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Similaire à Brief Report: Increasing Communication Skills for an Elementary-Aged Student with Autism Using the Picture Exchange Communication System (20)
2. 226 Kravits, Kamps, Kemmerer, and Potucek
icons and generalization to novel school settings Measurement
(Schwartz, Garfinkle, & Bauer, 1998). Verbalizations
increased for talkers but not for nonverbal children The frequency of spontaneous language including
in the study. The purpose of the current study was to requests (i.e., words or approximations asking for items
(a) evaluate the effectiveness of teaching PECS on the or help), comments (i.e., labeling or describing items,
spontaneous communication of an elementary-aged situations), or expansions (adding new elements to pre-
child with autism, (b) determine feasibility of use by vious utterances) was selected as the target behavior
the mother, classroom teachers, and peers across home (dependent variable) to be treated with the PECS.
and school environments, and (c) note effects in con- Requests and comments were counted only if they
junction with social skills training for social interaction occurred without prompting (i.e., no instruction, ques-
behaviors. tion within 5 seconds prior).
Data were collected by the experimenters for lan-
guage behaviors that occurred within 10-minute sam-
METHOD
ple periods. When the student communicated, the
observer recorded what the student communicated, the
Participant, Settings, Materials
mode (e.g., verbal, symbol, sign), the function (e.g.,
Molly was a 6-year-old girl with a diagnosis of request, comment), and to whom (i.e., adult or peer) the
autism. She was integrated, with the assistance of a para- student was communicating. Repeated verbalizations
professional, in a half-day kindergarten program in the were recorded as one communicative episode, ending
public school. In addition, she received 30–60 minutes after a 5-second pause.
of special education services per day from the learning Social interaction data were collected in 5-minute
center teacher and language therapist. Molly’s score on intervals using a laptop computer programmed with the
the Vineland indicated a 2 years 8 months performance Multi Option Observation System for Experimental
level. Scores on the Wechsler Preschool and Primary Studies (MOOSES) developed by Tapp, Wehby, and
Scale of Intelligence (WPPSI-R) were within the 27th Ellis (1992). This system was used to code the dura-
percentile for verbal behavior and the 1st percentile for tion of interaction between Molly and her peers or the
adaptive behavior. Her developmental age was 2–2.5 adults in her environment. Once an interaction (i.e., ini-
years on the Psychoeducational Profile-Revised (PEP- tiation followed by a response within 5 seconds) was
R). When prompted, Molly communicated using 1- to observed, it was keyed in and continuously recorded
2-word utterances (e.g., “Want cookie”), but her speech until the observer keyed the end of the interaction; see
was difficult to understand, and her frequency of initi- prior reports for program description (Kamps, Potucek,
ations was very low. She also used gestures and eye con- Gonzalez-Lopez, Kravits, & Kemmerer, 1997).
tact to communicate, but she initiated and used more Language samples and social interaction data were
verbalizations at home with her mother than with teach- collected at least once every session across all settings
ers or peers at school. Thus, the PECS was chosen to (i.e., two times a week in journal time and centers, two
provide Molly with an effective communication system or three times a week at home).
across settings and to increase her spontaneous initia- Interobserver agreement was collected for each
tions and interactions with others in her environment. language variable for 11% of the observation sessions.
Settings for the study included leisure and snack The mean percentage of agreement for content of the
time in Molly’s home and play periods with peers dur- verbalizations was 93% in baseline and 91% in inter-
ing journal (writing/coloring in notebooks followed by vention; 97% in baseline for mode (icon versus sign ver-
play) and center activities (free play) at school. All set- sus verbal) and 96% in intervention; and 89% in
tings were similar to free time with play with others as baseline for function (i.e., spontaneous request versus
a primary activity and the inclusion of peers at school. comment) and 86% in intervention. Reliability was
Materials consisted of food (e.g., popcorn, candy, soda, computed on an item-by-item basis, with the number
cookies), toys (e.g., Casio piano, Koosh Balls, Slinkys, of agreements divided by the number of agreements
markers, Silly Putty), and games (e.g., Don’t Break the plus disagreements. Reliability for social interaction
Ice). Graphic symbols/icons (line drawings) of items data for 14% of the MOOSES files was computed me-
were taken from the Mayer-Johnson Picture Commu- chanically using software that matched the files of the
nication Symbols (1990) or were hand drawn (2 2- primary and second observers with the mean agreement
inch black and white). at 86%.
3. PECS 227
Design and Procedures Phase I, Physically-Assisted Exchange, consisted of
teaching Molly to initiate a communicative exchange
A multiple baseline design across settings (Baer,
by giving her a picture of a desired item/activity to the
Wolf, & Risley, 1968) was used to document treatment
trainer. Training consisted of placing the item slightly
effectiveness. The experimental conditions included
out of her reach. When she reached for the item, a
two baseline conditions and two treatment phases that
prompter (seated behind Molly) assisted her using
occurred during play activities at home and school.
“hand over hand” to pick up the picture and hand it to
the trainer. If she did not reach within 3–4 seconds, the
Baseline (A1)
trainer prompted from behind. The receiving trainer
Molly was observed while in play situations across held out her hand serving as a cue. Once the picture
all settings before teaching using the PECS. Reinforcer touched the hand of the receiving trainer, the trainer
assessment was also conducted once before beginning stated “Oh, you want _____,” and the requested item
baseline. Then in baseline, sessions included a variety was given to the student. Delays were increased to pro-
of available materials, including those noted as pre- mote spontaneity and discrimination. The criterion for
ferred items from the reinforcer assessment. These were Phase I consisted of Molly exchanging the pictures in-
available without contingent requests during the play dependently without the prompter’s assistance and
time. Data were collected on the frequency of Molly’s without the open hand cue from the trainer for 80% of
spontaneous language and social interaction across the teaching period trials (typically 5–10 each session,
4 weeks in all settings (i.e., home, centers, and journal with 17 trials in the initial session to teach picking up
time). Verbalizations to Molly were typical to the set- the icon and the exchange). Phase II, Expanding Spon-
tings (i.e., directions for the activity, some questions taneity, consisted of three steps: the introduction of the
regarding her needs, general commenting). The school communication board (pictures attached with Velcro),
activities were more independent play with occasional an increase in the distance of the receiving trainer and
adult interactions, whereas the mother engaged in more Molly, and an increase in the distance of the board from
chatting during the leisure activities with general com- Molly. Again, 80% correct, independent requesting was
menting and some contingent questioning (e.g., “What the criterion. Phase III, Discrimination of Pictures,
do you want?”). consisted of discrimination between multiple pictures
on the communication board, correspondence checks
Baseline (A2) (use of icons to force correct discriminations based
upon preferences), and picture size reduction (initial
During the second baseline condition, the com-
size 2 2 inches, then 1 1 inches). Phases I–III
munication board with symbols was introduced across
were taught to criterion in the home setting, and then
all environments, but Molly was not prompted to use
treatment was implemented in classroom settings.
it. Data were collected under the same conditions as
All sessions consisted of both teaching periods and
those described in the A1 condition across 1 week at
play periods. The procedures of the PECS were taught
home, 12 weeks during centers, and 17 weeks during
during the teaching periods (5–10 trials, approximately
journal time.
5 minutes) immediately followed by the free play pe-
riods (15–20 minutes), during which a choice of items
Treatment (B)
and activities was available for play contingent on re-
The PECS was implemented during play activities questing using the PECS (the same materials as avail-
across all settings following procedures as outlined in able in baseline, with new items assessed periodically).
the manual (Frost & Bondy, 1994). The PECS is an Peers at school also received brief training in use of the
AAC system that uses a variety of behavioral tech- PECS with Molly. Data were collected under the same
niques to teach children to communicate. These tech- conditions as those described in the A1 and A2 condi-
niques are incorporated into six teaching phases that tions, during the play periods after training. Note that
target different components of communication (i.e., initially during PECS training in the home, reinforcer
spontaneous requesting, discriminating, building sen- assessment was conducted before training and those
tence structure, responding to questions). Phases I–III materials were used in training. When free play began,
as outlined in the training protocol were conducted in however, the mother chose an activity that typically
this study, including reinforcer assessment at the be- was not an activity from those determined as reinforcers
ginning of each training session (Frost & Bondy, 1994). based on assessment. Although preferred items from
4. 228 Kravits, Kamps, Kemmerer, and Potucek
the assessment were still available, the mother directed
Molly to use the item she selected, rather than allow-
ing Molly to choose her activity. Thus, beginning with
the 13th session of the home intervention phase, Molly
was allowed to choose (with the icon initiation) which
items to use during free play. A total of 71 trials over
five training periods was required to reach criterion for
Phases I–III at home, 41 trials over eight sessions were
required in centers, and 15 trials over five sessions were
required in journal time. Once criteria for the phases
were reached, reinforcer assessment and a minimum of
five training trials continued at the beginning of ses-
sions; however, the time for training became much
shorter over time as Molly mastered initiations with
PECS.
Social Intervention with the PECS (C)
During this condition, the PECS was used in com-
bination with social skills training to increase the du-
ration of Molly’s interaction with her peers. Molly’s
peers were instructed on how to keep her engaged dur-
ing game playing situations (games were used in place
of free choice activities). Peer training was conducted
for four sessions, followed by peer practice (i.e., a few
minutes of models and reminders) conducted before
each play/leisure period. Social skills included sharing
materials, taking turns, asking and answering questions,
and extending the play interactions. Training included
defining the skill, modeling, and practice trials with the
peers and Molly. Data were collected under the same
conditions as described. Fig. 1. Total frequency of spontaneous icon-based language and
icon-plus verbals (i.e., requests, comments, and expansions) across
settings.
RESULTS AND DISCUSSION
As displayed in Figure 1, the total frequency of curred in all settings, with 38 learned icons and
spontaneous language using icons or icons plus ver- 4–8 icons used during 10-minute intervention sessions.
bals per 10-minute session increased during settings Intelligible verbalizations also showed increases in two
when the PECS treatment conditions were imple- of three settings, home and journal time, with a range
mented. Effects were consistent across home and school of 15–16 at home and 5–8 at school. Thus, spontaneous
and when PECS was used by the mother, teachers, and language, which often included icon use but also in-
peers. No use of icons was demonstrated during base- cluded some verbal language without the icons, in-
line (although icons were present), and with the PECS creased with the intervention. At home, Molly averaged
instructional protocol, Molly demonstrated successful 8–9 initiations during play in baseline (all verbal) and
use of the augmentative system. An increase in initia- 18 during PECS (icons and verbals). During school cen-
tions at home was noted when materials from the rein- ters, Molly averaged 3–5 initiations in baseline, with
forcer assessment and training were also available increases to 11 during the intervention. During journal
during free play, indicating choice as a critical aspect time, similar effects were noted with a mean of 4 –7
to increasing spontaneity within PECS. initiations in baseline and 14 during intervention. These
Table I. presents mean data by condition for use findings indicate that increased spontaneous language
of icons, as well as spontaneous verbalizations and du- included both increased verbalizations and icon use in
ration of social interaction. Reliable use of icons oc- two settings. The t tests indicated significantly more
5. PECS 229
Table I. Means of Behaviors by Session tively). These increases reflect increased contact with
a small number of peers rather than increases in the
A1 A2 B C
number of peers contacted.
Mean frequency of icon use
Home 0 0 5.2 4
Centers 0 0 4.4 6.5 SUMMARY
Journal time 0 0.8 7.8 7.6
Mean frequency of intelligible verbalizations This study provided an empirical demonstration of
Home 9.6 5.8 15.5 16
the effectiveness of PECS in increasing spontaneous
Centers 2.5 5.3 7.2 5.8
Journal time 6.0 3.8 6.5 8.3 communication skills for a young child with autism.
Mean frequency of initiations = icon verbalizations or These findings are consistent with descriptive reports
icons verbalizations or verbalizations alone (e.g., Bondy & Frost, 1994; Schwartz et al., 1998) and
Home 9.9 8.0 17.4 19.0 experimental reports documenting specific strategies
Centers 2.5 5.2 11.2 11.0
such as the use of child preference/choice and time
Journal time 7.7 4.3 14.2 14.3
Mean duration of social interaction with peers delay tactics in language intervention (e.g., Dyer, 1989;
(300 seconds total time) Halle, 1982; Koegel et al., 1987). Findings expand prior
Home 38 0 16 54 studies by including an older child (kindergarten age)
Centers 71 31 54 173 and by including the home as an intervention setting.
Journal time 60 26 146 183
Experimenters also noted that Molly’s use of the sys-
tem helped her become a much more spontaneous per-
son using the icons in home and school activities. The
duration of Molly’s peer interactions increased in jour-
initiations (df 1, F 114.9, p .01) and verbal- nal time, and the frequency increased in both, from 0
izations (df 1, F 30.1, p .01) during interven- to 2 in baseline to 7 in centers and 13 in journal time
tion sessions over baseline sessions. Observations also using the PECS, clear documentation for the social va-
indicated, however, that Molly did not significantly in- lidity of the system in school. Before the PECS, ob-
crease the range of spoken vocabulary during inter- served communication was nonverbal, more passive
vention. For younger children, it has been reported that (e.g., gestures, smiles), and primarily directed toward
if verbal language begins, it generally occurs after ap- the adults. It is unclear, however, what social effects
proximately a year in the PECS program (Bondy, Hoff- were from PECS alone versus PECS plus the social
man, & Glassberg, 1999). Thus, this case was not a skills booster sessions. Limitations thus include the
reliable one for study of the PECS in regards to verbal confound of the social skills enhancement, a confound
language acquisition due to (a) prior verbal language to PECS alone as an intervention, and no generaliza-
by Molly as exhibited in baseline and (b) length of the tion or follow-up probes. Future research with PECS
intervention. should include (a) implementation with multiple par-
The duration of social interaction with peers (see ticipants and those with varying levels of functioning,
Table I) was also monitored to note treatment effects. (b) long-term study of PECS with completion of the
Minimal changes were noted at home for interaction training protocol (advancement through all six training
time with use of the PECS, but this is likely an effect phases) and use of PECS across longer periods of the
of opportunity as Molly’s brother was the only “peer” school day, and (c) alternative social interventions in
available at home, with an occasional friend from combination with the PECS.
school. At school, however, increases were only noted
with PECS intervention in one of two settings ( journal
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