Moving On From PECS An Introduction ACE Centre Network Day 20th March 2012 Karen Bailey and Rachel Moore ACE Speech and Language Therapists

An Introduction PECS (Picture Exchange Communication System) is a useful tool for developing communication Well known tool for teaching skills for developing communication What if an individual doesn’t develop functional speech? INTRODUCTION TO PRESENTATION BY KB WITH SUPPORT FROM RM IF NEEDED We will go thru just some ideas for supporting children, young people and adults in moving onto a pointing low, light or high tech VOCA Throughout and since the end of the CAP Project ACE has continued to receive regular referrals for individuals on the ASD PECS has often been introduced but for reasons such as the maintanence of the book due to the volume of vocabulary there is a need to explore other options to support the individual. From the ACE Centre’s experience a course was developed – Moving On From PECS to share successful ideas, stratgies and equipment specificually for those with Autism. The challenge for this presentation was what to include from our day course as you will see today there are many products and strategies to support children, young people and adults with Autism. So following on from Nicky’s presentation we wanted to give you a whistle stop tour of some of the ideas from our day course. Key points that assessment focuses on include: -low tech options and benefits PECS vs pointing system -light tech options – static screen displays and features of these vs high tech dynamic screen displays -access to the computer to develop literacy and language alongside the communication tool. We have included some of the individuals that we have worked with to give examples of why a particular communication strategy worked for them. PECS seems to be an essential step in learning to engage in social interaction and functional communication. Behavioural approach. Go through the key elements of PECS? Brainstorm (see the leaflet) e.g Visual support – but more than this as provides functional communication system Can be used in conjunction with other approaches such as TEACCH, ABA etc Suitable for all ages and for a range of communication diffs. Can be used anywhere. Based on ABA (see next slide). Reinforcers are established and communication is developed using these. Teaches skills critical to communication such as approaching another person from the start. Clear programme to follow – 6 phases (1- physical exchange, 2- Distance and Persistence, 3- Picture Discrimination, 4- Sentence Structure, 5- Answering Questions, 6- Commenting, Also Attributes and Language expansion). Speech Development – more than a year on into the programme, Delaware AP have found 76% of all children placed on PECS acquiring speech as sole communication system or augmented by a picture-based system. Does not delay or hinder speech.

Why was PECS developed? From PECS Training Manual - Lori Frost & Dr Andy Bondy Different communication systems had been tried & failed because of:- lack of initiation for communication lack of response to social rewards poor motor imitation KB Lack of initiation: no motivation to communicate with partner, no joint focus, no turn taking poor motor imitation – signing not used by some competing hand movements when attempting to point – for pointing to pictures/words (e.g. flapping etc) Unmotivated by the social aspect of communication

? Question ? What about individuals who no longer need PECS to initiate communication and… have not developed functional speech? or need visual support in order to speak? KB In new manual have now added ‘Speech output vocabulary is as large as PECS vocabulary’. In video have also acknowledged that youngsters may need visual support in order to speak, however, it appears that some individuals need visual support to communicate.

Criteria for giving up PECS according to PECS trainers From PECS Training Manual- Frost & Bondy Speech vocabulary is as large as PECS vocabulary Initiation with speech is intact Length of spoken utterance is as long as PECS utterance Speech is intelligible to untrained listener KB The issue with this is what about those who haven’t developed speech? See next slide. 1 – we do not want the child to lose vocabulary so PECS and spoken vocab size should be the same at least. VOCA – vocab size should have as many words as PECS book. Consider the aspects of a device that will facilitate this –static vs dynamic display. 2 – is the initiation with PECS or Speech (is the speech happening because of the visual prompt of PECS or are they talking over their sentence strips instead of relying on the prompts)? VOCA – this initiation will need to be taught as exchange doesn’t happen with all devices. 3 – verbal sentences must be as long as PECS or we are denying valuable communication skills. VOCA – dynamic displays have “sentence strip” equivalents. 4 – communication should be functional and effective therefore PECS is needed if speech is unintelligible. VOCA – using a VOCA will provide a clear verbal output. Consider all these issues before ending PECS. Also we would not remove a system but rather transition away from PECS. Child should be frequently appraoching an adult, using variety of words, variety of sentence forms that everyone understands.

Alternative AAC resources No Tech - Signing Low Tech - Books and charts Voice output Communication Aids Therefore we need to consider alternative communication systems Accessed with hands/ by pointing Need to discuss PECS and non-PECS strategies and how these can help us tailor the AAC system to the individual.

When moving on from PECS… Consider the importance of… Pointing Modelling Visual prompts We will now look at the following points that are important aspects of a communication system when moving on from PECS – consider for low and high tech POINTING Understanding that pointing can be used to communicate Individuals are often already pointing to their PECS system MODELLING Modelling – using their resources (their book/charts/device) as a 2-way system – both communication partners using them - modelling in context is an important part of using book/charts/devices VISUAL PROMPTS These may be essential for some youngsters in order to produce speech. But do not need the PECS system Pat Mirenda 2000 discusses the importance of maintaining a visual prompt, in some cases this can be needed even when an individual develops the ability to express themselves through speech. The message is ‘don’t take the visual prompt away because someone can mange a behaviour well when the prompt is in place – they may only be managing it well because the visual prompt is there. (‘AAC and Autism: What Do We Really Know?’) When changing to a new symbol system or AAC device do this gradually as young person with ASD will be managing their communication well within their familiar system.

KB Use pointer to show how a youngster with autism could use the early stages of using communication book Andrew stickers Rachel you want stickers (comment NOT question) Andrew help Rachel want help? I help you Rachel Pretty picture Rachel more stickers (comment NOT question) Partner is not questioning the young person, they are commenting and scaffolding their language

Modelling in action VIDEO – ‘Iman2’ - Clare modelling

Benefits of managing a pointing system speed fluency creativity portability maintenance KB Speed – quicker to point Fluency - When producing a sentence in PECS have to hold the ideas in your head while carrying out the mechanics of building up vocab on a message strip – adds an additional cognitive & physical load Creativity – linguistic creativity, ability to generate more varied linguistic structures (can be done through PECS but takes a long time – see speed. Fluency) Portability – as more vocab needed with PECS more bulk & weight – quotes parents –Craig, others Maintenance – eating, posting, loosing, wrongly re-positioned, adding new vocab, laminating

Social Request Describe Question Direct Give Information Language Functions Core Vocabulary Fringe Vocabulary Social Request Describe Question Direct Give Information Creativity - Possibly use the Café activity here? Illustrate the type and number of different language functions which can be achieved with a relatively small core vocabulary arranged alongside topic based pages Consistent arrangement vs PECS arrangement (symbols get moved around) What is core vocabulary? These are examples of the type of functional language that children start to use at a surprisingly early age, typically 18 m to 3 years Social - Like picture See\Look picture pretty picture Request - Who, What Can I Describe big small many pretty messy Question – why/what Direct - You help you draw you go!!! Give Information I draw picture Picture stickers I write Emma

Pointing in action Low tech book KB James Video 2 ‘JL Postassess T2 C2 Louder_01’ – Working with SLT to direct her using comm book – ‘You draw …..’ Able to clarify if she had not clearly understood and points to the symbol again and also speech. He is using speech while pointing and interacting but needs the visual support to do so.

Pointing in action Voice Output Communication Aid KB Video 1 ‘Reilly iPad modelling‘ Video 2 ‘Reilly navigating iPad‘ With modelling initially, Rielly used the iPad to generate a sentence to describe a picture. He was able to navigate between pages and find appropriate vocabulary on each page with support. Although he did not explore the iPod during the assessment session it was felt that this device was more appropriate in size for his needs and therefore it was decided that the iPod would be trialled over a loan period of 4 weeks. At the end of this period we will make a decision as to whether a iPod for communication will be purchased with Proloquo2Go and iMainGo case. His father is keen for it to be a separate device to his home iPod which is currently a tool for fun! Visual prompting by adult initially but faded. Able to navigate between pages. Good fine motor control so smaller device needed – iPod.

Alternative AAC resources Books and charts Speech output devices A range of equipment with examples of features which are of special relevance to individuals on the spectrum. However, there is a wide range of equipment, and any of it can be considered. Access – pointing, touchscreen (capacitive vs resistive), scrolling, keyguards, transferring symbols, Portability: can they carry it can they ‘walk and talk’ is it rugged Vocabulary storage / retrieval: one hit, one message Sequencing dynamically Text Choice will depend on: cognitive/communicative potential access method support form of representation Speech -Varies across devices: Some have synthesised speech only Some have digitised speech only Some allow a mix User preference Device complexity

Concerns when moving on from PECS Loss of familiar system Not building up a complete sentence Typical concerns expressed by those involved with a youngster using PECS

Case Study - Henry On the autistic spectrum Limited understanding in most situations Limited speech and expressive language Exceptional knowledge and use of language associated with the world of dinosaurs Highly supportive team around Henry who are prepared to put time into generating resources for him Henry – boy with limited understanding except for the world of dinosaurs with which he was very familiar and had an exceptionally wide knowledge. Masser/assessments/resources/Clicker 5/ assessment grids/ Henry Spiller [Following Henry's initial assessment we started by introducing the Clicker 5 forced order template. He quickly moved on from this, no longer needing forced order for understanding the word order of a sentence or for staying on task. We can now do a variety of programmes using Clicker 5, eg a Quantities programme, Clicker 5 phonics, a Counting Book in Clicker Paint, and sentence building. He's particularly enjoyed sentence building and is confident with what's expected of him, which is a big leap from initially starting out using forced order templates. I think the key for us has been introducing new grids specifically adapted to Henry's interests (dinosaurs, Doctor who etc!), and also incorporating his mastered sight reading words into the sentence building programme. Alongside the specific programmes using Clicker 5 we also introduced a variety of Clicker 5 talking books with Henry, initially to whet his appetite for the lap top. We started out by making him talking books about animals, events at school, stories about his home life and outings. He really enjoyed these, particularly seeing videos and pictures of himself! We were then able to introduce a variety of Talking books and Clicker 5 activities to prepare him for classroom topics. This really helped in differentiating his work and more broadly, his integration into lessons. We covered topics ranging from food tech, history, - the victorians, tudors etc - to science - electricity, sound and light -and geography - the coast, and so on. We put a combination of Henry's photos, images and video from you tube into the talking books, and he would then be prepared for classroom activities, differentiated for him on the lap top -for example matching activities, sentence building and so on. Some of these activities Henry did on the lap top, some were laminated paper resources which matched the images on the lap top].

Case Study - Henry Clicker 5 was introduced to develop his expressive language as well as his literacy Important features included visual support (symbols) and auditory feedback Be aware of using too much media in the grids but do use this as a reward The reason for using Clicker - developing Henry's expressive language as well as his literacy through the use of Clicker, the importance of the symbols, the auditory feedback etc.  Also, the reward, the fact that we discovered too much media reward makes him too high, but reward at the end of an activity is really motivating.  Henry – Has ASD and is a boy with limited understanding except for the world of dinosaurs with which he was very familiar and had an exceptionally wide knowledge. [Following Henry's initial assessment we started by introducing the Clicker 5 forced order template.

Henry’s grids Following an assessment Clicker 5 was introduced to Henry Open grid: (grids from assessment day Planet Earth, with and without sound) Forced order: (forced order Jurassic park story) Moving on to open grids He quickly moved on from this, no longer needing forced order for understanding the word order of a sentence or for staying on task. We can now do a variety of programmes using Clicker 5, eg a Quantities programme, Clicker 5 phonics, a Counting Book in Clicker Paint, and sentence building. He's particularly enjoyed sentence building and is confident with what's expected of him, which is a big leap from initially starting out using forced order templates. I think the key for us has been introducing new grids specifically adapted to Henry's interests (dinosaurs, Doctor who etc!), and also incorporating his mastered sight reading words into the sentence building programme. Forced order, to support sentence structure and keep Henry on task. This was a step which was important for Henry in order to learn what was expected of him, however, he moved on from this stage quickly. Open grids. We discovered the pitfalls of overdoing the sound and media files with an autistic child! The initial series of grids needed to be remade as Henry became over stimulated by the many sound effects embedded in the grids. Clicker 5 grids became an essential way of supporting all areas of the curriculum for Henry.

Assessment grids

Clicker Forced Order Forced order – Can only choose between the highlighted cells. Initially only 1 cell at a time, then a 3 choice option. Next page button and full stop to speak the sentence. Show Clicker grid if time.

Clicker More Forced Order More complex forced order. Show Clicker grid if time.

Henry’s grids Following an assessment Clicker 5 was introduced to Henry Talking story: (dinosaur Talking Book) Alongside the specific programmes using Clicker 5 we also introduced a variety of Clicker 5 talking books with Henry, initially to whet his appetite for the lap top. We started out by making him talking books about animals, events at school, stories about his home life and outings. He really enjoyed these, particularly seeing videos and pictures of himself! We were then able to introduce a variety of Talking books and Clicker 5 activities to prepare him for classroom topics. This really helped in differentiating his work and more broadly, his integration into lessons. We covered topics ranging from food tech, history, - the victorians, tudors etc - to science - electricity, sound and light -and geography - the coast, and so on. We put a combination of Henry's photos, images and video from you tube into the talking books, and he would then be prepared for classroom activities, differentiated for him on the lap top -for example matching activities, sentence building and so on. Some of these activities Henry did on the lap top, some were laminated paper resources which matched the images on the lap top]. Talking stories: these were used to motivate Henry, but also to prepare him for novel situations and to replay and discuss situations he had been in.

Clicker Talking Story Stories – buttons on the right - View movie clip Adding voice recording Listening to the sentence bar Next page Show Clicker grid of time.

Henry moving on Talking books to help with transition into new school. Included pictures and video of school, new teachers and peers, new classroom etc iPad: “We found ‘Pictello’ fantastic!” Visual instructions / visual stories Visual schedules The software and lap top have also been very helpful in preparing him for transition to his new secondary school. We made him talking books with pictures and video of his new school alongside specific activities he did this Summer to familiarize him with his new teachers, new peers, new classroom. Henry also now has an ipad. ‘We've found pictello fantastic for him’. It's really helped making social stories for him to use when we are out and about - most recently when we went on holiday and there was a lot of waiting in queues at the airport! The iPad has been great too for making visual schedules, so he can quickly look at a daily or weekly visual timetable to see what's happening next.

Useful apps Pictello: for creating stories based on visual scenes Visual schedules: e.g. First then visual schedule for autism with text, voice and picture.

CONCLUSION PECS can be an important first step in the path towards social interaction When this first step has been achieved, other methods should be considered for further developing communication PECS has become very popular in British Schools (it has even been suggested it should be used with all children with communication difficulties). ‘Moving on from PECS’ describes a positive approach to the situation, However, studies are beginning to show that there are strategies such as Natural aided language which can be successful in encouraging the communication of autistic youngsters. Natural Aided language – “Increasing Communication Skills in Students with Autism Spectrum Disorders: The AAC Technology Solutions”, Joanne M Cafiero PhD, undated, <http://www.outersound.com/cafiero/articles/10-07-1.htm> (retrieved 12 July 2006) We have looked at ways of taking children forward who have started with PECS (appropriately or not!) in order that they can enjoy more of the creativity and fluidity inherent in spoken language. We have attempted to do this by introducing the idea of Moving on from PECS

Future ACE Centre Courses Getting Started with AAC Thursday 22nd March 2012, 10am to 4pm ACE Oxford Moving On From PECS Wednesday 30th May 2012, 10am to 4pm iPads, iPods and Communication Tuesday 3rd July 2012, 10am to 4pm Delegate fee for above one-day courses - £120 Also mention that we offer tailor made workplace training! For more information contact the training coordinator.