As a relatively new speech and language therapist, every client provides me with new challenges and pushes me to be better at my job. This summer, I began working with a new client whose cute little face continues to motivate me to be the best speech therapist that I can be. This little boy is 5 years old who has a diagnosis of Autism and is currently non-verbal (not speaking). His parents are wonderfully dedicated and wanted two things more than anything. Firstly, a functional way for him to communicate his wants and needs and secondly, more than anything they want him to begin to speak.
When working with children who are not speaking yet, the first thing that any speech therapist will do is provide the child with a way to communicate without speech. Communication methods that are used to supplement or replace speech are called Augmentative and Alternative Communication (AAC). The form of AAC that is often used with young non-verbal children who have autism is called the Picture Exchange Communication System (PECS). This is the form of AAC that I chose to use with the little boy that I am working with.
What is PECS?
PECS was designed to teach functional communication skills to people who have little or no verbal communication abilities. The goal of PECS is spontaneous and functional communication. The child using PECS is taught to exchange a picture of an item that they want for the actual item. In this way, the child is initiating communication and is able to communicate his wants and needs. As the child progresses through the phases of PECS, the child learns to form simple sentences using the pictures, answer questions and make comments.
PECS was carefully designed in 1985 at the Delaware Autism Program by Lori Frost and Andy Bondy and they designed the PECS Protocol to have six phases.
Today I am going to describe Phases 1 to 3 to you! Why not all 6 phases you ask? Honestly...because I am sleeeeepy! My bed is calling my name and I cannot wait to jump into it. Therefore Phases 4 to 6 will come to you tomorrow :)
Update: Phases 4 to 6 are now up on the blog as well! Click here to read!
Before implementing the PECS protocol, you need to choose reinforcing items which you know that the child loves. This will guarantee that when the child sees it, they will want it! For the little guy that I worked with, my reinforcer inventory included stickers, felt pictures that could be stuck on a felt board, bubbles, singing songs, and pop-up toys. Reinforcers will differ from child to child.
Phase 1: How to Communicate
The goal in this phase is for the child to pick up the picture symbol and hand it to his/her communication partner. Two adults are required in this phase: one to act as the a 'Helper' and one to act as the Communication Partner. A picture of the reinforcing item is placed in front of the child.
Let's say that the child loves to play with a ball toy. Above is a picture of the balls that the child loves and the picture symbol that corresponds to the balls The communication partner begins by playing with or holding up a ball (and keeping the other balls out of sight). No verbal help is given as the child reaches toward the desired item. Instead, the Helper redirects the child to pick up the picture symbol and place it into the open hand
of the communication partner. The communication partner then immediately
hands the ball to the child and names the item/says 'ball.' You can then repeat this procedure with the other balls.
PECS training should take place across all activities and environments. For example, if the child is playing outside and wants to go onto the swing, grab the picture symbol for 'swing' and prompt the child to give the picture to the Communication Partner, before helping the child onto the swing. In this way, the child will learn to generalise his skills across all settings, activities and people.
As the child gets the hang of what is expected in Phase 1, begin to fade the physical prompt from the helper and then fade open hand cue from the Communication Partner.
Phase 2: Increasing Spontaneity
During this phase, the child will pick up the picture symbols without any prompting. Begin to increase the distance between the child's communication book and/or Communication Partner. This will give the child the opportunity to learn to access the picture symbol, go to the Communication Partner, and gain their attention before making the request. As in Phase 1, the Communication Partner immediately hands the desired item to the child and names it.
It is really exciting when a child spontaneously begins to use PECS without any prompting. Imagine you have a non-verbal child who could suddenly express to you what he wants to eat or play with. I remember getting a text message from my client's mum while I was away on holiday to tell me that her son found the picture symbol for 'biscuit' in his communication book and gave it to his mum to request a biscuit all by himself and without any prompting! It was the first time that he had made a request using PECS outside of his speech therapy sessions. The pride that I felt in my heart when I saw that text message was I am sure only a fraction of the pride that his parents felt! It's moments like those that make me truly proud to be a Speech & Language Therapist.
Phase 3: Discrimination
The goal during this phase is to teach the child to discriminate between picture symbols. At the beginning of Phase 3, the communication book has only two pictures: a highly preferred item and and a non-preferred item. For example, you may have a picture of a 'ball' and an unrelated item such as a 'sock.' The Communication Partner has both items and waits for the child to make a request. As soon as the child chooses the picture of the 'ball', the Communication Partner provides social reinforcement (e.g. 'Good choice!') and then immediately hands the ball to the child and names it as the exchange is made. However, if the child gives the picture of the 'sock' then you would hand the child the actual sock without any social reaction. As the child becomes more successful, you can increase the number of pictures in the communication book.
I learned to choose activities very carefully during my sessions while training PECS. It is very important to choose reinforcing items but equally important to provide as many opportunities as possible to use PECS throughout the session. Luckily, I found out that my client loooooves playing with felt pictures and also loooooves the Gruffalo book. I had just the activity!
As you can see, there are many pieces that make up the above activity. I made picture symbols for every animal and item available and then held all the felt pieces hostage until my client requested the animal that he wanted to make up the very specific scenes that he had in his head. I was able to get around 20 requests during this activity using PECS. In previous phases, I used a generic 'animals' picture for this activity and then I chose the animal to give to my client. However now, my client got to choose the animals that he really wanted! It was super interesting to his mum and I to watch him request the animals that he wanted to make up the scene that he had in his head.
At the end of this phase, the child's communication book should contain a variety of objects, food items and activities and as always should be available to the child at all times. The child is now able to look through all of the pictures, choose the picture of something that he wants and then give it to the desired Communication Partner. For example, if the child wants to go to the park, he may find the picture for 'park' and give it to his mum. Or if he is hungry and wants a banana, he will find the picture for 'banana.' At this point, I gave advice to my client's mum about how to organise the Communication Book into categories such as 'food', 'toys,' 'tv shows,' and 'places.'
And that sums up Phases 1 to 3 of PECS! Goodnight! Love to all!
Update: Click here to read about Phases 4 to 6
Labels: AAC, Communication