Program. Autism Spectrum Disorders (ASD) Wendt: Strategies in AAC IN-ABC 2013

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1 Evidence-based Strategies in Augmentative and Alternative Communication (AAC) Oliver Wendt, Ph.D. Department of Speech, Language, and Hearing Sciences Purdue University Indiana Association of Behavioral Consultants (IN-ABC) Annual Conference 2013 Program Prominent AAC Strategies for ASD & Developmental Disabilities Manual Signs and Gestures Picture Exchange Communication System (PECS) Speech-Generating Devices (SGDs) Moving from PECS to SGDs and ipads Case Examples and Demonstration Discussion Autism Spectrum Disorders (ASD) Triad of symptoms with 1. Impairments in language and communication Deficits in language can range from completely nonverbal to acquiring the ability to speak. 2. Impairments in social interaction Results in lack of motivation to communicate with other people even when these individuals have acquired some language competence and use. 3. Restricted and repetitive patterns of behavior Pre-occupation with restricted patterns of interest can impede social and communicative development.

2 Proportion of Nonverbal Children with ASD Autism includes a delay in, or lack of the development of spoken language (American Psychiatric Association, 2000) 14-25% of children diagnosed with an autism spectrum disorder (ASD) present with little or no functional speech (Lord & Bailey, 2002; Lord, Risi, & Pickles, 2004) Autistic disorder only: 50% of children are functionally non-verbal No sufficient natural speech or writing to meet their daily communication needs (Light, Roberts, DiMarco, & Greiner, 1998) Candidates for intervention in augmentative and alternative communication Other Developmental Disabilities (DD) Intellectual Disability: umbrella term for large range of syndromes and conditions that result in cognitive impairment Commonly experience significant difficulty with spoken communication Many do not use speech as primary mode of communication High incidence of problem behavior Cerebral Palsy Unique motor control issues Up to two thirds also experience intellectual disability Proportion of Nonverbal Children with DD Prevalence of Intellectual Disability is between 1-3% worldwide (WHO, 2001) ID may be largest proportion of school-age individuals that require AAC supports Up to 38% of preschool-age children with ID have AAC needs (Beukelman & Mirenda, 2013) AAC is crucial part of service delivery to this population (National Joint Committee for the Communication Needs of Persons with Severe Disabilities, 2003)

3 AAC and Autism AAC strategies particularly used in ASDs/DDs: Manual signs and gestures Pictographic symbols sets/systems High technology speech generating devices (SGDs) for synthesized and/or digitized speech output Practitioners face difficult task selecting a suitable approach Evidence-based practice (EBP): Using research outcomes as a major basis for clinical and educational decisions (Lloyd, 2001) Evidence-based Strategies in AAC MANUAL SIGNS AND GESTURES Manual Signs Manual signs: unaided form of communication; unaided communication does not rely on any aids or devices external to the body and uses only body parts (Lloyd et al., 1997). One of the first forms of AAC applied to non-speaking individuals with ASD; introduced in the 1970s and used successfully for more than 30 years Can refer to a natural sign language (e.g., American Sign Language) or to production of manual signs as a code for a spoken language By the mid-1980s, manual signing was often used in combination with speech, this approach was labeled as total or simultaneous communication (SC)

4 Manual Signs (cont.) Gestures Manual Signs Why Choose Manual Signs? Easy to imitate (Sundberg, 1990) Individuals with ASD may have difficulty controlling vocal folds but display strengths with imitating actions Signs are less transient than words (Fulwiler & Fouts, 1976) Less frustrating to learn than vocal speech May overcome negative history associated with speech (Sundberg & Partington, 1998) Manual Signs: Empirical Evidence Expressive signing 5 studies including 22 participants concentrated on teaching manual signs and monitoring sign production as an outcome variable Across experiments teaching manual signs highly effective Simultaneous communication (SC): Barrera, Lobato-Barrera, and Sulzer-Azaroff (1980) taught one participant expressive language skills using three different instructional methods: Simultaneous communication superior to sign alone and oral training

5 Manual Signs: Empirical Evidence (cont.) Expressive signing, simultaneous communication: Remington and Clarke (1983) compared simultaneous communication versus sign alone training in two participants: no difference Saraydarian (1994), group study: 10 participants exposed to training program that taught object referents in the form of simultaneous communication, sign alone instruction and oral instruction sign alone condition superior, effect size g = 0.36 indicating moderate effect Manual Signs: Empirical Evidence (cont.) Receptive speech: Brady and Smouse (1978) compared effects of SC (Effect Size = 100 %) vs. sign alone (ES = 50 %) training on receptive speech in one participant. Carr and Dores (1981) provided SC training to three participants and measured their correct responses on a receptive language discrimination task: Effect sizes were 100 % for each one. Manual Signs: Empirical Evidence Summary Summary: Both groups of experiments, expressive speech and receptive speech, yield high outcome scores Evidence suggests it is a viable communication option Possible explanations for effectiveness: Better choice than vocalization because it is easier to prompt an action than a vocalization (Sundberg, 1990) Involves more iconic representation than spoken language (Sundberg) Motor imitation is an easier behavior to teach because the teacher can make use of physical prompting and fading procedures (Sundberg & Partington, 1998)

6 Manual Signs Limitations More and more research studies are revealing motor control problems in ASD Clumsiness Poor muscle tone Difficulty with fine and gross motor skills Seen in about 80% of children with autism, but not part of diagnostic criteria (Hilton et al., 2012; Isenhower et al., 2012) Children with ASD often acquire only limited sign vocabulary and signs tend to be poorly articulated Burden on communication partners: social environment may not be fluent in sign language Manual Signs Limitations (cont.) Intelligibility: Rotholz et al. (1989): two adolescents with autism were taught to order fast food interacting with staff unfamiliar to them 0-25% of manual sign requests were understood % of graphic symbol requests were understood Manual Signs Conclusions Future research implications: Lack of studies comparing manual signing or gestures against an aided mode of communication such as graphic symbols More comparative efficacy studies are needed to clarify if learners with autism actually do better and/or have a preference for one communication modality over another How to use manual signs as part of a multi-modal communication system consisting also of graphic symbols, communication boards, SGDs, and vocalizations (when available) need research into effective strategies for teaching the conditional use of manual signs

7 Gestures Gestures: body movements or sequences of coordinated body movements to represent an object, idea, action, or relationship without the linguistic features of manual signs Examples: pointing or yes-no headshakes One of the earliest developing non-linguistic forms of unaided communication (Loncke & Bos, 1997) Individuals with autism, however, rarely use gestures as an alternative communication strategy, even if they have difficulty speaking (Loveland, Landry, Hughes, Hall, & McEvoy, 1988) Why Choose Gestures? Use of gestures serves as a precursor to later development of language skills (Morford & Goldin- Meadow, 1992) Gestural behavior also important for establishment and maintenance of social interaction and social reciprocity (Garfin & Lord, 1986; Koegel & Frea, 1993) Appropriate for early AAC intervention to facilitate symbolic development Motor demands not as much of an issue as with manual signs Gestures: Empirical Evidence Two studies focused on teaching gestural communication skills Buffington, Krantz, McClannahan, and Poulson (1998) taught gestures in combination with oral speech, measured frequency of correctly produced gestural and verbal responses: PND scores of highly effective for all four participants Carr and Kemp (1989) provided training in communicative pointing (e.g., to obtain toy), observed frequency pointing occurred: again PND scores of highly effective for all four participants

8 Gestures: Empirical Evidence Summary Summary: Appears to be very effective communication option but limited amount of studies at this time Compared to manual signs it seems that gestures are underrepresented and not well researched in this population Surprising, because of its correlation with vocal use and preceding speech development More research needed to build up the empirical support for gestural communication Also need more comparative efficacy studies Evidence-based Strategies in AAC EXCHANGE-BASED GRAPHIC SYMBOL SETS Picture Exchange Communication System (PECS) Structured behavioral intervention program to teach use of visual-graphic symbols for communication (Bondy & Frost, 1994) Teaches to make requests by handing/ exchanging symbols for desired items

9 Picture Exchange Communication System (PECS) Picture Exchange Communication System (PECS) protocol (Bondy & Frost,1994) Phase I: Physical Exchange Phase II: Expanding Spontaneity Phase III: Picture Discrimination Phase IV: Sentence Structure Phase V: Responding to What do you want? Phase VI: Responsive and Spontaneous Commenting Why Choose PECS? Requires very few prerequisites Only prerequisite individual can clearly indicate wants and needs First skill taught in PECS is requesting Often targeted in early instruction of individuals with developmental disabilities due to motivational considerations (Reichle & Sigafoos, 1991) Systematically targets spontaneous communication acts, a particular deficit in autism PECS graphic symbols are highly iconic Can be easily recognized by the learner and are more recognizable by communicative partners PECS: Empirical Evidence Systematic reviews (particularly meta-analyses) are preferred evidence to document empirical support: Preston and Carter (2009) Increase in communication skills in most learners, effects on problem behavior reduction and increasing natural speech less clear Hart and Banda (2010) Increases in functional communication skills in all but 1 subject Flippin, Reszka, and Watson (2010) Promising but not yet established evidence-based intervention for facilitating communication in children with ASD ages 1 11 years

10 PECS Summary Considerable empirical support for using PECS as a beginning communication strategy Overall shows strong effectiveness for teaching initial requesting skills Some evidence to indicate: more effective than manual signing in terms of requesting Effect is less clear for other outcome variables such as speech production, social or challenging behavior When treatment goals is speech production no sufficient evidence to inform practice in favor of PECS or manual signing In general, mixed results on this outcome measure PECS Summary (cont.) Methodological issues in PECS studies Often lack investigation of maintenance Skill generalization sometimes reported, but what counts as generalization varies greatly Participant descriptions lack detail Sparse reports of treatment integrity PECS appears as a promising intervention that presents with emerging empirical support, but critical questions are still to be answered Evidence-based Strategies in AAC SPEECH-GENERATING DEVICES

11 Speech-Generating Devices (SGDs) Portable, computerized devices producing synthetic or digitized speech output when activated Graphic symbols are used to represent messages, activated by finger, switch, head stick, etc., selecting a symbol from the display LightWRITER BIGMack SGDs (cont.) SGDs (cont.) Fixed Display Graphic symbols located in separate squares of a grid, organized into rows and columns Limited vocabulary Dynamic Display Selection from a display results in a new array of graphic symbols Larger vocabulary sets

12 SGDs (cont.) Visual Scene Displays Language concepts are embedded into contextual scenes Objects and events within the photograph are then used as symbols for communication May be used in a dynamic display system Not ideal for learners with severe autism due to sensory processing difficulties SGDs (cont.) Example of a child with ASD using an SGD: IXE_k&NR=1 Example of synthetic speech output: p#top Why Choose SGDs? Allows composing more detailed messages Enable user to communicate very precise requests and prevent communication breakdown Voice output (aka speech output) may facilitate acquisition and maintenance of communication skills Producing speech can be perceived as more natural Better intelligibility Easier to get attention Higher likelihood of receiving a listener response

13 Why Choose SGDs? (cont.) ipads and other tablet devices are Lightweight and portable Cost-efficient compared to dedicated SGDs Easy to program Highly motivating to use Socially appealing (peer acceptance) SGDs: Empirical Evidence Ganz, J. B., Earles-Vollrath, T. L., Heath, A. K., Parker, R. I., Rispoli, M. J., & Duran, J. B. (2012). A meta-analysis of single case research studies on aided augmentative and alternative communication systems with individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, Van der Meer, L. A. J., & Rispoli, M. (2010). Communication interventions involving speechgenerating devices for children with autism: A review of the literature. Developmental Neurorehabilitation, 13, SGDs: Empirical Evidence Van der Meer, & Rispoli (2010), systematic review: Found 23 studies with a total of 51 children aged 3-16 years Positive outcomes reported for 86% of studies, most commonly targeting requesting skills Potentially effective option for teaching communication skills in ASD Ganz et al. (2012), meta-analysis: Included 8 studies on SGDs, 9 studies on PECS, 7 other graphic symbols Effect size estimates were 99% each for SGDs and PECS, 61% for others SGD or PECS use yields significantly higher effects

14 SGDs: Empirical Evidence (cont.) Schlosser et al. (2009): SGDs represent a viable and effective AAC option for individuals with ASD Empirical evidence speaks a clear message, effectiveness of SGDs no longer a question Wendt and Golinker (2012): SGDs are one part of the standard of care to improve the functional communication and other outcomes for clients with ASD Important when applying for SGD funding from insurance agencies! Evidence-based Strategies in AAC MOVING FROM PECS TO SPEECH-GENERATING DEVICES Research Questions Practitioners/parents: after successful mastery of (initial) PECS phases, can the child move on to a SGD? (Grether, 2007) research into innovations to the PECS protocol is a laudable direction and should be continued using rigorous methodologies (Schlosser & Wendt, 2008) Project goals: - Modify traditional PECS protocol for implementation and transition to an SGD - Evaluate the effects of such a modified PECS protocol on increasing requesting skills, social-communicative behaviors, and emerging speech - Evaluate effectiveness of a particular device for such purpose that is built upon PECS principles

15 Experimental Design Multiple Baseline Design across participants (Baer, Wolf, & Risley, 1968) Intervention phase split into PECS phases and SGD phases, followed by maintenance phase 3 children, 9-11 yrs., severe autism and non-verbal Dependent measures: Requesting skills: number of correct requests during 20-trials session Social-communicative behavior: number of responses including eye contact, physical orientation towards comm. partner, positive affect via smiling/laughter Emerging speech: word vocalizations or word approx. Materials and Setting Traditional PECS book with PCS symbols for desired items Proxtalker - sentence strip that actually speaks : picture card is put on ProxTalker display speak out the symbol referent in form of prerecorded digitized speech - several picture cards can be combined to speak sentences - symbols used were identical to PECS symbols Departmental Speech Clinic, 3 sessions per week Modified PECS Protocol (Preference Assessment) Phase I: Physical Exchange Phase II: Expanding Spontaneity SGD Implementation Phase III: Picture Discrimination Phase IV: Sentence Structure Phase V: Responding to What do you want? Phase VI: Responsive and Spontaneous Commenting (Original PECS protocol by Bondy & Frost, 1994)

16 Baseline Video Clip PECS Phase I Video Clip End PECS Phase II Video Clip End

17 ProxTalker Phase II Video Clip Beginning ProxTalker Phase V End SPEAK all! The purpose is to help teach the process of constructing sentences Customizable to each child s specific needs Allows the instructor to use recorded audio and custom images Seamlessly connects with PECS or ProxTalker intervention Selection Area on top replaces PECS book Sentence Strip at bottom speaks selected graphic symbols Shuffle button" randomly regroups graphic symbols DOWNLOADABLE ON ITUNES (free app) Appstore>Education>Purdue>SPEAKall!

18 Autism Apps can be Noisy Places for Those Who Cannot Process It ipad Phase End Moving from Mid-Technology (ProxTalker) to High- Technology (ipad) Effects on Requesting Skills

19 Effects on Social- Communicative Behavior Effects on Emerging Speech QEEG Brainmap of Neurotypical Individuals

20 Participant on 6/18/11 Participant post-intervention 12/9/11 Further Research on SPEAK all! Multiple Baseline Design across settings (Baer, Wolf, & Risley, 1968) Intervention repeated across clinic, home, and school environments following PECS instructional phases ipad with SPEAK all! replaces ProxTalker, intervention starts immediately with ipad Dependent measures: Requesting skills: number of correct requests during 20-trials session Emerging speech: word vocalizations or word approx. ipad and SPEAK all! Participant 3 - Baseline

21 ipad and SPEAK all! Participant 3 Middle Stages ipad and SPEAK all! Participant 3 End Participant 3 Requesting Clinic 1 attr. 2 attr. ipad gone speech only ipad fade out School 2 attr. 1 attr. speech only ipad gone ipad fade out 1 attr. speech only ipad gone 2 attr. ipad fade out Home Baseline Ph 3 Ph 4 Ph 5 Maintenance

22 Participant 3 - Speech Clinic 2 attr. speech only ipad fade out ipad gone 2 attr. ipad fade out 1 attr. ipad gone speech only School 2 attr. 1 attr. ipad gone speech only ipad fade out Home Baseline Ph 3 Ph 4 Ph 5 Maintenance ipad and SPEAK all! Participant 2 - Beginning ipad and SPEAK all! Participant 2 End

23 Participant 2 - Requesting 1 attr. School 1 attr. 1 attr. Baseline Ph 3 Ph 4 Ph 5 Maintenance Participant 2 Speech Home 1 attr. 1 attr. School 1 attr. Clinic Baseline Ph 3 Ph 4 Ph 5 Maintenance SPEAK all! Parent Training Young Girl - Baseline

24 SPEAK all! Parent Training Young Girl - Intervention SPEAK all! Parent Training Young Girl - Intervention SPEAK all! Parent Training Young Girl Maintenance & Generalization

25 Conclusions Findings provide support that AAC can have facilitative effect on natural speech development There may be a particular role for shaping echolalic utterances Refute myth that AAC prevents speech Confirm augmented input may enhance expressive and receptive communication development Confirm PECS principles (behavioral) hold true regardless of modality Conclusions (cont.) All participants mastered ipad intervention, but varied in ability to complete later protocol phases; effects are replicable across settings Gains in speech production most notable for echolalic child able to request in spoken sentences after fading out ipad Other participants varied in effects on natural speech production Pre-treatment speech skills and degree of cognitive impairment likely moderator variables Conclusions (cont.) Results underscore the potential of including parents for maximizing benefits of AAC intervention in autism Clinicians should recognize the value of joint parent-professional partnerships, and develop expertise for parent training

26 Acknowledgements Aforementioned projects were supported by Project Development Team within the ICTSI NIH/NCRR Grant Number RR Technology Development Grant from the Innovation and Commercialization Center Information Technology Research Fellowship from Purdue Center for Families Purdue Research Foundation International Travel Grant Acknowledgements (cont.) Thanks to ProxTalker.com, LLC for providing devices! Thanks to Purdue EPICS Team! Thanks to the families who agreed to participate in our research! Acknowledgements (cont.) Thanks to the following individuals for their help with data collection and reliability analyses: Colleen Coleman Zhihua Dong Casey Hobbs Kim LeCleir Minghua Tan

27 Further Information on SPEAK all! / SPEAK now! Apps Download on itunes (free app) Appstore>Education>Purdue>SPEAKall! Instructional Videos: Support Site: Contact Oliver Wendt, Ph.D. Department of Speech, Language, and Hearing Sciences HEAV 202D, Purdue University West Lafayette, IN , USA olli@purdue.edu Web: Questions???

28 References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.: text revision). Washington, DC. American Speech-Language-Hearing Association. (2005). Roles and responsibilities of speech-language pathologists with respect to augmentative and alternative communication: Position statement. ASHA Supplement, 25, 1-2. Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, Bates, E., Camaioni, L., & Volterra, V. (1975). The acquisition of performatives prior to speech. Merrill-Palmer Quarterly, 21, Beukelman, D. R., & Mirenda, P. (2005). Augmentative and alternative communication: Supporting children and adults with complex communication needs (3 rd ed.). Baltimore: Brookes. Bondy, A. S., & Frost, L. A. (1994). The picture exchange communication system. Focus on Autistic Behavior, 9, Carpenter, R., Mastergeorge, A., & Coggins, T. (1983). The acquisition of communicative intentions in infants eight to fifteen months of age. Language and Speech, 26, References (cont.) Drager, K. D. R., et al. (2006). The effect of aided language modeling on symbol comprehension and production in 2 preschoolers with autism. American Journal of Speech-Language Pathology, 15, Flippin, M., Reszka, S., & Watson, L. R. (2010). Effectiveness of the Picture Exchange Communication System (PECS) on Communication and Speech for Children with Autism Spectrum Disorders: A Meta-Analysis. American Journal of Speech-Language Pathology, 19, Fuller, D. R., Lloyd, L. L., & Stratton, M. M. (1997). Aided AAC symbols. In L. L. Lloyd, D. R. Fuller, & H. H. Arvidson (Eds.), Augmentative and Alternative Communication: A Handbook of Principles and Practices (pp ). Needham Heights, MA: Allyn and Bacon. Goossens, C., Crain, S., & Elder, P. (1992). Engineering the preschool environment for interactive, symbolic communication. Birmingham, AL: Southeast Augmentative Communication Conference Publications. Grether, S. (2007, November). Moving children with autism from PECS to a SGD. Paper presented at the Annual Convention of the American Speech- Language-Hearing Association, Boston, MA. Guyatt, G., & Rennie, D. (2002). Users guides to the medical literature. Essentials of evidence-based clinical practice. Chicago, IL: AMA Press. References (cont.) Hart, S. L., & Banda, D. R. (2009). Picture Exchange Communication System with individuals with developmental disabilities: A meta-analysis of single subject studies. Remedial and Special Education, 31, Light, J. C., Roberts, B., DiMarco, R., & Greiner, N. (1998). Augmentative and alternative communication to support receptive and expressive communication for people with autism. Journal of Communication Disorders, 31, Lloyd, L. L. (2001, March). Evidence based practice. Why and what with an emphasis on research issues. Paper presented at the Early Childhood Intervention Research Seminar, University of Pretoria, South Africa. Lloyd, L. L., Fuller, D. R., & Arvidson, H. H. (Eds.) (1997). Augmentative and alternative communication: A handbook of principles and practices. Needham Heights, MA: Allyn & Bacon. Loncke, F., & Bos, H. (1997). Unaided AAC symbols. In L. L. Lloyd, D. R. Fuller, & H. H. Arvidson (Eds.), Augmentative and Alternative Communication: A Handbook of Principles and Practices (pp ). Needham Heights, MA: Allyn and Bacon. Lord, C., & Bailey, A. (2002). Autism spectrum disorders. In M. Rutter & E. Taylor (Eds.), Child and adolescent psychiatry (4th ed., pp ). Oxford, UK: Blackwell.

29 References (cont.) Lord, C., Risi, S., & Pickles, A. (2004). Trajectory of Language Development in Autistic Spectrum Disorders. In M. L. Rice & S. F. Warren (Eds.), Developmental Language Disorders: From Phenotypes to Etiologies (pp. 7-29). Mahwah, NJ: Erlbaum. Loveland, K. A., Landry, S. H., Hughes, S. O., Hall, S. K., & McEvoy R. E. (1988). Speech acts and the pragmatic deficits of autism. Journal of Speech and Hearing Research, 31, Morford, M., & Goldin-Meadow, S. (1992). Comprehension and production of gesture in combination with speech in one-word speakers. Journal of Child Language, 19(3), Petticrew, M., & Roberts, H. (2006). Systematic Reviews in the Social Sciences: A Practical Guide. Malden, MA: Blackwell Publishing. Prelock, P. A. (2006). Autism Spectrum Disorders: Issues in Assessment and Intervention. Austin, TX: Pro-Ed. Lord, C., & Bailey, A. (2002). Autism spectrum disorders. In M. Rutter & E. Taylor (Eds.), Child and adolescent psychiatry (4th ed., pp ). Oxford, UK: Blackwell. Lord, C., Risi, S., & Pickles, A. (2004). Trajectory of Language Development in Autistic Spectrum Disorders. In M. L. Rice & S. F. Warren (Eds.), Developmental Language Disorders: From Phenotypes to Etiologies (pp. 7-29). Mahwah, NJ: Erlbaum. References (cont.) Preston, D., & Carter, M. (2009). A review of the efficacy of the Picture Exchange Communication System intervention. Journal of Autism and Developmental Disorders, 39, Romski, M., & Sevcik, R. A. (1993). Language comprehension: Considerations for Augmentative and Alternative Communication. Augmentative and Alternative Communication, 9, Romski, M., & Sevcik, R. A. (1996). Breaking the speech barrier: Language development through augmented means. Baltimore: Brookes. Saraydarian, K. A. (1994). Simultaneous referent recognition-production training for nonverbal children with autism. Unpublished doctoral dissertation, Columbia University Teachers College, New York, New York. Schlosser, R. W., & Wendt, O. (2008). Augmentative and alternative communication intervention for children with autism: A systematic review. In J. K. Luiselli, D. C. Russo, & W. P. Christian (Eds.), Effective Practices for Children with Autism: Educational and Behavior Support Interventions that Work (pp ). Oxford, UK: Oxford University Press. References (cont.) Schlosser, R. W., Wendt, O., Sigafoos, J. (2007). Not all systematic reviews are created equal. Evidence-based Communication Assessment and Intervention, 1(3), Schuler, A. L., & Baldwin, M. (1981). Nonspeech communication and childhood autism. Language, Speech, and Hearing Services in Schools, 12, Scruggs, T. E., Mastropieri, M. A., & Casto, G. (1987). The quantitative synthesis of single subject research methodology: Methodology and validation. Remedial and Special Education, 8, Scruggs, T. E., Mastropieri, M. A., Cook, S. B., & Escobar, C. (1986). Early intervention for children with conduct disorders: A quantitative synthesis of single-subject research. Behavioral Disorders, 11, Wetherby, A. M., & Prizant, B. M. (Eds.). Autism Spectrum Disorders: A Transactional Developmental Perspective. Baltimore, MD: Paul H. Brookes.

30 References: PECS Studies Anderson, A. E. (2001). Augmentative communication and autism: A comparison of sign language and the Picture Exchange Communication System. Unpublished doctoral dissertation, University of California, San Diego. Angermeier, K., Schlosser, R. W., Luiselli, J. K., Harrington, C., & Carter, B. (In press). Effects of iconicity on requesting with the picture exchange communication system in children with autism spectrum disorder. Research in Autism Spectrum Disorders. Carr, D., & Felce, J. (2007a). 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(4), Ganz, J. B., Simpson, R. L., Corbin-Newsome, J. (2007). The impact of the picture exchange communication system on requesting and speech development in preschoolers with autism spectrum disorders and similar characteristics. Research in Autism Spectrum Disorders. References: PECS Studies (cont.) 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 acquisition, speech, socialcommunicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35, Lund, S. K. & Troha, J. M. (2007). Teaching young people who are blind and have autism to make requests using a variation on the picture exchange communication system with tactile symbols: A preliminary investigation. Journal of Autism and Developmental Disorders. Marckel, J. M., Neef, N. A., & Ferreri, S. J. (2006). A preliminary analysis of teaching improvisation with the picture exchange communication system to children with autism. Journal of Applied Behavior Analysis, 39, Son, S. H., Sigafoos, J., O Reilly, M., & Lancioni, G. E. (2006). Comparing two types of augmentative and alternative communication for children with autism. Pediatric Rehabilitation, 9, Tincani, M. (2004). Comparing the picture exchange communication system (PECS) and sign-language training for children with autism. Focus on Autism and Other Developmental Disabilities, 19(2), References: PECS Studies (cont.) Tincani, M., Crozier, S., Alazetta, S. (2006). The picture exchange communication system: Effects on manding and speech development for school-age children with autism. Education and Training in Developmental Disabilities, 41(2), Travis, J. (2006). The effectiveness of the Picture Exchange Communication System (PECS) as an augmentative communication system for children with Autism Spectrum Disorders (ASD): A South African pilot study. Unpublished Master s thesis, University of Cape Town, Cape Town, South Africa. Yoder, P. & Stone, W. L. (2006). A randomized comparison of the effect of two prelinguistic communication interventions in the acquisition of spoken communication in preschoolers with ASD. Journal of Speech, Language, and Hearing Research, 49, Yoder, P., & Stone, W. L. (2006). Randomized comparison of two communication interventions for preschoolers with autism spectrum disorders. Journal of Consulting and Clinical Psychology, 74(3), Yokoyama, K., Naoi, N., & Yamamoto, J. (2006). Teaching verbal behavior using the picture exchange communication system (PECS) with autism spectrum disorders. Japanese Journal of Special Education, 43(6),

31 References: SGD Studies Parsons, C. L., & La Sorte, D. (1993). The effect of computers with synthesized speech and no speech on the spontaneous communication of children with autism. Australian Journal of Human Communication Disorders, 21, Schlosser, R. W., & Blischak, D. M. (2001). Is there a role for speech output in interventions for persons with autism? A review. Focus on Autism and Other Developmental Disabilities, 16, Schlosser, R. W., & Blischak, D. M. (2004). Effects of speech and print feedback on spelling by children with autism. Journal of Speech, Language, and Hearing Research, 47, Schlosser, R. W., Blischak, D. M., Belfiore, P. J., Bartley, C., & Barnett, N. (1998). Effects of synthetic speech output and orthographic feedback on spelling in a student with Autism: A preliminary study. Journal of Autism and Developmental Disorders, 28, References: SGD Studies (cont.) Schlosser, R. W., Sigafoos, J., & Koul, R. K. (2009). Speech output and speech-generating devices in autism spectrum disorders. In In P. Mirenda, T. Iacono, & J. Light (Eds.), AAC for Individuals with Autism Spectrum Disorders (pp ). Baltimore, MD: Paul H. Brookes. Schlosser, R. W., Sigafoos, J., Luiselli, J., Angermeier, K., Schooley, K., Harasymowyz, U., & Belfiore, J. (2007). Effects of synthetic speech output on requesting and natural speech production in children with autism. Research in Autism Spectrum Disorders, 1, Sigafoos, J., Didden, R., & O Reilly, M. (2003). Effects of speech output on maintenance of requesting and frequency of vocalizations in three children with developmental disabilities. Augmentative and Alternative Communication, 19, References: PECS to SGDs Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, Bondy, A., & Frost, L. (1994). The Picture Exchange Communication System. Focus on Autistic Behavior, 9, Grether, S. (2007, November). Moving children with autism from PECS to a SGD. Paper presented at the Annual Convention of the American Speech-Language-Hearing Association, Boston, MA. Pace, G.M., Ivancic, M.T., Edwards, G.L., Iwata, B.A., & Page, T.J. (1985). Assessment of stimulus preference and reinforcer value with profoundly retarded individuals. Journal of Applied Behavior Analysis, 18, Preston, D., & Carter, M. (2009). A review of the efficacy of the Picture Exchange Communication System intervention. Journal of Autism and Developmental Disorders. DOI /s y

32 References: PECS to SGDs (cont.) Reichle, J., & Sigafoos, J. (1991). Establishing an initial repertoire of requesting. In J. Reichle, J. York, & J. Sigafoos (Eds.), Implementing augmentative and alternative communication: Strategies for learners with severe disabilities (pp ). Baltimore: Paul H. Brookes. Romski, M., & Sevcik, R. A. (1993). Language comprehension: Considerations for Augmentative and Alternative Communication. Augmentative and Alternative Communication, 9, Romski, M., & Sevcik, R. A. (1996). Breaking the speech barrier: Language development through augmented means. Baltimore: Brookes. Schlosser, R.W., & Wendt, O. (2008). Augmentative and alternative communication intervention for children with autism: A systematic review. In J.K. Luiselli, D.C. Russo, & W.P. Christian (Eds.), Effective Practices for Children with Autism: Educational and Behavior Support Interventions that Work (pp ). Oxford, UK: Oxford University Press.