PRESENTED BY: TAMRA BELL, M.A. CCC-SLP & SARA GILBERT, M.S. BCBA APRIL 22, 2016 CHATTANOOGA AUTISM CONFERENCE American Sign Language (ASL) vs. Picture Exchange Communication System (PECS)

Communication Estimates show that 50% of children on the Autism Spectrum are non-vocal (Frankel, Leary & Kilman, 1987) Non-vocal, not the same as non-verbal Research has shown that children with poor verbal imitation skills are the ones most likely to need a form of augmentative communication system to develop spoken language HELP

Types of Augmentative Alternative Communication (AAC) PECS ASL/SL iPad/iPhone/Android  Proloquo2Go  Lamp  MyVoice  SmartEdTech  Smartstones Touch  Talking Tablet  Tap To Talk DynaVox Bluebee Pals Free - $3,000 (and up)

American Sign Language (ASL) What is ASL?  Visual Language  Shape, placement, and movement of the hands  Facial expressions  Body movements  Used predominately in the US and many parts of Canada  Accepted as a ‘foreign’ language requirement at many high schools and college universities.  Has its own rules of grammar and syntax  A living language that changes over time

How is ASL taught to those on the Autism Spectrum?  Preference assessment: What does the child like?  Choose specific items based on preference assessment  3 nouns, 3 verbs  Manding (requesting) sessions  Use fading and shaping procedures to teach the sign  Always have to use signs chosen to receive those items throughout day in all environments  Do NOT use mega mands (requests): more, please, thank you American Sign Language (ASL) Therapist signs & says item Child signs (chance at saying item or therapist says item) Therapist signs & says item

Verbal Operants Bubbles Tact: What is this? “Bubbles” ‘Do this’ blow bubbles Listener Responding: pop bubbles Mand: “Bubbles” Feature: round Function: blow Class: toy Intraverbal: Blow the bubbles. Echoic: say bubbles “bubbles” Visual Perception: matching & classifying bubbles

American Sign Language (ASL) Sign Sign & Vocal Vocal Try for vocal attempts 3 times, then reinforce (don’t want to weaken all attempts to communicate)

Some typical reasons why ASL teaching may fail  First signs taught are not mands (requests)  First signs taught are mega mands (more, please, yes/no, thank you)  First signs resemble each other (eat and drink)  Failure to establish a signing community (child’s caregivers)  Failure to require sign outside of the training sessions  First signs too difficult to do (okay to modify signs) American Sign Language (ASL)

 Sign language does NOT delay the acquisition of spoken language, it may actually enhance it  There is evidence that some children’s spoken language is enhanced by the use of sign language  Benefits included higher levels of initiation, eye-contact, and vocalization following the end of treatment  Almost all children on the Autism Spectrum can learn to sign, despite motor imitation deficits American Sign Language (ASL)- Research

 May lead to improved vocal verbal behavior in children who are vocal but engage in frequent delayed echolalia or video-type scripting  Acquired more easily (faster and accurately) than picture symbol systems (just pointing)  Several studies have shown that when using sign language, you are stimulating the same part of the brain used for vocal language  By using these meaningful hand movements which activate this area of the brain make learning a new word easier American Sign Language (ASL)- Research

Pros of ASL  Does not require technology  Similarities with vocal language  Always have your hands with you (don’t have to carry around a book)  Immediate responding  Can be used in all forms of communication (requesting, labeling, fill-in, conversation, etc.)- It is a language  Gives child a visual to go with a vocal to aid in understanding Cons of ASL  Difficult for those who don’t have good fine motor imitation skills  Not everyone knows ASL (community)  ‘But I don’t know SL’ (caregivers)  Likely to scroll or overgeneralize signs when first learning SL American Sign Language (ASL)

University of Washington undergraduate team developing gloves that translate sign language Can find video on you tube: gloves that translate sign language American Sign Language (ASL)

Who is an ideal candidate for ASL?  Has basic motor planning and fine motor imitation skills  Allows others to use hand over hand prompts  Anyone of any age  If other methods of communication that have not worked (or used mega mands in the past using ASL)  If have difficulty scanning and receptively identifying items American Sign Language (ASL)

o What is PECS? o PECS is a low-tech augmentative/alternative communication system Picture Exchange Communication System (PECS) PHASE I - How to Communicate Students learn to exchange single pictures for items or activities they really want. PHASE II - Distance and Persistence Still using single pictures, students learn to generalize this new skill by using it in different places, with different people and across distances. They are also taught to be more persistent communicators. PHASE III - Picture Discrimination Students learn to select from two or more pictures to ask for their favorite things. These are placed in a communication book—a ring binder with Velcro® strips where pictures are stored and easily removed for communication.

PHASE IV - Sentence Structure Students learn to construct simple sentences on a detachable sentence strip using an “I want” picture followed by a picture of the item being requested. Attributes and Language Expansion Students learn to expand their sentences by adding adjectives, verbs and prepositions. PHASE V - Answering Questions Students learn to use PECS to answer the question, “What do you want?” PHASE VI - Commenting Students are taught to comment in response to questions such as, “What do you see?”, “What do you hear?” and “What is it?”. They learn to make up sentences starting with “I see”, “I hear”, “I feel”, “It is a”, etc. Picture Exchange Communication System (PECS)

Some typical reasons why PECS teaching may fail  Confusing visual supports/ picture schedules with PECS  Choosing items that are not strong motivators  The child must want the object enough to reach for it when offered  Skipping important steps without checking for mastery  Ex. Discrimination step- preferred v. non preferred An easily contented child will take whatever is offered  Ex: traveling before discrimination =

Video example  Patient is 3 years, 11 months  Primarily nonverbal – weak receptive language  Is beginning to verbalize clear words during Joint Action Routines (described later)  Does not initiate communication spontaneously  Great difficulty with motivation to communicate  Reinforcer identification is difficult  Expanding vocabulary in Phase I  Just beginning to introduce traveling (Phase II) o Required great support for first few weeks Picture Exchange Communication System (PECS)

Video example  Patient is 5 years, 0 months  Nonverbal – strong receptive language  Is beginning to make intentional verbalizations and word approximations during Joint Action Routines (including PECS), but these are inconsistent and unpredictable  Mastered Phases I, II, III  Phases IV – VI will not be introduced  Uses Manual Sign and SGD in other settings Picture Exchange Communication System (PECS)

Research o Preston and Carter (2009) – Meta-analysis o Total of 27 studies (3 were Randomized Controlled Trials, the rest were a mix of group design and single subject) o Findings: o 99.7% of all subjects in all studies mastered Phase I o An increase in speech production was noted when time delay strategies were introduced during Phase IV in 3 studies o Statistically significant increases were found in: o Spontaneous initiation of communication o Frequency of speech o Number of different words used o Non-imitative speech o Some challenges were noted: o Children did not maintain skills in some studies when treatment was discontinued o Overall conclusions: PECS can be an effective evidence based treatment for some children Picture Exchange Communication System (PECS)

Research Other findings: Flippin et al., Meta-analysis of 11 studies – 8 single subject, 3 group design Small to moderate positive effects on communication Speech outcomes vary widely Conclusion: overall demonstrated adequate evidence that PECS is an evidence based treatment approach Gordon et al, – Randomized controlled trial – 84 children across 15 schools All children increased in spontaneous communication Continued effects were seen at follow up 9 months later Children with less severe language impairments and less severe autism symptoms demonstrated greatest response Picture Exchange Communication System (PECS)

Research Other findings: Schreibman and Stahmer, 2013 Randomized controlled trial: 39 children- comparing PECS to a naturalistic behavioral intervention (PRT) Both interventions resulted in an increases in spoken language Parents were satisfied with both treatment experiences Mentioned that PECS was harder work, but did not rate it less positively Picture Exchange Communication System (PECS)

Advantages of PECS  Methodology similar to Joint Action Routines/ Communicative Temptations*  Allows time delay for speech development  Target’s initiation of communication  Minimal prerequisite skills  Minimal fine motor skills  Recreates back and forth of communication  Quick fading of prompts  Concrete – recognizable by unfamiliar communication partners Disadvantages of PECS  Restricted to requests  Other communication functions are artificially prompted  Poor sentence formulation  Missing genuine noun-verb combos  Missing protests and refusals  Labor intensive  Limited to vocabulary in book  Training/implementation errors  Generalization and maintenance  Especially in home environment Picture Exchange Communication System (PECS) *Snyder-McClean et al.( 1984), Sussman, F. ( 2012), Wetherby & Prizant (1989)

Who is an ideal candidate for PECS  A child may be a match for PECS if they…  Are a limited verbalizer  Have trouble initiating Even if verbalizing, may help initiation of communication  Are prompt dependent  Are preschool age Though could be younger or older  Are an emerging verbalizer Picture Exchange Communication System (PECS)

Research There have been a few studies comparing the effectiveness of these two approaches  Adkins, T. & Axelrod, S. (2002): Single subject case study  The results showed that PECS was a more effective communication method for this child  Barlow, et al. (2013): 3 subject case study, children had severe language impairments  The results showed that PECS was acquired more readily for all subjects  Tincani, M. (2004): 2 subject case study  One child responded better overall with PECS  One child responded better overall with ASL  Both were noted to make better vocalizations when using ASL  Chambers, M. & Rehfeldt, R. (2003): 3 subject case study  All 3 children were successful with PECS and ASL  Generalization was noted to be better with PECS  All children were better at requesting items that were not present when using PECS ASL vs PECS

Choose the system that works for the child based on your treatment objectives and your child's strengths/weaknesses These questions may be helpful when evaluating the usefulness of each system:  Will this approach be learned quickly to replace maladaptive behaviors?  Will this approach allow for effective communication for multiple purposes of communication (requesting, labeling, commenting, etc.)?  Does this approach facilitate development of vocal words?  How difficult will this system be for the child? or for the child's family?  Does the child have difficulty initiating communication?  Is the child overly prompt dependent when communicating? Clinical Decision Making

Adkins, T. & Axelrod, S. (2002). Topography ‐ versus selection ‐ based responding: Comparison of mand acquisition in each modality. The Behavior Analyst Today, 2, 259 ‐ 266. Barlow, K., Tiger, J., Slocum, S. & Miller, S. (2013). Comparing acquisition of exchange ‐ based and signed mands with children with autism, The Analysis of Verbal Behavior, 29, Chambers, M. & Rehfeldt, R. (2003). Assessing the acquisition and generalization of two mand forms with adults with severe developmental disabilities. Research in Developmental Disabilities, 24, 265 ‐ 280. Flippin et al (2010). Effectiveness of the Picture Exchange Communication System (PECS) on Communication and Speech for Children with Autism Spectrum Disorders: A Meta-Analysis. American Journal of Speech-Language Pathology, 19, Gordon et al. (2011). A communication ‐ based intervention for nonverbal children with autism: What changes? Who benefits? Journal of Consulting and Clinical Psychology, 79, 447 ‐ 457. Preston, D., & Carter, M. (2009). A Review of the Efficacy of the Picture Exchange Communication System Intervention. Journal of Autism and Developmental Disorders, 39, 1471 – References

Schreibman, L., & Stahmer, A. (2013). A Randomized Trial Comparison of the Effects of Verbal or Pictorial Naturalistic Communication Strategies on Spoken Language for Young Children With Autism. Journal of Autism and Developmental Disorders, 44, 1244 – Snyder-McClean et al. (1984). Structuring joint action routines: A strategy for facilitating communication and language development in the classroom. Seminars in Speech and Language, 5, Sussman, F. (2012). More Than Words: A Parent’s Guide to Building Interaction and Language Skills for Children with Autism Spectrum Disorder or Social Communication Difficulties. Toronto: Hanen Program. Tincani, M. (2004). Comparing the Picture Exchange Communication System and sign language training for children with autism. Focus on Autism and Other Developmental Studies, 19, 152 ‐ 163. Wetherby, A., & Prizant, B. (1989). The expression of communicative intent: Assessment issues. Seminars in Speech and Language,10, References

Layton, T. & Watson 1. (1995) Enhancing communication in non-verbal children with autism. In K. A. Quill (Ed)Teaching Children with autism: Strategies to enhance communication and socialization. (pp ) New York: Delmar Publishers. National Academy of Science (2001). Commission on Behavioral and Social Sciences and Education. Educating Children with Autism Konstanantareas, M., Webster, C., and Oxman, J. (1979) Manual language acquisition and its influence on other areas of functioning in four autistic and autistic-like children. Journal of Child Psychology and Psychiatry and Allied Discipines, 20, Layton, T. (1988) Language Training with autistic children using four different modes of presentation. Journal of communication Disorders, 21, Layton, T. & Baker, P. (1981) Description of semanticsyntactic relations in an autistic chyild. Journal of Autism and Developmental Disorders, 11, Schaeffer, B., Kollinzas, G., Musil, A., & McDowell, P. (1978) Spontaneous verbal language for autistic children through signed speech. Sign Language Studies, 21, Sundberg, C. and Sundberg, M. (1990) Comparing topography-based verbal behavior with Stimulus selectionbased verbal behavior, The Analysis of Verbal Behavior, 8Y Tincani, Matt (2004). Comparing the Picture Exchange Communication System and Sign Language Training for Children with Autism. Focus on Autism and other Developmental Disabilities. Fall, 19, Yoder, P. and Layton, T. (1989) Speech following sign language training in autistic children with minimal verbal language. Joumal of Autism and Developmental Disorders, 18,

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PRESENTED BY: TAMRA BELL, M.A. CCC-SLP & SARA GILBERT, M.S. BCBA APRIL 22, 2016 CHATTANOOGA AUTISM CONFERENCE American Sign Language (ASL) vs. Picture Exchange Communication System (PECS) Thank you for attending our presentation!