CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION For children with developmental delay who are nonverbal, does the use of augmentative and alternative communication (AAC) increase social participation in the classroom and at home? Schriebman, L., & Stahmer, A. (2014). A randomized trial comparison of the effects of verbal and pictorial naturalistic communication strategies on spoken language for young children with autism. Journal of Autism and Developmental Disorders, 44, 1244 1251. http://dx.doi.org/10.1007/s10803-013-1972-y CLINICAL BOTTOM LINE: This study examined the effectiveness of two naturalistic interventions, the Picture Exchange Communication System (PECS) and Pivotal Response Training (PRT), in an early intervention context. Early intervention involved treating children in their natural environment (their home). The goal of this study was to compare the spoken language outcomes for young, minimally verbal children with autism [who were] taught communication (p. 1245) with either the PECS or PRT. Each intervention used behavioral techniques (activities to stimulate initiation of communication, reinforcement of communication, etc.), and PRT also used motivation training for families as an intervention technique to promote communication. The results of this study demonstrate that children in the PECS and PRT groups gained similar levels of spoken language at the end of the study. In addition, 78% of the participants in both groups were using at least 10 spoken words to communicate in their daily routines at the conclusion of the study. The results may suggest that the PECS is just as effective as PRT in increasing the verbal communication skills of children with autism spectrum disorder (ASD) when implemented in a naturalistic context. The authors concluded that more research is needed to analyze generalization and maintenance of skills gained through either PECS or PRT. Further research is also needed to ascertain how the child s individual characteristics may influence the effectiveness of each treatment. Occupational therapy professionals are highly involved in the early intervention process, and their knowledge of PECS and PRT techniques and effectiveness can allow for the implementation of augmentative and alternative communications during an early time in the child s life. Consequently, such usage may assist children in building communication skills and responses that may benefit their daily routines and future occupations. RESEARCH OBJECTIVES List study objectives. 1
Compare the spoken language outcomes for young, minimally verbal children with autism [who were] taught communication using either Picture Exchange Communication System (PECS) or Pivotal Response Training (PRT) (p. 1245). DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial SAMPLE SELECTION How were subjects selected to participate? Please describe. Subjects were selected from referrals to university-based autism research centers or programs. Inclusion Criteria Diagnosis of ASD Age younger than 48 months Possession of no more than nine intelligible words Absence of evidence for diagnosis of primary mental retardation, neurological pathology or major sensory impairment (p. 1245) Absence of prior treatment involving either PECS of PRT (p. 1245) Parental willingness to participate in parent training sessions Exclusion Criteria Absence of an ASD diagnosis Age older than 48 months Possession of more than nine intelligible words Primary diagnosis of mental retardation, neurological pathology, or major sensory impairment Parental unwillingness to participate in parent training sessions SAMPLE CHARACTERISTICS N = (Number of participants taking part in the study) 39 #/% Male 34/87% #% Female 5/13% Ethnicity Not reported Disease/disability diagnosis ASD INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary Group 1 Brief description of the intervention Children in this group received PRT training. These sessions focused on the development and spontaneous use of spoken language in functional and naturalistic contexts. 2
How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Group 2 Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? 20 Parent training took place at one of two university clinic sites. Child intervention took place in the child s home. Undergraduate students who were trained in PRT treatment Children received intervention five times a week for 2 hr each session for 15 weeks. This intervention was followed by 8 weeks of 2 2-hr sessions per week. 23 weeks Children in this group received PECS training. These sessions focused on teaching the children to use the PECS symbols to communicate. This protocol involved providing a naturalistic context for the children to use their PECS symbols to engage in communication. 19 Parent training took place at one of two university clinic sites. Child intervention took place in the child s home. Undergraduate students who were trained in PECS treatment Children received intervention five times a week for 2 hr each session for 15 weeks. This intervention was followed by 8 weeks of two 2-hr sessions per week. 23 weeks Intervention Biases Check yes, no, or, and explain, if needed. Contamination: Co-intervention: Timing: Participants in both groups were receiving other interventions during the study. Because this study took place over a period of 6 months, it is possible that the children could have acquired some spoken language on the basis of development alone. 3
Site: Use of different therapists to provide intervention: This study used different undergraduate students for each group and for each of the two sites, which could have led to differing treatment sessions. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1 The Mullen Scale of Early Learning (MSEL) This measure assessed the cognitive ability of the children, in particular the expressive language portion. Measure 2 Measure 3 The Expressive One-Word Picture Vocabulary Test Revised (EOWLPVT) This measure assessed the children s expressive language vocabulary. MacArthur Communicative Developmental Inventory (CDI) This measure assessed participants early language competence and looked at both receptive and expressive language components. 4
Measure 4 Measure 5 Vineland Adaptive Behavior Scale (2nd ed. (VABS) This measure assessed the children s independence in their living environment and how competent they were at completing daily tasks. Postintervention Parent Satisfaction Survey This survey measured parent satisfaction after the intervention ended. It looked at the parent s overall impressions, program effectiveness, child improvements, intervention techniques, and the parent training sessions. This measure was used postintervention. Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or, and if no, explain. Some of the assessment coders used in this study were not blinded to the treatment conditions of each child. Recall or memory bias. Check yes, no, or and if yes, explain. Others (list and explain): 5
RESULTS List key findings based on study objectives. Include statistical significance where appropriate (p <.05). Include effect size if reported. Twelve of the 19 children in the PECS group reached Phase 6 of training. This means that they had mastered requesting and were working on learning how to use their PECS symbols to comment. Seventy-eight percent of the participants from both groups were using at least 10 spoken words at postintervention assessments. The researchers concluded that the PRT and PECS programs may be equally effective at teaching children to communicate in naturalistic contexts, given that statistically significant improvements were noted in spoken language and vocabulary, as well as adaptive communication, when time was viewed as the main effect. The authors reported that parents were satisfied with the interventions overall. Parents rated the PECS a 5.7 average score and the PRT a 6.0 average score (with a rating of 7 being the most satisfied). Parents reported improvements in all areas of communication, self-help skills, and behaviors, with a moderate rating of 4.4 (with a rating of 7 being the most satisfied). Was this study adequately powered (large enough to show a difference)? Check yes, no, or and if no, explain. Were appropriate analytic methods used? Check yes, no, or and if no, explain. The researchers used an analysis of variance to analyze the results of the study. Were statistics appropriately reported (in written or table format)? Check yes, no, or, and if no, explain. Statistics were clearly represented in a chart on p. 1248 of the study. Was the percent/number of subjects/participants who dropped out of the study reported? Two families dropped out before the intervention began. One family moved out of the treatment area, and the other declined to participate in the intervention sessions. Limitations What are the overall study limitations? There was no control group in this study, which limits the ability to make conclusions about whether the children acquired language from the interventions or just from normal development. Participants were only nonverbal and minimally verbal children, which limits generalizability to populations of verbal children. 6
CONCLUSIONS State the authors conclusions related to the research objectives. The authors concluded from the results of the study that the majority of young children with autism can learn spoken language. They also stated that the PECS and PRT might be equally useful in teaching children how to communicate, because both intervention groups showed improvements in spoken language and vocabulary as well as adaptive communication. It is worth noting that parents reported the PECS to be more difficult to implement at home, although the parents in each group were satisfied. The researchers also stated that the research done with the PECS and PRT will help early interventionists who target communication in young children to provide more individualized treatments. This work is based on the evidence-based literature review completed by Mackenzie Berger, BS, OTS, and Carmela Battaglia, PhD, OTR/L, Faculty Advisor, Keuka College. CAP Worksheet adapted from "Critical Review Form--Quantitative Studies." Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 7