Conference calls

Ripples in a pond
Editor Avril Nicoll reports from a day celebrating 10 years of the Picture Exchange Communication System (PECS) in the UK.
Lori Frost, co-developer of the Picture Exchange Communication System, says she likes not being able to identify the profession of people in the classroom. This ethos of shared responsibility and commitment was evident in the mix of people attending the 10th birthday celebrations of PECS in the UK. The Edinburgh event had parents, teachers, nursery nurses, a foster carer and speech and language therapists participating. PECS is a low-tech AAC tool designed to encourage initiation of communication (see figure 1). It was developed by Lori Frost and Andrew Bondy in the United States while Lori was working with children aged from 2-6 years with autism, many of them not talking. She reflects that when she graduated she knew a lot about what to teach but was woefully unprepared how to teach. As is often the case, a particular client inspired the thinking that led to the development of PECS. This boy was 4 years old, nonspeaking, hadnt learnt sign language or speech imitation, didnt want to be touched, couldnt isolate his pointer finger and - not surprisingly - was very frustrated and aggressive. Although he would tap a communication board, he wasnt doing this communicatively. Lori describes being kept awake thinking, I dont know what to do with this boy because nothing is working. Re-examining the definition of communication was key to finding a solution. Loris definition is that: Not all behaviours are communicative Communication must occur between two people The speaker directs behaviour to the listener The listener mediates access to the reinforcer (what the speaker wants). Rather than encouraging her client to indicate a picture on a communication board, Lori recognised that as the speaker he actually needed to take the picture to someone. This forced social interaction and brought a focus on the person (listener) rather than the board. Lori says there are no prerequisites for PECS other than that the client needs to want something and the picture that is used in phase I is merely their ticket for getting it. of an 8 year old boy called Conall, describes herself as very stubborn in ensuring PECS is done properly. In talking about how Pictures mean the world to her son, Julies own role in ensuring the success of PECS through encouraging this spontaneity is clear. When Conall used his PECS folder in a caf, for example, Julie explained he had to show the lady rather than her. Parents stories are vital in raising awareness among professionals about the real, day in day out experience of living with autism and other developmental disorders. Their stories also demonstrate how essential it is to acknowledge, appreciate and support parents coping strategies and expertise. Conall was successfully introduced to PECS at his special school when he was 7 by a teacher trained in the approach. His mother was funded and encouraged by the school to attend a 2 day course so that Conall could bring his form of communication home. It was fascinating to hear how this has led to him being a happier child who improvises a lot with his symbols (eg. used chips as didnt have carrot sticks), becomes excited over his achievements and instigates taking his PECS folder with him wherever he goes even when thats stomping off to his room in the huff. He maintains his own PECS folder, expresses emotions and tastes and makes informed choices (out of two) independently. Although life for the family remains challenging given Conalls dietary preferences, sensory intolerances and erratic sleep pattern, Julie describes the reduction in stress and increase in family cohesion as being like ripples in a pond. She adds that PECS is about helping a child develop into the adult they should be. PECS is administered in the UK by Pyramid Educational Consultants (www.pecs.org.uk). Discussion with Lori, Julia Biere (Pyramid Consultant) and delegates confirmed that one of the major challenges with PECS, as with many other approaches, is ensuring it is offered in a way that is true to its philosophy and therefore in a way that will work. Its fairly normal practice for one person from a team to attend training and then to cascade what they have learnt to colleagues, which can lead to a Chinese Whispers effect and a focus on the symbols rather than the spontaneous communication. For this reason, both Lori and Julia are very positive about the role of Pyramid Consultants in supporting UK trainees with PECS implementation. Pyramid is an approach to education which runs from wake up to bedtime. It recognises that developmental disorders impact on the whole day, not just communication, and is heavily influenced by Applied Behaviour Analysis (ABA)
Figure 1 PECS at a glance Reproduced from http://www.pecs.org.uk/general/ what.htm (Accessed 5 November 2008)

Phase I Teaches students to initiate communication right from the start by exchanging a single picture for a highly desired item. Phase II Teaches students to be persistent communicators- to actively seek out their pictures and to travel to someone to make a request. Phase III Teaches students to discriminate pictures and to select the picture that represents the item they want. Phase IV Teaches students to use sentence structure to make a request in the form of I want _____. Phase V Teaches students to respond to the question What do you want? Phase VI Teaches students to comment about things in their environment both spontaneously and in response to a question. Expanding Vocabulary Teaches students to use attributes such as colours, shapes and sizes within their requests.

learning theory. Lori describes herself as on a mission to teach Speech-Language Pathologists about ABA, which is somewhat controversial in the speech and language therapy world. She cautions people not to be put off by the most commonly held beliefs about ABA / the Lovaas Method as being in your face and requiring lots of repetition, as this is such a small part. Loris early experience involved collaboration with occupational therapists and teachers, and included tying shoelaces and changing diapers. Language and communication was integrated in the whole day. She has asked herself what makes certain classrooms, homes and people take off with such an approach, and believes a flat hierarchy can help as well as each individual being smart, enthusiastic, motivated and willing to share. Her special contribution to the team as a speech-language pathologist has included knowledge of the developmental sequence and of pragmatics.

Name the feelings

Spontaneous requesting

The defining feature of PECS is that it teaches spontaneous requesting as the first skill. If a child who uses PECS is prompt dependent or is not acting spontaneously, Lori argues this is because they have never been taught or taught properly to request spontaneously. Julie McGhee, the mother 16

Loris husband and PECS co-developer is behaviour analyst Andrew Bondy. He presented his most recent thinking on how we help children with autism develop the language of emotions. When typically developing children fall, we might see the bleeding, but they also cry. When they eat ice cream, we notice they eat quickly, but they also smile. They show pain and pleasure, so we comment on this and name the feelings. Typically

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

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HPC updates
Speech and language therapists can now update their details with the Health Professions Council online. All registrants should have received a letter with details of how they can activate their account. Each registration certificate and authentication card are valid for two years. The authentication card is needed to update details online or over the phone (0845 3004 472, Monday-Friday, 8am-6pm). www.hpc-uk.org/registrants/yourdetails/

Conference calls

Communication support needs discussed

What About Us?

l-r Andrew Bondy, Sue Baker (Clinical Director of Pyramid UK) and Lori Frost cutting the cake at a celebration in London

developing children therefore have many natural opportunities to learn the language that matches how they feel. Andrew says what may be different with children with autism is that they are less likely to show the pain or pleasure so we deal with the situation without giving sufficient feedback on the feelings. As Andrew says we have strange conversations about how a child doesnt feel pain while the real issue is around the lost opportunity for language acquisition that will help keep them healthy, safe and secure in future. Children need to have the language for how they feel before they can understand that language applied to other people. Andrew therefore suggests we generate a list of emotions a child needs to be able to talk about and ask ourselves how we can get the child to feel this way. Contrast is all important, so there need to be opportunities to experience emotions we dont like so much such as anger and pain. While ethically this presents challenges, he argues that it is important for teams and parents to have these conversations and agree on a plan appropriate to each individual. As well as celebrating the present, birthdays give us the chance to reflect on the past and look to the future. PECS started in the United States over 20 years ago and the ripples have spread worldwide. But, while speech-language pathologists in the United States are very involved with it, my impression is that in the UK it is mainly driven by teachers. One experienced speech and language therapist told me that she has found many people mistakenly believe PECS is about pointing. While this may benefit some non-verbal children, it is unlikely to help those who need the exchange to develop their spontaneous communication skills. I would be interested to hear how readers have contributed to the successful implementation of PECS please either e-mail me directly (avrilnicoll@speechmag.com) or go to the forum http://members.speechmag.com/forum/. SLTP Talking Mats has also celebrated its 10th birthday. See editor Avril Nicolls report from a Symposium held to mark the event at www.speechmag.com/Members/.

What about us, the report from a participative action research project, is recommending a number of improvements to promote the emotional wellbeing of young people with learning difficulties in inclusive secondary schools and colleges. In terms of communication, the collaboration between Cambridge Universitys Faculty of Education and the Foundation for People with Learning Disabilities notes that the young people lacked experience in being asked for their views but that their confidence grew with support and practice. The report says (p.42), Some of the young people we spoke to were not really sure, at first, what their views were. This might have been either because they had not considered what they thought, because they were unsure how to express these ideas or because they had never been asked. A particular difficulty with transition periods moving between lessons and during breaks was highlighted and the young people asked for access to safe areas such as libraries or learning centres or to have access to support, supervision or an activity they enjoy. What About Us? www.learningdisabilities.org.uk/ information/news/?EntryId17=31340&p=2

Communication aids manufacturer Toby Churchill has asked John Bercow MP to press the government to address the communication support needs of the post-19 population. The MP recently completed the eponymous Review of Services for Children and Young People (0-19) with Speech, Language and Communication Needs. Toby Churchill Chairman David Collison invited Mr Bercow to the companys headquarters to see their latest products and to offer support for the Reviews findings. Discussion included examples of good practice in funding communication aids. www.toby-churchill.com

Teachers want ADHD training

Seventy six per cent of the teachers responding to an online survey said they would benefit from some form of communication with qualified healthcare professionals about ADHD. Tickbox.net conducted the survey of 1050 primary and secondary school teachers in the UK on behalf of drugs company Janssen-Cilag. While 83 per cent of those surveyed said they could recognise the symptoms, they did not feel that they were suitably equipped or supported to deal with a child with ADHD in the classroom and would welcome more training. Attention Deficit Hyperactivity Disorder is characterised by general inattention and impulsivity which also impacts on communication. There is a National Attention Deficit Disorder Information and Support Service at www.addiss.co.uk.

Down syndrome Spreading the word research

Speech and language therapists have until the 31st January to take advantage of Early Bird rates for the Royal College of Speech & Language Therapists Scientific Conference. Partners in Practice Spreading the Word aims to provide an interactive forum for practitioners, researchers and educationalists within the profession and in related fields. The two day programme will cross all client groups and include oral and poster presentations, plenary sessions with keynote speakers, workshops and symposia. The conference takes place at the Queen Elizabeth II Conference Centre, Westminster, London from 17-18 March 2009. The EarlyBird rate for RCSLT members is 299.63, rising to 329 from February. For more information and to book, visit www. rcslt.org.

Down Syndrome Education International has been awarded a grant by the Big Lottery Fund to test a structured language and reading teaching programme in UK primary schools. The four year randomised controlled trial will be delivered by the pupils teaching assistants. Professor Charles Hulme at the Centre for Reading and Language at the University of York is collaborating in the research. He said, Existing evidence suggests that an integrated approach to teaching reading and language skills might be particularly effective for children with Down syndrome. We will trial a teaching approach that combines a structured reading instruction programme with an oral language programme.We expect this approach to be highly beneficial to these childrens reading skills, and to also directly benefit their oral language skills. www.downsed.org

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