Introduction - hannahroseportfolio.files.wordpress.com · Web viewTo support children with ASD, Augmentative and Alternative Communication (AAC) systems, have been developed to

Law, Hannah 16282496

Student details

Name/Student Number Hannah Law 16282496

Course Bachelor of Education (Primary) - OUA

Unit details

Unit code EDC471

Unit name Professional Learning and Development in Education

Unit lecturer or tutor Murray Brooker

Assignment details

Topic Assessment 1 - Literature Review

Due date 30 Mar 18 Word count 3299

Extension granted No Extension date

Is this a resubmission? No Resubmission date

Declaration

I certify that the attached material is my original work. No other person’s work or ideas have been used without acknowledgement. Except where I have clearly stated that I have used some of this material elsewhere, I have not presented this for assessment in another course or unit at this or any other institution. I have retained a copy of this assignment. I have read and understand the Curtin University of Technology document Academic Integrity at Curtin: Student guidelines for avoiding plagiarism.

Name/signature Hannah Law Date: 29 March 2018

1


Contents

Introduction..............................................................................................................................3

Key Terms and Definitions.......................................................................................................3

Methodology.............................................................................................................................4

Limitations............................................................................................................................4

Method of Collection.............................................................................................................5

Major Focuses..........................................................................................................................5

Key Findings............................................................................................................................6

Communication Outcomes...................................................................................................6

Speech Outcomes................................................................................................................6

Joint Attention.......................................................................................................................7

Acquisition............................................................................................................................7

Generalisation......................................................................................................................8

Maintenance.........................................................................................................................8

Discussion................................................................................................................................8

Conclusion.............................................................................................................................10

Reference List........................................................................................................................11

Appendix................................................................................................................................15

Introduction Autism Spectrum Disorder (ASD) is a developmental disability that significantly affects verbal

and non-verbal communication as well as social interaction. Approximately 50% of children

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with ASD fail to acquire functional language (Rosenberg, Westling & McLesky, 2009). Often

displaying unintelligible verbalisations and gestures, which lack the non-verbal cues needed

for others to successfully decode their messages (Rosenberg et al., 2009). Leaving children

with ASD, limited communication and choice-making opportunities. Which, not only impedes

reciprocal interactions but can manifest in outbursts of challenging behaviour (Hwang &

Hughes, 2000; Frea, Arnold, & Wittinberga, 2001).

To support children with ASD, Augmentative and Alternative Communication (AAC) systems,

have been developed to either supplement existing speech or act as the primary

communication method (Mirenda, 2003). However, most systems in the available pool rely

on the assumption that once a child knows a word, they will be able to use it in all contexts

(Bondy & Frost, 2001). Given the need for validity and specificity when selecting an AAC, the

purpose of this literature review is to analyse studies conducted on one of these systems,

being, the Picture Exchange Communication System (PECS). Developed by Bondy & Frost

(2001), PECS teaches functional communication to children with limited speech. The

development of PECS as an AAC is promising, as it doesn’t rely on the comprehension of

adult prompts and has minimal prerequisite skills for successful completion (Yoder & Stone,

2006; Mirenda, 2003). With many reports indicating PECS can be taught quite rapidly

(Charlop-Christy, Carpenter, LeBlanc, & Kellet, 2002).

PECS appears to be an effective tool in developing communication skills in children with

ASD. However, the widespread use of PECS preceded controlled studies (Charlop-Christy

et al., 2002), with early reports indicating a lack of consensus on its efficacy and its ability to

be generalised. Therefore, this review examined 22 child-centred, single participant and

group studies, to evaluate the quality of research available. By identifying and comparing

methodologies, research designs and PECS implementation, while also analysing key

findings regarding specific communicative outcomes. This review aims to examine and

discuss how effective PECS is at improving communication skills in children with ASD.

Key Terms and Definitions - Augmentative and Alternative Communication (AAC) : augment means to add or

enhance, alternative means a choice or a substitute.

- Communication/Communicative act is the exchange of information through speaking,

writing, or another medium.

- Mand is a request (derived from command and demand).

- Picture Exchange Communication System (PECS) is a self-initiated, functional

communication system.

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MethodologyThe two major group studies featured in this review are both randomised control trials (RCT;

Howlin, Gordon, Pasco, Wade, & Charman, 2007; Yoder & Stone, 2006). Considered the

gold standard in experimental research, participants are randomly divided into either a

control or intervention group (Horn, Snyder, Coverdale, Louie, & Roberts, 2009). However,

RCTs appear to be rare in educational research (Preston & Carter, 2009). Therefore, many

of the studies feature a single participant, multiple baseline design, which provides an

opportunity to answer specific questions about PECS, by targeting different participants,

settings and behaviours. Two of the studies used an alternating treatment design, comparing

the effectiveness of PECS against an alternative AAC (Bock, Stoner, Beck, Hanley, &

Prochnow, 2005; Tincani, 2004). In several studies, a changing criterion design was also

included to correlate with the changing criteria for each stage of PECS (Preston & Carter,

2009). But only one study (Park, Alber-Morgan, & Cannella-Malone, 2011), used it as its

primary design method.

The participants ranged from 18-months to 12 years, with all, except one, requiring a specific

diagnosis of Autism, ranging from mild to severe. Participants had little or no functional

language, with two studies specifying this to be ten vocalisations or less (Lerna, Esposito,

Conson, Russo, & Massagli, 2012; Yoder & Stone, 2006). As the primary focus was the

effectiveness of PECS implementation, most of the studies stipulated that the children were

to have no prior experience with PECS. Though, two studies (Marckel, Neef, & Ferreri, 2006;

Paden, Kodak, Fisher, Gawley-Bullington, & Bouxsein, 2012) sought participants that used

PECS independently to extend their skills. Settings included the participants home or

school, with three studies using an isolated room to conduct baseline assessments (Paden

et al., 2012; Yoder & Stone, 2006; Yokoyama, Naoi, & Yamamoto, 2006). Additionally, eight

of the included studies utilised generalisation probes, which required either a change in

setting completely, (Tincani, Crozier, & Alazetta, 2006) or the introduction of an alternate

communicative partner (Tincani, 2004).

LimitationsSeveral methodological limitations may impact the findings of the current review. Firstly, the

level of impairment for each participant was often omitted or vague. With one study (Liddle,

2001) including seven participants that were not diagnosed with ASD. Further, several

studies failed to identify how each of the participants was diagnosed, with two requiring

educational or reported diagnosis over a clinical diagnosis (Tincani et al., 2006; Magiati &

Howlin, 2003). These unknowns make it difficult to provide comparable results, given that

the range in behaviours, cognitive, language and social function varies greatly between

individuals with mild to severe Autism (Rosenberg et al., 2009). However, as most of these

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studies focus on the development of communication or verbal skills following PECS training,

all specified a pre-intervention level of communication.

Secondly, procedural implementation of PECS varied significantly, with some using only part

of the system to focus on stages I - IV (Bock et al., 2005; Jurgens, Anderson, & Moore,

2009; Lerna et al., 2012; Park et al., 2011; Pasco & Tohill, 2011; Tincani, 2004). Which is in

line with the focus for the listed studies, as intervention up to this point emphasises non-

verbal requests from communicative partners (Bondy & Frost, 2001). While studies that used

the whole system focused on the frequency, spontaneity or complexity of word phrases

(Ganz & Simpson, 2004; Travis & Geiger, 2010). Lastly, the level of mastery varies

considerably, ranging from 75 – 90% accuracy. With only three studies using the

recommended 80% for independent mands (Ganz & Simpson, 2004; Jurgens et al., 2009;

Tincani et al., 2006). Creating disparities in the time spent teaching PECS, from as little as 2

hours (Frea et al., 2001) to as many as 26 hours (Yoder & Stone, 2002).

Method of CollectionVideo recording and observation were the primary methods for collecting data throughout

the studies. (Carr & Felce, 2007; Howlin et al., 2007; Ganz & Simpson, 2004; Tincani, 2004).

Multiple studies used a frequency count in addition to this, counting the number of trials, or

correct responses per criteria for different stages of PECS (Charlop-Christy et al., 2002;

Jurgens et al., 2009; Park et al., 2011; Tincani, 2004; Yokoyama et al., 2006).

Observation windows were often placed directly following a PECS training session. Many of

the single participant studies allocated a relatively short time frame for participants to

produce the desired results, ranging from 5-20 minutes per observation period (Bock et al.,

2005; Charlop-Christy et al., 2002; Ganz & Simpson, 2004; Greenberg, Tomaino, & Charlop,

2012; Kravits, Kamps, Kemmerer & Potucek, 2002). However, two extended the period of

observation to 30 minutes, which were both centred on mands during free play (Anderson,

Moore, & Bourne, 2007; Yokoyama et al., 2006). Conversely, the group studies conducted

follow up observations, to identify the long-term effects of PECS intervention against control

groups (Carr & Felce, 2007; Howlin et al., 2007; Lerna et al., 2012; Yoder & Stone, 2002).

Major FocusesAs previously mentioned, majority of studies included in the current review only observe

PECS to level IV. Consequently, 16 of these primarily focus on the frequency of behaviours

such as independent, prompted and spontaneous requests (See Appendix). With some

studies also exploring the social dynamic of a request through joint attention. Studies that

implemented higher stages of PECS (IV-VI), also examined the frequency, intelligibility and

complexity of vocalisations (See Appendix). Along with the rate of acquisition, likely to

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confirm claims that it is more rapidly acquired than other AACs (Bondy & Frost, 2001). On

the other hand, three of the included studies focused on providing specialist PECS training

to teachers, parents and support staff to affect PECS implementation (Howlin et al., 2007;

Magiati & Howlin, 2003; Park et al., 2011). Differing again, is the study conducted by Pasco

& Tohill (2011), who explored a range of pre-treatment characteristics to predict a child’s

likely degree of PECS progress.

Key FindingsCommunication OutcomesCommunication outcomes identified from the current literature include the frequency of

mands, PECS exchanges and communication initiations (See Appendix). Overall, there was

a substantial impact on child’s ability request desired items, with increases in mands seen

across the board. Notably, the number of spontaneous requests also appears to increase

following PECS intervention (Marckel et al., 2006; Magiati & Howlin, 2003; Tincani et al.,

2006). Though interestingly, only one participant (Liddle, 2001) was unable to master PECS

level I to request desired items. Social-communicative impacts were also reported, with an

immediate reduction in aggression and other challenging behaviours once PECS was

introduced (Anderson et al., 2007; Charlop-Christy et al., 2002; Frea et al., 2001). Lerna et

al. (2012) also found that PECS generated significant increases in desired behaviours and

communicative acts in unstructured settings. Further, when comparing PECS against other

AACs, PECS was easier to progress through (Bock et al., 2005) and promoted more

requests, mainly, when used by children with limited joint attention (Tincani, 2004; Yoder &

Stone, 2006).

Speech Outcomes Research suggests that the use of AACs may facilitate the development and production of

speech (Mirenda, 2003). Amidst this research, Charlop-Christy et al. (2002) acknowledge

that several features of PECS are designed to promote vocal behaviours. This finding is

reiterated in Tincani et al. (2006), who identified that speech development is most notable in

stage IV, as participants begin to use phrases in conjunction with their requests.

Comparatively, Yokoyama et al. (2006) posited that verbal behaviour was under the

functional control of a mand. However, two studies disagreed, finding that spontaneous

vocalisations increased regardless (Charlop-Christy et al., 2002; Kravits et al., 2002).

Overall, the effectiveness of PECS on speech development remains somewhat unclear.

Many of the included studies observed an increased frequency of verbal behaviours

following PECS training (Anderson et al., 2007; Charlop-Christy et al., 2002; Ganz &

Simpson, 2004; Kravits et al., 2002). With a notable increase in the complexity or length of

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vocalisations, particularly within studies that continued beyond stage IV (Travis & Geiger,

2010). However, Howlin et al. (2007) failed to witness any increase in spoken language, with

participants showing continued communication impairments. Similarly, Tincani (2004)

observed a decline in vocalisations, as participants increased mands to facilitate

communication instead. However, a delay procedure was implemented to increase

vocalisations to that of sign language (Tincani et al., 2006), generating the highest frequency

of vocalisations once implemented (Yokoyama et al., 2006).

Joint AttentionJoint attention is a communicative act that requires the participant to look at both the picture

being exchanged and the communicative partner (Frea et al., 2001). This skill has been

identified as a critical component of the social-communication deficit present in children with

ASD (Bock et al., 2005). Three of the included studies examined the behaviour of initiating

joint attention, with encouraging results. Frea et al. (2001) reported increased joint attention

and engagement with the teacher when manding, which led to a decrease in aggressive and

challenging behaviour. Interestingly, Lerna et al. (2012) posits that this rise in joint attention

is linked to the increased frequency of mands. Similarly, the two studies that compared joint

attention to other AACs found that PECS produced significantly higher initiations than its

counterparts (Lerna et al., 2012; Yoder & Stone, 2006). Particularly in children with one

initiation or less during pre-treatment, who subsequently made nearly three times more

initiations following PECS training (Yoder & Stone, 2006).

AcquisitionCharlop-Christy et al. (2002) were the first to empirically assess PECS acquisition and found

that children acquired PECS within an average of 170 minutes, with rapid acquisition during

stages III and V. Ganz & Simpson (2004) reported that the rate of mastery is slightly longer

than that of Charlop-Christy et al. (2002). However, in subsequent studies, they are often

referred to together, as the benchmark for PECS acquisition. Occurring also in Jurgens et al.

(2009) and Anderson et al. (2007) who stated PECS was acquired in line with the two

previous studies.

Greenberg et al. (2012) also observed quick acquisition. However, participants took nearly

double the time of Charlop-Christy et al. (2002). On the other hand, Tincani et al. (2006)

reported a considerably lower rate of acquisition in comparison to the benchmark studies.

Suggesting that selected items may have had less reinforcement value. The described

variance in PECS acquisition is possibly due to differing pre-treatment characteristics, which,

as previously mentioned, lacked consistency across the included studies. However, it’s

important to note, the rate of acquisition while varying would still be quicker than AACs

(Bondy & Frost, 2001).

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GeneralisationThe purpose of a generalisation probe is to reproduce the initial findings of the study in an

unfamiliar scenario, contributing to the efficacy of PECS in broader contexts. Despite the

small portion of studies that included generalisation probes (See Appendix), the results are

relatively positive. As the frequency of mands was for the most part, able to be replicated

across settings, items and people. Conversely, Bock et al. (2005) observed a slight decrease

in manding across all participants. Further, Greenberg et al. (2012) identified one participant

who was inconsistent with initiations until further training was provided in the new setting.

This resistance to initiate communication is characteristic of children with ASD, and the

inability to change manding behaviour is consistent with studies on language intervention

(Bock et al., 2005).

MaintenanceThe maintenance of PECS training outside of an intense study environment produced mixed

results. In some cases, there were notable consistencies in the level of PECS used, as well

as the communicative and verbal behaviours. These were particularly evident in Charlop-

Christy et al. (2002) and Yokoyama (2006) who found that maintenance of the system had

occurred six, eight and 12 months following termination of PECS training. Furthermore, it

was identified that maintenance of these behaviours also occurred in both trained and

generalised settings (Bock et al., 2005; Yokoyama et al., 2006). However, Howlin et al.

(2007) found that the positive results initially displayed were not maintained at the time of the

follow up. Positing that once consultation had concluded, less reliable or less frequent

implementation of PECS was utilised by the teacher.

DiscussionThis review looked at 22 single participant and group studies to gain insight into the

effectiveness of PECS training in developing communication skills in children with ASD. The

effectiveness of PECS was measured across variables such as participants, settings and

descriptors, with some comparing PECS against other AACs. The body of research

reviewed shows that PECS is a well-established and promising system for improving

communication in children with ASD, as a significant increase in mands was observed

across the board. Demonstrating that children with ASD can initiate a request to support

their own needs. Particularly in children with severely limited pre-treatment joint attention

(Yoder & Stone, 2002).

While some state that speech development occurs in conjunction with the increase in

mands. Speech development because of PECS training remains largely unclear, as some

studies implemented procedural changes to entice speech from participants. While others

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observed no improvement in speech, likely due to participants inability to progress through

the system. Though interestingly, one study found that seven children without a diagnosis

were all able to improve their communication skills alongside the diagnosed participants

(Liddle, 2001). Concomitant social behaviours were also observed, reporting an immediate

reduction in aggression and challenging behaviours. Providing evidence for communication

to be considered as a primary goal for children with challenging behaviour (Frea et al.,

2001). When compared to other AACs, PECS proves to be an excellent system, as it

requires fewer prerequisite skills that facilitates more mands and easy acquisition. Though,

may follow other AACs in terms of developing speech.

The maintenance of PECS is a developing area of research, as minimal studies have

examined the long-term effects of PECS training. Overall, the results show mixed reliability

in the maintenance of PECS intervention. While there were notable consistencies in the

communicative and speech behaviours, the level of implementation that occurred following

the studies dropped off significantly. Indicating a requirement for teachers to be adequately

trained to support optimal PECS implementation in the long term (Howlin et al., 2007). On

the contrary, the generalisation of PECS was positive. Despite the small sample size,

participants of the studies were able to generalise their skills. However, the type of

generalisation varied, with participants transferring their skills across a range communicative

partners, descriptors and settings.

However, the many variables in methodologies, participants and treatment, means that

results of PECS will remain primarily individualised to the circumstances of each study. The

lack of fidelity and consistency in pre-treatment characteristics means that it is difficult to

determine which characteristics or factors contribute to the best outcomes in communication

and speech development. This inconsistency also describes the variance in PECS

acquisition, as cognitive function contributes to a participants understanding of the

communicative process. One included study did aim to predict PECS progress (Pasco &

Tohill, 2011). However, it utilised an extremely convoluted developmental profile, which

could not be implemented in a classroom environment without specialist assistance.

Discrepancies between the studies were also reflected in each child’s level of impairment,

ranging from very mild to quite severe. Therefore, results on speech development vary

greatly, as each study focuses on different elements of speech such as length of utterance,

intelligibility or complexity to suit the individual participant. Further, there were only two RCTs

included in the current review. Which led many of the included studies to rely on qualitative

data from a single participant, multiple base design. This presents a problem in comparing

results as it lacks sample size and experimental rigour.

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The results of the review demonstrate the need for more empirical evidence on a range of

issues regarding the implementation of PECS. The notable variances in results show that,

while increases do occur, the level of progress and development is entirely unique to the

participant. Therefore, study designs which include more experimental control should be

conducted to provide evidence on the efficacy of PECS. This is also the case for validating

generalisation results, as the two RCTS included did not include generalisation probes.

Further, more research is required to determine which specific pre-treatment characteristics

will lead to optimal results when implementing PECS. Alternatively, identify which

characteristics will generate variances in outcomes, so that future studies can deviate results

accordingly.

The development of speech following PECS training also requires additional research. As

the results remain largely unclear, it will be crucial for future studies to demonstrate the

connection between PECS and speech development without the use of procedural changes.

Or, identify which changes provide the best speech outcomes children in conjunction with

their pre-treatment characteristics. Additionally, the impact of teacher training should be

observed further. While the effects of no training are evident, the long-term frequency of

PECS use in the classroom following training remains uncertain.

ConclusionPECS is designed to support children with ASD who typically lack the social nuances to

initiate and engage in communicative acts with the people around them. The studies

reviewed provide some evidence that PECS may be useful in developing communication in

children with ASD, who have little to no speech. The main benefits being communicative

initiations, or mands to request desired items. Though, the level of progress through the

system appears entirely unique. Therefore, identification of pre-treatment characteristics and

settings that produce optimal results needs to be investigated further. Additionally, the

conduct of studies that provide more experimental control is paramount in determining the

efficacy of PECS implementation in generalised settings.

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Appendix

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Introduction - hannahroseportfolio.files.wordpress.com · Web viewTo support children with ASD, Augmentative and Alternative Communication (AAC) systems, have been developed to

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