by Andy Bondy & Lori Frost
When we began developing the Picture Exchange Communication System (PECS) protocol in the mid-1980s, all picture-based communication systems involved having children (or adults) point to or touch a picture to communicate. At that time, there were a few electronic communication devices, but they were expensive and very time-consuming to program. The development of PECS, however, had nothing to do with the expense or time commitment of these devices. Rather, it had everything to do with how children, especially very young children with Autism Spectrum Disorder (ASD), used the systems. Communication requires interacting with another person in some way, including speaking, signing or using pictures. Unfortunately, some children use their voices, fingers, or pictures in ways that are not interactive—they speak when no one is around, or they push buttons on devices when alone in a room. It appeared that many children were using these devices more as toys (perhaps to produce sounds) than as communication devices.
Therefore, within PECS, the first lesson involves what to do with the picture—give it to another person who will then give you the item you want—NOT what is the meaning of this picture. This focus parallels what happens for typically developing children: they learn to communicate with their parents before they learn to say specific words. Whereas in normal language development, functional requests and comments seem to co-develop, the PECS protocol begins with requesting to take advantage of more powerful reinforcers, especially for those with ASD.
When to Introduce Speech-Generating Devices: Transitioning from PECS
The most important question regarding the use of speech generating devices (SGDs) is when to introduce the device—at the beginning of intervention or within a transitional sequence. The problem with trying to use the device from the beginning of a very young child’s training, especially those with ASD, is that these learners often do not have fundamental functional communication skills. Learning to push a button on a device—even if pushing the button is followed by a sound being emitted by that device—does not guarantee that communication has taken place. Communications need to be initiated spontaneously and completed independently in order to be effective in real world contexts.
Although there are some reports that children with ASD can learn to use such systems from the start, none of these studies actually controls for type of use: is it being used as a toy, where the reward for use stems from interacting with the device itself, or is it being used in order to engage in functional communication, where use is controlled by the presence and reaction of someone else? Furthermore, several reviews (Lorah et al., 2014; Still et al., 2014) of the most recent studies show the acquisition of remarkably small vocabularies as a result of using these devices, ranging from 1 to 15 pictures. There are no publications demonstrating a large, robust repertoire of pictures (or speech acquisition) when SGDs are used as the initial communication modality.
There is a large evidence base for the use of PECS as an initial communication system with children with ASD and other disabilities.
The option that we strongly recommend involves transitioning from PECS to a device. There is a large evidence base for the use of PECS as an initial communication system with children with ASD and other disabilities. A recent randomized control trial comparing PECS to a speech-based protocol with 19 children with ASD who entered with a mean age of 2.5 and used fewer than 10 spoken words showed that this group averaged over 80 spoken words within six months and that virtually all acquired a functional picture repertoire (Schreibman & Stahmer, 2014). Therefore, we strongly urge that families and practitioners begin with PECS for those individuals who have no (or severely limited) functional communication skills.
As a general guideline, we recommend that individuals not be transitioned from PECS to an SGD until they have mastered Phases I through IV of the standard PECS training protocol. Completion of PECS Phase IV ensures mastery of the following PECS-based skills, which we consider prerequisites to transitioning to an SGD. Specifically, we recommend that the learner has an established history of spontaneous and independent use of the following skills with his or her PECS book prior to the team considering a transition to an SGD.
- Persistence in identifying and approaching communication partners across environments
- Discrimination between 20 pictures in a picture array
- Navigating from page to page while building a Sentence Strip™
- Pointing with index finger to individual pictures during Sentence Strip exchange
Choosing an SGD or app must be done with care to ensure that all PECS skills can be transferred to the SGD or app and that continued language and vocabulary growth is achievable. Most SGDs allow for customization of a variety of options including language software, vocabulary organization, picture size, when and how the device’s voice is activated, how the message is cleared, and whether pictures are arranged on scrolling pages or successive pages. This degree of tailoring will require that someone on the student’s team know how to make changes to the default setup of the device or app so that navigational complexity for each message is minimized. Initial lessons should be conducted with activities that are familiar and motivating to the PECS user and during which he or she interacts with the communication partner for a variety of communicative exchanges. The team should write a step-by-step sequence of all actions the learner must complete to construct and deliver the message in an interactive manner. This sequence should include accessing and turning on the device, navigating to and selecting the correct vocabulary to construct the message, activating the voice, and preparing the device for the next communicative exchange. We recommend using the evidence-based teaching strategies from the PECS protocol to teach device use. These strategies include the 2-Person Prompt Procedure, appropriate reinforcement use, backward chaining, Correspondence Checks and 4-Step and Backstep Error Correction procedures.
Using the PECS IV+ App as a Speech-Generating Device
The PECS IV+ iOS app looks just like a PECS book. It allows users to construct a multi-picture Sentence Strip™ via a dedicated Sentence Starter™ page and up to 20 digital PECS book pages for the in-app voice to speak. Navigation features that can be quite complex with some AAC apps are minimized within the PECS IV+ app. The student only has to learn to switch between the Sentence Starter page and various tabs within the digital PECS book and to then ‘speak’ and clear the Sentence Strip.
In addition to the simple navigation requirements of the app, what is unique about PECS IV+ is that pictures can be rearranged on the Sentence Strip without having to delete them, and a time delay can be set to encourage speech. Setting this option results in a 3-5 second delay between the student tapping the picture to speak on the Sentence Strip and hearing the voice speak the word. Within the PECS protocol, this strategy has been demonstrated to be effective at eliciting speech from the user.
Our observations regarding the initial needs of children with ASD remains as they were many years ago—our first obligation is to teach children the importance of interacting with someone else as the cornerstone of functional communication. As communication repertoires expand, at some point it becomes important to consider whether technological advances can accelerate vocabulary growth or transitioning to speech. When such transitions are planned, it is our ethical responsibility to assure that no skills are lost within the transition. We believe that the evidence is clear that using the PECS protocol rapidly promotes functional communication and that for many of those who do not then develop broad speech skills, transitioning to an SGD device such as the Phase IV+ app will prove to be beneficial.
Lorah, E., Parnell, A., Whitby, P., & Hantula, D. (2014). A systematic review of tablet computers and portable media players as speech generating devices for individuals with autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(12), 3792-3804.
Still, K., Rehfeldt, R. A., Whelan, R., May, R., & Dymond, S. (2014). Facilitating requesting skills using high-tech augmentative and alternative communication devices with individuals with autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders, 8(9), 1184-1199.
Schreibman, L. & Stahmer, A. (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), 1244-51.
Andy Bondy, PhD, is president and co-founder of Pyramid Educational Consultants, Inc. Dr. Bondy is an innovative leader in the field of autism and applied behavior analysis. He directed a statewide public school system for students with autism for fourteen years. He is co-author of the PECS Training Manual. He also wrote the Pyramid Approach to Education, a training manual that offers an integrated orientation to developing effective educational environments blending applied behavior analysis with functional activities and create communication strategies. Dr. Bondy received his MA and Ph.D. from the UNC Greensboro, and completed his clinical internship in 1976 at the University of Kansas Medical Center. Dr. Bondy has presented numerous papers, lectures and workshops in regional, national and international conferences and conventions on behavior analysis, PECS and the Pyramid Approach to Education. He has remained active in research and writing, and continues to develop new and innovative methods of helping children with autism and related developmental disorders.
Lori Frost, M.S., CCC/SLP, is vice-president and co-founder of Pyramid Educational Consultants, Inc. She is co-author of the PECS Training Manual. She has been the driving force behind creating this unique system that allows children with limited communication abilities to initiate communication with teachers, parents, and peers. Ms. Frost has a wealth of background in functional communication training and applied behavior analysis. She has assisted in the development of a number of training packages designed to teach language and academic skills. Ms. Frost received her BA in speech pathology and audiology from the University of Arkansas, and MS in speech and language pathology from the University of North Carolina at Chapel Hill in 1982. She has worked in many public and private school settings as a speech pathologist. As a Pyramid consultant, Ms. Frost has traveled across the country and the world, teaching workshops on PECS and the Pyramid Approach to Education. She has presented a number of papers and lectures on autism and communication, co-authored several articles and chapters, and is respected by professionals in her field as a leader in functional communication systems.