1. Methods This study was originally conceived as a multiple-baseline across settings. Due to extenuating circumstances, child data was not able to be gathered sufficiently in the child’s home environment. Thus, it is presented as a changing-criterion design within the child’s school environment. “Molly” is a 7-year old girl identified as having Leber’s congenital amaurosis, nystagmus, and classic autism. Her communication age equivalence for receptive language = 2-3 yrs and for expressive language = 1 yr. The study was conducted in a self-contained classroom. Molly was known to have both aggressive (biting others) and self-abusive behaviors (punching the side of her head). Her non-compliant/disruptive behaviors included dropping to the floor when being guided to a new location, hiding under her desk, chewing objects, and wailing. A formal and informal reinforcement assessment was conducted to determine the items that Molly found the most desirable. This included a videotaped forced choice item by item assessment of both edible and non-edible reinforcers as well as an interview using a person-centered planning approach with her family and service providers. Object symbols were created using parts of actual objects which were glued to cut countertop squares (for durability) based on Molly’s most preferred items. Grade 1 braille labels were placed at the bottom of each object symbol (with labels in print on the back for the communication partners). This was to offer her exposure to word labels during communication sessions. Sample representation of referents include: a 2X2 piece of a mouse pad glued to the countertop square for a preferred item: a mouse pad; the lid to a small play doh container to represent play doh; actual goldfish crackers sealed in glue stuck on the countertop to represent goldfish. Phase one of instruction included symbol exchange to teach her to request one item (only one presented). Physical prompts were faded until the exchange was independent. Phase two of instruction included having Molly travel to her communication partner in the room to make the exchange for one symbol. Phase three included discrimination amongst symbols, starting with highly preferred and non-preferred and gradually increasing the array of symbol choices to 6. Phase four included sentence construction, teaching her to place the “I want” card in large raised print and braille on a sentence strip in front of the desired object symbol and make the exchange. Adapting Picture Exchange Communication (PECS) for a Child with Blindness and Autism: A Case Study Amy T. Parker, M.S.S.W., C.I.; Devender R. Banda, Ph.D. BCBA; Roseanna C. Davidson, Ed.D.; Lan Liu-Gitz, Ph.D. Research Basis The prevalence of autism may be higher in persons with visual impairment (11.6%) in comparison with the general population (0.6%); CDC reports indicate that the risk of autism increases with the severity of visual impairments (CDC, 2007; Mukaddes et al., 2007). Originally developed by Andrew Bondy and Lori Frost in 1985, PECS was primarily used with young children with ASD who had limited or no functional speech (Frost & Bondy, 2002). Blending applied behavioral analysis principles of differential reinforcement/shaping with communication principles such as learning to intentionally send a message to a listener, PECS was designed to support the development of functional communication (Charlop-Christy, Carpenter, Le, LeBlanc & Kellet, 2002). PECS, both because of its visual support for communication and its basis on behavioral principles, has been characterized as an instructional strategy that lends itself to meeting the functional communication needs of some students with ASD (Johnston, Nelson, Evans & Palazolo, 2003; Charlop-Christy et. al., 2002). There are six distinct phases in the PECS teaching protocol which include: how to communicate, distance and persistence, picture discrimination, sentence structure, responding to questions, and commenting (Frost & Bondy, 2002). Within each phase there are subcomponents for systematically teaching students to engage in specific exchanging behaviors with a communication partner to gain access to items or activities that the student desires (Bondy & Frost, 1994). During this study’s implementation, Lund & Troha (2008) published a multiple-baseline design study which included three students with autism and congenital blindness using three-dimensional object symbols within the PECS protocol.. In conducting their study, they drew from the work of Rowland & Schweigert (2000) as well as Turnell & Carter (1994) to create the object symbols within the PECS intervention phases. Of all three participants, only one gained to level 3 of the PECS intervention (discrimination between 2 symbols). Research Question: Can an adapted version of the PECS intervention protocol be successfully implemented with students who have severe visual impairments and autism? Changing Criterion Across PhasesDiscussion Molly’s success with PECS offers the field an example of the power of functional communication both for the person as well as for her communication partners. Conclusions from this study are limited because of a lack of experimental control; however there is a promising trend in this particular child’s progress to level 4 in PECS and in the number of symbols acquired. Most research on PECS (along with most AAC interventions) has been conducted with children who are reported to have typical vision; this case study offers a basis for further study on modifications that may be beneficial to children with severe visual impairments who are non-verbal. It is particularly time-intensive to create durable object symbols for communication. Through systematic assessment, it was determined which objects would be most motivating. Molly’s inherent curiosity led us to create 23 relevant symbols based on her interest and classroom context. Because these symbols were parts of objects glued on countertop squares, they were particularly large. They were stored on a countertop area with plastic drawers. The communication book with the most frequently chosen symbols was placed near the drawers of referent symbols. Modifications to the PECS protocol included not only additional sound cues, but a reduced requirement for the student to search for the communication book or to guess where the partner was located; however, the book and symbols were kept in a consistent location so that Molly could easily go to that area of the class. “Correspondence checks” were adapted so that objects were in very close range and incorporated high-contrast so that Molly could use her residual vision. The study also incorporates Grade 1 braille for exposure to basic corresponding words with objects. This area needs more careful exploration to develop studies that might link this type of communication training with more formal literacy development. The tactual and conceptual qualities of “attributes” or “descriptors” needs further exploration and time for implementation for students with visual impairments using this system. Conclusions Limited conclusions may be drawn from this study due to its lack of experimental control; however, valuable qualitative data indicates that this intervention had practical and social value for the participant in her school setting. Pre-post data suggests improvements in the domains of functional communication, speech production, active engagement, indices of happiness, and positive behaviors at school. Data from this study is being analyzed to design a more rigorous experimental study across participants. Qualitative data from this study conjoined with evidence from Lund & Troha’s study (2008), offers suggestions to practitioners on how PECS may be effectively adapted for individuals with severe visual impairments. Additional research will only enhance the field’s evaluation of PECS as an evidence-based intervention for students with visual impairments and multiple disabilities. References Bondy, A.S, & Frost, L.A. (1994). The Picture Exchange Communication System. Focus on Autistic Behavior, 9, 1-19. CDC. (2007). Prevalence of Autism Spectrum Disorders-Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2002. Centers for Disease Control and Prevention. Charlop-Christy, M., Carpenter, M., Le, L., LeBlanc, L., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS) with children with autism: assessment of PECS acquisition, speech,social communicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35, 213-231 Frost, L, & Bondy, A.S. (2002). The picture exchange communication system training manual. Newark, DE: Pyramid Education Products. Johnston, S., Nelson, C., Evans, J., & Palazolo, K. (2003). The use of visual supports in teaching young children with autism spectrum disorder to initiate interactions. Augmentative and Alternative Communication, 19(2), 86-103. Lund, S.K., & Troha, J.M. (2008). Teaching young people who are blind and have autism to make requests using a variation on the Picture Exchange Communication System with tactile symbols: a preliminary investigation. Journal of Autism and other Developmental Disorders, 38, 719-730. Mukaddes, N.M., Kilincaslan, A., Kucucyazici, G., Sevketoglu, T., & Truncer, S. (2007). Autism in visually impaired individuals. Psychiatry and Clinical Neurosciences, 61, 39-44. Rowland, C., & Schweigert, P. (2000). Tangible symbols, tangible outcomes. Augmentative and Alternative Communication, 16, 61-78. Turnell, R., & Carter, M. (1994). Establishing a repertoire of requesting for a student with severe and multiple disabilities using tangible symbols and naturalistic time delay. Australia and New Zealand Journal of Developmental Disabilities, 19, 193-207. Results All baseline and intervention sessions were coded using data forms. More than 60 % of the intervention sessions were videotaped. Molly acquired the use of adapted PECs through level 4 where she was independently constructing sentence strips to make requests. Molly acquired the use of 23 symbols (including edibles and non-edibles). This greatly exceeds the progress made by students in previous studies (Lund & Troha, 2008). Non-edible symbols included: Trampoline, Swing, Tricycle, Rocking Frog, Shapes, Mat, Music CD, Duck toy, Toothbrush, Play doh, Mouse pad, Mat, Lego, Ball, Molecule Ball, Keyboard, and Box. Referents for edibles included: Cotton candy, Goldfish, Oreos, Water, Nerds, and Gum. Data was collected on using the symbols in the following locations: outside (playground); self-contained class, OT room, and in a community setting (retail shop). Molly was able to use these symbols consistently with 6 communication partners (her paraprofessional, teacher, OT, SLP, and two members of the research team). On one occasion Molly was supported to use PECS with her peers (who also have multiple disabilities). Molly had an acquisition rate that exceeds previous studies with sighted children with multiple disabilities (Schwartz et. al., 1998). Molly also progressed to level 4 of PECS protocol after 21 sessions and may have progressed further if the school session had continued. Molly was introduced to Level 5 which incorporates the added skill of adding an specific attribute symbol to a requested item. In the PECS protocol one common way to teach attributes is through preferred color discrimination paired with an object. Such as “I want” + “red”+ “candy”. Molly’s functional vision evaluation did not indicate that she responded to color. Data from her learning media assessment did indicate a discrimination amongst textures. Molly did indicate a preference for a specific type of doh- seeming to prefer playing with a doh with a specific tougher malleability. This was a difficult adaptation to make because of level of abstraction required to distinguish between attributes such as “hard” and “soft” using a tactual cue. Molly could discriminate her doh preference by container lid differences; however these did not present themselves as “attributes” but rather as specific referents themselves as a gestalt rather than parts of a sentence. Numbers were briefly introduced using 48 point raised line symbols with braille number signs for the numbers 1 and 5; to attempt to teach her to request more of something that she liked. This concept needed further exploration and planning by members of the research team, so after a few trials, it was abandoned to explore in a future study. Ideally this concept could be approached as Molly became well-versed in using PECS. Gradually, the team could work with her educational team to build number concepts and practice throughout the day and teach her direct correspondence with number symbols. The team agreed that she needed more solid footing in PECS to continue the attribute phase. Molly experienced the following gains in her functional communication testing according to pre-post speech & language evaluation measures: an increase from verbally prompted monosyllabic utterances to multiple syllabic utterance, and increased joint attention/engagement. For example, at baseline Molly’s communication partner may prompt her to say “chip” before she received a chip. Molly would approximate the word: “chip”. In her post-evaluation, Molly was “reading back”/touching her sentence strip and saying “I want doh” after she had constructed the sentence strip independently. In her baseline speech evaluation, Molly was found to communicate predominantly through body movements, orienting away from her partner or towards a partner, and co-active movements. In her post-intervention speech evaluation, Molly was found to communicate frequently using PECS and limited unprompted speech. Molly’s indices of happiness (frequencies of smiling, laughing) increased from baseline to intervention as did her mean length of time engaged in activities with a communication partner (from 10 minutes in baseline to 40 plus minutes post-intervention). Indicating some level of social validity of the intervention for Molly. Molly’s rates of aggressive, disruptive or self-abusive behavior decreased according to video samples of baseline to intervention phases. Copyright 2008: Amy Parker, Devender Banda, Roseanna Davidson & Lan Liu-Gitz