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									                               INCORPORATING SIGN LANGUAGE WITH PECS 1

Incorporating Sign Language with the Picture Exchange Communication System


                              Ashley Stevens

                         Arizona State University
                                      INCORPORATING SIGN LANGUAGE WITH PECS 2


       For many non-verbal children with an autism spectrum disorder (ASD),

communication is one of the toughest areas to teach. These children are easily

irritable, self-injurious and if speech does not develop, it can be limited to echolalic

and unusual productions. The aim of this demonstration lesson was to incorporate

both American Sign Language (ASL) and the Picture Exchange Communication

System (PECS) into one coherent communication intervention. While this

intervention is limited to students who have been exposed to PECS previously, it

does show great promise that the two ways of communicating can be used together

to form a more effective and universal communication platform for the student.
                                     INCORPORATING SIGN LANGUAGE WITH PECS 3

  Incorporating Sign Language with the Picture Exchange Communication System


       Autism is a neurodevelopmental disorder that affects 1:110 children today

(Center for Disease Control and Prevention {CDC}, 2009). Autism is characterized by

deficits in communication, social interaction and restrictive and repetitive behaviors

(American Psychiatric Association, 2000). Impairments in communication can

include “a delay in or total lack of, the development of spoken language” (American

Psychiatric Association, 2000). Additionally, it has been said that approximately

one-third to one-half of children on the spectrum will not have functional speech at

all (Preston & Carter, 2009) and that approximately 50% of children diagnosed with

autism will not develop functional language as adults (Tincani, 2004). As

communication plays a vital role in our interactions with others, it is an important

skill to teach those on the spectrum who are lacking in this area.

       Augmentative and alternative communication systems (AAC) are used to

replace or enhance emerging communication skills (Ganz & Simpson, 2004). There

are two types of AAC systems, aided and unaided. Aided systems are ones in which

additional materials are required for implementation whereas unaided systems

require no additional equipment (Ganz, 2004). The Picture Exchange

Communication System (PECS) is an example of an aided AAC. American Sign

Language (ASL) is an example of an unaided AAC. Both systems show positive

results in teaching non-verbal children on the spectrum how to communicate

(Tincani, 2004).
                                      INCORPORATING SIGN LANGUAGE WITH PECS 4

       Sign language is best taught to non-verbal children on the spectrum who are

able to imitate and have only limited problems in fine motor skills (Ganz, 2004).

There is empirical evidence that shows that teaching signs and speech productions

simultaneously increases the child’s potential for communication in children with

autism (Tincani, 2004) (See Frame 3). Sign language is usually taught as a means of

requesting for the child and as such, should be paired with reinforcement (Vail,

2008). Sign language is also seen to be more effective in the development of speech

(Silverman, 1996). This is thought to be true as sign language, like speech, is a

“topographic form a communication”. This means that each word demands a

different behavior (movement of the tongue, posturing of the hands, fingers, ect)

and that this more complex nature of sign language is a more natural transition into

speech (Silverman 1996).

       PECS is a picture based intervention that was developed for children with

deficits in social-communication (Charlop-Christy, 2002). Through the use of basic

behavioral interventions such as shaping and transfer of a stimulus after delay, PECS

uses the pictures as a basis for communication (Charlop-Christy, 2002). The child is

taught to use the PECS board to create “sentences” using the picture cards. There

are three major benefits to using the PECS system: first, it requires very few

complex motor skills of the participant and the adult does not need to learn an

additional language like ASL (Charlop-Christy, 2002); second, the system is fairly

low-cost and easy to learn; third, the first skill taught in PECS is requesting which

has been targeted in early language development due to the high motivational levels

(Preston, 2009) (See Frame 2). Additionally, a review of the literature on PECS
                                      INCORPORATING SIGN LANGUAGE WITH PECS 5

conducted by Preston and Carter (2009) showed that PECS is easily learned by most

participants and “provides a means of communication for individuals with little or

no functional speech” (Preston, 2009, p.1471).

       By design, PECS is intended to teach requests or mands before labels or tacts

(McCoy, 2009). As stated in the lesson discussion, Schantz said “You are so right that

giving students ways to communicate is so important” (August 4, 2011). The child is

taught that communication is rewarding as they are immediately given an item of

desire (McCoy, 2009). Another benefit to the PECS intervention is that it uses visual

means instead of auditory for communicate (McCoy, 2009). It is widely known that

individuals on the autism spectrum often display deficits in verbal skills but have

advanced visual skills (McCoy, 2009). Interventions that play off of this knowledge

often have greater success in children on the spectrum. Additionally, as stated in the

lesson discussion, “The one thing that can be helpful with PECS is that it can be

designed to fit the student (different styles of folders, clipboards, wallets to carry

their photos).” (Schantz, August 5, 2011). PECS is also very natural and some

teachers have been known to say that “ I have used aspects of PECS with children

with autism without even knowing it” (Sanchez, August, 8, 2011).

       While both systems have their advantages and their disadvantages, it is

unlikely that one single system is best for the diverse needs of all children with

autism and as with all interventions, the individual needs of the child should be

assessed before choosing a single system. In the lesson discussion, Tse stated “While

I have to admit that I have never been a huge fan of PECS because of it's limitations

(e.g., PECS book needs to be taken everywhere, the amount of time it requires for a
                                      INCORPORATING SIGN LANGUAGE WITH PECS 6

learner that has many pages of acquired icons to find a specified picture, etc.), your

paper has helped me realize that even if it is not the most ideal form of

communication, it is definitely a stride in the right direction. ‘The research on

functional communication has shown that when a child has a mechanism to use for

communication, whether it is a manual sign, a spoken word, or another method, it

can replace the function of the behavior problem and thus decrease or eliminate its

occurrence’ (Charlop-Christy & Jones, 2006, pp. 106). “ (August 4, 2011). To me, Tse

summed up a perfect reason for implementing a second form of communication

with the PECS intervention. In a study conducted by Tincani (2004), the PECS

system was compared to sign language training in two elementary school students

with autism. He found that in one child, sign language training proved to be more

beneficial, whereas in the second child, the PECS training gave greater results

(Tincani, 2004). These results showed that acquisition of both PECS and sign

language depends on the needs of the individual child (Tincani, 2004).

       Through the use of both the PECS intervention and sign language, the

interventionist is able to get the child to attend to their face and mouth (Libling,

2000) by encouraging eye contact and also increase imitation skills through the use

of signs. The interventionist can also use the verbal outputs as an opportunity to

select a new intonation to encourage correct pronunciation (Libling, 2000). These

skills are vital for later effective social communication and the earlier in the

intervention the child is exposed to them, the more encouraging future

communication will be.
                                       INCORPORATING SIGN LANGUAGE WITH PECS 7

       Social communication is vital to development as it promotes inclusion of the

child into the community. According to Renzaglia (2003), “inclusion is a philosophy

that urges schools, neighborhoods, and communities to welcome and value

everyone, regardless of differences” (p. 140). It’s main goal is to “create a life that is

both satisfying and successful for a person with a disability” (Renzaglia, 2003,

p.141). Having a means of communicating with a wide variety of people will

encourage inclusion in the community for the individual.

       This lesson aims to show you how the PECS intervention and sign language

can be used together as a single means of communicating for an individual with

autism. While many parents struggle with the choice between PECS and sign

language as an intervention means, this intervention allows more advanced PECS

users to then incorporate sign language into their communication repertoire and

hopefully lead more naturally to speech production.


Participant and Setting

       One six year, 11 month old, Caucasian female with an autism spectrum

disorder (ASD) was used as the focus of the intervention. This student was first

diagnosed with ASD at the age of 2 years 9 months by a pediatrician and further

confirmed by a child psychiatrist at 3 years of age. The diagnosis was made

according to the Diagnostic and statistical manual of mental disorders (DSM-IV)

(American Psychiatric Association, 2000). This student’s ASD is co-morbid with

epilepsy, celiac disease and has severe language delay.
                                      INCORPORATING SIGN LANGUAGE WITH PECS 8

       At the time of the intervention, the students verbal capability was limited to

3 single words “all done” and “go”. These three words are not easily understood by

those outside of her immediate family or therapy team. Additionally, she has been

using approximately ten signs on a regular basis. These signs are: more, open, eat,

drink, candy, push, help, thank-you and play. This student began a PECS program

three years ago and while she has not yet moved past level 3, she is fluent in level 3

skills. She is encouraged to use the sentence structure of level 4 but this is prompted

on seventy percent of occasions. The student has excellent eye contact and joint

attention skills.

               The setting for the intervention was an in-home applied behavior

analysis (ABA) program. The student had sessions with the interventionist three

times a week for 90-minute sessions. This natural setting is consistent with the ideal

environment for teaching both PECS and sign language (Ganz, 2004).

Baseline Assessments

       Before beginning the intervention for the data collection period, a baseline

assessment was conducted using a Functional Behavior Assessment (FBA) and a

Preference Test (PT). It was decided by the current therapy team that we would

focus on decreasing self-injurious behaviors as these tend to be a product of

frustration when the student is unable to communicate her wants and needs. We

then defined self-injurious behaviors are those behaviors in which the student bites,

hits or picks at herself including, but not limited to, her hand, arm, foot, or lip. We

also included head-banging though this behavior has been extinct for some time

now. The results of the FBA are shown in table 1.
                                             INCORPORATING SIGN LANGUAGE WITH PECS 9

Table 1. Self Injurious Behaviors

Session                              Bite    Hit   Pick   HB

Monday                               2       3     0      0

Wednesday                            4       3     1      0

Friday                               1       5     0      0

                 Average: 2.3       3.6     .33    0

          A PT was also given daily. The student was given a choice of three known

favorite treats and activities via pictures of each of these. The student selected her

reinforcer for the day and placed it on her picture schedule in the spot marked

“students choice”.


          A standard three-ring binder adorned with Velcro strips was used for the

PECS portion of the intervention (See Frame 6). The binder is composed of pages

filled with various 1” x 1” color photos. The photos are a mix of actual photos from

an instant camera as well as images from the Picture Communication Symbols

Communication Book (Mayer-Johnson Company, 1994). On the front of the binder is

the picture schedule which uses the PECS photos to compose a schedule for other

ABA therapies. For this particular intervention we only used the picture schedule as

a means of placing the cards for the participant to use. See Table II for a complete

description of the phases of PECS (See frames 4-5).
                                              INCORPORATING SIGN LANGUAGE WITH PECS 1

Table II. Phases of PECS as Described by Frost and Bondy (2001)

Phase                                                                       Description

Reinforcer assessment                                  Informally offering the student a number of items or
                                                       foods to determine which are more highly preferred.
1: Basic Picture Exchange                              The student is required to approach an adult, give
                                                       him or her a picture, and receive the preferred item.
2: Increasing Distance                                 Student is taught to retrieve a picture from their
                                                       communication binder which had been moved away
                                                       from them, walk to a communicative partner, and
                                                       persist in handing the picture to the communicative
3: Picture Discrimination                              Two items, one preferred by the participant and one
                                                       non-preferred, are presented to the participant and
                                                       corresponding pictures are placed on the front of the
                                                       PECS binder.
4: Sentences                                           The student is taught to take a sentence starter (ex. “I
                                                       want”) from the PECS binder and place it on a
                                                       sentence strip. They are then taught to follow this up
                                                       with a preferred item and exchange the entire
                                                       sentence strip for the item.
5: Responding to “What do you want”                    The student is able to request a variety of items in
                                                       response to the question “what do you want”
6: Responsive and Spontaneous Communication            The student can answer additional questions such as
                                                       “what do you see” and “what do you have”


         During natural play, the PECS binder was placed within reach of the student.

During the data collection period, trials were conducted at 20 per session and

mastery was considered met at 80% of the trials performed for 3 sessions (See

Frame 7).

         As the student had been using PECS quite fluently for a few years, she knows

how to open the binder when asked “what do you want” (Phase 4) (Frost and

Bondy, 2001) and scan the pictures to select her activity. After completing a few

shoebox tasks, the student was asked to select her reinforcer. She was given the

choice of a favorite snack, her swing and a book. The student scanned the pictures

and selected the snack from the book and handed it to the interventionist. Once the
                                      INCORPORATING SIGN LANGUAGE WITH PECS 1

picture was handed over, the interventionist signed the word on the card (eat was

used for food of any kind) as well as said the word “eat” verbally. The child is then

taught the sign using hand over hand to help position their fingers and hands

correctly. Again, the word is produced verbally and through the sign (See Frames 7-

9). Eventually, time delay is then used to wait for the student to imitate the sign. If

the sign is not imitated after a few seconds, the interventionist prompted with

“(insert students name) does it! Eat” and signs the word again. Once the sign was

imitated by the student, the interventionist handed over the reinforcer (the favorite

snack) and verbally praised the correct trial. If the student required hand over hand

or prompting, it was not considered a completed trial for data collection sake.

       The ideal target for this intervention is someone who has been exposed to

PECS training and has mastered the first three levels at a minimum. This makes the

integration of sign language training and PECS more natural and less confusing for

the student. It is also important that the verbal responses continue to be a part of

both the PECS and sign language training. Once the card is handed over to the

interventionist it should immediately be followed by signing and verbally saying the

word. Results of the intervention are listed in Table III and Table IV.
                                                   INCORPORATING SIGN LANGUAGE WITH PECS 1

Table III. Signs imitated spontaneously during intervention

Session    Sign Imitated                   Speech samples

1           “eat”                           None
            “candy”                         “guh” (known for gum)
            “play”                          None
            “open”                          None
2           “eat”                           None
            “block”                         None
            “candy”                         None
            “push”                          “puh” (known for push)
            “open”                          None
            “help”                          None
3           “help”                          None
            “drink”                         None
            “eat”                           None
            “close” *                       None
*this sign was taught for the first time this week and was used spontaneously during the third session

Table IV. Self Injurious Behaviors Post-Intervention

Session                                Bite     Hit     Pick     HB

1                                      1        2       2        0

2                                      1        1       0        0

3                                      2        0       1        0

                  Average:           1.3       1        1         0


          As Table IV shows, self-injurious behaviors seemed to be at their lowest

frequency, the more the student was communicating with the interventionist. The

results from this week of data collection showed great promise for the addition of

future signs into the child’s repertoire. For this particular student, we are trying to

increase the amount of verbal productions she does and we are doing this by

encouraging them while signing. She is also rewarded for any spontaneous verbal

production that has communicative intent. Her therapy team has defined

communicative intent as those verbal productions that are similar in sound to the
                                        INCORPORATING SIGN LANGUAGE WITH PECS 1

actual word (ie- “guh” is known to be a verbal production meaning gum). During this

week of data collection, the sign for “close” was introduced for the first time to the

student. This sign was chosen because the student already uses open when asking

for a new toy or to open a door so we thought the natural transition from open

would be to close. As the signs are so similar, the student picked up on the new sign

fairly quickly and used it on her own by the final session of the week. This is very

encouraging for the therapy team who previously had set a goal of adding one new

sign a week to the student’s lessons.

Limitations and Future Expansions

       As mentioned previously, this intervention is best used on children who have

been exposed to PECS previously and are able to discriminate between pictures to

choose the item of interest (See Frame 10). This is not a first step intervention as it

combines two different forms of communication into one. While some children

might be able to pick up both at one time, for most children this would be confusing

and might lead to a decrease in communication.

       This intervention, like both PECS and sign language individually, has optimal

outcome when it is used in a natural setting. The intervention should become part of

the child’s daily routine and every adult that interacts with the child on a regular

basis should be taught how to effectively execute the intervention.

       This intervention, like sign language and PECS is though of as a means of

producing word utterances in children with ASD. This intervention should be

thought of as long-term and should continue to evolve as the child picks up on the

new signs and begins to produce verbal utterances.
                                    INCORPORATING SIGN LANGUAGE WITH PECS 1

       The results of this week of data collection showed positive effects and thus

other in-home ABA therapy teams should consider this intervention as a possible

AAC system. This intervention has great potential for positively impacting the verbal

outputs of non-verbal children with ASD.
                                    INCORPORATING SIGN LANGUAGE WITH PECS 1


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