Shelley K. Lund Æ Jeanette M. Troha. Introduction

Transcription

1 DOI /s ORIGINAL PAPER 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 Shelley K. Lund Æ Jeanette M. Troha Ó Springer Science+Business Media, LLC 2007 Abstract This study used a single-subject multiple baseline across participants design to evaluate the effectiveness of a modified picture exchange communication system (PECS) teaching protocol with tactile symbols. Three students (two male, one female) aged years who had autism and were blind participated in the study. The instructional program involved three phases. First, each participant learned to exchange a tactile symbol with his/her communication partner to request a preferred item/ activity. Second, the distance between the communication partner and the participant was increased. Third, the participants were required to discriminate between two dissimilar tactile symbols. One out of three participants completed all phases of the instructional program. Although the other two participants did not complete the program, they demonstrated improvement from baseline responding rates. This study provided preliminary results that using tactile symbols with strategies from PECS may be an effective method to teach requesting to youth who are blind and have autism. Keywords Picture exchange communication system Autism Tactile symbols Augmentative and alternative communication Communication intervention Visual impairment S. K. Lund (&) J. M. Troha Department of Communication Sciences and Disorders, University of Wisconsin-Milwaukee, P.O. Box 413, Milwaukee, WI 53201, USA sklund@uwm.edu Present Address: J. M. Troha Lakeview Specialty Hospital and Rehab, Waterford, WI, USA Introduction Children with autism often have difficulty demonstrating many early communication skills such as participating in turn-taking; making it known that they want an activity continued; using pointing, vocalizing, or shifting eye gaze to make their needs/wants known; or telling an adult that assistance is needed (Wetherby et al. 2000). One of the key features of autism is difficulty establishing and maintaining social reciprocity which limits opportunities for individuals with autism to initiate conventional communication (Wetherby et al. 2000). PECS and Autism The picture exchange communication system (PECS) was developed by Bondy and Frost to teach children with autism independent, self-initiated functional communication. The program initially focuses on teaching the child to hand a picture to his/her communication partner in exchange for a desired item or activity. The act of requesting is targeted because tangible outcomes initially are more motivating to children with autism than are social outcomes (Bondy and Frost 2001, p. 727). PECS has six phases of instruction: picture exchange, increased distance, picture discrimination, sentence construction, answering questions, and commenting (Frost and Bondy 2002). The first four phases focus on teaching the child to use a symbol to make a request, while the final two address expanding the range of communicative functions used by the child. PECS is designed to facilitate spontaneous communication by utilizing applied behavior analysis in the prompting, reinforcement, and error correction during each phase (Frost and Bondy 2002).

2 The initial research is promising; PECS has been shown to be an effective way to teach young children with autism and developmental disorders to make requests (Carr and Felce 2007; Charlop-Christy et al. 2002; Ganz and Simpson 2004; Howlin et al. 2007; Kravits et al. 2002; Schwartz et al. 1998). Studies have also reported increases in speech production (Charlop-Christy et al. 2002; Ganz and Simpson 2004; Kravits et al. 2002), increases in social interaction (Carr and Felce 2007; Kravits et al. 2002), and decreases in challenging behavior (Charlop-Christy et al. 2002; Frea et al. 2001) after PECS training. Two studies have compared PECS to other intervention approaches. Yoder and Stone (2006) used a randomized controlled trial to compare the effects of PECS and responsive education and prelinguistic milieu teaching (RPMT) on requesting, turn taking, and joint attention. The results revealed the group that received RPMT demonstrated better turn taking and joint attention than the PECS group; however, the PECS group issued more requests than the group that received RPMT. These results indicate that PECS may be more effective than other instructional procedures to teach children with autism to make requests. However, Tincani (2004) found mixed results when comparing PECS to sign language training for two participants. One of the participants used more requests with PECS than sign language, although the reverse was true for the other participant. The author suggested that hand motor control may have played a role in the participants progress and that PECS may be superior to sign language training for individuals with poor motor control. PECS has also been used with adults with developmental disabilities with mixed results (Stoner et al. 2006). Five adults with severe to profound cognitive disabilities were introduced to PECS in their group homes. Three of the five participants completed all phases of the intervention program and used their communication books for functional communication during community outings. Two participants made limited progress. These two participants had more severe disabilities than the three who were successful with PECS. The researchers suggested that the cognitive and motor demands of PECS might have been too complex for these individuals with profound physical and cognitive impairments. Ganz and colleagues (2005) reported the case study of a young girl who was not initially successful with traditional PECS training. However, after modifying the instruction to incorporate the use of objects as symbols, she was able to make choices between two items in a controlled setting. The intervention still focused on the act of exchange as a method for requesting; however the requesting behavior had to be shaped in a more gradual manner than in traditional PECS. Individuals with profound disabilities may have more difficulty learning PECS; however individualized modifications may be beneficial (Ganz et al. 2005). Autism and Visual Impairment Recent research has indicated that the prevalence of autism may be higher in individuals with visual impairments (11.6%) than in the general population (0.6%); and the risk of autism increases with the severity of visual impairment (CDC 2007; Mukaddes et al. 2007). Many instructional programs for individuals with autism, including PECS, rely heavily on using vision in their teaching, because children with autism are believed to learn better with visual rather than auditory cues (Towbin et al. 2002). However, what is the best method to teach communication to a child with autism and concomitant severe visual impairment (i.e., blindness)? Can the PECS approach be adapted to other modalities that would be accessible to individuals who have autism and are blind? Although their use in the PECS approach has not been studied, tactile symbols might potentially be used by children with both autism and severe visual impairments. Tactile Symbols and Visual Impairment Tactile symbols (i.e., symbols that are three dimensional or textured) are often used for individuals who have complex communication needs and visual impairments (Lloyd et al. 1997). Whole or partial objects with either direct or associated relationships to their referents can be used. An example of a whole object with direct relationship to its referent is using a cup to represent the concept of drink. Using part of the strap from a bicycle helmet to represent bike is an example of a partial object with an associated relationship to its referent. Textured symbols may bear some similarity to the referent; for example, a raised piece of plastic in the shape of a pretzel could represent the actual snack item, or they may be arbitrary, such as using piece of fake fur to represent juice. Early research in the uses of tactile symbols often employed arbitrary representations in an effort to demonstrate that participants with profound disabilities could use textures symbolically (Locke and Mirenda 1988; Mathy- Laikko et al. 1989). Later research has looked at more functional use of tactile symbols for communication by individuals with dual sensory impairments and multiple disabilities. Rowland and Schweigert (1989) reported two case histories in which they taught two children to use tactile symbols. Sybil was a 6-year-old girl with severe hearing and visual impairments and developmental delays who learned to use three-dimensional symbols to request

3 leisure activities. She required an average of 24 sessions to master use of the first three symbols in functional contexts. Over the course of 2 years she learned to use a total of 22 tactile symbols. By the end of this period, her rate of learning had increased, as she only required an average of 11 sessions to master the final three symbols taught. The second case reported was Daniel, a 4 year, 6-month-old boy with severe hearing loss and progressive visual impairment. Tactile symbols were introduced for both expressive and receptive communication. Across 4 years he was able to functionally use symbols for 45 items and 14 activities. Murray-Branch and colleagues (1991) used a promptfree strategy to teach two adolescents (Jessie and Sarah) with dual sensory impairments and severe cognitive impairments to make requests by finding a textured symbol and giving it to their communication partner. For the first symbol taught, Jessie completed the intervention program in 2 months. Within 3 months, she was consistently using five textured symbols to make requests. Subsequently, new textures were introduced every two weeks until she was using 20 textures. Sarah also learned to make requests using tactile symbols, however her progress was slower than Jessie s. She required 6 months to learn the first symbol-referent relationship. Subsequent symbols were learned more quickly, approximately one to 3 months per texture. At the time the case report was published, Sarah was using three textures to make requests and choices. The lone experimental study in the literature on the use of tactile symbols with individuals with visual impairments used a single-subject multiple probe design to evaluate the effectiveness of a naturalistic time delay procedure in teaching a child to use tactile symbols to make requests (Turnell and Carter 1994). Michael was 8 years, 7 months of age and had physical, cognitive, hearing, and visual impairments. His developmental level was estimated to be 6 7 months. Over the course of the study, he learned to use three textured symbols to make requests. He required 29 instructional sessions to learn the first symbol, six sessions for the second symbol, and five sessions for the third. After acquiring the first symbol, Michael demonstrated generalization of learning to the second and third symbols before instruction was implemented with these symbols. This resulted in rising baselines in the second and third conditions, which resulted in the loss of experimental control; therefore the cause and effect relationship between the instructional procedures and the results must be interpreted with caution. The Present Study These studies suggest that tactile symbols can be used to teach basic functional communication to individuals with cognitive disorders concomitant with visual impairments; although most of the evidence has been reported as case studies and no studies have been published with experimental control. The studies previously described in this paper provide evidence that PECS can be an effective method to teach sighted children with autism to make requests. However, no studies are presently available to assess the potential of incorporating tactile symbols into the PECS system for children with autism and visual impairments. Thus, the purpose of this study was to explore the effectiveness of modifying the PECS instructional strategy to teach requesting to children with autism and visual impairments. Specifically, the study was designed to answer the following question: Can combining tactile symbols with modified instructional strategies from PECS be an effective method to teach children with autism and visual impairments to make requests? Method Participants Three students participated in this study. All participants had the following characteristics: (a) blind (i.e., having no usable vision as reported by an ophthalmologist), (b) severe language delay, as reported by their speech-language pathologist, (c) cognitive impairment, as reported by their teachers and stated in any previous cognitive evaluation, (d) under 18 years of age, (e) met the state of Wisconsin Department of Public Instruction criteria for autism (Wisconsin Administrative Code 2001), (f) no formal instruction in the past year in phases one through three in the picture exchange communication system, and (g) hearing within normal limits. In addition, all of the participants were identified as having autism by their school diagnostic team using the Childhood Autism Rating Scale (Schopler et al. 1988), although these scores were not made available to the researchers. A summary of the participant s demographic information is presented in Table 1. Brent 1 Brent was a 17-year-old boy. He was blind resulting from pre-phthisical eye in the right eye and pre-phthisical eye with total retinal detachment secondary to uveitis in the left eye. He was also identified as having cognitive delays and autism. Brent s cognitive impairment was in the moderate to severe range, per school report. He was mostly dependent on others for all his activities of daily living. 1 Pseudonyms were used to protect the participants identities.

4 Table 1 Participants demographic information Participant number Name Age Gender Diagnoses Educational setting Communication age equivalence a 1 Brent 17 M Autism, CD,VI, S/L Self-contained classroom Receptive language = 2 4 years a Expressive language = 1 2 years a 2 Aaron 13 M Autism, CD, VI, S/L Self-contained classroom Receptive language = 2 3 years a Expressive language = 2 3 years a 3 Sarah 12 F Autism, CD, VI, S/L Self-contained classroom Receptive language = months b Expressive language = 9 12 months b Note: CD = Cognitive delay; VI = Visual impairment; S/L = Speech and language impairment a As measured by the Oregon project for visually impaired and blind preschool children: skill inventory (Brown et al. 1991) b As measured by the Rossetti infant toddler language scales (Louis 1990) Brent s primary mode of communication was speech, along with using tactile symbols to follow a daily schedule and to make some choices. Although Brent had been exposed to some tactile symbols, he had not been taught with any phases found in PECS. Brent did not initiate communication with the tactile symbols and required verbal and physical prompts in order to use them communicatively. Brent demonstrated the following receptive skills nonverbally: responding to the command no, following one- and two-step directions, identifying objects, responding to simple yes/no questions, and identifying staff by the sound of their voice. Expressively, Brent used the greetings of hi and bye when verbally prompted, labeled some common objects, and said no to stop some activities. Aaron Aaron was a 13-year-old boy. He was blind resulting from congenital optic nerve hypoplasia. Aaron s cognitive impairment was reported to be in the severe range and he was identified as having autism. Aaron was able to follow a few one- and two-step directions in order to participate in some of his daily living activities. Aaron s primary mode of communication was using tactile symbols for following a daily schedule and making choices. Four years ago, Aaron was introduced to tactile symbols. During this previous instruction, verbal and physical prompts were used in a most-to-least prompting hierarchy; however, Aaron had limited success and thus the prompts were not faded during the teaching process. At the beginning of this study, Aaron was still dependent on verbal prompts to use tactile symbols communicatively. In addition, Aaron rarely sought out a communication partner unless verbally prompted. Receptively, Aaron responded to the command no, followed one- and two- step directions, matched objects to their labels, recognized people by the sound of their voice, pointed to body parts, and responded to some action words. Expressively, he had a spoken vocabulary of approximately words; however, most of his speech was produced as echolalia. In addition, he did not initiate interaction with communication partners. Sarah Sarah was a 12-year-old girl. She was blind due to optic nerve hypoplasia. Sarah had a cognitive impairment which was reported to be in the severe range and was identified as having autism. In addition to expressive and receptive language delays, Sarah was diagnosed with apraxia of speech. Sarah s primary mode of communication was using tactile symbols for following a daily schedule and making choices. She used tactile symbols to make choices; however, she required verbal prompts to locate the symbols and to make a choice. Sarah rarely sought out a communication partner unless verbally prompted. Four years prior to the study, Sarah was introduced to tactile symbols. At that time, verbal and physical prompts were used in a most-to-least prompting hierarchy; however they were not faded during the teaching process. The only time she was given the opportunity to communicate using the tactie symbols was in response to the question, What do you want? Sarah s receptive language skills included following simple commands, pointing to body parts, attending to objects mentioned in conversation, responding to the prepositions in and out, and finding common environmental objects when labeled. Sarah s expressive language skills included imitating consonant-vowel (CV) combinations and names for familiar objects, producing about eight CV and consonant-vowel-consonant (CVC) simple words. She used her speech to request some basic needs (e.g., ta for eat ) and to protest; however, due to her apraxia her speech was less than 20% intelligible.

5 Materials Tactile symbols representing preferred objects or activities were created for each participant. The symbols were mounted on a 3 3 inch square piece of cardboard. A description of each symbol and what it represented is presented in Table 2. A blank piece of cardboard the same size as the target symbol was used as a distracter symbol during baseline, and the discrimination sub-phase of instruction. The symbols were mounted with Velcro to a 4 8 inch piece of Plexiglas. Design The present study used a single-subject multiple baseline across participants design (McReynolds and Kearns 1983) consisting of two phases: baseline and intervention. The dependent variable was the level of support required by the participant to use a tactile symbol to request the targeted item/activity (i.e., finding the communication partner and handing her the tactile symbol). Baseline measures of the dependent variable were taken across a minimum of three sessions and staggered across the participants to demonstrate experimental control. Intervention included three sub-phases: symbol exchange, distance and persistence, and discrimination. A maximum of 30 intervention sessions were held to set a specific start and end to the intervention phase. Thirty sessions were selected because the authors thought this would be a reasonable number of sessions to complete between the initiation of the study and the end of the school year. Procedures All sessions were conducted at the participants school. Five min sessions were scheduled for each participant per week. The sessions were scheduled to be held once a day; however, if a student was absent, make-up sessions were scheduled as possible. No more than two sessions Table 2 Tactile symbols for each participant Participant Referent Representation Brent Computer Flat marble with piece of masking tape over it that felt like the computer mouse Aaron Rain stick Piece of plastic with rice n it that made the sound of the rain stick Sarah Crash pillow Piece of material from pillow case occurred per day. The instructional team, which consisted of a master s-level student in communication sciences and disorders (i.e., J. M. Troha) and a Certified Occupational Therapy Assistant (COTA), conducted all sessions. Both members of the instructional team had been employed at the participants school for at least 2 years and were familiar to the participants. During all sessions J. M. Troha served as the communication partner and the COTA served as the instructor. In order to ensure consistent implementation of the procedures, the instructional team practiced the procedures until they could perform the steps in each phase independently without reference to written instructions. Selection of targets Prior to baseline, the instructional team chose a preferred item/activity for each participant to be used for intervention. An item/activity was deemed to be preferred if the participant demonstrated a positive response to it (e.g., smiling or laughing when it was presented, or reaching for it when taken away). Tactile symbols were developed to represent the selected items/activities. Baseline Each participant s use of tactile symbols to make requests was measured at baseline. The same procedures were used as for phase three of instruction, however no prompting was provided. The instructor presented the participant with a tactile symbol and a distracter symbol on the piece of Plexiglas. The communication partner stood approximately two arm-lengths from the participant and indicated her presence by saying Hi, it s choice time. The instructional team waited and observed if the participant used the symbol to make a request (i.e., picked up the symbol, walked to and handed it to the communication partner). A minimum of three baseline sessions were held to demonstrate stable responding rates for the first participant. The baseline phase was extended by one session for each subsequent participant to provide experimental control in the multiple baseline design. After each participant demonstrated stable baseline performance, intervention began. Intervention Intervention consisted of three sub-phases: symbol exchange, distance and persistence, and discrimination. These sub-phases were based on PECS teaching procedures (Frost and Bondy 2002) but adapted to accommodate the

6 participants visual impairments. The instructional procedures used in this study differed from standard PECS teaching procedures (Frost and Bondy 2002) in several significant ways: training was limited to a single communication partner and one symbol, the communication partner provided verbal cues to the participants indicating her presence and location, and a modified least-to-most prompting hierarchy was used. These adaptations were made based on three factors: (a) the participants blindness, (b) their lack of progress in previous instruction which used a most-to-least prompting hierarchy, and (c) the singlesubject experimental design. An extended discussion of these modifications and their possible effects on the intervention are presented in the discussion section. The general procedures were similar for all phases; the specific procedural steps for each phase and sub-phase are presented in the Appendix. Phase One The goal of the first phase of instruction, symbol exchange, was to teach the participants to pick up the tactile symbol and hand it to the communication partner. During this phase the participants were only presented with the target symbol and the communication partner was one arm-length from the participant. The instructor placed the symbol on the Plexiglas, held it in front of the participant and placed the participant s hand on the Plexiglas, touching the symbol. The communication partner indicated her presence by saying, Hi, it s choice time. For the first two sessions of this phase the instructor used hand-over-hand manipulation (HOH) on all trials to help the participant pick up the tactile symbol and hand it to the communication partner. This was done to introduce the tactile symbol to the participant and to associate the symbol with the item/activity it represented. After receiving the tactile symbol, the communication partner said Oh you want and provided the participant with the requested item/activity. Five HOH trials were conducted for two consecutive sessions. During the third intervention session, a modified leastto-most prompting hierarchy was implemented. After the communication partner indicated her presence, the instructional team waited for a response from the participant. The level of prompting provided was based upon the participant s response. If the participant did not initiate any response within five seconds, the instructor used HOH to assist the participant in picking up the symbol and handing it to the partner. If the participant reached for or touched the tactile symbol but did not pick it up, the instructor provided a physical prompt by nudging the participant s elbow. If the physical prompt was not successful in eliciting the target behavior, the instructor provided HOH prompting. If the participant attempted to hand the symbol to the communication partner but did not release it into her hand, the communication partner issued the verbal prompt, give it to me. If the verbal prompt was not successful, the instructor provided a physical prompt. For each trial the instructional team recorded the level of prompt required for the participant to exchange the symbol: Independent (no prompt), verbal, physical, or HOH. Phase one continued until the participant had at least four independent responses out of five trials (80% accuracy) for two consecutive sessions. Phase Two The second phase of instruction, distance and persistence, focused on teaching the participant to hand the tactile symbol to his/her communication partner; however the distance between the participant and partner was increased. The increase in the distance between the communication partner and the participant was included to require the participants to seek out their communication partner, something none of the participants did at the start of the study. The procedures were similar to phase one except the communication partner was two arm-lengths away from the participant. The prompting hierarchy was similar to phase one, with slight modification due to the distance between the participant and communication partner. If HOH was needed, the instructor manipulated the participant to pick up the symbol then held the participant s elbow and guided him/her to the communication partner (sighted guide). A physical prompt was recorded if the participant picked up the symbol independently, but required sighted guide to traverse the distance to the communication partner. The verbal prompt, give it to me was given if the participant picked up the symbol, independently walked to the communication partner, but did not release the symbol into the partner s hand. Again, this phase continued until the participant completed at least 4/5 trials independently for two consecutive sessions. Phase Three The third phase, discrimination, required the participants to find the desired symbol from a field of two choices. During this sub-phase a distracter symbol and the target symbol were placed about ½ inch from each other on the Plexiglas. The right/left placement of the target symbol was randomized from trial to trial. The partner was two armlengths away. In order to let the participants know there were two symbols on the Plexiglas, at the start of the

7 session the instructor placed the participant s hand on the Plexiglas between, but in contact with, both symbols. The prompting was similar to phase two with the following exception: if the participant started to move his/her hand toward the distracter symbol, a physical prompt (slight nudge) was given to steer the participant s hand to the target symbol. The phase continued until the participant achieved at least 4/5 independent responses for two consecutive sessions. Data Collection and Analysis Both members of the instructional team independently recorded the participants responses during all trials. During baseline, responses were recorded as independent (I), incorrect ( ), or no response (N/R). During instruction, the team recorded the level of prompt that was required for the participant to complete each trial. The participants accuracy level was calculated by dividing the number of independent responses by the number of trials in the session. The percent accuracy for each session was graphed for each participant. The graphs were inspected for change in level and slope of data between baseline and the final phase of intervention. Reliability Reliability of the data was determined by calculating the percentage of inter-judge agreement for 100% of the data. At the end of each session, the instructional team compared the data they recorded to each other. The percent agreement was calculated by dividing the number of agreements by the number of agreements plus the number of disagreements. Any disagreements were resolved by consensus. The rate of agreement for Brent and Aaron was 100% across all sessions. The mean rate of agreement for Sarah was 100% for baseline and 95% for intervention (range %). Results Graphs depicting the participant s progress are presented in Fig. 1. Experimental control was demonstrated though stable staggered baselines across each participant. The number of sessions held for each participant ranged from sessions across 2 months. Only one participant was successful in completing all sub-phases of instruction; however, all participants demonstrated improvement from baseline responding rates. Brent Brent completed 3 baseline and 18 intervention sessions. There was a distinct change in the slope and level of Brent s data between the baseline and instruction phases as shown in Fig. 1. He required 11 sessions to reach criterion for symbol exchange, five sessions for distance and persistence, and two sessions for discrimination. During the symbol exchange phase, Brent achieved his first independent trial during the sixth intervention session (session 9). Aaron Aaron completed four baseline sessions and 30 intervention sessions. Aaron required 17 sessions to reach criterion for the symbol exchange phase. He completed 13 sessions for the distance and persistence phase, but he did not meet criterion before reaching the maximum of 30 intervention sessions. Although he did not complete all phases of instruction, there was a distinct change in slope and level of Aaron s data between baseline and instruction as shown in Fig. 1. During sessions 14 and 15 his performance decreased dramatically. He was agitated before the start of these sessions and even though he was given more breaks, he still required more intrusive prompting in comparison to his previous sessions. During the distance and persistence phase, Aaron required a significant amount physical prompting during all the sessions. He did not have any independent responses until the eleventh session of phase two (session 32). Sarah Sarah completed five baseline and 26 instructional sessions. She only completed 26 instructional sessions because absences prevented her from completing 30 sessions before the end of the school year. Sarah did not meet the criterion of 80% independence across two consecutive sessions for the first phase of instruction, symbol exchange; however she did show an increase in independent responses. Figure 1 presents a change in slope and level of Sarah s data between baseline and instruction. Although there was no change in the accuracy of Sarah s performance between sessions 6 through 14, her prompting data revealed that she required progressively less intrusive prompts. Sarah required a significant amount of HOH prompting in the beginning of instruction, but as intervention progressed this decreased and she had more independent responses.

8 Fig. 1 Proportion of participants independent responses during baseline and intervention 100% 90% 80% Brent Inde p end e n t R espons es 70% 60% 50% 40% 30% 20% 10% Baseline Symbol Exchange Distance & Persistence Discrimination 0% Session 100% Aaron 90% 80% I n dep e nden t R espons es 70% 60% 50% 40% 30% 20% 10% 0% Session Sarah 100% 90% 80% In dep enden t Re spons e s 70% 60% 50% 40% 30% 20% 10% 0% Baseline Intervention Session

9 Discussion Several studies have demonstrated the effectiveness of using PECS with children who have autism or developmental disabilities (e.g., Bondy and Frost 1994; Charlop-Christy et al. 2002; Ganz and Simpson 2004;Schwartzetal.1998) as well as the effectiveness of using tactile symbols with individuals who have visual impairments (e.g., Murray-Branch et al. 1991; Rowland and Schweigert 1989; Turnell and Carter 1994). The present study has provided some initial evidence that using tactile symbols with instructional strategies based on PECS may be an effective method of teaching individuals who are blind and have autism to make requests. Although only one participant completed all phases of the intervention, all of the participants demonstrated progress in the intervention program. The overall goal in any intervention is to have the participant be as independent as possible. All of the participants in the present study increased their independent responses from baseline. Even though the participants in this study were limited by the number of 30 intervention sessions, their rate of progress was similar to some reports of sighted children using PECS (Kravits et al. 2002; Schwartz et al. 1998) and individuals with visual impairments learning to use tactile symbols (Murray-Branch et al. 1991; Turnell and Carter 1994). In the present study, one participant (Brent) completed all three phases of intervention in less than 1 month; requiring 11 sessions to complete phase one, five sessions to complete phase two, and two sessions for phase three. The other participants did not complete all of the phases of the instructional program, nor progress as quickly as Brent; however, Aaron completed phase one in 17 sessions conducted over three and a half weeks and Sarah s performance was showing improvement at the completion of 27 sessions. The participant s rate of learning was comparable to the sighted children in previous studies of PECS (Kravits et al. 2002; Schwartz et al. 1998). On average, the sighted participants in the Schwartz et al. (1998) study learned to exchange a symbol within 2 months from the start of intervention. It took another 2 months for the students to master the distance and persistence phase. The participant in the case study reported by Kravits et al. (2002), took 17 sessions to master the symbol exchange phase. In studies teaching tactile symbol use, participants required anywhere from 29 sessions (Turnell and Carter 1994) to 6 months (Murray-Branch et al. 1991) to master the use of one symbol. Previous reports show great variation in rates of learning and the current study s participants rates of learning fall within this range. It is likely that the participants cognitive and language levels impacted their rates of learning. Brent had the highest cognitive and language levels and progressed more quickly than Aaron and Sarah. In addition, Sarah who had the lowest cognitive and language levels demonstrated the slowest progress. Other studies have also shown that individuals with more severe cognitive impairments have slower rates of learning for both tactile symbols (Murray-Branch et al. 1991) and PECS (Stoner et al. 2006). Of the two participants in the Murray-Branch et al. (1991) study, the individual with more significant cognitive impairment took substantially longer to master use of one symbol than the other participant (6 months vs. 2 months). By the time the study was reported, she had continued to make progress and had mastered the use of three symbols. Both Aaron and Sarah were making progress at the endofthecurrentstudy;itislikelythattheywouldhave continued to show improvement with additional intervention sessions, had the study continued. Modifications to PECS This study departed from PECS procedures in a number of ways. The reasons for making these modifications and their potential impact on the participants progress are presented below. PECS procedures encourage the use of multiple communication partners with teaching opportunities spread throughout the day. According to the PECS training manual, the learner should have at least 30 trials/opportunities spread throughout the day during phases one and two (Frost and Bondy 2002). The current study used one instructional team in one context for teaching. This study was a preliminary investigation in the area of tactile symbols and PECS; therefore, it was important to closely control the instruction by having a consistent instructional team. However, having only two individuals conduct the instruction restricted the number of intervention sessions that could be held each day. In addition, this study was a preliminary investigation of these procedures and the participants school team wanted evidence of their effectiveness before implementing them on a larger scale. The restricted opportunities and contexts likely impeded the participants progress in the current study. Additional opportunities to practice making requests may have allowed them to progress more quickly through the intervention program. According to standard procedure, multiple symbols are introduced in phase one before moving to phase two (Frost and Bondy 2002). The current study only introduced one symbol in phase one. This was done because the researchers wanted the participants to have the opportunity to progress to phase two during the time constraints of the study. The ability to seek out a communication partner was something that none of the participants did at the initiation of the study; this component was one of the defining reasons we selected the PECS protocol for the basis of this study. Also, due to the multiple baseline design, it was important to follow the participant s use of one symbol through all of the phases. In order for tactile symbols to be

10 a functional method of communication for the participants, they will need to be able to use a variety of symbols. Additional symbols could have been introduced subsequently as replications of the research design, however were beyond the scope of this preliminary study. One of the key features of PECS relies on the learner initiating communication by seeing the desired object and reaching for it; then the instructor physically prompting the learner to exchange the symbol. When working with students with visual impairments, the PECS manual suggests noisily presenting the item or letting the individual interact with the item before taking it away (Frost and Bondy 2002, p.60). Some of the items/activities used as reinforcers in the current study did not make sufficient noise that the participants could identify their presence by sound alone (e.g., pillow). Additionally, the researchers felt that indicating the presence of the item by allowing the participant to interact with it and then taking it away would have been confusing given the participants complete blindness. Therefore, the communication partner used the auditory cue, Hi, it s choice time to indicate her presence and location to the participant. This cue was designed to let the participant know that (a) a communication partner was present, and (b) it was time where they could make choices about leisure activities. The use of this auditory cue could have resulted in the participants becoming dependent upon that cue; something that was not addressed in this study. Future research should examine excluding the cue or systematically fading it. The largest digression from PECS procedures occurred in the prompting hierarchy. Two of the three participants had previously been introduced to tactile symbols using a most to least prompting scheme. At that time, due to their limited responses, the prompts were not faded and resulted in prompt dependency. Therefore, a modified least to most hierarchy was used in this study. Although standard PECS procedures eschew the use of verbal prompts, the authors felt they were needed due to the participants blindness. For example, during phase one in standard PECS, the communication partner cues the learner to release the symbol by opening her palm. Such a physical gesture would be meaningless to the participants in this study, therefore the verbal cue, give it to me was used. However, this cue was only used if the participant had already picked up the symbol independently and did not release the symbol into the communication partner s hand. Traditional PECS avoids verbal prompts because of their intrusiveness and the likelihood that they can breed dependency. In the present study, it did not appear that the participants became dependent upon the verbal prompts. When prompting was required it was most likely HOH or physical prompts; overall, verbal prompts were used infrequently. In addition, all of the participants progressed to independent responses beyond the use of verbal prompts. Limitations and Directions for Future Research One limitation of this study was that there was limited replication of the treatment effect. Even though there are a very limited number of individuals that fit the criteria for inclusion in the study, the outcomes of the study would have been stronger if the intervention had been replicated across contexts or additional symbols. As discussed earlier, the limited instructional opportunities may have impeded the participants progress. Therefore future research investigating the use of PECS with tactile symbols should allow for multiple teaching opportunities and be conducted over an extended time period to allow the participants opportunity to make maximal progress. Another possible direction for further research would be to combine tactile symbols with a voice output communication aid (VOCA) that would speak the request and provide auditory feedback to the participant. Locke and Mirenda (1988) introduced a VOCA with tactile symbols to a boy with severe physical, speech, and visual impairments. They reported that it appeared he was aware of the speech output and that it may have served an important feedback function in his learning. Incorporating both auditory and tactile modalities in the present study might have clarified the communicative exchange for the participants and thus facilitated their learning. Conclusion The results of the current study provided preliminary evidence supporting the use of tactile symbols with instructional strategies adapted from PECS to teach children who were blind and had autism to make requests. This study demonstrated the effectiveness of combining these two components into a successful instructional format which could be utilized by other researchers, teachers, therapists, and professionals when teaching children with multiple disabilities. The act of communication is one of the most powerful abilities one can have; therefore, it is imperative that further research be conducted in this area to discover methods children with visual impairments and multiple disabilities can utilize in order to communicate efficiently and effectively. Acknowledgements Portions of this article were submitted by J. M. Troha in partial fulfillment of the requirements for the Masters of Science degree, Department of Communication Sciences and Disorders at the University of Wisconsin-Milwaukee. A preliminary version of this paper was presented at the Annual Convention of the American Speech-Language Hearing Association, San Diego, CA in November 2005.

11 Appendix Procedures Baseline Intervention Symbol exchange Distance and persistence Discrimination Stimuli Location of communication partner Procedure Length of phase Target symbol and distracter L/R placement randomized each trial Target symbol placed in center of Plexiglas choice board Target symbol placed in center of Plexiglas choice board Target symbol and distracter L/R placement randomized each trial 2 arm-lengths away 1 arm-length away 2 arm-lengths away 2 arm-lengths away Place P s hand on symbols. If P Independently picks up hands target symbol to CP, record I ; otherwise record NR P1 3 sessions; P2 4 sessions; P3 5 sessions Place P s hand on symbols, if no response within 5 s implement prompting scheme. Record most intrusive prompt required for P to hand symbol to CP 4/5 I trials for 2 consecutive sessions Place P s hand on symbols, if no response within 5 s implement prompting scheme. Record most intrusive prompt required for P to hand symbol to CP 4/5 I trials for 2 consecutive sessions Place P s hand on symbols, if no response within 5 s implement prompting scheme. Record most intrusive prompt required for P to hand symbol to CP 4/5 I trials for 2 consecutive sessions Note: P = Participant, CP = Communication partner; HOH = hand-over-hand; I = Independent References Bondy, A. S., & Frost, L. A. (1994). The picture exchange communication system. Focus on Autistic Behavior, 9, Bondy, A. S., & Frost, L. A. (2001). The picture exchange communication system. Behavior Modification, 25, Brown, D., Simmons, V., & Methuin, J. (1991). The oregon project for visually impaired and blind preschool children: A skills inventory (5th ed.). Medford, OR: Jackson Education Service District. Carr, D., & Felce, J. (2007). The effects of PECS teaching to phase III on the communicative interactions between children with autism and their teachers. Journal of Autism and Developmental Disorders, 37, CDC. (2007). Prevalence of Autism Spectrum Disorders Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, Centers for Disease Control and Prevention. Charlop-Christy, M. H., Carpenter, M., Le, L., LeBlanc, L. A., & Kellet, K. (2002). Using the picture exchange communication system (PECS) with children with autism: Assessment of PECS acquistion, speech, social-communicative behavior and problem behavior. Journal of Applied Behavior Analysis, 354, Frea, W. D., Arnold, C. L., & Vittimberga, G. L. (2001). A demonstration of the effects of augmentative communication on the extreme aggressive behavior of a child with autism within an integrated preschool setting. Journal of Positive Behavior Interventions, 3, Frost, L., & Bondy, A. S. (2002). The picture exchange communication system training manual. Newark, DE: Pyramid Educational Products. Ganz, J. B., Cook, K. E., Corbin-Newsome, J., Bourgeois, B., & Flores, M. (2005). Variations on the use of a pictorial alternative communication system with a child with autism and developmental delays [Electronic Version]. Teaching Exceptional Children Plus, 1, Article 3. Retrieved June 2, 2007 from Ganz, J. B., & Simpson, R. L. (2004). Effects on communicative requesting and speech development of the picture exchange communication system in children with characteristics of autism. Journal of Autism and Developmental Disorders, 34, Howlin, P., Gordon, R. K., Pasco, G., Wade, A., & Charman, T. (2007). The effectiveness of picture exchange communication system (PECS) training for teachers of children with autism: A pragmatic, group randomised controlled trial. Journal of Child Psychology and Psychiatry, 48, Kravits, T. R., Kamps, D. M., Kemmerer, K., & Potucek, J. (2002). Increasing communication skills for an elementary-aged student with autism using the picture exchange communication system. Journal of Autism and Developmental Disorders, 32, Lloyd, L. L., Fuller, D. R., & Arvidson, H. H. (1997). Augmentative and alternative communication: A handbook of principles and practices. Needham Heights, MA: Allyn and Bacon. Locke, P. A., & Mirenda, P. (1988). A computer-supported communication approach for a child with severe communication, visual, and cognitive impairments: A case study. Augmentative and Alternative Communication, 4, Louis, R. (1990). The Rossetti infant-toddler language scale. East Moline, IL: LinguiSystems. Mathy-Laikko, P., Iacono, T., Ratcliff, A., Villarruel, F., Yoder, D. E., & Vanderheiden, G. (1989). Teaching a child with multiple disabilities to use a tactile augmentative communication device. Augmentative and Alternative Communication, 5, McReynolds, L. V., & Kearns, K. P. (1983). Single-subject experimental designs in communicative disorders. Baltimore: University Park Press. Mukaddes, N. M., Kilincaslan, A., Kucucyazici, G., Sevketoglu, T., & Tuncer, S. (2007). Autism in visually impaired indiviudals. Psychiatry and Clinical Neurosciences, 61,

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