1. What’s the Emperor Wearing These Days
What’s the Emperor Wearing These Days? Communication, Speech Generating Devices, Apps, and the Picture Exchange Communication System
Andy Bondy, PhD
Pyramid Educational Consultants, Inc.
ABAI 10th Annual Autism Conference
Jan. 20, 2016
New Orleans, LA

2. Verbal Operants Mand Tact Intraverbal Echoic Textual Autoclitic
Described verbal behavior in terms of the functional relations between controlling variables and verbal responses
Mand
Tact
Intraverbal
Echoic
Textual
Autoclitic
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3. Copyright, 2015, Pyramid Ed. Consultants, Inc.
Is Modality the Key?
“In defining verbal behavior as behavior reinforced through the mediation of other persons, we do not, and cannot, specify any one form, mode, or medium. Any movement capable of affecting another organism may be verbal.” (Skinner, 1957, Verbal Behavior, p. 14)
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4. Deprivation/Motivating Operation (MO)
Pure Mand
Antecedents
Deprivation/Motivating Operation (MO)
Behavior
Pure Mand
Consequence
Specified by Mand
(concrete or social)
Examples
Deprived of a ball- says, “I want a ball.”- gets a ball
Hit by a child- says, “Go away!”- other person goes away
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5. . . . . … (Audience) Srein+ SD RV SD RV Srein V + SD
Mand (figure 1, p. 38, Skinner’s Verbal Behavior)
(Speaker)
(Audience)
Bread, please
bread .
Thank you
You’re welcome .
Srein+ SD
Srein V SD RV RV . . … R S
Srein V + SD Rv DV
Bread, please
Passes bread
Thank you
You’re welcome
(Listener)
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6. What is the difference between a toy and a communication device?
The use of a toy is reinforced by aspects of the toy- or a feature that is inherent in the toy
Enhanced reinforcers can be achieved interactively
A communication device must lead to ‘verbal behavior’ wherein the reinforcer is mediated by ‘the listener’ (e.g., audience, communicative partner, someone else, etc.)
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7. Toy vs. device
When a toy makes a “oink” sound, do we attribute the sound to the child?
But if he uses an app on an iPad, now we attribute that he speaks?

8. Discrimination training issues
No SD without SΔ
No big without little
No red without blue (or whatever)
No I/me without you
No happy without sad!
No ‘hello’ without ‘goodbye’
No polite ‘please’ without normal useage
? Please kick me the ball
Assure target vs. contrast…
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9. When should reinforcers be provided?
Immediately for new skills
½ second rule
Consider discrimination training within Phase IIIA of PECS
Upon touching the correct picture, reinforcement is provided (not upon giving it to the CP)
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10. Why compare new strategies with the PECS protocol?
Nearly 150 published articles
At least
80 data based or case studies
Several RCTs
12 articles - descriptive
6 literature reviews
Articles generated in 13 countries including the USA, UK, New Zealand, Brazil, Greece, Japan, Australia, France, Peru
See
Always update this slide to reflect current stats on website.
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11. Interesting recent publications
Maglione et al. (2012), Nonmedical Interventions for Children With ASD: Recommended Guidelines and Further Research Needs.  Pediatrics
“… agreed that applied behavioral analysis, integrated behavioral/developmental programs, the Picture Exchange Communication System, and various social skills interventions have shown efficacy.”
Guideline: “Individuals 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 PECS”
“We identified no controlled trials or observational studies on the efficacy or effectiveness of Augmentative and Alternative Communication devices. A small number of single-subject studies have been conducted, with mixed results.”
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12. Large-scale, federally funded, Randomized Controlled Trials (RCTs) comparing PECS training to established speech-based interventions
Thirty-nine preschoolers with autism (20 to 45 months of age) producing fewer than 10 words (50% using zero words), randomly assigned to receive either PECS Training or PRT for 6 months. After 6 months of intervention, the majority (78%) of children in both groups were producing more than ten words, with no differences in speech production in those who received PECS (gained 83 words on average) vs PRT (gained 71 words on average).
Same % in both groups for those showing no improvement in speech- implication for risk analysis?
Schreibman, L., & Stahmer, A. C. (2014). A randomized trial comparison of the effects of verbal and pictorial naturalistic communication strategies on spoken language for young children with autism.  Journal of Autism and Developmental Disorders, 44(5),

13. Publications related to comparing PECS (and/or PE) with other SGD/VOCA devices
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14. Speech vs. No-speech SGD
Sigafoos et al. (2003). Effects of Speech Output on Maintenance of Requesting and Frequency of Vocalizations in Three Children with Developmental Disabilities
3 kids 2 w ASD Single switch producing “I want more”
“There were no major or consistent differences across the two conditions for the three children, suggesting that access to preferred objects was the critical variable maintaining use of the SGDs.”
No impact on use or vocalizations
Schlosser et al. (2006) Effects of synthetic speech output on requesting and natural speech production in children with autism: A preliminary study
5 ASD 8-10 yrs; >10 spoken. 8 pics (4 per condition)
SPEECH condition- name of the object spoken by the synthesizer
NO-SPEECH condition (the speech output was turned off) the experimenter pointed to the symbol without depressing the key
No difference across kids
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15. Do SGD users understand ‘the voice’?
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16. PECS vs. VOCA literature review (2007)
Lancioni et al. (2007) PECS and VOCAs to enable student with developmental disabilities to make requests: An overview of the literature (1992 to 2006)
Of 173 PECS-related users only 3 ‘considered failures’
Of 39 VOCA-related users only 3 ‘considered failures’
Major limitation- many did not follow PECS protocol
Of the 20 studies involving VOCAs here are the # of pictures per study:
1, 2, 4, 3, 4, 2, 8, 3, 6, 2, 1, 1, 1, 1, 2, 1, 4, 8, 4, MEAN = 3.0 (range 1-8)
Very little said about impact on speech overall though this comment: “The fact that speech output improved in studies using PECS programs rather than in studies using VOCAs might be somewhat surprising.”
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17. Early PECS/VOCA comparison
Beck et al. (2008) Comparison of PECS and the use of a VOCA: A Replication
4 ASD preschoolers 4 wks of training (11 sessions- Added vocalization measures)
PECS Phase I, II, IIIA and IIIB fairly faithful to PECS protocol
VOCA training same as in Bock (No responses in baseline)
Reasonable rapid PECS acquisition- all faster w PECS (2 no acquisition of Phase I w VOCA)
Virtually no differences in speech production and very small repertoires-
NO clear advantage w VOCAs regarding speech production
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18. More recent studies…
Son et al. (2005) Comparing two types of augmentative and alternative communication systems for children with autism
Not PECS; 2 items, No ‘Phase I’ after 24 sessions…
Flores et al. (2012) A comparison of communication using the Apple iPad and a picture-based system
Not PECS, 3 items, “provided explicit instruction”; ‘mixed’ results
Lorah et al. (2013) Evaluating Picture Exchange and the iPad™ as a Speech Generating Device to Teach Communication to Young Children with Autism
Not PECS, 3 items, in PE condition 60 trials to ‘Phase I’, 3 of 5 slightly faster on SGD

19. More recent studies…
van der Meer et al. (2012a) Comparing Three Augmentative and Alternative Communication Modes for Children with Developmental Disabilities
Not PECS, 3 items, verbal prompting and EC, Sign option- represented by a picture; 2 of 4 very slow acquisition of PE;
van der Meer et al. (2012b) A further comparison of manual signing, picture exchange, and speech-generating devices as communication modes for children with autism spectrum disorders
Not PECS, 4 items, 2 faster PE, 1 PE=SGD, 1faster SGD, verbal prompts and EC

20. van der Meer, et al. 2013
Van der Meer et al Teaching multi-step requesting and social communication to two children w ASD with three AAC options, AAC
iPad with Proloquo2Go (15 pics) vs PE (15 pics) vs MS (13 signs); 2 w ASD, 10 and 11 yr (in previous study), 8-9 reinforcers
“The PE system for both children consisted of 15 laminated graphic symbols…For example, placing the I WANT , CHOCOLATE , and PLEASE symbols from the laminated A4 card onto the separate sentence strip resulted in a sentence that was spoken aloud by the partner as I want chocolate please .”
All this complexity within first 15 pictures!
“Only 13 signs were taught for MS because the signs for HELLO and GOOD BYE and PLEASE and THANK YOU are the same.” !
“Results suggest the procedures were moderately successful in teaching two-step requesting for both participants, as well as three-step requesting and the more social communication skills of (a) initiating greetings, (b) answering questions, and (c) using etiquette for one of the participants.”
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21. van der Meer et al con’t

22. More recent studies…
Boesch et al Comparative efficacy of the Picture Exchange Communication System (PECS) versus a speech-generating device: Effects on requesting skills
“One of the more notable benefits of SGDs over PECS and other graphic symbol based systems is the additional speech feedback they provide for the learner. This extra speech modeling may help promote faster skill acquisition…”
“Similar to natural speech production, the speech signal from the SGD is immediately made available to anyone within hearing distance. Unlike with picture exchange systems, there is no training required from the communication partner to comprehend the communicative message. As a result, the user achieves greater communicative independence and untrained communicative partners can comprehend the message.”

23. Boesch et al. con’t 3 w ASD, 8 snack items
Said used PECS protocol- close but not quite
Used 2-person prompt to hand over SGD
Outcome
No statistical differences for all three across 2 conditions
All had significant discrimination issues…. All three failed to ‘master’ discrimination
Phase I and II limited to one type of reinforcer (snack) and only distance to CP
“During the first sessions of SGD training, all participants had difficulty picking up the device, carrying, and handing it to trainer 1.”

24. Teaching an Intraverbal?
Lorah et al. (2015). The acquisition of intraverbal responding… J Dev Phys Dis,
2 w ASD (12, 8), Proloqu2Go
5 pics on screen “I am..” “My favorite toy..” “I live..” and 2 distractors
Questions: Vocal “How old..” “What’s favorite..” “Where do you live?”
Is touching these pics properly viewed as an Intraverbal? How is it distinct from “Touch age” “Touch toy” “Touch address”? What is the SD?
From discussion: “…participants acquired the ability to respond to an intraverbal statement.”

25. 2014 publication raises hope…
Hill & Flores, (2014). TechTrends, 58,
5 kids, 3-9 (3Aut & 2DD)- 3 already at Phase V PECS at start… Used PECS-protocol to teach iPad app ( “Prologuo2Go)
“One of the students demonstrated more requesting behaviors when using the iPad™ with Proloquo2goTM application, showing a clear difference in data paths (Kent), although it is unclear if he was actually requesting with the iPad™ or responding to hearing the sound that resulted when he touched the icon.”
“The authors recommend that PECS™ phases I-III be mastered before the iPad™ is introduced, to ensure the students master these prerequisite skills since they are more difficult to scaffold (break into smaller units for teaching and then build additional skills) using the iPad™.”
Copyright, 2015, Pyramid Ed. Consultants, Inc.

26. Transitional issues with PECS
Frost, L. and McGowan, J. (2011) Strategies for Transitioning From PECS to SGD. Part I: Overview and Device Selection. Perspectives on Augmentative and Alternative Communication
Frost, L. and McGowan, J. (2012) Strategies for Transitioning From PECS to SGD. Part II: Maintaining Communication Competency. Perspectives on Augmentative and Alternative Communication
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27. Why consider a transition?
The PECS vocabulary is large
Concerns exist regarding the speed of communication
The learner has not developed speech and voice output is wanted by others
People are looking for a “better” system
How large is too large? Amy, the student we will be profiling, soon had a picture vocabulary of The youngest student Amanda profiled at last year’s talk had over 600 words or pictures in his book.
Speed of communication: AAC is inherently slower than speech, but even the best voice output system is slower than speech
“Better” : often people ask for “modern” or more technologically advanced communication. Or if child is having trouble with picture discrimination or team wants ‘faster’ progress, people assume this is a fault of PECS or the PECS protocol and then assume that a high-tech device will “teach” discrimination.
Make point that whatever problems exist with PECS will persist with a device.
Film critic Roger Ebert gave Apple's VoiceOver technology two thumbs up in allowing him to communicate after losing his voice to cancer surgery, but said his health insurance would only offer to cover an $8,000 device that didn't work nearly as well.
Celebrated Astrophysicist Stephen Hawking has selected and is using NeoSpeech's Text-to-Speech engine, VoiceText, as his new voice. VoiceText is integrated into Dr. Hawking's communicator, E Z Keys, enabling him to clearly communicate with the outside world
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28. Candidacy for Transition
Mastery of picture discrimination
Able to discriminate among pictures in an array of several icons and pictures spread across several categories
Able to navigate through several pages within a PECS book
Mastery of at least PECS Phase IV
Independently constructs and exchanges at least 2-picture Sentence Strip
Joy’s Note: When children are provided with a device without discriminating between a minimal of 20 pictures, it is our experience that they are typically augmenting their communication with gestures, signs, and speech. We are addressing those students who we feel are ready to transition to an SGD as their primary means of communication, and PECS would eventually only be available as a back up system.
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29. Instant feedback for correct picture selection
The picture flashes and enlarges while
a male or female voice names the item
Alternative strategies for simple discrimination
Correspondence Checks involving multiple preferred items
“When the Verbal and Visual Feedback options are selected, as soon as the learner touches the correct picture the App provides immediate visual feedback and verbal labeling of the item. The App provides no visual or verbal feedback when the child touches the photo of the non-preferred item.”
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30. Is preference an issue? How can it be measured?
Do changes in teaching strategies permit a ‘true’ assessment of preference?
When ‘toy’ and ‘SGD’ are co-mingled what does ‘preference’ assess?
Are we always guides by preference when selecting skill targets?
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31. Questions associated with using an SGD for acquisition of VB
What is the response identified as the ‘verbal behavior’?
It must involve doing something to the communicative partner.
What is the training protocol?
? 2-person prompting to promote initiation
? Task-analysis with backward-chaining strategy
Does it involve several Phase II elements?
Does it incorporate discrimination strategies?
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32. More questions… Are error correction strategies used?
How is sentence structure taught?
Is delayed prompted used to promote/encourage vocalization?
Are attributes taught within mand function?
Is commenting taught? Spontaneous too?
How is vocabulary expansion planned?
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33. PECS vs High-Tech AAC
The question isn’t whether technology is good or bad, but how to properly use it. Tech innovations need a foundation of proven teaching methods.
The use of technology does not guarantee the use of science- especially the science of teaching!