Evaluating Picture Exchange and the ipad as a Speech Generating Device to Teach Communication to Young Children with Autism

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1 J Dev Phys Disabil (2013) 25: DOI /s REVIEW ARTICLE Evaluating Picture Exchange and the ipad as a Speech Generating Device to Teach Communication to Young Children with Autism Elizabeth R. Lorah & Matt Tincani & Jessica Dodge & Shawn Gilroy & Anna Hickey & Donald Hantula Published online: 1 February 2013 # Springer Science+Business Media New York 2013 Abstract The purpose of the study was to compare picture exchange (PE) and an ipad based speech generating device (SGD) in teaching mands to five preschool boys diagnosed with autism. Participants preferences for each device were assessed following training. Three participants met mastery criterion for mands using the SGD more quickly, while two participants met mastery criterion for mands using PE more readily. However, the overall rate of independent manding across training and maintenance was higher for four participants using the SGD. Four participants demonstrated a clear preference for the SGD device and one for PE. Results are consistent with previous research showing that acquisition of alternative communication modalities varies across children with autism, and supports the use of assessment to determine modality preference. Keywords Autism. Mand. Picture exchange. Speech generating device. Voice output communication aid. Augmentative and alternative communication It is estimated that 25 to 61 % of persons with autism fail to develop functional speech output (Weitz et al. 1997). Augmentative and alternative communication (AAC) systems, such as picture exchange (PE) and speech generating devices (SGD) have been shown to be effective in teaching individuals with autism to acquire a communicative (e.g., mand) repertoire (Goldstein 2002; Rispoli et al. 2010; Lancioni et al. 2007; Mirenda 2003). Skinner (1957) first described the mand as a verbal operant under the control of a condition of deprivation or aversive stimulation in which the response form specifies the reinforcer. Subsequent research has shown that mand training benefits individuals with autism in terms of decreasing challenging behavior (e.g., Durand 1999) and, in some cases, increasing speech production (e.g., E. R. Lorah (*) : M. Tincani : J. Dodge : S. Gilroy : A. Hickey : D. Hantula Temple University, Philadelphia, PA, USA erlorah@temple.edu

2 638 J Dev Phys Disabil (2013) 25: Charlop-Christy et al. 2002). Therefore mand training is often incorporated into instructional sequences for children with autism (e.g., Koegel and Koegel 2006; Lovaas 1981, 2003; Maurice et al. 2001). Within the domain of AAC, two broad categories exist, aided and unaided (Mirenda 2003). Unaided AAC does not require any equipment and includes manual signs and gestures. Aided AAC includes device based systems such as the Picture Exchange Communication System (PECS) (Frost and Bondy 2002), other forms of PE (i.e., those not implementing the PECS training protocol), and SGD or speech generating devices (SGD) (also referred to as Voice Output Communications Aids, or VOCA) (Mirenda 2003) The PECS system entails a highly prescribed six-phase training sequence (Frost and Bondy 2002). As such, if a PE training protocol does not follow this outlined six-phase sequence, it is classified only as PE (Lancioni et al. 2007). SGDs are electronic devices that rely on the speaker s pressing of a picture or text depicting the desired item or activity on an electronic screen with enough force to evoke a digitized SGD message (Lancioni et al. 2007). The use of handheld technology has become widely accepted as part of the classroom-learning environment, as such devices are readily available to students and teachers (Peluso 2012). Using a device such as an ipad as a SGD may be more normalizing and less stigmatizing for a person with a disability than a PE notebook. The ipad is a common and somewhat coveted consumer product. A child carrying and using an ipad may be viewed as quite typical, if not envied by peers and others in the natural environment. Additionally, because the voice output of an ipad SGD is non-directional, gaining the listener s attention before communicating is not a necessarily part of initial communication training. Comparisons of the effects of PE systems and SGDs on the mand repertoire with persons with autism and intellectual disabilities have yielded mixed results, which is not surprising given differences between procedures and devices across modalities. Bock et al. (2005) compared acquisition rates of mands and device preferences of six four-year-old boys diagnosed with a developmental disability and found that three children acquired mands using PECS at a slightly faster rate, while three children acquired mands using both devices at equal levels. Generalization probes following training suggested that preferences for PECS or SGD varied among subjects and did not necessarily mirror acquisition data. Similarly, Son et al. (2006) compared the effectiveness of SGD and PECS in acquiring mands with three participants. All participants acquired mands with SGD and PECS at similar levels, though two of three of the participants demonstrated a preference for PECS. Beck et al. (2008) adapted the PECS protocol for use with a SGD, while comparing acquisition rates of mands using SGD and PECS in four preschool children with developmental disabilities. All four participants communicated more independently with PECS; however, participants were required to exchange and carry a 6 6 cm picture symbol in the PECS condition; while participants were required to carry a substantially larger and heavier SGD device during this condition. Therefore, it is possible that differential response effort confounded results in favor of PECS in this study. Comparison studies have yielded mixed results for PE and PECS in comparison to SGD, suggesting the need for further study. Furthermore, recent technological advances have produced much smaller, lighter, and potentially easier to use devices,

3 J Dev Phys Disabil (2013) 25: which can be converted to SGDs through relatively inexpensive software, such as Proloqu2Go. Few peer reviewed studies have compared PE with ipad based software programs as AAC systems. Finally, interactive technology with the ipad is now readily available in many educational settings, and can potentially be useful for other curriculum areas besides communication (Peluso 2012). Flores et al. (2012) compared acquisition of communication in five school-aged children with autism across picture exchange and the ipad as a SGD. Results showed higher levels of manding in the ipad condition for three participants and equal levels of manding for ipad and PE for the other three participants. One limitation of this investigation was participants previous training history with PE (Flores et al. 2012). As such, future investigations seeking to compare acquisition rates and device preference should be conducted with participants who have no or little history of communication training with either modality. The focus of the current investigation was (a) to compare acquisition of a mand repertoire with PE and the ipad - based SGD for five children with autism and (b) to evaluate children s preference for either device. Methods Participants Participants were five children, all male, diagnosed with autism, with a mean age of 4.5-years as shown in Table 1. Joel received 26.5 h of classroom instruction, 30-min per week of group and individual speech therapy, 45-min per week of occupational therapy, and 8 h per month of behavior supervision. Axel received 26.5 h of classroom instruction, 30-min per week of group and individual speech therapy, 45- mintes per week of occupational therapy, and 8-h per month of behavior supervision. Aaron received 26.5 h of classroom instruction, 30-min per week of group and individual speech therapy, 45-mintes per week of occupational therapy, and 8-h per month of behavior supervision Peter received 10 h per week of classroom-based instruction, 30-min per week of group and individual speech therapy, 45-min per week of occupational therapy, and 8 h per month of behavior supervision. Rick received 10 h per week of classroom-based instruction, 30-min per week of group and individual speech therapy, 45-min per week of occupational therapy, and 8 h per month of behavior supervision. All participants had VB-MAPP Barriers Assessment (Sundberg 2007) scores ranging from absent to limited for both manding and echoic repertoires. Teachers reported that none of the participants had a history of formal mand training, using either PE or SGD, at the onset of the study. Materials and Setting During PE training, baseline and training the materials included 3 3 cm laminated pictures depicting one tangible item and a velcro picture exchange book. The PE book was plastic and contained a Velcro strip on the cover, where the picture was secured. These pictures were produced using the application Proloqu2Go and were identical to pictures used for SGD training. The SGD baseline and training materials

4 640 J Dev Phys Disabil (2013) 25: Table 1 Participant information Name Diagnosis Age VB-MAPP, Barriers mand score VB-MAPP, Barriers echoic score Joel Autism Absent 4- Absent Axel Autism Limited 2-Limited Aaron Autism Absent 4-Absent Peter Autism Absent 4-Absent Rick Autism Absent 3-Weak were an ipad II and the application Proloquo2Go, which provided 3 3 cm pictures depicting an item on the screen of the ipad. During both conditions, sessions were conducted in the participant s classroom at a child-sized table, with child-sized chairs, where the instructor sat within two feet, to the left, the participant. Sessions were conducted in an unused area of the classroom, which had a partition segregating it from the remainder of the classroom. Experimental Design An alternating treatment design with initial baseline was used for the study (Cooper et al. 2007). Following baseline, PE and the ipad training conditions were presented in random order across five participants (i.e., Axel began training with the SGD, while Aaron began training with PE) and included an equal number of training trials across each device. When students met mastery criterion across both devices, a device preference assessment was conducted. Dependent Measures and Definitions During all phases of the study, frequency data were collected on independent and prompted mands, which were then converted to a percentage of independent mands. Trials to criterion were calculated post-hoc. For PE, an independent response was defined as the participant grasping and placing a picture symbol depicting an item into the hand of the listener/instructor without gestural, verbal, or physical prompts. For SGD, an independent response was defined as the participant touching the picture on the screen of the ipad depicting an item with enough force to evoke the digitized SGD output (e.g., ball. ) without gestural, verbal, or physical prompts. Experimenters Each experimenter had at least 3 years of applied experience in both mand training and ABA instruction generally. Two of the experimenters were masters-level students in ABA. The third was a doctoral student in Educational Psychology and a Board Certified Behavior Analyst. Additionally, each experimenter had attended trainings on prompting strategies and data collection and had demonstrated these skills for the primary investigator prior to the commencement of the study.

5 J Dev Phys Disabil (2013) 25: Interobserver Agreement & Procedural Fidelity Interobserver agreement (IOA) data were collected for 42 % of all training and during 100 % of baseline and 100 % of the device preference assessments. IOA data were calculated by dividing the number of agreements by the number of agreements plus disagreements 100. IOA during baseline, training, and the device preference assessment was 100 % for both picture exchange and SGD manding. A procedural fidelity checklist was used to ensure that the procedures were completed as outlined. Procedural fidelity data were collected during all sessions, throughout the study and indicated that procedures were followed at 100 % fidelity across all conditions of the study. General Procedures Stimulus Preference Assessment A multiple-stimulus without replacement preference assessment (MSWO; DeLeon and Iwata 1996) was conducted for each participant prior to baseline and training to determine items to be used in communication training. First, an opened-ended preference survey was provided to each of the participants teachers to determine which items would be presented during the MSWO. The results of the MSWO preference assessment provided a rank of the participant s preferences and the three items ranked highest were used for communication training during both PE and SGD training. Baseline Baseline data were collected during 10-min sessions. These sessions were broken into trials, which consisted of one opportunity to respond, with trials per session. The sessions continued until stable responding was determined for independent manding. During each baseline session, the three top ranking items from the MSWO were placed within the participant s view, yet out of reach, and the participant was instructed to pick one. The item that the participant reached for first was used for each respective baseline trial. The ipad and Velcro PE communication book with the corresponding picture on the screen or cover were both available for the participant to request the item. The placement of the ipad and Velcro PE communication book were systematically rotated between trials to control for hand dominance. The experimenter did not interact with the participant during the baseline phase unless he independently manded for the item using either modality. If the participant independently manded for the item, the experimenter gave the participant access to that item for 30 s. If the participant did not request the item within 30-s, an item selected at random, from the top three ranked items, was presented to the participant for 30 s. This was done to maintain the participant s interest and decrease the likelihood of disruptive behavior. The randomly selected item was then removed from the participant and the next trial began. Trials continued until the 10-min session was completed. Mand Training Mand training was conducted in sessions, which consisted of 15 trials. Like baseline, during each trial the experimenter presented the participant with three preferred items as identified through the preference assessment, and the participant was instructed to pick one ; the item that the participant reached for used for each respective training trial. Immediately after the reaching response, either the PE

6 642 J Dev Phys Disabil (2013) 25: device or the ipad was placed in front of the participant, with the picture depicting the item on the PE book or ipad screen, in a field of one picture. The item remained in view of the participant but beyond his reach. A constant time delay with full physical prompts (Sigafoos et al. 1989) was used to teach manding across both modalities. If the participant did not independently mand for the item within 5 s of its presentation, the experimenter provided a full physical prompt to either evoke the digitized message or the selection and exchange of the picture. No SGD prompting was used during training. Following prompted or independent responding, the participant was granted access to the item for 30 s after which the item was removed and the next trail began. Trials continued in this sequence either until the participant was exposed to 15 trials, at which point, the session was considered complete. Sessions continued in this sequence until the participant met a mastery criterion of 80 % unprompted responses, respectively, across two consecutive sessions. A maximum of two sessions per device were conducted per day. For all but one participant (Rick), maintenance sessions were conducted for each modality following acquisition. sessions for each modality were implemented if a participant met acquisition criteria for the modality, and continued until the participant reached acquisition criteria for both modalities. At least one maintenance session was implemented per modality prior to the preference assessment to help ensure that any differential responding during the device preference assessment was not due to lack of acquisition. sessions were conducted in the same manner as training; however, no prompting occurred during maintenance sessions. Duration of maintenance sessions varied from 5 to 10 min, depending on the rate of independent responding; however, there were always 15 trials per session. Device Preference Assessment The device preference assessment was conducted in the same manner as baseline. Both devices were presented in a random order of location (i.e., to the right and left side of the participant) to control for possible hand and location dominance. Three-to-four, 10-min preference assessments were conducted per participant. Results Joel Results for Joel across baseline, training, maintenance, and device preference assessment conditions are depicted in Fig. 1. During baseline, he independently manded using PE an average of 3 % of the time, (range, 0 14 %) and independently manded using SGD an average of 7 % of the time, (range of 0 14 %). During training, Joel averaged 57 % independent responding (range, %) with PE and met mastery criterion for PE during the 15th session of training. He averaged 77 % independent responding (range, %) with SGD and met mastery criterion on16th training session. data were collected during two sessions for PE and averaged 90 % independence (range, %) and for one session for SGD with 100 % independence.

7 J Dev Phys Disabil (2013) 25: Baseline Training & Device Preference Assessment 100 SGD Percentage of Independent Mands PE Sessions Fig. 1 Joel s percentage of independent mands. This figure depicts Joel s percentage of independent manding with picture exchange (PE) and the speech generating device (SGD) during baseline, training, maintenance, and the device preference assessment Figure 1 shows that Joel demonstrated preference for the SGD device during all four preference assessment sessions, in that he used the SGD during 52 of the 60 communication opportunities. He averaged 85 % independent responding using the SGD (range, %) and 11 % independent responding using PE (range, 6 13 %). Axel Results for Axel across baseline, training, maintenance, and device preference assessment conditions are depicted in Fig. 2. Axel independently manded using PE an average of 9 % (range, 8 10 %) during baseline. He never independently manded using the SGD. During training, Axel averaged 97 % (range, %) independent responding with SGD and met criterion in the 3rd session. Axel averaged 83 % (range, %) independent responding during PE training sessions, and met criterion in the 8th session. Axel averaged 100 % independent responding during maintenance for the SGD. He averaged 86 % independent responding (range, %) for PE. Figure 2 shows that Axel demonstrated preference for the SGD in that he used the SGD device for 59 out of 60 communication opportunities. Axel averaged 98 % (range, %) independent responding using SGD and 2 % (range, 0 6 %) independent responding using PE. Aaron Results for Aaron across baseline, training, maintenance, and device preference assessment conditions are depicted in Fig. 3. Aaron never manded using either device

8 644 J Dev Phys Disabil (2013) 25: Baseline Training & Device Preference Assessment 100 Percentage of Independent Mands SGD PE Sessions Fig. 2 Axel s percentage of independent mands. This figure depicts Axel s percentage of independent manding during picture exchange (PE) and voice the speech generating device (SGD) baseline, training, maintenance, and the device preference assessment Baseline Training & Device Preference Assessment 100 SGD Percentage of Independent Mands PE Sessions Fig. 3 Aaron s percentage of independent mands. This figure depicts Aaron s percentage of independent manding with picture exchange (PE) and the speech generating device (SGD) baseline, training, maintenance, and the device preference assessment

9 J Dev Phys Disabil (2013) 25: during baseline. During training, Aaron averaged 84 % (range, %) independent responding and met mastery criterion for SGD during the 7th session of training. Aaron averaged 55 % (range, %) independence responding during PE and met mastery criterion in the 16th training session. data were collected during five sessions for SGD and averaged 86 % (range, %) independent responding and for one PE session during which Aaron responded with 93 % independence. Figure 3 shows that Aaron demonstrated preference for the SGD device during all four preference assessment sessions, in that he used the SGD during 56 of the 60 communication opportunities. He averaged 94 % independent responding using the SGD (range %) and 4 % independent responding using PE (range, 6 13 %). Peter Results for Peter across baseline, training, maintenance, and device preference assessment conditions are depicted in Fig. 4. Peter never manded using either device during baseline. During training, Peter averaged 66 % (range, %) independent responding and met mastery criterion for SGD during the 13th session of training. Peter averaged 50 % (range, 0 87 %) independence responding during PE and met mastery criterion in the 22nd training session. data were collected during four sessions for SGD and averaged 98 % (range, %) independent responding and for one PE session during which Peter responded with 64 % independence. Baseline Training & Device Preference Assessment 100 SGD Percentage of Independent Mands PE Sessions Fig. 4 Peter s percentage of independent mands. This figure depicts Peter s percentage of independent manding with picture exchange (PE) and the speech generating device (SGD) during baseline, training, maintenance, and the device preference assessment

10 646 J Dev Phys Disabil (2013) 25: Figure 4 shows that Peter demonstrated preference for the SGD device during all three preference assessment sessions, in that he used the SGD during 25 of the 32 communication opportunities. He averaged 78 % independent responding using the SGD (range %) and 4 % independent responding using PE (range, 0 13 %). Peter did not respond with either device during 20 % of communication opportunities (range, %). Only three preference assessment sessions were conducted with Peter due to time constraints. Rick Results for Rick across baseline, training, maintenance, and device preference assessment conditions are depicted in Fig. 5. Rick never manded using either device during baseline. During training, Rick averaged 76 % (range, %) independent responding and met mastery criterion for PE during the 12th session of training. Rick averaged 58 % (range, %) independence responding during SGD and met mastery criterion in the 23rd training session. data were collected during five sessions for PE and averaged 95 % (range, %) independent responding. data were not collected for SGD due to time constraints. Figure 5 shows that Rick demonstrated preference for the PE device during all four preference assessment sessions, in that he used PE during 53 of the 60 communication opportunities. He averaged 89 % independent responding using PE (range %) and 15 % independent responding using the SGD (range, %). Baseline Training & Device Preference Assessment 100 PE Percentage of Independent Mands SGD Sessions Fig. 5 Rick s percentage of independent mands. This figure depicts Rick s percentage of independent manding during picture exchange (PE) and the speech generating device (SGD) during baseline, training, maintenance, and the device preference assessment

11 J Dev Phys Disabil (2013) 25: Discussion The focus of the current investigation was (a) to compare acquisition of a mand repertoire with PE and an ipad based SGD for five preschool children with autism and (b) to evaluate children s preferences for either device. To answer these questions, data were collected on independent manding using both PE and the ipad Version II as a SGD, using an alternating treatment design and a device preference assessment. First, though it is apparent from results that participants demonstrated differential acquisition of PE and SGD during training, data in Figs. 1, 2, 3, 4 and 5 show that the constant-time delay teaching procedure increased their levels of independent responding in both modalities. Considering the first research question regarding the relative effects of training in each modality, on average, the SGD required fewer training sessions for participants to meet a mastery criterion of 80 % independent manding. Three of participants met criterion for manding with the SGD more readily, while five participants met criterion for manding with PE more readily. In terms of overall percentages of independence in either modality, SGD produced higher rates of independent manding with an average of 85 % independent responding during training and maintenance across all participants while PE produced only 64 % of independent responding across all participants. These findings differ from Bock et al. (2005) and Beck et al. (2008), who found that PECS was acquired at a slightly faster rate for the majority of participants when compared to a SGD device. In previous comparison studies, the PECS protocol was used with both modalities. Because the SGD device was substantially larger and heavier than pictures used during PECS training, differential response effort may have produced the higher levels of responding for PECS in these studies, particularly during phase II of PECS, which requires the user to carry the picture or device to a listener. In contrast, the current study did not require the user to carry either pictures of the ipad based SGD, thus eliminating this potential confound. Consistent with Son et al. (2006), the results of the device preference assessment varied among participants, though all demonstrated strong preferences for one modality or the other, and four of five strongly preferred the SGD over PE. Interestingly, results of the preference assessment matched the device that produced the most independent manding with all of the participants. These results differ somewhat from previous studies, which showed that participant performance during preference assessment did not always match acquisition (e.g., Son et al. 2006; Bock et al. 2005). Finally, the results differed from the Flores et al. (2012) investigation, in that the all of the participants in the current study demonstrated a clear preference for either the ipad or PE. However, as previously noted, the participants history with the systems may have been a factor accounting for acquisition and preference in the Flores et al investigation. Limitations A limitation of the current study is the absence of discrimination training for either modality. That is, participants were only taught to select or exchange one picture at a time rather than choosing the correct picture from an array. Discrimination between

12 648 J Dev Phys Disabil (2013) 25: pictures training is an important component of mand training in AAC in that it allows the speaker to request a variety of specific items (Bondy and Frost 2001). Although this study did not incorporate discrimination training between pictures, all five participants acquired the topography necessary for manding across both devices, as is consistent with Phase 1 of the PECS protocol (Frost and Bondy 2002). Additionally, the distribution of training sessions was a limitation of the study. For each participant, two training sessions occurred per instructional day across both PE and the ipad. This may have affected acquisition rates given the possibility of carryover effects while teaching manding using multiple modalities. To limit this possible effect, the presentation of the devices was randomized and alternated across participants. Future Research Additional research investigating the ipad as a SGD device is warranted. Importantly, future research should address discrimination of the acquired mand repertoires with multiple pictures and extended SGD vocabularies, and generalization of mand responses across trainers and environments. Finally, future research should investigate the collateral effects of the acquisition of a mand repertoire using the ipad as a SGD such as the effects of the acquired repertoire on vocalizations and/or disruptive behaviors, relations with peers and on teacher/instructional aide behavior toward the child. Despite these limitations, the use of a training procedure employing a constant time delay with full-physical prompts was effective in the acquisition of a mand repertoire in all participants across both PE and the SGD. For three participants the ipad as a SGD was acquired more readily than PE. For one participant PE was acquired more readily than the SGD device; however, the SGD produced more independent responding across all training and maintenance sessions. One participant acquired PE more quickly than the SGD. Four participants demonstrated a preference for the ipad as a SGD, while one participant exhibited preference for PE. References Beck, A. R., Stoner, J. B., Bock, S. J., & Parton, T. (2008). Comparison of PECS and VOCA: A replication. Education and Training in Developmental Disabilities, 43, Bock, S. J., Stoner, J. B., Beck, A. R., Hanley, L., & Prochnow, J. (2005). Increasingfunctional communication in non-speaking preschool children: Comparison of PECS and VOCA. Education and Training in Developmental Disabilities, 40, Bondy, A. S., & Frost, L. A. (2001). The picture exchange communication system. Behavior Modification, 25, Charlop-Christy, M., Carpenter, M., Le, L., LeBlanc, L., & 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, Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper Saddle River: Pearson. DeLeon, I. G., & Iwata, B. A. (1996). Evaluation of a multiple-stimulus presentation format for assessing reinforcer preferences. Journal of Applied Behavior Analysis, 29,

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