Article Review

1. Article Review Comparative efficacy of the Picture Exchange Communication System (PECS) versus a Speech-Generating Device: Effects on Social-communicative Skills and Speech Development Presented by: Anna Gill April 7, 2014

2. Questions being investigated • What comparative effects are there between PECS and an SGD on enhancing: • Social communication skills?’ • Eye contact • Physical orientation • (social) smiling • Natural speech production? • Verbalizations • Word approximations • Does not include vocal stereotypy (squealing, raspberries), jargon or echolalia

3. Participants • School-aged children • All participants had a diagnosis of Autism • Childhood Autism Rating Scale (CARS) scores indicated at least moderate to severe range of Autism • No other diagnoses mentioned • None of the participants were using a formal communication system or receiving any other type of intervention at the time of the study • Language assessment at baseline: MacArthur-Bates Words and Gestures Communication Development Inventory (CDI)

4. Participants • Christian: 6 y.o., Caucasian, English-speaking • Speaks 8 single words, 7 manual gestures • Nadia: 7 y.o., Hispanic, English and Spanish at home • Non-verbal • Previous exposure to pictures (not PECS) • 3 manual gestures • Zeth: 10 y.o., Caucasian, English at home • Non-verbal • 4 manual gestures

5. Treatment conditions • Picture Exchange Communication System (PECS): • Protocol by Bondy & Frost (1994) • Examined Phases I – III • Speech-Generating Device (SGD): • Logan ProxTalker • Up to 5 buttons on which picture cards can be attached • Activation is by pressing down on the picture card • Device was set on the table for each of the sessions

6. Preference assessment • 3 stages to determining preferred items • Parent interview • Trial assessment • Forced choice • Authors created 2 ranked lists of food reinforcers for each participant • One list to be used during the PECS condition • Other list for the SGD condition

7. Treatment duration • Participants were seen 2-3 times/week • Sessions took place in the clinic (Nadia and Zeth) or home (Christian) • Sessions were structured, mainly taking place at a table, with participant in a chair (except Phase II) • Sessions were approximately 15 minutes long • Period of study approximately 5 months

8. Treatment phases • Baseline • Phase I • Phase II • Phase III (5 subphasesbut later modified) • Follow-up • Maintenance • Mastery Criterion: Child must independently request reinforcers in at least 80% of the opportunities, in both treatment conditions, over 2 consecutive sessions

9. Results • Authors noted that all participants demonstrated “increased social-communicative behaviours” during Phase II PECS • No increase in speech production across participants in either treatment condition

10. Limitations of this study • Authors had 3 behaviours for participants to demonstrate social communication skills • Apparently each behaviour was recorded separately but the data was coded under only ONE umbrella term (“social-communicative behaviours”) • One social-communication behaviour was “physical orientation”; Think – what is Phase II PECS?? • Christian had very marginal speech skills (but was functionally non-verbal); Nadia and Zeth were reported to have had no speech skills – no wonder there was no increase in speech production noted!

11. Limitations of this study • What about other SGDs? • Icon size a factor? • Did the participants have other diagnoses (e.g., DD)? • One of the authors (Anu Subramanian) is apparently an S-LP • Why wasn’t there a more thorough comparison of language skills prior to and following the study? • Authors not verify parent responses on the MacArthur-Bates Words and Gestures CDI before or after intervention(see report of parent responses for Zeth)

12. Take home messages • Be careful how you define and measure “social skills” • Social-communication skills need to be explicitly taught by other approaches; not sure PECS is the best • Current research regarding use of AAC and increase in speech often (but not always) depends on child’s skills BEFORE implementation of AAC • i.e., evidence of SOME spoken language at onset of treatment is a strong predictor for later speech development (Schlosser & Wendt, 2008; Ganz & Simpson, 2004)

13. References Boesch, M. C., Wendt, O., Subramanian, A., & Hsu, N. (2013). Comparative efficacy of the Picture Exchange Communication System (PECS) versus a speech-generating device: effects on social-communicative skills and speech development. Augmentative and Alternative Communication, 29(3), 197-209. Boesch, M. C., Wendt, O., Subramanian, A., & Hsu, N. (2013). Comparative efficacy of the Picture Exchange Communication System (PECS) versus a speech-generating device: Effects on requesting skills. Research in Autism Spectrum Disorders, 7(3), 480-493. Ganz, J., Parker, R., & Benson, J. (2009). Impact of the picture exchange communication system: Effects on communication and collateral effects on maladaptive behaviors. Augmentative and Alternative Communication, 25, 250-261. Schlosser, R. W., & Wendt, O. (2008). Effects of augmentative and alternative communication intervention on speech production in children with autism.: A systematic review. American Journal of Speech-Language Pathology, 17, 212-230.