Friday, October 1, 2010

PECS

I am always amazed that PECS (Picture Exchange Communication System) is not being more widely used among those in my profession to help children. PECS is a program based on ABA (applied behavioral analysis) that teaches a non-verbal child to communicate with others by using pictures. I learned it over 10 years ago and it is now my first choice in my tool arsenal for helping non-verbal or minimally verbal children to begin to communicate. It is almost the magic "bullet" so to speak for most of these children. So, I have decided to post the basic steps. If you want the full training you need to attend a workshop. But here are the basics that I use in my speech therapy practice.

Step One: Identify things that are motivating for the child. These things need to be controllable by the communication partner. I like to start out with a snack like goldfish crackers or small consumable items, but some children respond better to a toy or other item. Some toy ideas are small wind-up toys that must be wound again or other such activated toys, marble to be rolled down a marble works maze and quickly retrievable by you (before the child), toy car rolled down a ramp, disney toy, etc. It often depends on the likes of the particular child. It is key that you are able to regain control of the toy or that the item requires a request for more, again, or continuation.

Step Two: Make a picture of the item. You can get almost any pictures by printing them off of Google Images, or take a real photo, or you may be lucky enough to have a picture program such as Boardmaker. Real pictures are great but representational graphics (drawings or clip art) usually work well too. If the picture will be used frequently, consider laminating it or covering it in clear contact paper or packaging tape to increase durability.

Step Three: At first you will need a helper. Place the picture in front of the child. The communication partner holds the desired item in view of the child. When he reaches for the item the communication facilitator (you sitting behind the child) directs his hand to the picture, assists him in picking it up, and then handing it to the communication partner (person with the goodies). The partner immediately gives the child a treat and then places the picture back in front of him. This process is repeated until the child figures out that handing over the picture gets him what he wants. Most children figure this out quickly if the item is sufficiently motivating. Note about assistance: At first you may need to assist the whole process hand over hand style. Then you may simply need to assist parts such as directing the hand onto the picture or picking it up or giving it to the partner. Only assist what needs assistance. The partner can assist by holding out their hand to receive the picture as a cue to the child.

Step Four: As soon as he starts retrieving the picture and handing it over himself, you fade (only assist steps needed) or stop assisting him altogether (or else he will never become independent with the task). It is also important to fade the cue of an open hand waiting for the picture. We do not want the child only to request when prompted (prompt dependent). We want him to become a self-initiating communicator.

See a demo of this phase: PECSvideo

This process needs to be practiced until the child is consistently initiating and requesting the desired items, one at a time, over several sessions.
Step Five: Change the communication partner so that the child learns to do this with several people. *Can also introduce Distance and Persistance training at this point.

Step Six: Introduce two items for choices. Present choices of two items and give him the one he hands you. Now the child is learning he has the power to make a choice! ChoicesVideo

Step Seven: To teach him to discriminate between the pictures more closely, you can present a liked choice and a disliked choice (ex: cheetohs vs. pickle). When he wants a cheetoh and gets a pickle (or vice versa), he may get mad but will soon learn to pay attention.

Other Steps: PECS presents some other factors to be learned in the process but I tend to teach in this order presented, and it has worked for my clients. Once we achieve these basics, I add the other parameters.

*Distance: Move away from the child so that the child has to get up and come to you to deliver the picture.

*Persistance: Move the picture away from the child so that the child has to seek out the picture to request the item. You can also turn away from the child, so that he has to get your attention.
Demo
Advanced Applications: Because it is a picture based system, it can later go on to be used to develop the child's abilities to generate phrases, sentences, and to answer and use questions. The use of pictures is invaluable to the teaching process for vocabulary and concept development. PECS can also be used to establish schedules for basic routines or daily tasks and ease the children through transitions in their day and help them understand what is happening and what will happen throughout the hour or day. If they have a schedule to refer to, they understand that they will eventually get to a desired activity if they first complete other tasks. This can eliminate lots of frustrations for everyone.

The real beauty of this system is multi-fold. It teaches the child several very critical elements of communication:

1. Communicative Intent: Learning the power of communication: If I communicate, I can get something I want rather than being at the mercy of others to anticipate my needs & I have to interact with another person in order to achieve an end goal or get a desired item.

2. Reciprocal Communication: Communication is a two-way street. Communication requires an exchange with another person (give and take).

3. Referencing Skills: Looking at or noticing others in the environment is often a missing skill in those with autism. Some believe it is one of the major reasons why some with autism often seem clueless to the environment or have such dramatic reactions to changes or transitions. They fail to notice the cues around them. Having to deliver a picture to a partner requires them to notice the partner. I often hold the item up by my face so they will have to look up at me to retrieve the item. Or, I will hold my hand to receive the picture a bit higher than needed, to direct the eyes to me. Later in the process after the child has consistently learned the basic requesting, I require at least a quick glance at me before giving the desired item.

4. Improved Behavior: Once the child understands he has an effective method for communication, many of his problematic behaviors like throwing tantrums tend to disappear. It is very frustrating to be unable to communicate and get things you want or need when you want or need them. Some children who may appear autistic due to the behavioral issues sometimes turn out to be simply speech/language impaired.

5. Verbal Skills: I always pair verbal models with the pics: When the child gives me the goldfish pic, I may say, "goldfish" or "I want a goldfish" or "You want a goldfish." Most of the time the child will begin imitating the verbalizations. This does not mean you need to stop using PECS. But if the child uses the verbal request, you do not need to insist on picking up the picture before rewarding. After all, being verbal is the ultimate goal.

As an SLP (speech language pathologist), I always start here rather than with a voice output device. Devices are great but do not teach the other critical communication pieces as well as picture exchange. Of course, if the child has those skills already and just cannot verbalize effectively (such as a child with apraxia of speech) then a device would be the best choice. I like the Dynavox devices, but that will be material for another blog...

For more info or to find workshops: PECSwebsite

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