provides material rewards for communication in the context of the communi‐ cative exchange, giving children with autism better reason to learn to communicate without artificial reinforcement. PECS allows children with autism who have little or no communica‐ tion abilities, a means of communicating non-verbally. Children using PECS are taught to approach another person and give them a picture of a desired item in exchange for that item. By doing so, the child is able to initiate communication. The child with autism can use PECS to communicate a request, a thought, or anything that can reasonably be displayed or sym‐ bolized on a picture card. PECS works well in the home or in the classroom [16]. PECS is a low-tech AAC system. It does not require any electronic devices. It uses laminated line drawings and a phase-wise implementation protocol.

#### **4.1. PECS phases**

AAC system regularly to ensure that it continues to be the most effective communication

**• Include AAC in educational plan**: Every school going child with special needs has an Individual Education Plan (IEP). If a child is need of using an AAC system, it is important that training in AAC usage be included in the IEP. However, the AAC inclusion should not be as a separate area. Rather, it should be listed as a strategy or technique that a student will

**• Develop community care plan**: The child requires a community care plan when it is time to leave the school. The plan should include needed revisions to the AAC system as the AAC user prepares for a major life transition. The AAC inclusion in the community care plan

For children with autism who have severe speech and language delay, the goal of intervention should focus on developing their functional communication. Teachers and caregivers may enable a child to communicate functionally by selecting to teach those words/forms concepts that are meaningful and relevant to the child's environment; teaching the child to use the words/forms in functional manner, and preparing communication partners in the environment to respond to words/forms used by the child in functional manner. Given the importance communication has as a predictor of future social and educational development and later quality of life, it is imperative that intervention program for children with autism stress on alternative means of communication. These alternatives means consisting of visual icons, symbols and manual signs, capitalize on strong visual processing ability in many children with autism [1]. Picture Exchange Communication System or PECS, as it is commonly known, is an AAC system that primarily uses pictures to teach functional communication skills. Developed at the Delaware Autism Program by Bondy and Frost [15], PECS provides children with communication deficits a method to communicate in social settings. According to the designers of PECS, the rationale for PECS emerged from the failure of traditional techniques such as speech imitations, signing, and picture point systems. These techniques relied only on the teacher to initiate communication and did not enhance children's capacity to initiate social interaction. According to Bondy and Frost, PECS has several advantages over other commu‐ nicative interventions for young children with autism. Speech training is very slow and leaves children no way to communicate in the interval until they can speak some words, if they acquire the ability at all. AACs using speech or sign also require children to have the ability to share a point of focus with an adult and to imitate actions that they see the adult do, both behaviours that children with autism have difficulty with. Finally, according to Bondy and Frost, typically developing children learn language in part because of the associated social rewards for doing so. Their social deficits mean that children with autism are generally not sensitive to such social rewards. Thus, they have little incentive to learn language. The protocol used in PECS provides material rewards for communication in the context of the communi‐

tool for the child.

212 Autism Spectrum Disorder - Recent Advances

use to complete educational goals.

should be of similar nature as that in the IEP.

**4. Picture exchange communication system**

PECS is introduced by teaching a child to give a picture of a desired item to a "communicative partner", who immediately responds to the request by giving the desired item. With time the child learns discrimination of pictures and how to put them together in sentences. In the more advanced phases, the children are taught to answer questions and to comment. The PECS program has six phases of teaching.


### **5. Research support for AAC and PECS**

A variety of AAC methods have been used with people with autism who are either nonverbal or cannot speak intelligibly. Many of them have been investigated through single subject research protocols. In a meta-analytical research study [17] twenty-four single-case studies were analyzed via an effect size measure, the Improvement Rate Difference (IRD). Three research questions were investigated concerning the overall impact of AAC interventions on targeted behavioural outcomes, effects of AAC interventions on individual targeted behav‐ ioural outcomes, and effects of three types of AAC interventions. Results indicated that, overall, aided AAC interventions had large effects on targeted behavioural outcomes in individuals with ASD. AAC interventions had positive effects on all of the targeted behav‐ ioural outcome; however, effects were greater for communication skills than other categories of skills. Effects of the Picture Exchange Communication System and speech-generating devices were larger than those for other picture-based systems, though picture-based systems did have small effects. AAC is a multisensory intervention. SGDs provide a child with auditory feedback, images and symbols on communication boards and touch screens provide visual and tactile cues and reinforcement to give substance to words that are often abstract (e.g. "the") and difficult for children with autism to understand. AAC can help individuals with autism manage the challenges of social communication. When eye contact, facial expressions and sensory stimulation are over whelming individuals with autism may disengage from social interactions. A speech generating device can be their "voice" to clearly communicate messages and thereby encourage appropriate socialization. Evidence suggests that early augmented language intervention that emphasizes opportunities for communication and capitalizes on family involvement using AAC gets results. For this reason, and unlike conventional speech therapy, AAC therapy involves training both the user and his or her communication partners at home and in the community [18]. A study investigated the effect of AAC intervention on language and social behaviour of children with autism. The children were given training to use Makaton Vocabulary Language Program, a system of AAC. Results indicated that use of AAC had a positive effect on children's receptive and expressive language, and also enhanced social behaviour [1]. Researchers compared PECS and MTS (match the sample) methods on mastery of picture discrimination tasks. During MTS intervention, the children were asked to match a given picture to one of a set of objects. Correct matches were rewarded with w preferred item. In the PECS condition, child-preferred and non-preferred items were dis‐ played, and the child was given two corresponding pictures. When the child gave one of the pictures, he/she received the matching item. Four out of five children required fewer trials to master the picture discrimination tasks under PECS condition than MTS condition [19]. Children with autism with poor communication abilities were taught spontaneous demand skill through PECS and cognitive interventions. Results showed that children learned spon‐ taneous communication during PECs training. They were able to generalize the skills to nonstructured setting too. Cognitive interventions served as necessary scaffold for acquisition of task [20].

**•** *Sentence Structure*: Now the child is taught to use two pictures/symbols in combination. One symbol for the phrase 'I want' and the second for the desired item. At this stage, the child is given about 20-25 pictures on a communication board and a Velcro sentence strip on which to fix the appropriate cards. Initially the symbol for 'Í want' is fixed on the strip before it is given to the child, and the child is expected to select the desired item's symbol from the collection of symbols, fix it the adult for getting the item. Mastery of this phase occurs when the student can successfully add the symbols for both "I want" and the desired item to the sentence strip and exchange the sentence strip with a communicative partner without any

**•** *Responding to 'What do you want?'*: In this phase, skill to responding to a question is taught. A desired item and 'Í want' symbol are available. The adult points to the 'Í want' symbol and asks 'What do you want?'. The child is expected to put the "I want" and the desired object's picture/symbol on a sentence strip and give it to the adult for exchange. As the child learns the skill, the adult slowly increases the time gap between asking the question and pointing to the "I want" symbol in order to help the child understand that the exchange can take place only when the "I want" symbol is placed before the symbol of the desired object.

**•** *Responsive and Spontaneous Commenting*: In the sixth and the last phase the child learns to answer/comment to questions similar to 'what do you want?' The communication board now may contain a symbol for "I see" below the 'Í want" symbol along with several symbols that do not represent highly desired items. The adult shows one of the less desirable objects, the symbols for which is one the board, and asks the child 'What do you see?". The child is slowly led to place "I see" symbol on the sentence strip before the corresponding symbol for the object shown. The training follows the same process of prompting and rewarding correct response as in the previous phases. When the child gives the correct response, the adult reinforces it by saying "yes, you see a \_\_\_", and provides a reward of child's choice. The child is taught to answer several questions of similar nature such as "what do you have? What do you hear?, and what is this?" following the same procedure. In order to ensure that responses are generalized, the questions are asked by at least two different adults after the

A variety of AAC methods have been used with people with autism who are either nonverbal or cannot speak intelligibly. Many of them have been investigated through single subject research protocols. In a meta-analytical research study [17] twenty-four single-case studies were analyzed via an effect size measure, the Improvement Rate Difference (IRD). Three research questions were investigated concerning the overall impact of AAC interventions on targeted behavioural outcomes, effects of AAC interventions on individual targeted behav‐ ioural outcomes, and effects of three types of AAC interventions. Results indicated that, overall, aided AAC interventions had large effects on targeted behavioural outcomes in

The child now picks up the skills of forming phrases to express his/her needs.

prompts on 80% of trials.

214 Autism Spectrum Disorder - Recent Advances

child demonstrates skill acquisition.

**5. Research support for AAC and PECS**

According to the guidelines on nonmedical interventions that address cognitive function and core deficits in children with autism spectrum disorders (ASDs) and sets priorities for future research, there is scientific evidence (from controlled trials and observational studies) of the effectiveness of the Picture Exchange Communication System (PECS) in increasing child-toadult initiated communication, primarily requesting communication acts. Therefore, Individ‐ uals with ASDs who have limited verbal language, or those who do not respond to multiple interventions aimed at improving communication, should be offered the opportunity to use the PECS [21]. A randomized clinical trial compared Pivotal Response Training (PRT), a verbally-based intervention to PECS on acquisition of spoken language by 39 young (2-4 years), nonverbal or minimally verbal children with autism. The children were randomly assigned to either PRT or PECS condition. All children received 23 weeks of intervention. The measured dependent variables included overall communication, expressive vocabulary, pictorial communication and parental satisfaction. Children in both intervention groups demonstrated increases in spoken language skills, with no significant difference between the two conditions. Majority of the children exited the program with more than 10 functional words. Parents were very satisfied with both programs but indicated that PRT was easier to implement [22]. PECS has been found to be an effective intervention for reducing maladaptive behaviours in children with autism. In a study, 3 young boys with autism were given PECS training and its effect on requesting, use of intelligible words and maladaptive behaviour was measured. Results indicated that all participants quickly learned to make requests using pictures and that two used intelligible speech following PECS instruction. Maladaptive behaviours were variable throughout baseline and intervention phases [23]. Effectiveness of PECS protocol for the first three phases was evaluated with 3 adults with autism. A multiple baseline across participants design was used to assess the effect of the training package consisting of a video, written and verbal instructions, modelling, rehearsal, and feedback. Results showed significant improve‐ ments relative to baseline in a short amount of training time, and that skills generalized to a learner with a severe developmental disability [24].

### **6. Method**

This experimental study used a pre-test post-test control group design. The study sought to determine the effect of PECS intervention on development of functional language of children with autism, and to compare the acquisition of functional language abilities by children who received the PECS intervention to those who did not.

#### **6.1. Subjects**

The study was conducted in Mumbai, India on 30 children in the age range of 8 to 12 years. The participating children were selected from 3 special classes for children with autism and intellectual disabilities. The subjects consisted of nonverbal and minimally verbal children with autism. As per records their psychometric performance placed them in the range of severe to moderate intellectual disability. The schools they attended provided speech and language intervention but the intervention was not AAC based. After selection all children were preassessed on Functional Language Assessment Scale (FLAS). Subsequently, they were ran‐ domly assigned to experimental and control groups so that each group had 15 children. The experimental group received PECS intervention for 15 sessions of 30 minutes each. The control group continued with the language intervention provided by the school.

#### **6.2. Instruments**

The researchers used PECS intervention and Functional Language Assessment Scale as instruments. A brief description of both is given below.

**•** *PECS Intervention*: The intervention consisted of the first 3 phases of PECS, namely, picture exchange, expanding spontaneity, and picture discrimination. PECS phases were taught using such techniques of applied behavioural analysis (ABA) as prompting, shaping and reinforcement.

communication and parental satisfaction. Children in both intervention groups demonstrated increases in spoken language skills, with no significant difference between the two conditions. Majority of the children exited the program with more than 10 functional words. Parents were very satisfied with both programs but indicated that PRT was easier to implement [22]. PECS has been found to be an effective intervention for reducing maladaptive behaviours in children with autism. In a study, 3 young boys with autism were given PECS training and its effect on requesting, use of intelligible words and maladaptive behaviour was measured. Results indicated that all participants quickly learned to make requests using pictures and that two used intelligible speech following PECS instruction. Maladaptive behaviours were variable throughout baseline and intervention phases [23]. Effectiveness of PECS protocol for the first three phases was evaluated with 3 adults with autism. A multiple baseline across participants design was used to assess the effect of the training package consisting of a video, written and verbal instructions, modelling, rehearsal, and feedback. Results showed significant improve‐ ments relative to baseline in a short amount of training time, and that skills generalized to a

This experimental study used a pre-test post-test control group design. The study sought to determine the effect of PECS intervention on development of functional language of children with autism, and to compare the acquisition of functional language abilities by children who

The study was conducted in Mumbai, India on 30 children in the age range of 8 to 12 years. The participating children were selected from 3 special classes for children with autism and intellectual disabilities. The subjects consisted of nonverbal and minimally verbal children with autism. As per records their psychometric performance placed them in the range of severe to moderate intellectual disability. The schools they attended provided speech and language intervention but the intervention was not AAC based. After selection all children were preassessed on Functional Language Assessment Scale (FLAS). Subsequently, they were ran‐ domly assigned to experimental and control groups so that each group had 15 children. The experimental group received PECS intervention for 15 sessions of 30 minutes each. The control

The researchers used PECS intervention and Functional Language Assessment Scale as

**•** *PECS Intervention*: The intervention consisted of the first 3 phases of PECS, namely, picture exchange, expanding spontaneity, and picture discrimination. PECS phases were taught

group continued with the language intervention provided by the school.

instruments. A brief description of both is given below.

learner with a severe developmental disability [24].

216 Autism Spectrum Disorder - Recent Advances

received the PECS intervention to those who did not.

**6. Method**

**6.1. Subjects**

**6.2. Instruments**


(P) to 50, they were categorized and scored in the same manner as in FLAS*.* For details of FLAS structure and sample of items included in it please refer to Table 1.

#### **6.3. Procedure**

The intervention commenced after assessing the children's baseline functional language skills on FLAS. All 30 children were underwent the assessment before being randomly assigned to experimental and control groups. The assessments were done following the steps given below.


Once the participating children were assigned to experimental and control groups, the parents of experimental group children were shown how to use FLAS (P), and then asked to record their child's response to each item with respect to receptive and expressive language. The parents were provided pictures and models where real objects could not be used. The inter‐ vention began once the assessment process was completed. As stated earlier, only 3 phases of PECS training was considered for intervention. Each child received 15 sessions of intervention of 30 minutes duration. A description of intervention steps is given below.

**a.** As PECS is based on the principles of ABA, determining the motivator for a child was important. Hence, parents and teachers of experimental group children were consulted for this. A list of reinforcers to be used in subsequent sessions was made.


Autism and Functional Language Development – An Experiment with AAC Intervention http://dx.doi.org/10.5772/59137 219


**Table 1.** FLAS structure and sample of items

(P) to 50, they were categorized and scored in the same manner as in FLAS*.* For details of

The intervention commenced after assessing the children's baseline functional language skills on FLAS. All 30 children were underwent the assessment before being randomly assigned to experimental and control groups. The assessments were done following the steps given below. **•** For assessment of receptive language, a child was asked to pick up the picture of a named item from a group of 2-3 pictures. If the child selected correct picture without any prompts he/she was allotted 4 points. A prompted response was marked anywhere between 3 and 1

**•** Since the research was conducted on nonverbal or minimally verbal children with autism, expressive language was measured in terms of the child's ability to match a picture to a given object. A child was shown a real object or its model and asked to pick up the picture from a set of pictures that represented the object. Scoring was similar to that for receptive

Once the participating children were assigned to experimental and control groups, the parents of experimental group children were shown how to use FLAS (P), and then asked to record their child's response to each item with respect to receptive and expressive language. The parents were provided pictures and models where real objects could not be used. The inter‐ vention began once the assessment process was completed. As stated earlier, only 3 phases of PECS training was considered for intervention. Each child received 15 sessions of intervention

**a.** As PECS is based on the principles of ABA, determining the motivator for a child was important. Hence, parents and teachers of experimental group children were consulted

**Receptive Language Items Expressive Language** CR **RVP RGP RPP CR RVP RGP RPP Food items** ⋅ biscuit ⋅ chocolate ⋅ wafer ⋅ apple ⋅ banana ⋅ samosa **Classroom items**

of 30 minutes duration. A description of intervention steps is given below.

for this. A list of reinforcers to be used in subsequent sessions was made.

FLAS structure and sample of items included in it please refer to Table 1.

depending on the level of prompt required by the child.

**6.3. Procedure**

218 Autism Spectrum Disorder - Recent Advances

language.

**b.** The initial sessions aimed to help a child learn how to communicate. The first session began by showing the child the desired item, and encouraging him/her to pick up the matching picture. Since the children wanted the reinforcer, they could pick up the corresponding picture easily. At this point only one picture card was introduced. For children who required assistance to understand the concept of exchanging the picture for what they desired, another adult prompted them to give the card to the communicating partner who held the desired item. Once the children learned the process of exchanging picture card for desired item they were shown other items and their corresponding pictures. Both correct and prompted responses would be followed by a reinforcer. This ensured that a prompted response shaped into correct response as the sessions progressed. The selection of items for a given session was based on the child's level of functioning as pre-tested on FLAS.


While the children in the experimental group received PECS training for 15 sessions, those in the control group continued with the language intervention program provided in their schools. After intervention period all children were post tested on FLAS. Parents of experimental group children were asked to reassessed their children on FLAS (P). Figures 1-6 show some inter‐ vention sessions.

**Figure 1.** Introducing a desired food item with matching picture

Autism and Functional Language Development – An Experiment with AAC Intervention http://dx.doi.org/10.5772/59137 221

**Figure 2.** Learning to match object to picture

what they desired, another adult prompted them to give the card to the communicating partner who held the desired item. Once the children learned the process of exchanging picture card for desired item they were shown other items and their corresponding pictures. Both correct and prompted responses would be followed by a reinforcer. This ensured that a prompted response shaped into correct response as the sessions progressed. The selection of items for a given session was based on the child's level of functioning as

**c.** Once the children learned social interaction by exchanging picture cards for items sitting on a desk with a communicating partner, the intervention moved to the second phase of PECS training. The researchers introduced distance between the picture card and the communicating partner. Now the cards were either kept on a nearby table or stuck on a board. The children were expected to pick up the card and take it to the communicating partner. They were taught persistence by increasing the distance from the partner with

desired item, so they learned to walk across the room to complete interaction.

**d.** Distractor picture cards were introduced during the third and last phase of training. Different picture cards served as distractors for teaching a child to select the target picture. The cards consisted of pictures of items included in the FLAS. Children's responses were shaped though the required level of prompts. Initially this was done sitting on a desk with the communicating partner. As the children learned to give correct response, distance was reintroduced in the session. Hence, the children were expected to select the target picture from a set of pictures on a board and bring it to the adult for the interaction to be completed.

While the children in the experimental group received PECS training for 15 sessions, those in the control group continued with the language intervention program provided in their schools. After intervention period all children were post tested on FLAS. Parents of experimental group children were asked to reassessed their children on FLAS (P). Figures 1-6 show some inter‐

pre-tested on FLAS.

220 Autism Spectrum Disorder - Recent Advances

vention sessions.

**Figure 1.** Introducing a desired food item with matching picture

**Figure 3.** Exchanging picture card for desired food item

**Figure 4.** Selecting target picture from a group of pictures

**Figure 5.** Introducing verb cards

**Figure 6.** Introducing distance between picture and desired object
