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While blind assessments were not conducted at Site 2, there were no across-site differences in scores by group or time period across the sites. Results are summarized in Table 2. A per protocol analysis was followed, resulting in the exclusion of the two participants who were initially enrolled in the study but discontinued. No data beyond pre-treatment assessments were available for either participant.
Type I error probability was maintained at. Main and interaction effects of time and treatment condition were analyzed.
Means by condition and time period are listed in Table 2. The frequencies for each category by condition are available from the authors. For each dependent measure, a main effect of time indicated improvement in child behavior in areas of spoken language, adaptive communication, and spoken vocabulary.
When collapsed across conditions, gains on each of these assessments from pre-treatment to post-treatment to follow up were statistically significant. In many cases, effect sizes were quite large, especially for vocabulary, the main target of the intervention. There was no main effect of treatment type for any assessments. Standard deviations were quite large for a majority of measures indicating a heterogeneous set of individual response patterns in both conditions.
Of the 19 children in the PECS condition, 12 reached Phase 6, that is, they had mastered requesting and were learning to comment using pictures.
Two children reached Phase 5 responding and attributes , two reached Phase 4 requesting items using a sentence strip , two reached Phase 3 learning to discriminate pictures , and one reached Phase 2. The three children in Phases 2 and 3 were not using spoken language to communicate. Of the children who reached phase 4 or higher, all but four of them one in Phase 4 and three in Phase 6 were reported to have more than 10 words on the CDI.
Of the children who reached Phase 6, five of them had expressive language age equivalent scores on the MSEL of less than 12 months, indicating the possibility that their complexity of communication was higher when using PECS.
Parents were satisfied with the intervention overall, with mean ratings of 5. Overall improvement across all areas of communication, self help skills, and behavior was moderate with mean ratings of 4. Parents rated the general teaching format and usefulness of the program highly at 6. Parents rated the specific intervention strategy difficulty at 5. We conducted analyses of weekly number of hours the participants received other treatment while participating in this investigation.
T-test analyses of speech therapy and occupational therapy PRT: Due to the lack of a usual care control group we cannot draw conclusions regarding the relationship between gains in spoken language and either of the treatment conditions. One intervention modality was not superior to the other. Results indicate that based on mean scores, the 2- to 3-year-old, nonverbal and minimally verbal children in both the PRT and PECS conditions made similar gains in spoken communication.
On average, children gained approximately 80 spoken words across the 6-month study period, although we found extreme variability in the verbal progress of enrolled children. However, this needs to be explored further in future research to examine generalization of skills and use of specific types of communicative functions.
Similar to other studies, e. Parents in both groups were satisfied with the intervention and reported progress in their children. However, parents found PECS to be more difficult to implement in the home. This is in contrast to PRT where materials in the current, natural environment were all that was required.
Reportedly, some parents and practitioners have been reluctant to recommend augmentative communication systems for children with autism, fearful that these systems may interfere with the development of spoken language.
Given the randomized comparison design, these findings suggest that PECS may be as effective as naturalistic verbal language training programs such as PRT for facilitating language. It is noteworthy that PECS did not inhibit growth in spoken language. However, due to the variability in child progress these data also raise questions regarding when to use which methodology. It is hoped future research in this area will assist our efforts to individualize treatment protocols in this area.
As was expected, average change on standardized assessments misrepresented a wide variability of treatment response.
A unique contribution of the present study, as compared to most previous treatment studies, is that many of the participants were under 3 years of age and minimally verbal. Further studies and further analyses of the current data set will examine the specific predictors of positive outcomes in an effort to determine whether child characteristics may indicate differential responding to either intervention. In the only other direct comparison of PECS and a naturalistic behavioral verbally-based approach RPMT , Yoder and Stone a , b found a main effect in favor of PECS for spoken vocabulary measures in a similar sample of participants as the present study.
This contrasts our findings of no difference between the conditions. One possibility is that the participants in the studies differed on some key characteristics object exploration, social initiation, avoidance that were not assessed in the current work. It is also possible that the different measures utilized in the current study i. Given that to date there have been so few randomized clinical trials of these communication interventions it is likely that further research directed at these important questions will yield clarification of these, as well as other, issues.
There are some limitations to this study. As noted above the present study did not include a no-treatment control group. Therefore treatment gains may have been due to development rather than a function of either intervention.
Further research will be necessary in order to address whether gains maintained across time and environments. This study was limited to only nonverbal and minimally verbal young children with autism and therefore may not generalize to children who are verbal at a young age.
A subset of assessments was conducted by coders who were aware of the treatment condition, which represents a threat to the internal validity of the findings. The results of this study suggest that a majority of young, nonverbal or minimally verbal children with autism will learn to use spoken language at a young age. This is a very promising finding that is consistent with current early intervention literature. The PECS system did not appear to inhibit or facilitate the development of spoken communication.
Decisions regarding whether to recommend one system over another will likely ultimately be determined by research focusing on generalization and maintenance of communication gains, and the point in treatment when change to the other system should be considered. Further, an important variable in this decision will undoubtedly be child characteristics associated with success with either system. For example, Yoder and Stone a found that PECS was superior for the development of nonimitative words for children who entered treatment with higher levels of object exploration while RPMT was superior for children who entered with relatively low object exploration.
Thus research focusing on child characteristics associated with response to these treatment modalities will serve to inform early intervention targeting communication in young minimally verbal children with autism and allow interventionists to provide more tailored interventions.
This research was supported in part by U. The authors acknowledge the ongoing support and important contributions of Drs. Andrew Bondy and Gail McGee for providing consultation and supervision to ensure appropriate program procedures. We also wish to thank Dr. Allison Jobin for her valuable contributions to the preparation of this manuscript and to Dr.
Mark Appelbaum for statistical consultation. National Center for Biotechnology Information , U. J Autism Dev Disord. Author manuscript; available in PMC May 1. Schreibman and Aubyn C Stahmer. Author information Copyright and License information Disclaimer. The publisher's final edited version of this article is available at J Autism Dev Disord.
See other articles in PMC that cite the published article. Method Participants Participants included referrals to two university-based autism research programs who met the following criteria: Table 1 Child Demographic Variables at Pre-treatment. Open in a separate window. Intervention Both PRT and PECS use motivation and child initiation as a basis for facilitating communication and are based on the principles of applied behavior analysis.
Pivotal Response Training PRT Parents and therapists were trained to target the development and spontaneous use of functional spoken language. Parent Satisfaction At post intervention parents completed a satisfaction survey consisting of questions regarding their overall impressions of the program including program effectiveness, intervention techniques, child improvements, and the parent education format.
Outside Interventions We conducted analyses of weekly number of hours the participants received other treatment while participating in this investigation. Conclusions The results of this study suggest that a majority of young, nonverbal or minimally verbal children with autism will learn to use spoken language at a young age. Acknowledgments This research was supported in part by U.
Contributor Information Laura E. References American Psychiatric Association. Diagnostic and statistical manual of mental disorders. The Picture Exchange Communication System. Assessment of PECS acquisition, speech, social-communicative behavior, and problem behavior.
Journal of Applied Behavior Analysis. Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder.
Frost L, Bondy A. The Picture Exchange Communication System training manual. Pyramid Educational Products; The impact of the picture exchange communication system on requesting and speech development in preschoolers with autism spectrum disorders and similar characteristics.
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