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THE USE OF THE PICTURE EXCHANGE COMMUNICATION

SYSTEM TO IMPROVE COMMUNICATION SKILLS

IN A CHILD WITH MULTIPLE DISABILITIES

Shu-li Lin

National Taiwan Normal University, Department of Special Education

(162, Ho-Ping E. Road, Sec. 1, Taipei, 10610, Taiwan)

ABSTRACT

This project was carried out mainly to examine the effects of using the picture exchange

communication exchange system (PECS) in an effort to improve communication skills in

a 5 year and 11 months old child with multiple disabilities. A partnership between the

researcher and the family was key. Only four of the six PECS phases (i.e., the Physical

Exchange, Distance and Persistence, Simple Discrimination, and Sentence Structure)

developed by Frost and Bondy (2002) were selected to teach this child because of her

hearing loss and lack of language ability. The training sessions took place in the child’s

home. The researcher and the family first systematically assessed the target behaviors

of the child and possible strategies. They then developed the intervention. Family

training included an introduction or review of PECS theory and instructions on using the

PECS. Ongoing consultations and input from the family, especially the child’s mother,

formed the basis of the intervention. An embedded single-case design was used to

collect and analyze the data through ongoing note-taking and systematic observation.

The interventions produced positive changes for the target behaviors of this child.

Keywords: multiple disabilities, Picture Exchange Communication System (PECS),

functional communication

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For over two decades, an augmentative and alternative communication (AAC)

system has been recommended to a variety of individuals with communication disorders

(Hourcade, Pilotte, West, & Parette, 2004). The Picture Exchange Communication

System (PECS) has recently become a widely used AAC system for teaching functional

communication skills (Schwartz, Garfinkle, & Bauer, 1998). The PECS is a unique

AAC training package originally developed for use with preschool children with autism,

pervasive developmental disorders (PDD), and other socio-communicative disorders

which inhibit functional behavior or socially acceptable speech.

In order to demonstrate functional communication skills, children using PECS are

taught to approach and give a picture of a desired item to a communicative partner in

exchange for that item. By being provided a vision and exchangeable tool and the

tangible reinforcers, the PECS user initiates a spontaneous communicative act for a

concrete outcome within a social context. Thus, “reinforcement strategies, distinct

teaching strategies, error correction strategies, and generalization strategies are essential”

for teaching individuals to use PECS (Frost & Bondy, 1994, p. 3). In other words,

through the application of the principles of Applied Behavior Analysis (ABA), this

approach emphasizes the development of one’s functional communication skills and the

independence of the communication modality. Overall, it is a system that does not

require complex materials, expensive equipment, comprehensive testing, or highly

technical training for trainers (Frost & Bondy, 2002).

This project was carried out mainly to examine the effects of using the picture

exchange communication exchange system (PECS) in an effort to improve functional

communication skills in a 5-year 11-month old girl with multiple disabilities. Four of

the six PECS phases (i.e., the Physical Exchange, Distance and Persistence, Simple

Discrimination, and Sentence Structure) developed by Frost and Bondy (2002) were used

to teach this child. Specifically, the research questions of this project included: (a)

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Could the functional communication skills of a 5-year 11-month old child with multiple

disabilities be improved following the PECS training? (b) Could the eye contact

behaviors of a 5-year 11-month old child with multiple disabilities be increased following

the PECS training? (c) Could the disruptive behaviors related to communication

functioning of a 5-year 11-month old child with multiple disabilities be decreased

following the PECS training? And (d) Could the spontaneous language of a 5-year

11-month old multiple disabled child who had hearing impairment and no spontaneous

vocal repertoire be increased following the PECS training?

Method

Participants and Settings

The participant of this project, Cassie, was a 5-year 11-month old girl with

diagnoses of multiple disabililties. When Cassie was about three years old, Cassie was

diagnosed as hearing impairment (78dB for left ear and 107dB for right ear), mental

retardation, and autism. A recent administration of the Developmental and Behavior

Scales (Heep Hong Society for Handicapped Children, 1997) showed a developmental

score of 53 for Cassie, suggesting a 1 year 11/12 month developmental age. Anecdotal

reports from Cassie’s mother and observation by the author indicated that Cassie not only

could not vocally imitate words and phrases because of her hearing impairment but also

often used disruptive behaviors to “communicate” in her daily activities. Further,

Cassie’s overall performance on the critical communication skills checklist (Frost &

Bondy, 2002) included: (a) often used disruptive behaviors (e.g., yelling, throwing things)

to make requests and to refuse, (b) used tantrums to respond to transition between

activities and to “wait,” (c) most often not responding to directions (including visual and

oral directions), (d) could respond to desired items, and (e) played only by herself most

of the time.

Cassie’s intervention took place at her home (located in a middle size city of north

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Taiwan), which had three bedrooms, a living room, a dining room, a study room, a small

kitchen, and a bathroom. Through videotaping, data on structured training sessions was

collected mainly in the living room, dining room, and study room of the house. Data on

Cassie’s daily practice of PECS and disruptive behaviors was collected in various parts

of the house through observing daily functional activities.

Families Training

Approximately two weeks prior to the actual training, the author met with Cassie’s

families for training. Cassie’s mother and the author took turns being Cassie’s trainer or

communicative partner in all structured training sessions. The mother’s 12 years of

experience as an elementary school teacher helped provide a strong basis for this

partnership. During two-week training period, each member of Cassie’s family was

trained to apply the PECS and reinforcement system to Cassie.

Assessment Instruments

Data was gathered through the following instruments. First, during the

pre-training phase, the Critical Communication Skills Checklist (CCSC; Frost & Bondy,

2002)) was used to assess Cassie’s current functional communication skills. Second,

the Reinforcer Worksheet was employed to collected information regarding effective

reinforcers for Cassie (Frost & Bondy, 2002). Third, the Monitoring Progress

Worksheets were used to monitor the progress Cassie made each phase (Frost & Bondy,

2002). Finally, a coding sheet and a data collection sheet were also used to collect data

on Cassie’s eye contact behaviors and disruptive behaviors.

Materials

In this training project, pictures and reinforcers were the main materials. We

prepared 16 pictures of desirable or contextually appropriate items, pictures of irrelevant

or non-preferred items, and the corresponding items based on the results of reinforcer

assessment. Further, we also used the nine items to be distracters. The actual pictures

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made for Cassie were on black 1.5”×1.5” paper covered with lamination films

(Mayer-Johnson, 1981). Each picture included key information (general information

was placed on the upper part of the picture) and digital photos or black-and-white line

drawings (pictorial icons). In addition, we used a commercially available PECS

communication book (7.5”×6”), which included insert pages, a miniature sentence strip,

and Velcro○R strips, to store and arrange Cassie’s communication pictures.

Design and Procedure

This project employed an embedded single-case design to collect and analyze the

data. This project consisted of five parts: pre-training assessment, the Physical

Exchange phase, Distance and Persistence phase, Simple Discrimination phase, and

Sentence Structure phase.

Pre-training assessment. The pre-training assessment consisted of four parts.

First, we used the FDPBF to collect information related to Cassie’s basic skills in various

areas and demographic information of Cassie’s family. Second, we used the CCSC to

assess Cassie’s current functional communication skills. Third, three procedures were

used to collect information related to reinforcers: (a) interviews with Cassie’s family, (b)

observing Cassie in an unstructured situation, and (c) conducting a formal reinforcer

assessment by using the Reinforcer Worksheet. Fourth, we collected the baseline data

for both measures of eye contact behaviors (five sessions) and disruptive behaviors (three

days). Finally, the repertoire of pictures and spoken words acquired for Cassie prior to

intervention were measured.

Phase I: The physical exchange. The terminal objective of this phase was to

teach spontaneity: Upon seeing a “highly preferred” item, Cassie would pick up a picture

of the item, reach toward the communicative partner, and release the picture into the

trainer’s hand. For doing this, we used backward chaining and faded prompts to track

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whether Cassie completed each step of the exchange independently or if she needed a full

physical prompt or a partial physical prompt. Throughout the whole phase, we

monitored the level of assistance Cassie needed with the pick up, the reach, and the

release while Cassie’s mother and the author took turns being the trainers. The

communicative partner was in front of Cassie and the physical prompter was in back of

Cassie. A highly preferred item (e.g., pudding) was held by the communicative partner

out of reach of Cassie and the picture of the item was on the table between Cassie and the

communicative partner. Overall, the following six rules suggested by Frost and Bondy

(2002) were used to guide the training: (a) trainers (i.e., communicative partner and

physical prompter) waited for Cassie to reach for the item; (b) no verbal prompts were

used; (c) communicative partner only presented one picture at a time and frequently

switched between reinforcers; (d) arranged various opportunities throughout the day for

Cassie to make requests; and (e) used different types of reinforcers.

Phase II: Distance and persistence. The terminal objective of this phase was:

Cassie went to her communication board, pulled the picture off, went to the trainer, got

the trainer’s attention, and released the picture into the trainer’s hand. Five tangible

items and their corresponding pictures were prepared for Cassie (i.e., pudding, bubbles,

Crackers, m & m chocolate, potato chips). In this phase, Cassie and the trainer sat at a

table as in Phase I while the communicative partner attached one picture of a highly

preferred item for Cassie via Velcro○R to the front of a communication book. Based on

Cassie’s progress, the communicative partner gradually placed the picture on the

communication book at varying distances (i.e., from one foot to seven feet) to expand

Cassie’s spontaneity. In this phase, some principles used in the previous phase were

still followed. Further, data at this phase was collected through trial-by-trial monitoring

progress data sheets and monitoring progress anecdotal data sheets to assess Cassie’s

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performance. The anecdotal data sheets provided enough information for the next

trainer to assess at what level (distance) to begin training during the following session.

Phase III: Picture discrimination. The terminal objective of this phase was:

Cassie needed to request desired items by going to a communication book, selecting the

appropriate picture from an array, going to a communicative partner, and giving the

picture to the partner. Basically, this phase consisted of three parts: (a) Phase IIIA

(simple discrimination): discrimination between a highly preferred icon and a distracter

icon (1 preferred item vs. 1 distracter item), (b) Phase IIIB (conditional discrimination):

discrimination between pictures of two reinforcing item, and (c) Phase IIIC:

discrimination between multiple pictures (i.e., 3 items, 4 items, and 5 items). Overall,

the following procedures were used to conduct the structured training sessions: (a) Cassie

and trainer sat at a table, facing each other; (b) no verbal prompts or physical prompter

were used; (c) the communicative partner enticed Cassie with both items in one hand and

kept a free hand for accepting the picture; (d) the trainer varied position of pictures on the

communication board regularly until Cassie mastered discrimination; (e) 4-step error

correction procedure was used to correct Cassie’s error reactions when Cassie made any

errors throughout the whole phase; and (f) conducted reinforcer assessments three times

(Frost & Bondy, 2002). Further, Cassie’s family also created various opportunities in

daily functional activities to entice/increase Cassie’s spontaneity.

Phase IV: Sentence structure. The terminal objective of this phase was: Cassie

must request present and non-present items using a multi-word phase by going to the

book, picking up a picture of “I want,” putting it on a sentence strip, picking out the

picture of what was wanted, putting it on the sentence strip (e.g., “I want bubbles.”),

removing the strip from the communication board, approaching the communicative

partner, and giving the sentence strip to communicative partner. Based on this objective,

the following materials were prepared: the communication book, a sentence strip that

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could be Velcroed○R to the communication board and to which pictures could be attached,

an “I want” picture, reinforcing objects/activities (as used in Phase III), and the

corresponding pictures. Overall, in addition to following the rules used in last phase,

we also used “Backward Chaining” to teach Cassie sentence strip construction. In

terms of reading or pointing to every word regarding the item pictures of the sentence

strip, we did not require Cassie to really read the sentence strip out loud but requested her

to point each picture on the sentence strip to the communicative partner before giving it

to communicative partner because of her hearing problem and lack of language ability.

Targeted Behaviors and Data Collection

During training sessions in which the procedural and data-collection protocols were

simulated, Cassie’s mother was trained by the author to record all instances of Cassie’s

target behaviors to a criterion of at least 90% accuracy. The following four procedures

were used to collect and analyze data. First, the daily training practices were tracked by

using the monitoring progress worksheets and quantitative descriptions were drawn from

these data. Second, through videotaping at 3-7 times a week for 30 minutes for 45

structured training sessions, the measure of eye contact behaviors Cassie showed in each

structured training session was collected and analyzed via event recording on a coding

list (Bentzen, 1992). This measure was operationally defined by the percentage of the

first meaningful glimpse at each target objective (i.e., reinforcer, item picture,

communicative partner) in each initiative exchange behavior during structured training

sessions. To this measure, we did not record “repeat” behaviors and behaviors produced

after prompt or correct. Third, Cassie’s disruptive behaviors were collected by Cassie’s

mother and coded by two observers. The measure was operationally defined by the

frequency on the occurrence or nonoccurrence of target behaviors related to

communication functioning (e.g., yelling, pulling, crying, loud humming, tantrum-like

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behavior, etc.) throughout the day. Finally, number of pictures Cassie learned in PECS

each week was also collected during the pre-training assessment period and each phase of

the PECS intervention.

Interobserver Reliability

To collect interobserver reliability data, 33% of data collected from monitoring

progress worksheets and the targeted behaviors for 30% videotapes of structured training

sessions were checked by the second observer independently. The second observer was

trained in the operational definitions of all targeted behaviors and use of the data

collection form. Interobserver reliabilities collected from all the resources were

determined by calculating the number of agreements between the two observers divided

by the number of agreements plus disagreements multiplied by 100 (Goh, 1996; Tawney

& Gast, 1984). Mean interobserver reliabilities of data collected from monitoring

progress worksheets, eye contact behaviors, and disruptive behaviors were 96.50%,

90.48%, and 95.50% respectively.

Results

The PECS Acquisition Data in Each Phase

Phase I: The physical exchange. This phase was lasted 12 days (eight structured

training sessions). At the first structured training session of this phase, Cassie required

full physical prompts for all three steps in the exchange sequence during the first four

trials. We diminished full physical prompts at Trial 5. At Trial 8, we started using

different reinforcers to prevent Cassie from getting tired of the same reinforcer (V-7/4;

IT-1). The same situation was continued for four days. From Session 5, Cassie no

longer needed full physical prompts and was able to spontaneously produce correct

exchange behaviors at different room of the house (i.e., dining room, living room, study

room) (V-7/5; IT-2). Therefore, we stopped collecting trial-by-trial data and used

anecdotal data sheets to monitor daily exchange activities (IA-6, 7). At Session 8,

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Cassie made no progress (i.e., the physical prompting was not induced) (V-7/7; IMPA-3).

Consequently, we again conducted two sessions using the trial-by-trial data sheet to

determine specific areas of weakness (V-7/8, 7/9; IT-4, 5). At Session 11, Cassie again

clearly showed progress in that less physical prompting was needed as training

progressed (V-7/11; IA-6). This was lasted two sessions (V-7/12, 7/15; IA-7, 8). The

correct rate in the last structured training session for Cassie was 100%. We then moved

on to Phase II.

Phase II: Distance and persistence. This phase was lasted seven days (six

structured training sessions). At the first session of this phase, the author

(communicative partner) moved Cassie’s book around one foot away from her. By the

end of the session, Cassie was able to walk two feet to get the picture on her

communication book and then four feet to get to the communicative partner (V-7/18;

IIT-1). At Trial 7 of the second session, Cassie was able to get picture to exchange

different reinforcers with different communicative partner (the author and Cassie’s

mother) from four feet (V-7/18; IIT-1). However, at the third session, Cassie again

required assistance to travel to the communicative partner, so we move the book back

closer to Cassie (i.e., one foot) (V-7/19; IIT-2). To build a firm basis for this phase, we

kept this distance for another session (V-7/20; IIT-3). At Session 4, Cassie again

showed more independence at traveling to communicative partner (V-7/21; IIT-4).

Therefore, we again increased the distance (from two feet to seven feet) to the book since

then for two sessions (V-7/22, 7/23; IIA-5, 6). Monitoring progress anecdotal data

demonstrated that Cassie made progress across trainings. Based on Cassie’s progress,

we then moved room to room of the house at the following two sessions. By the end of

the last session of this phase, Cassie was able to walk from seven feet to reach the

communicative partner without prompts (physical guidance) from the physical prompter

and went to get the picture when it was not directly in front of her (V-7/24; IIA-7).

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Then we moved to Phase III.

Phase III: Simple discrimination. At the first discrimination trial session of

Phase IIIA, we probed Cassie reaction to a preferred item and a distracter item. We

started with pudding (Cassie’s favorite item) and red pepper (Cassie’s dislike item).

Cassie initially gave the red pepper picture to communicative partner and reacted

negatively when we gave her the red pepper. Her reactions were consistently negative

by throwing it away when given the red pepper by Trial 4 of the first session of Phase

IIIA. However, by the end of this session, she began to reliably give the correct picture

(pudding). In the seventh discrimination training trial of the same session, although

Cassie exchanged the picture of the contextually inappropriate item, she did not have a

negative response to receiving the red pepper. This happened again on the next trial, so

the trainer selected another item (paper clip) to use as the contextually inappropriate

distracter item. The second item did elicit a negative response, so the trainer continued

to use it on the next three trials. We then switched to a different distracter (spoon)

(V-7/25; IIIA-1). The same practice was continued for three sessions. During these

sessions, we regularly changed different preferred items and distracter items to train

Cassie. The videotapes of these four structured training sessions and monitoring

progress data sheets demonstrated that Cassie made progress across training (V-7/26,

7/27, 7/29; IIIA-2, 3, 4). Cassie was able to give the correct picture 100% by the end of

this phase (V- 7/31; IIIA-5), so we then moved on to Phase IIIB.

At the beginning of Phase IIIB, we probed Cassie’s reaction to two preferred items.

We started with pudding and bubbles (both were Cassie’s favorite items). Cassie

reacted negatively by trying to grab another item when given the item she did not really

want at the third trial of Session 1 of this phase. We continued to use the same item as

the contextually inappropriate distracter item on the rest of the trial. Cassie could give

the correct picture 60% by the end of the same session (V-8/2; IIIB-1). This was

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continued on the next two sessions (V-8/3, 8/5; IIIB-2, 3). In Trial 6 of the third

training session, Cassie exchanged the picture of the contextually inappropriate item

(pudding) but she did not have a negative response to receiving the item that the trainer

handed it to her (cookies). This happened again on the next two trials, so we tried

another item (toy car) to use as the contextually inappropriate distracter item at Trial 9.

The second item did elicit a negative response, so we kept using it on the next five trials

and then switched to a different distracter (m & m chocolate) (V-8/5; IIIB-3). Cassie

was able to give the correct picture 90% by the end of Session 4 (V-8/7; IIIB-4) and

100% by the end of Session 6 (V-8/10; IIIB-6). Then we used two preferred and one

distracter item.

Monitoring progress worksheets and structured training sessions collected by

videotapes showed that Cassie was able to discriminate between two preferred and one

distracter item with correct correspondence at the end of Session 2 (V-8/11; IIIC-2).

Due to Cassie’s success, we then incorporated some distance (three feet) training at

Session 3. To do this, we initially simplified the task for the first trial. Cassie

correctly discriminated between two preferred items with correct correspondence.

However, Cassie had one correspondence error when switching from bubbles to juice but

was correct again on the next trial. By the end of the same session, Cassie was able to

get the picture when it was not directly in front of her (V-8/12; IIIC-3). We did this for

one more session to assure Cassie’s discrimination skills. Cassie did perform

successfully at this session (V-8/13; IIIC-4). Then we returned to two preferred items

and a distracter item at Session 5. Cassie’s success demonstrated that she was able to

discriminate three pictures when the pictures were not directly in front of her (V-8/15,

8/16; IIIC-4, 5). Cassie was able to master discriminating between three pictures at

Session 7 and between four pictures at Session 8 (V-8/18, 8/19; IIIC-7, 8). Then we

added to five pictures. Still, Cassie could master discriminating between five pictures

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by the last session of Phase IIIC (V-8/21; IIIC-9). The percentage of correct response

for Cassie was 94.3% at the last session of this phase.

Phase IV: Sentence structure. This phase was lasted 10 days (six structured

training sessions). At the first session of this phase, the author (communicative partner)

created a communicative opportunity to elicit Cassie to pick up the picture of the item

and began to reach to the author. The author then intercepted the reach and physically

prompted Cassie to put the picture on the sentence strip and then physically prompted

Cassie to exchange the entire strip. Over the course of Trials 3-5 at the first session, the

communicative partner was able to fade the physical assistance, and Cassie could

independently attach the reinforcer picture to the strip. On Trial 6 of the same session,

the author moved the “I want” picture off the sentence strip and when Cassie reached for

the reinforcer picture, the author physically prompted her to remove the “I want” picture

and put it on the strip. By doing this, Cassie was able to independently complete

constructing the sentence strip and exchange it (V-8/22; IV-1). At Session 3 of this

phase, Cassie had mastered assembling the sentence strip and was able to exchange it but

still needed physical assistance to point to/tap each picture at this time (V-8/24; IV-3).

However, on Trial 7 of Session 5, Cassie was able to independently complete the

assembly, the exchange, and the pointing. Cassie showed the same reaction on the next

trial of the same session, so we added a correspondence check to assess discrimination

skills that enabled Cassie to master sentence strip construction (V-8/28; IV-5). By the

end of Session 7 of this phase, Cassie not only could construct the sentence strip and

exchange it but also was able to point out each picture of the sentence strip to the

communicative partner (V-8/31; IV-6). The percentage of correct responses for Cassie

at this session was 97.1%.

Eye Contact Behaviors

We found Cassie’s eye contact behaviors to reinforcer had been great since the

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beginning of the trainings and throughout the whole training period. Through

processing the PECS training, Cassie’s eye contact behaviors to item picture made

obvious progress during Phases III and IV. Cassie’s eye contact behaviors with

communicative partner increased throughout the PECS training but not as great as eye

contact behaviors to item picture. As shown in Table 1, Cassie exhibited mean

percentages of 70.0% (reinforcer), 33.3% (item picture), and 6.7% (communicative

partner) in pre-training phase. Mean percentages of Cassie’s eye contact behaviors

increased to 78.6%, 26.2%, and 8.20% in Phase I, 81.1%, 19.0%, and 12.4% in Phase II,

88.0%, 61.0%, and 18.0% in Phase III respectively. Cassie continued increasing her

eye contact behaviors in Phase IV. The mean percentages of this phase were 94.6%,

82.9%, 27.0%, a further 6.6%, 21.9%, and 9.0% increases respectively.

Table 1

Overall Results of Eye Contact Behaviors in Structured Training Sessions and

Disruptive Behaviors in Each Observing Day for Cassie

Eye Contact Behaviors (Mean Percentage) Targets

Phase Reinforcer Item Picture Communicative

Partner

Disruptive Behaviors

(Mean Number

/Percentage)

Pre-Training 70.0% 33.3% 6.7% 9.33 (93.3%)

I 78.6% 26.2% 8.2% 8.50 (85.0%)

II 81.1% 19.0% 12.4% 8.25 (82.5%)

A 91.0% 61.9% 13.8% 6.00 (60.0%)

B 90.0% 60.5% 17.1% 4.66 (46.6%)

C 83.2% 60.7% 23.2% 2.75 (27.5%) III

Mean (88.8%) (61.0%) (18.0%) 4.47 (44.7%)

IV 94.6% 82.9% 27.0% 2.00 (20.0%)

Disruptive Behaviors

The maximum number of disruptive behaviors for each week was 10.0 (see Table 1).

As shown in pre-training phase, Cassie exhibited a mean of 9.33 points out of a possible

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10 points (93.3%). In Phase I, Cassie’s mean number of disruptive behaviors decreased

to 8.5 (85.0%), an 8.3% decrease in the number of behaviors observed. In Phase II,

Cassie’s mean number of disruptive behaviors almost maintain the level of 8.25 (82.5%),

only a 2.5% decrease. In Phase III, Cassie decreased her disruptive behaviors with a

mean score of 4.47 points out of 10.0 points (44.7%), a 37.8% decrease with PECS. In

Phase IV, Cassie continued decreasing her disruptive behaviors. Her mean score at this

phase was 2.00 out of 10.0 points (20.0%), a further 24.7% decrease.

Pictures Learned in PECS

As shown in Figure 1, Cassie did not know any pictures during the first three weeks

and could only discriminate two pictures. However, by Week 5, Cassie had made

obvious progress. By the end of the PECS training, Cassie had 23 pictures in her

repertoire across nine weeks. At the same time, Cassie did not develop any verbal

imitation throughout the training sessions.

Figure 1. Number of Pictures Cassie Learned in PECS.

Social Validity

Following the intervention, Cassie’s family was asked to complete a social validity

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instrument (SVI). Results were used to establish information regarding Cassie’s

family’s perceived efficacy of the PECS intervention. All the members of Cassie’s

family indicated that the PECS was not only useful but also easy to use for Cassie.

They also felt that the use of PECS could decrease Cassie’s disruptive behaviors. As

Cassie’s mother said, “Cassie exhibited decreased disruptive behaviors with the use of

PECS. This was particularly obvious during Phase IIIB and Phase IV (SVI-M).” All

Cassie’s family also agreed that the PECS training would produce a lasting improvement

in Cassie’s communication functioning and could be as effective in other places beside

home (e.g., school). In other words, Cassie’s family was satisfied with the effects of the

PECS and would continuously encourage Cassie to use the PECS in her daily activities.

Of course, they would recommend the PECS to others. Further, both Cassie’s father

and mother believed that the PECS would be appropriate for a variety of communication

situations. On the other hand, when being asked if there were any difficulties or

challenges for the family during the period of the PECS training, Cassie’s mother said, “I

don’t think it is a challenge. We (the whole family and Cassie) are having fun while

learning something together. It is fun for the family (SVI-M).” The following

statement indicated by Cassie’s mother might be the best description for this PECS

training project:

The PECS opens a door for us to communicate with Cassie. I think it’s also the

best method so far we can find for her to communicate with others. I should say,

“It gives us some hope with Cassie.” Before the PECS training, we really did not

know what to do with Cassie; we were hopeless. In other words, we did not know

what Cassie really wanted most of the time and felt quite frustrated…..Now she

seems not so far away from us. It is really worth it (SVI-M)

Discussion

This project was carried out mainly to examine the effects of using the PECS in an

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effort to improve communication skills in a 5-year 11-month old girl with multiple

disabilities. The data from this project indicates that in terms of the PECS acquisition

data in each phase, rate of eye contact behaviors, frequency of disruptive behaviors

related to communication functioning, and the number of pictures learned in PECS,

PECS did increase Cassie’s functional communication behaviors. No gain in initial

spontaneous vocalizations was observed. Significantly, Cassie’s disruptive behaviors

decreased while the number of pictures she learned in PECS increased. In other words,

the PECS provided Cassie with a good channel through which to learn a functional

system of communication. These findings are consistent with those of Bondy and Frost

(1994) and support the use of PECS as an AAC system that can be used to help children

with severe expressive language disorders. Overall, these results extend current

knowledge because they confirm the benefit of PECS in increasing functional

communication skills of children with multiple disabilities.

At the beginning of this project, we were worried that Cassie’s multiple disabilities

might affect the training. However, during the training, we found that Cassie was easy

to teach because of the passive characteristics of Cassie’s autism. According to Wing

and Gould, although most of children with passive autism have difficulties in actively

initiating a behavior when interacting with others, they are able to accept physical

touching from others, play with other kids which being led, and make requests of what

he/she wants from others. In other words, this kind of autistic child is easier to teach

and prospects for their development in the future are usually better than for children with

other kinds of autism (cited as Shyu, 2003).

Moreover, Cassie’s eye contact to reinforcer had been greater than the behaviors to

item picture and with communicative partners from the beginning of the training program

until the end. One reason for this might be also because of another characteristic of

Cassie’s autism. According to Shyu (2003), most children with autism usually respond

PECS 18

better to substances than to human beings. This provides some evidence confirming the

importance of reinforcers used in the training. In other words, the reinforcers used to

train the participant should be the items that he/she really likes. Additionally,

comparing the trends of Figures 2 and 3, we found that Cassie’s disruptive behaviors

related to communication functioning decreased while the number of pictures Cassie

learned in PECS increased. This further confirms the hypothesis that Cassie’s

disruptive behaviors before the PECS training might be because she lacked a proper

communication channel. The PECS training might be a good start for Cassie’s future.

Although the data presented here is promising, many questions raised by these data

have been left unanswered. First, only one child participated in this study. It is

unknown whether the intervention would have produced the same results across

randomly selected participants. Although PECS can be modified to use with

individuals of all ages and “with a variety of communicative disorders” (Frost & Bondy,

1994, p. 2), given the diversity of abilities that individuals with multiple disabilities, it is

not known if PECS could benefit all such individuals. Further, although the use of

PECS requires few complex motor movements on the part of the speaker

(Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet., 2002; Frost & Bondy, 1994), the

users who have severe physical disabilities may not be appropriate for using PECS.

Second, the intervention of this project was only constructed at Cassie’s home.

Although the PECS use was successful for Cassie in a home setting, it is impossible to

know whether or not Cassie would exhibit similar performance in other settings. In

other words, to determine whether PECS is a valid training package for functional

communication, it must be evaluated in terms of children’s ability to use the system

spontaneously and across various settings and activities. Third, as previously

mentioned, we did not complete all six phases of the PECS; only four phases of PECS

were chosen to teach Cassie. An intervention across all phases of the PECS for Cassie

PECS 19

might have produced different results. Fourth, it is important to note that this project

lacks experimental data and cannot pinpoint the cause of the growth in communicative

behavior. Rather, the data produced from this project only demonstrates that children

with multiple disabilities learned to use PECS in a functional manner as part of a

comprehensive educational program. Moreover, it is also important to note that we did

not control for changes due to maturation. Therefore, although we cannot make causal

claims about the link between the changes in Cassie’s communicative behaviors, we

observed that Cassie did learn to use this communication system efficiently and used it

effectively in a home setting.

Based on the findings and limitation of this project, some implications for research

and practice should also be addressed. First, the partnership between the author and the

participant’s families was critical to the success of this project. In other words, the

addition of this information regarding using PECS within home setting through a

partnership of the author and the participant’s families is the beginning of another path of

investigation. Second, further research could investigate the benefits of PECS with

more individuals with multiple disabilities. Third, to facilitate an effective intervention,

proper use of reinforcement strategies is essential throughout the PECS training. This

can be started by conducting a thorough reinforcer investigation right from the beginning

of the intervention. Fourth, because of the limitation of the participants’ abilities and

research time, we did not complete all six phases of PECS. Empirical research also

needs to be done to explore whether a complete PECS intervention would benefit various

individuals with multiple disabilities. In other words, replication with more participants

and participants with different skill levels will be beneficial in understanding the best use

of PECS.

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PECS 20

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