Behaviour Analytic Perspective on Autism

Understanding children with autism: Students are expected to describe and critically analyse a case study of a child with autism that addresses a specific issue related to the field (no primary data collection!) from a behaviour analytic perspective. This section allows students to focus on an issue of their choice, that reflects learning during Workshops 1-4, e.g., early intervention, diagnosis of girls, parenting issues, cultural issues, rise of autism prevalence

Introduction:

Autism spectrum disorders (ASD) are neurodevelopment disorders and the individuals are diagnosed with ASD, who have deficits in social and communication skills, as well as exhibiting repetitive or stereotypical behaviours (American Psychiatric Association, 2013). In the Republic of Ireland, it is reported that, 1 in 68 children have autism (Shine Centre for Autism, 2020). This essay provides a hypothetical case example of a three year old young girl with ASD and discusses how this intervention improved her quality of life and his opportunities for the community access.

Autism spectrum disorder affects social communication. One of the most well-known characteristics associated with ASD is the problems associated with social communication. Language and communication underlines most learning in typically developing children so difficulties in these areas will have significant impacts on child’s overall development (Sundberg and Michael 2001). The inability to communicate effectively with others creates a considerable barrier to independent living for those with ASD (Frost and Bondy, 2002). For example in schools, the children may be using Lámh, PECS (Picture Exchange Communication System) or another electronic device to communicate their needs in school.

Baker (2021) explains, how PECS offers an exciting innovative approach for developing early communication skills by using pictures in a fundamentally different way from other picture-based systems. This system was initially developed by Andrew Bondy and Lori Frost in the USA for pre-school children with autism. PECS is now being effectively extended to a wider range of children with functional communication difficulties and also to older children and adults. PECS is known to be one of the popular methods to improve communication skills in the individuals with autism. The primary aim of PECS was to teach the children with autism to initiate communication, and it was later discovered that, PECS is ideal for non-verbal individuals as well as for those with limited expressive language (Bondy and Frost, 2002). Dooley (2001) supported the claims that, PECS is effective

in enhancing functional communicational skills of the children with ASD. Tien (2008) reviewed various different studies on the effectiveness of PECS for enhancing the functional communication skills of the children with ASD and the results of the studies reviewed the evidence of the effectiveness of PECS in particular for the individuals with ASD.

PECS is based on the idea that learning occurs as a result of the consequences of a particular behaviour. If behaviour leads to something the child wants, that behaviour is more than likely to occur again. Therefore, in PECS, when the children use the picture cards, they’re rewarded with the objects or action they’ve asked for those reinforcing their behaviour. In turn, it increases the likelihood that the children will keep using the cards for communicating needs and desires.

This system requires few complex motor movements on the part of the speaker and does not require the listener to be familiar with an additional language such as sign language (Bondy and Frost, 1994). It is important to understand that, a person with autism has significant challenges in communicating well through speech and to ensure that, these communication needs are addressed early in order to avoid loss of educational and social opportunities (Horovitz and Matzon, 2010). Communication difficulties are possibly the most common characteristic of ASD (Bondy and Frost, 2002) and these difficulties can be associated with challenging behaviours. Frost and Bondy (2002) highlighted that, PECS implementation focuses on the study of applied behavioural analysis by using discrete, evidence based teaching procedures to develop communication skills and this also includes techniques like prompting and prompt. Bondy (2001) emphasised that, the cornerstone to an analysis of communication from a behavioural perspective rests with Skinner’s Verbal Behaviour (1957), where the verbal behaviour of the speaker was under the stimulus control of the listener. He explains that, the role of the listener is to arbitrate reinforcement of the speaker in terms of consequences or social reinforcement.

According to Bondy and Frost (1994), PECS differs from other communication systems in three ways such that it immediately teaches initiating, its aim is to address the lack of motivation for social reinforcement and it does not need any prerequisite skills.

As professionals, we strive to find the interventions that will improve the lives of the person with ASD and their families, particularly in cases, where the individual’s behaviour causes distress to themselves and others (Emerson et al, 1994). The PECS system incorporates functional communicative responses that encourage meaningful interactions between the child and the environment (Frost and Bondy, 1994). Functional communication refers to a type of behaviour that is utilised to express needs, wants and feelings effectively that others can understand (American Speech Language-Hearing Association, 2017)

Other positive effects have been experienced with the use of PECS for example a decrease in challenging behaviour and enhanced social behaviour (Bondy and Frost, 1994). Several reports have suggested that, a large number of children who learn PECS also develop spoken language (Brandy et al 2016). Lerna et al. (2012) revealed that, PECS showed noteworthy improvements in social communication skills for the children with autism.

According to Bondy and Frost (1994), the development of speech may also arise from the pairing of the phrase that is spoken by the adult (“I want juice’’) with the pictorial communicative act of handing a PECS sentence strip to a communicative partner; thus the vocal and pictorial content are presented simultaneously and, if the child begins to imitate the vocalizations in later phases of PECS, the two responses may be reinforced simultaneously. A growing body of research suggests that, this system is a promising mode of communication as this approach is unique as it teaches the children to initiate communicative interactions within a social framework (Bondy and Frost, 1994) Once a child has passed through all 6 phases of PECS, he/she will be able to make his/her needs and wishes known, comment about aspects of their environment, respond to questions from others and partake in social etiquette: all the main functions of spoken language (Bondy and Frost, 2002). There are several studies in the literature on PECS and its impact on learners with complex needs and limited communication. Kaduk (2017) examined 11 studies determining that, PECS showed improvements in every participant’s communication skills, all of the studies examined demonstrated benefits for using PECS and determined that PECS is a useful tool for children with autism.

Charman et al. (2011) examined the form and function of spontaneous communication and outcome predictors in nonverbal children with autism. Overall they found that, PECS appeared to improve children's spontaneous communication for requesting using pictures, speech, or a combination of both. They also revealed that, PECS appears to have increased spontaneous speech in children, who could talk a little at baseline.

Case Study:

Picture Exchange Communication System (PECS) is utilised as an intervention, and relies on the principles of ABA and pictorial images that are used instead of words to develop functional communication skills. It is a method to teach young children or any individual with communication impairment.

Sarah is a three -year-old girl with ASD who receives early intervention services in her home. Sarah’s parents and her early intervention service provider have been discussing Sarah’s language delays. Her parents are concerned as she doesn’t initiate any communication, and notice that she is becoming increasingly frustrated at home when her needs are not met. Sarah mostly waits for others to interact with her before attempting to communicate. She typically communicates by leading adults by the hand, pointing at preferred objects, and pushing away no preferred objects. No other clear gestural communication attempts were evident. She attempts to imitate sounds and only occasionally makes unprompted requests for food items. However Sarah’s mother is able to identify what Sarah wants by closely observing her non-verbal cues such as pointing at the snack cupboard or refrigerator when she is hungry. Other family members often miss her cues and these results in frequent tantrums of screaming and crying. The team decided that Sarah needs a way to let her family and friends know her preferences and needs. Sarah is not using any words but uses her eye gaze, and will often point at preferred items within her reach, but for the most part she depends on her mother to anticipate her needs. Her team has decided to implement PECS as a means of teaching her some consistent communication skills, with an emphasis on initiating. The team suggest that, a communication system that is more generally understood will also better prepare her for preschool next year. The intervention team are aware that, PECS is regularly used in the school setting.

The teaching of PECS does not begin until some initial assessments have occurred. One of the important things that can be overlooked is the establishing of a reinforced hierarchy (Frost and Bondy, 2002).

In preparation for PECS’s training, a preference assessment was conducted to identify the most preferred items for use during PECS (Bondy and Frost, 1994). This first step of assessment was carried out by observing Sarah in a play area and by asking parents and therapists what the child preferred. It is so important to have pictures exchanged for items that the child prefers and not what the adults might want for them to communicate. During the following home visit, Sarah’s speech language therapist on the team follows the reinforced procedure for PECS by presenting items, two at a time, being sure to switch between left and right presentation across trials. Sarah’s mom watches the sampling and takes notes on which items are selected most frequently. Bondy (2001) highlighted that, the use of reinforces virtually immediately after the target behaviour is central for effective teaching. After the session is complete, her mother continues to sample reinforces throughout the week and document the items on a list of preferred/no preferred/ and neutral chart. After repeating this process several days, the therapist and Sarah’s family feel that, they have identified many highly desired items to begin PECS’s training.

To prepare the home for PECS’s digital pictures were taken of the as highly motivating items. They also printed out several copies of each of the pictures on the home computer and save a file of pictures on an external drive in case they needed to replace one. I organised the pictures in a communication book were each page of the communication book is sorted into categories. This way, the entire page can be removed and transported to the location where the items are in the home to encourage more opportunities for exchanges once the team moves to a relaxed training environment.

PECS is generally carried out over the six phases. Phase 1 is commonly called the physical exchange phase, where the therapist works as a communication partner. In this stage, Sarah’s role is to initiate her request for a preferred item and naturally learns the power of engaging in exchange and its consequences. When Sarah looked interested in the item, the therapist gave the child the picture card. Then Sarah was prompted to hand the picture card back to the therapist who after receiving the card, verbalized the request aloud "You want juice! You can have it". At this point, the requested item was given to Sarah. At first Sarah’s tantrums increased when her mom did not respond immediately to her pointing. Her communication helper consistently needs to support her to take the picture and hand it to the communication partner. They create laminated request boards for areas of the house where Sarah might want to ask for things. They put pictures next to the fridge and the pantry, in her toy closet, and in the bathroom. Sarah continues to make exchanges. Every so often, she needs a helper to remind her to initiate an exchange when she is tired. Sarah’s brothers and sisters are strongly encouraged to participate by being communication partners and helpers. Sarah’s family creates opportunities to exchange on shopping trips and out in the community by remembering to bring the PECS book with them on outings.

The second phase of the picture communication system was taught by using shaping. In phase 2, the spontaneous phase where the therapist moves away from Sarah, so that Sarah has to move towards the therapist to place the picture card in their hand. In this phase, there is a focus on reducing the prompts to promote the whole concept of independent communication. Sarah’s team feels confident that, she has learned the physically assisted exchange in Phase 1. They have had success fading the physical assist. Sarah is also using the exchange in a more relaxed environment around the house and out in the community. Sarah’s parents are committed to implementing PECS and the whole family is happy that her tantrums are much less frequent. In order to begin Phase 2, Sarah’s team plans to move the communication book with all of her pictures to a set place in each room of the house. During the training, the therapist comes to work with the family, and they practice having the communication partner move further and further away so that Sarah will have to walk over to that person to give them the picture. Sarah begins to tantrum again and needs support from the helper to carry the picture to the communication partner and place it in their hand. The team works hard to shape Sarah’s behaviour. It is important that that she continues to try and communicate without getting too frustrated. Sarah is consistently removing pictures from her book and placing them in the communication partner’s hand. She has successfully made phase 2 exchanges in many rooms in the house.

During Phase 3 which is called the discrimination training, Sarah was given more than one picture card and she had to choose a preferred object, and then gave that card to the therapist.

Initially, Sarah had a hard time distinguishing between the two pictures; however, eventually she could do that without any difficulty. In phase 4 which is “sentence structure”, Sarah was given a card with the phrase “I want ____” on it. This card now had to be used with the picture card showing what was desired. This was done so that Sarah would learn communication by using complete sentences. Even though Sarah could not yet read, she gradually learnt to recognise the words as sight words on the cards. In Phase 5, Sarah was directly asked “What do you want?” and she had to hand a picture card over. After the five phases, PECS was generalised to more than one therapist, and she was also taught how to communicate her experiences outside of the therapy room

We collectively made a PECS book for the school setting and printed out the reinforce assessment that we continuously compiled and updated. Sarah’s parents share with her school team that they want Sarah to continue working on PECS. The pre-school assures the family that several members of the team are PECS trained. Both teams agree to continue working on PECS and to meet monthly to share progress notes from school and from home. Data charts were utilised in order to track how the variables are addressed in the home and school environment. After the intervention, some speech appeared, but its frequency was low. While Sarah still needs a considerable amount of one-on-one educational support, she will be able to work independently for short periods of time and to interact with peers without much assistance. An important next step for Sarah is to continue to build her vocabulary with pictures in her book.

Conclusion

Autism spectrum disorder is a neurodevelopment disorder that can have a significant impact on an individual’s communication skills. Children with ASD with minimal expressive language require the use of augmentative alternative communication due to their severe communication requirements. Children with ASD often have a variety of social-communication deficits or delays,

which can lead to the inability to communicate functionally. As discussed above, the implementation of the PECS is widely utilised to increase social-communication skills. Several studies indicate that the impact of PECS on children with non-verbal autism on the development of communication skills is remarkable. Promoting communication in students with ASD is likely to improve the quality of life, decrease existing challenging behaviours, and allow the students to opt additional options related to independently interacting with others in the

community. The key to effective teaching is effective staff and parent training in the use of the system (Bondy & Frost, 1994). Though the children with

autism have extreme difficulty to express their feeling appropriately, the PECS can be utilised to help them successfully to communicate their needs while reducing the inappropriate behaviour. I believe that, it is important for everyone to have a mode of communication to effectively share their wants and needs. In my experience, I also found that, by providing children with a mode to communicate what they are feeling, that their inappropriate or challenging behaviours decreased drastically. I find this PECS system is rather different from other alternative communication systems in that it requires the child to initiate communication which I feel is vital. The child initially learns to approach the person and to exchange a picture that they want. This makes the communication more meaningful and rewarding. Chairman et al. (2007) emphasised that, continuous development needs to be monitored but also suggests that; support may be required to sustain newly acquired skills in PECS. PECS actually is a modified behaviour analysis approach to development of a communication system.

Among the concerns that are raised by use of PECS are the issues related to the use of pictures and other visual icons, there will be times when a child seeks to communicate about something not yet in their system.

Kaduk (2017) makes a very interesting point about the need for further study on the effects of PECS that had on children with autism years after initial implementation to determine long-term effects and benefits of using PECS.

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