Post on 05-Aug-2020
PICTURE EXCHANGE COMMUNICATION SYSTEM (PECS) –
REDUCING SELF-INJURIOUS BEHAVIOUR IN INDIVIDUALS WITH
AUTISM SPECTRUM DISORDER
By
SIMONE THERESA ELLEN BOURASSA
Integrated Studies Final Project Essay (MAIS 700)
submitted to Dr. Paul Kellogg
in partial fulfillment of the requirements for the degree of
Master of Arts – Integrated Studies
Athabasca, Alberta
April, 2014
Picture Exchange Communication System (PECS) – Reducing Self-Injurious Behaviour
in Individuals with Autism Spectrum Disorder.
ABSTRACT
Deficits in communication are characteristic of individuals with Autism spectrum
disorder and developmental disabilities. These deficits can impede their social
interaction, prevent inclusion in educational settings and inhibit their daily living skills.
An inability to communicate effectively with the environment can also predicate
challenging behaviour such as self-injury. These challenging behaviours can be
permanently physically damaging, socially inhibiting and continue through entire
lifetimes. Previous research has supported the use of strictly behaviour-based
interventions in reducing challenging behaviours. More recently research suggests that
challenging behaviour serves a communicative function, thus studies have begun to
explore the possibility of using speech and language-based interventions to reduce the
incidence of such behaviour. This study reviews the literature surrounding the
effectiveness of the applied behaviour analysis (ABA) based assessment tool, functional
behaviour assessment (FBA), in the reduction of self-injurious behaviour in autism. It
also reviews research which supports a language/communication-based intervention,
picture exchange communication system (PECS), for effectively reducing self-injurious
behaviour (SIB). The research question posed is: Is the use of Speech and Language
Pathology based intervention, the augmentative communication tool, picture exchange
communication system (PECS), effective in reducing the occurrence of self-injurious
behaviour in non-verbal individuals with Autism or developmental disabilities when used
in conjunction with the Applied Behaviour Analysis based Functional Behaviour
Assessment? The paper proposes an interdisciplinary approach, combining FBA with a
PECS intervention to successfully reduce self-injurious behaviour in individuals with
autism and developmental disabilities.
TABLE OF CONTENTS
Introduction ......................................................................................................................... 1 Literature Review............................................................................................................ 3
Behaviour Analysis Perspective ......................................................................................... 4 Speech and Language Perspective ...................................................................................... 6
Summary ......................................................................................................................... 9 Interdisciplinary Approach ........................................................................................... 12
Conclusion ........................................................................................................................ 13 References ......................................................................................................................... 15
Introduction
Many children diagnosed as being on the Autism Spectrum, struggle with
communication skills – skills which come naturally to neurologically typical children. It
is typical for this developmental disorder to be characterized by deficits in
communication both receptively and expressively. Poor communication skills are also
associated with challenging behaviour including self-injurious behaviour (SIB) (Park
2012). It is because of these delays in communication that the Picture Exchange
Communication System (PECS) has been developed (Bondy & Frost 2002).
Augmentative communication and devices such as the PECS system, the use of computer
programs, and Apple IPAD applications have often been used to assist with
communication for those on the Autism Spectrum. Often, augmentative communication
devices can reduce frustration and anxiety in the individual on the Autism Spectrum thus
resulting in less incidence of challenging behaviour (Weiss & Harris, 2001).
My practice as a behaviour consultant is based on the principles of Applied
Behaviour Analysis (ABA). When analysing challenging behaviour, ABA dictates that a
functional behaviour analysis (FBA) is required to determine the function of the
behaviour (Cooper et al, 2007). Typically, behaviours serve an escape or access function
whether it is for attention, sensory stimulation, preferred/un-preferred activities, and
tangible items or people (Cipani & Schock, 2007).
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At a recent conference on autism, the key note speaker, Jo Lynn Mullins – a
Board Certified Behaviour Analyst at the Institute for Applied Behaviour Analysis of Los
Angeles – indicated that this standard FBA is missing a key component: the awareness
that challenging behaviour is always serving a communication function (Matson 2009).
This progressive take on a traditional assessment tool was confirmation of what I had
suspected in my practical work. ABA theory dictates that if the behaviour serves an
attention seeking function we must render the behaviour ineffective in achieving its
function. I understand and agree with the logic behind this theory and in most situations it
is effective and easy to implement. This is not the case with SIB. I have employed a
number of different interventions based in ABA some of which have been effective, some
of which have been less effective. I have noticed that often SIB is exhibited as a form of
communication in individuals who are non-verbal or have limited oral language skills. It
is for these reasons I pose the question: Is the use of SLP based intervention –
augmentative communication tools (PECS) – effective in reducing the occurrence of
self-injurious behaviour in non-verbal individuals with Autism or developmental
disabilities when used in conjunction with the Applied Behaviour Analysis-based
functional behaviour assessment? Can we solve a behavioural problem with a language
intervention? Is self-injurious behaviour really behavioural communication? In an
attempt to answer this question, this paper will provide a thorough literature review and
analysis of current research from both Applied Behaviour Analysis and Speech and
Language Pathology disciplines.
PECS-Reducing Self-Injury in Autism
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Literature Review
There exists a wealth of literature and research surrounding the efficacy of the
PECS protocol to teach a functional communication system which can increase
communication and language acquisition in individuals with developmental disabilities,
intellectual disabilities, and Autism Spectrum Disorder (Ganz 2009, Bondy & Frost
2002). The effect of PECS on the reduction of challenging behaviour, such as self-injury,
is a field of limited empirical evidence and research (Ganz 2009, Frea 2001). Conversely,
the study of Functional Behaviour Assessment (FBA) in determining the maintaining
factors of challenging behaviour and self-injury is rich with empirical support (Iwata
1994, Cooper & Heron 2007, Cipani & Schock 2007, Radstaake 2013). In my
professional experience, the use of FBA alone (or other ABA based interventions for the
reduction of the challenging behaviour, self-injury) is not an effective method on its own
(Frea 2001, Durand 2001). The following is a review of current literature and research
from both the fields of Speech and Language Pathology (SLP) and Applied Behaviour
Analysis (ABA) which provide quantitative evidence showing a positive correlation
between the use of augmentative communication devices, and/or functional behaviour
assessment and the reduction of self-injurious behaviour in nonverbal individuals with
Autism or other developmental disabilities to support the combined use of FBA and
PECS in the effective reduction of challenging behaviour, specifically SIB. The literature
review will cover literature which examines the effectiveness of behavioural
interventions for reducing challenging behaviours, the use of interventions which stem
from the field of speech and language pathology, and those which combine the use of
PECS-Reducing Self-Injury in Autism
4
both behavioural and communication interventions, how they pertain to the proposed
study and support its significance.
Behaviour Analysis Perspective
The behaviourist perspective for dealing with challenging behaviour, such as self-
injury, maintains that a functional behaviour assessment is required to determine the
potential function that a behaviour is serving. Cooper & Heron (2007) propose it as the
preliminary assessment tool to be accessed when addressing problem behaviour, and
suggest that it is from the results of such an assessment that an appropriate behavioural
intervention will be developed. Cipani & Schock (2007) note that a functional
assessment typically yields four categories of perceived behaviour function: direct access,
socially mediated access, direct escape, and socially mediated escape. They go on to
describe behaviour function as the capacity of the behaviour to enable the individual to
get what he or she desires through immediate and unassisted access to an item, person, or
event; through access with the assistance of another person (e.g., Mother giving a child
the desired toy); through immediately and independently withdrawal of themselves from
a situation, from an item or a person; or through withdrawal of themselves via the
assistance of another person (e.g., a crying child being removed from a grocery store by a
parent). Cipani & Schock propose that the intervention to be implemented be based on
which perceived function the challenging behaviour is serving for the individual. Their
rationale for this is the concept that when the function of a behaviour is being reinforced,
the behaviour continues or increases. In order to decrease behaviour (according to applied
behaviour analysis) Cipani & Schock say that all reinforcement of the behaviour and its
function must stop. In other words, they are saying that by withdrawing reinforcement, or
PECS-Reducing Self-Injury in Autism
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preventing the behaviour from achieving its desired purpose the behaviour will no longer
be functional to the individual and thus, the individual will have no reason to engage in
the problem behaviour. Functional behaviour assessment has been proven to be an
effective tool in the evaluation of self-injurious behaviour. This tool can assist
professionals in ascertaining if the individual is more likely to engage in self-injury
during certain environmental conditions (Iwata et al., 1994). These authors suggest that
demand conditions (to escape a task or demand), play conditions when toys are not
present (to access toys), or conditions of social attention (to access, or escape attention)
can provide insight into what is reinforcing the behaviour and thus, recognition of what
behaviour to avoid reinforcing. Danov et.al. expand this concept outlining that
behavioural interventions based on the function of the problem behaviour, determined
through FBA, have been successful in their application to individuals with ASD
exhibiting SIB (Danov et.al. 2010). Danquah et. al. discuss strong evidence for
behavioural explanations in treating SIB (Danquah et.al. 2009). Much of the research
indicates that the cause of the challenging behaviour is best determined by completing a
FBA, which can allow for effective selection of an appropriate intervention (LaRue et. al.
2008)
Although the behaviour analysis perspective and functional assessment is
effective in determining the function of a behaviour according to the four categories
described by Cipani & Schock (2007), it does not explore specifically the potential
communicative function of self-injurious behaviour. However, Maurice & Green (1996)
suggest that determining the perceived function of a self-injurious behaviour through
functional behaviour assessment enables interventionists and those working with
PECS-Reducing Self-Injury in Autism
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individuals on the Autism Spectrum to implement behaviour-based interventions which
are effective in the reduction of most problem behaviours including those which are self-
injurious.
Speech and Language Perspective
Augmentative communication systems have been examined as a potential
intervention for the reduction of problem behaviour (Durand & Merges, 2001; Charlop-
Chrisy, 2002). Durand and Merges demonstrate that the use of such systems, including
picture exchange communication system (PECS), are effective in the acquisition of
language for children with Autism and also in reducing problem behaviour. Charlop-
Chrisy, in a study focusing primarily on the acquisition of speech in play and academic
settings with the use of PECS as an augmentative communication system, showed that
ancillary gains associated with increases in social-communicative behaviours and
decreases in problem behaviours were achieved. While they did not implement PECS as
an intervention specifically to reduce the problem behaviour, the association is made that
problem behaviour can decrease by increasing communication.
The PECS system was developed by Bondy and Frost and presented in their book,
A picture’s worth: PECS and other visual communication strategies in autism (2002).
They explain how to develop and implement a PECS system as a means to increase
communication and language acquisition in children who are developmentally delayed in
this area. They outline their system as a speech and language tool to improve
communicative ability but do not identify PECS as a tool for reducing challenging
behaviour. Tincani (2004) compares sign language and PECS, both augmentative
PECS-Reducing Self-Injury in Autism
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communication systems designed to improve a child’s ability to communicate, and
determines that both of these augmentative communication methods are effective.
Weiss and Harris (2001), in their text, Reaching out, joining in: Teaching social
skills to young children with autism, discuss the benefits of PECS and augmentative
communication systems for the integration of children with autism into social groups and
interaction with peers. They examine the advantages of having such a system in place to
assist children with autism to communicate effectively with others in their environment.
Weiss and Harris assert that the ability to communicate effectively can reduce isolation—
isolation which can lead to anxiety and stress. Further, they suggest that augmentative
communication systems, such as PECS, are useful in achieving reductions in isolation,
anxiety and stress. Since anxiety and stress can influence the occurrence of challenging
behaviours, including self-injurious behaviour.
Park et.al. (2012) investigate the relationship between language skills and
behaviour problems in pre-schoolers with autism. Their results demonstrate that there
was a relationship between receptive communication skills and the exhibition of
challenging behaviour. Indicating interventions targeting communication skills may lead
to a reduction in challenging behaviour.
A larger sample size study by Matson et. al. (2009) supports the findings of Park
et. al. (2012). Matson and colleagues’ results indicate lower levels of receptive
communication alone significantly correlated with higher levels of multiple topographies
of challenging behaviour, with SIB correlating highest, in children with Autism. The
PECS-Reducing Self-Injury in Autism
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findings of both of these studies indicate that there is a communicative function of
challenging behaviour and SIB.
The use of PECS has been demonstrated to be effective in the reduction of
challenging behaviour of a child with Autism (Frea et. al. (2001). In this particular case
functional behaviour assessment was used, but it alone did not differentiate any clear
communicative functions of the behaviour. Despite this fact, PECS was introduced and
found to be effective in reducing the challenging behaviour. The results support the
proposition that enhanced communication needs to be a primary goal for individuals with
challenging behaviour.
When evaluating the effectiveness in reducing SIB two communicative response
modalities were compared in the Danov et. al (2010) study of a child with Autism. The
authors found that SIB was eliminated during functional communication training sessions
with the use of picture cards (PECS), not verbal speech. These results promote the use of
PECS over verbal speech prompting when implementing function communication
training to reduce SIB.
Durand & Merges (2001) identify the importance of adopting a communicative
metaphor as a model for problem behaviour in their single subject study of a child with
Autism who engaged in SIB. Prior to the study a number of behaviour based
interventions (DRI, time-out from positive reinforcement, restraint) had been used to
reduce the challenging behaviour, with no long-term success. The authors outline that
these behaviours are not simply responses which require reduction and elimination, but
that they can be in fact methods in which the individuals are attempting to communicate
PECS-Reducing Self-Injury in Autism
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through behaviour. They suggest that attempting to eliminate challenging behaviours
through some reductive technique leaves the individuals without a means to communicate
needs and desires. Durand and Merges posit that other maladaptive behaviours also
known as “symptom substitution” or “response covariation” would be substituted for the
original challenging behaviours. In their study, the subject was taught to use an
augmentative communication device to communicate. As a result his SIB was reduced
dramatically.
Summary
A behavioural perspective maintains that functional behaviour assessment and
behavioural interventions are effective in the reduction of problem behaviour (Cooper &
Heron, 2007; Cipani & Schock, 2007; Danov et. al. 2010; Danquah et. al. 2009; LaRue
et. al. 2008; Iwata et al, 1994; Koegel et. al, 2009; Maurice & Green, 1996). A language
perspective maintains that augmentative communication strategies, such as PECS are
effective in increasing language and improving communication as well as reducing
challenging behaviour (Bondy & Frost 2002; Charlop-Christy et. al, 2002; Danov et. al,
2010; Durand & Merges 2001; Frea et. al. 2001; Koegel et. al 2009; Matson et. al. 2009;
Park et.al. 2012; Tincani 2004; Weiss & Harris 2001). These studies also indicate that
the ability to communicate effectively can reduce stress and anxiety, which potentially
can trigger problem behaviour. With increased capacity for communication as a result of
using an augmentative communication system, problem behaviours have been observed
to decrease (Charlop-Christy et. al, 2002; Danov et. al, 2010; Durand & Merges, 2001;
Frea et. al. 2001; Matson et. al. 2009; Park et.al. 2012; Weiss & Harris, 2001).
PECS-Reducing Self-Injury in Autism
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Research is limited but growing surrounding preliminary assessment of
challenging behaviour using both Functional Behavioural Analysis and the
implementation of a communication-based intervention such as PECS. This
interdisciplinary approach of combining the elements of the ABA and SLP disciplines is
proving to have successful results in reducing challenging behaviour such as SIB,
although further research is needed.
LaRue et. al. (2008) discuss the role of speech and language pathologists and
behaviour analysts in serving individuals with autism via functional communication
training (FCT). In their review, the authors suggest a collaboration of the two professions
for an integrated approach which promotes comprehensive programming and quality of
services provided to individuals with Autism who exhibit challenging behaviour. They
discuss the use of FBA to determine the function of a behaviour thus allowing
practitioners to teach the learner to achieve the same reinforcement, previous attained by
challenging behaviour, using an adaptive form of communication (LaRue et. al. 2008).
They suggest that by first conducting an FBA, the communication response can be
matched to the function of the challenging behaviour (e.g. requests for attention, escape,
etc.).
In further support of the use of FBA in conjunction with a communication
intervention such as PECS in the reduction of challenging behaviours, is the research
presented on functional communication training by Durand & Merges (2001). In their
study an FBA was conducted initially for the subject with Autism who exhibited SIB.
Following the FBA the authors implemented an augmentative communication system to
provide the individual with a form of communication other than the demonstration of
PECS-Reducing Self-Injury in Autism
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SIB. In this case SIB was reduced dramatically following the FBA and the
communication based intervention. The results of this study demonstrate the
effectiveness of an integrated SLP & ABA approach to challenging behaviour,
specifically SIB.
Any discussion of the implementation of a communication intervention in
conjunction with FBA of challenging behaviour raises the question of which form of
communication based intervention is best arises. The evaluation of two communication
modalities presented by Danov et. al. (2010) assists in answering this question. The
results of their study indicate that the use of a picture exchange based intervention
(similar to that of the PECS protocol) is more effective in the reduction of SIB than is a
verbal speech modality. Their research supports the use of a picture system over other
forms of communication interventions for reducing SIB in individuals with Autism.
In the research presented by Radsaake et. al. (2013), classroom teachers used
FBA procedures to identify the communicative functions of challenging behaviour
presented by three children with Angelman syndrome. PECS was introduced as an
intervention for SIB of one of the study subjects following the FBA. Results indicate that
the use of FBA to determine to communicative function of the challenging behaviour
combined with the PECS intervention was successful in significantly reducing the SIB.
This study provides additional support for the interdisciplinary approach of FBA used in
collaboration with PECS protocol as an intervention for SIB for individuals with
developmental and intellectual disabilities.
PECS-Reducing Self-Injury in Autism
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Interdisciplinary Approach
This research comprises elements of two disciplines—speech and language and
behaviourism or applied behaviour analysis. It poses a behaviour question and proposes
a speech and language solution. How can we reduce self-injurious behaviour? That is a
behavioural question. Will PECS reduce this behaviour problem? That potential solution
stems from the field of speech and language rather than the applied behaviour analysis
aspect of behaviourism. Functional behaviour analysis is a tool embedded in Applied
Behaviour Analysis, the augmentative communication tool, PECS, finds its roots in the
field of speech and language.
Interdisciplinary research is defined as “any study or group of studies undertaken
by scholars from two or more distinct scientific disciplines. The research is based upon a
conceptual model that links or integrates theoretical frameworks from those disciplines,
uses study design and methodology that is not limited to any one field, and requires the
use of perspectives and skills of the involved disciplines throughout multiple phases of
the research process” (Aboela et.al. 2007). Since this paper draws from both the Speech
and Language Pathology discipline and the Applied Behaviour Analysis discipline, by
reviewing the use of an intervention from both (functional behaviour assessment and
augmentative communication tools) in combination as a new intervention for self-
injurious behaviour (which is typically managed with an intervention based in applied
behaviour analysis only) this research topic provides a useful base of information for
further research for the field of Interdisciplinary Studies.
PECS-Reducing Self-Injury in Autism
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Conclusion
As outlined by LaRue et al. (2008) a significant and primary concern for
individuals with Autism and other developmental disabilities is the existence of
significant communication deficits, which place these individuals at risk for poor
outcomes such as maladaptive or challenging behaviour. Specifically self-injurious
behaviour is of particular concern as it can interfere with academic and social integration
as well as cause serious permanent physical harm. If these behaviours are not assessed
and the appropriate intervention is not implemented they can escalate and continue
throughout a lifetime (Danquah et. al. 2009). As demonstrated through the literature
review there exists significant evidence to support the use of an interdisciplinary
approach to managing and reducing self-injurious behaviour in individuals with autism
and developmental disabilities. As presented in much of the literature the effectiveness of
FBA alone has not proven as effective in reducing challenging behaviours as previously
thought. In fact, these behaviours are often exhibited as a form of communication. By
analyzing the potential function of such behaviours with FBA, professionals can target
specific communication modalities to replace the communicative function of the
challenging behaviour. This is a new form of intervention appears to be more effective
than the behaviour based interventions such as differential reinforcement, time-out from
reinforcement, etc. which have been considered to be most effective in addressing SIB.
As the field of interdisciplinary studies grows, specifically with respect to this research,
the quality of service and effectiveness of interventions specific to individuals with
autism or developmental disabilities will also grow and improve.
PECS-Reducing Self-Injury in Autism
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Much research is needed in the expansion of the interdisciplinary ideas proposed
in this paper. Many of the studies presented had small sample sizes, and not all the
behaviours evaluated were specifically self-injurious. This decreases the validity of the
research results relative to the question posed in this research paper. It is suggested that
future research with a specific focus on the mitigation of self-injurious behaviour might
prove valuable to both disciplines. However it must be said that the potential of this new
and growing interdisciplinary field of research presents encouraging preliminary results
for families of individuals with autism or developmental disabilities who engage in self-
injurious behaviour, the individuals themselves, the disciplines of speech and language
pathology and applied behaviour analysis, the practitioners who work within each field,
and educators and service providers who work directly with those individuals.
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Keywords
Autism spectrum disorder, Self-injurious behaviour, Picture exchange communication
system, Speech and language, applied behaviour analysis, functional behaviour analysis