Wendt: Evidence AAC in Autism CARD Conference 2011

Evidence-based Interventions in Program

Augmentative and Alternative
Communication (AAC) for  Intro: Autism Spectrum Disorders (ASD) and
Autism Spectrum Disorders Augmentative & Alternative Communication (AAC)
 Evidence-based Practice in AAC
What Does the Research Say?  Reviewing the AAC in ASD Evidence Base
 Manual Signs and Gestures
Oliver Wendt, Ph.D.
 Graphic Symbol Sets and Systems
Department of Speech, Language,
 Picture Exchange Communication System (PECS)
and Hearing Sciences
Purdue University BREAK
 Speech-Generating Devices (SGDs)
National Autism Conference 2012  Moving from PECS to SGDs
College Park, PA

Autism Spectrum Disorders Atypical Communication

(ASD) Development
Triad of symptoms with  Ages associated with early gestures in typically
1. Impairments in language and communication developing (TD) children:
 Deficits in language can range from completely  Reaching 6-9 months
nonverbal to acquiring the ability to speak.  Giving 8-11 months
2. Impairments in social interaction  Showing 8-13 months
 Results in lack of motivation to communicate with  Pointing 9-14 months
other people – even when these individuals have (Bates et al., 1975; Carpenter et al., 1983)
acquired some language competence and use.
3. Restricted and repetitive patterns of behavior  Gestures are precursor to later speech and
 Pre-occupation with restricted patterns of interest language development
can impede social and communicative development.  Early symbolic form of communication

Atypical Communication Atypical Communication

Development (cont.) Development (cont.)
 Children with ASD tend to rely on more Gestural use characterized by:
primitive gestures  Fewer gestures are combined with
 Leading vocalizations than in TD children
 Pulling  Less pointing (protodeclarative gesturing)
 Manipulating partner’s hand
 Fewer conventional gestures

 Use of unconventional behavior to

communicate (both verbal and non-verbal)
(Wetherby et al., 2000)

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Wendt: Evidence AAC in Autism
Language Difficulties
When expressive language develops, first word often
spoken between 2-3 yrs., but early language marked by
 Delay in development of intentional communication
 Greater propensity to use challenging behavior to
communicate
 Limitations in joint attention, range of communicative
functions, higher proportion of imperatives
 Repetitive or idiosyncratic language
(Prelock, 2006)
Proportion of Nonverbal
Children
 Autism includes a “delay in, or lack of the
development of spoken language”
(American Psychiatric Association, 2000)
 14-25% of children diagnosed with an autism
spectrum disorder (ASD) present with little or no
functional speech (Lord & Bailey, 2002; Lord, Risi, &
Pickles, 2004)
 Autistic disorder only: 50% of children are functionally
non-verbal
 no sufficient natural speech or writing to meet their daily
communication needs (Light, Roberts, DiMarco, & Greiner,
1998)  Candidates for intervention in augmentative
and alternative communication
AAC and Autism (cont.)
 AAC strategies particularly used in ASDs:
 Manual signs and gestures
 Pictographic symbols sets/systems
 High technology speech generating devices
(SGDs) for synthesized and/or digitized speech
output
 Practitioners face difficult task selecting a
suitable approach
 Evidence-based practice (EBP):
 Using research outcomes as a major basis for
clinical and educational decisions (Lloyd, 2001)
CARD Conference 2011
Language Difficulties
(cont.)
Repetitive or idiosyncratic language
 Perseveration
 Echolalia
 Incessant questioning
 Pronoun reversal
 Frequent use of imperatives
 Difficulty with function words
 Comprehension difficulties
 Neologism (producing invented words)
 Challenging behavior to serve social functions
 Speech deviation in pitch, rhythm, and inflection
AAC Definition
 Augmentative and Alternative
Communication (AAC):
(1) The supplementation or replacement of natural
speech and/or writing. (Lloyd, Fuller, & Arvidson,
1997, p. 1)
(2) The area of research, clinical and educational
practice … to compensate for temporary or
permanent impairments, activity limitations, and
participation restrictions of persons with severe
disorders of speech-language production, and/or
comprehension. (ASHA, 2005, p. 1)
Evidence from Recent Systematic
Reviews of AAC in Autism
Results from systematic reviews will be highlighted
 General efficacy of AAC in ASD
 Schlosser, R. W., & Wendt, O. (2008). Effects of augmentative and
alternative communication intervention on speech production in
children with autism: A systematic review. American Journal of
Speech-Language Pathology, 17(3), 212-230.
 Schlosser, R. W., & Wendt, O. (2008). Augmentative and
alternative communication interventions for children with autism. In
J. K. Luiselli, D. C. Russo, & W. P. Christian (Eds.), Effective
Practices for Children with Autism: Educational and Behavior
Support Interventions that Work (pp. 325-389). Oxford University
Press.
 Wendt, O. (2007). The effectiveness of augmentative and
alternative communication for individuals with autism spectrum
disorders: A systematic review and meta-analysis. Doctoral
dissertation, Purdue University, 2006. Dissertation Abstracts
International: Section A: Humanities and Social Sciences, 68, 213p.
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Wendt: Evidence AAC in Autism CARD Conference 2011

Evidence from Recent Systematic Evidence from Recent Systematic

Reviews (cont.)
 Manual signs and selection-based graphic symbol
sets and systems:
 Wendt, O. (2009). Research on the use of manual signs and
graphic symbols in autism spectrum disorders: A systematic
review. In P. Mirenda, T. Iacono, & J. Light (Eds.), AAC for
Individuals with Autism Spectrum Disorders (pp. 83-139).
Baltimore, MD: Paul H. Brookes.
 Exchange-based graphic symbol systems (i.e.,
Picture Exchange Communication System and
modifications), for example,
 Ganz, J. B., Parker, R., & Benson, J. (2009): Impact of the Picture
Exchange Communication System: Effects on Communication and
Collateral Effects on Maladaptive Behaviors. Augmentative and
Alternative Communication, 25, 250-261.
 Preston, D., & Carter, M. (2009). A review of the efficacy of the
Picture Exchange Communication System intervention. Journal of
Autism and Developmental Disorders, 39, 1471-1486.
Reviews (cont.)
 Speech-generating devices:
 Ganz, J. B., Earles-Vollrath, T. L., Heath, A. K., Parker, R. I.,
Rispoli, M. J., & Duran, J. B. (2012). A meta-analysis of single
case research studies on aided augmentative and alternative
communication systems with individuals with autism spectrum
disorders. Journal of Autism and Developmental Disorders, 42,
60-74.
 Van der Meer, L. A. J., & Rispoli, M. (2010). Communication
interventions involving speech-generating devices for children
with autism: A review of the literature. Developmental
Neurorehabilitation, 13, 294-306.

Why Look At Systematic Systematic Reviews Are

Reviews? Pre-filtered Evidence
 Goals: synthesis of the existing experimental research  Pre-filtered evidence is established when
literature on graphic symbol-based interventions
 Effectiveness measures someone with expertise in a substantive area
 Quantitative evaluation of study outcomes and study has reviewed and presented the
characteristics methodologically strongest data in the field
 Quality appraisal of study methodology
 Systematic review methodology is uniquely suited to (Guyatt & Rennie, 2002).
minimize bias in locating, selecting, coding, and
synthesizing this evidence (Petticrew & Roberts, 2006)
 Guided by criteria for appraising systematic reviews
(Schlosser, Wendt, & Sigafoos, 2007)
 Systematic reviews provide practitioners with pre-
filtered evidence (Guyatt & Rennie, 2002)

PND Calculation: An Example

Data Evaluation 14

PND = 6/10 = 60%

 Most studies employed single-subject 12

experimental designs
10
 Effectiveness measures for single-subject data
OUTCOME

 Percentage of Nonoverlapping Data (PND) 8

(Scruggs, Mastropieri, & Casto, 1987)

6

 Calculation of non-overlap between baseline and

successive intervention phases 4

 Identify highest data point in baseline and 2

determine the percentage of data points during Baseline Intervention

intervention exceeding this level 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

SESSIONS

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Wendt: Evidence AAC in Autism CARD Conference 2011

Interpretation of PND Scores

 PND statistic: The higher the percentage, the
more effective the treatment
 PND range 0-100%
 PND < 50% reflects unreliable treatment
 PND 50% - 70% questionable effectiveness
AAC in Autism: What Does the Research Say?
 PND 70% - 90% fairly effective
 PND > 90% highly effective MANUAL SIGNS AND
(Scruggs, Mastropieri, Cook, & Escobar, 1986)
GESTURES

Manual Signs Manual Signs (cont.)

 Manual signs: unaided form of communication; unaided  Gestures  Manual Signs
communication does not rely on any aids or devices
external to the body and uses only body parts (Lloyd et
al., 1997).
 One of the first forms of AAC applied to non-speaking
individuals with ASD; introduced in the 1970s and used
successfully for more than 30 years
 Can refer to a natural sign language (e.g., American
Sign Language) or to production of manual signs as a
code for a spoken language
 By the mid-1980s, manual signing was often used in
combination with speech, this approach was labeled as
“total” or “simultaneous” communication (SC)

Manual Signs: Empirical

Why Choose Manual Signs? Evidence
 Easy to imitate (Sundberg, 1990)  Expressive signing
 Individuals with ASD may have difficulty controlling  5 studies including 22 participants concentrated
vocal folds but display strengths with imitating on teaching manual signs and monitoring sign
actions production as an outcome variable
 Anderson, 2001
 Signs are less transient than words
 Carr, Binkoff, Kologinsky, & Eddy, 1978 (two
(Fulwiler & Fouts, 1976) experiments)
 Less frustrating to learn than vocal speech  Schepis et al., 1982
 May overcome negative history associated  Tincani, 2004
 Across experiments teaching manual signs yielded
with speech (Sundberg & Partington, 1998) an overall PND of Mdn = 100 % (Mn = 95 %, SD =
17.45)  “highly effective”

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Wendt: Evidence AAC in Autism
Manual Signs: Empirical
Evidence (cont.)
 Expressive signing, various outcome variables
 Carr, Kologinsky, and Leff-Simon (1987) taught three
individuals to sign action-object phrases: PND scores of
“highly effective” for all
 Hundert (1981) conducted manual sign training with one
participant under two conditions: single stimulus training
(PND = 67 %) versus multiple stimulus training (PND =
78 %)
 Keough et al. (1987) and Sommer, Whitman, and Keogh
(1988) taught one participant manual signs through
specific behavioral scripts: Mdn PND = 83.5 %  “fairly
effective”
Manual Signs: Empirical
Evidence (cont.)
 Expressive signing, simultaneous
communication:
 Remington and Clarke (1983) compared simultaneous
communication versus sign alone training in two
participants: no difference, both participants achieved
PND scores of 100 % in either condition
 Saraydarian (1994), group study: 10 participants exposed
to training program that taught object referents in the form
of simultaneous communication, sign alone instruction
and oral instruction  sign alone condition superior,
effect size g = 0.36 indicating moderate effect
Manual Signs: Empirical
Evidence Summary
 Summary:
 Both groups of experiments, expressive speech and
receptive speech, yield high outcome scores
 Evidence suggests it is a viable communication option
 Possible explanations for effectiveness:
 Better choice than vocalization because it is easier to
prompt an action than a vocalization (Sundberg, 1990)
 Involves more iconic representation than spoken
language (Sundberg)
 Motor imitation is an easier behavior to teach because
the teacher can make use of physical prompting and
fading procedures (Sundberg & Partington, 1998)
CARD Conference 2011
Manual Signs: Empirical
Evidence (cont.)
 Expressive signing, simultaneous
communication (SC):
 Barrera, Lobato-Barrera, and Sulzer-Azaroff (1980)
taught one participant expressive language skills
using three different instructional methods:
 Simultaneous sign training (PND = 89 %)
 Nonverbal sign-alone training (PND = 56 %)
 Oral training (PND = 67 %)
 Simultaneous communication superior to sign alone
and oral training
Manual Signs: Empirical
Evidence (cont.)
 Receptive speech:
 Brady and Smouse (1978) compared effects of SC
(PND = 100 %) vs. sign alone (PND = 50 %)
training on receptive speech in one participant;
gains in receptive speech assessed through
responses to verbal requests
 Carr and Dores (1981) provided SC training to
three participants and measured their correct
responses on a receptive language discrimination
task: PND scores were 100 % for each one.
Manual Signs Limitations
 More and more research studies are revealing
motor control problems in ASD
 Clumsiness
 Poor muscle tone
 Difficulty with fine and gross motor skills
 Seen in about 80% of children with autism, but not part of
diagnostic criteria
(Hilton et al., 2012; Isenhower et al., 2012)
 Children with ASD often acquire only limited sign
vocabulary and signs tend to be poorly articulated
 Burden on communication partners: social
environment may not be fluent in sign language
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Wendt: Evidence AAC in Autism
Manual Signs Limitations
(cont.)
Intelligibility:
 Rotholz et al. (1989): two adolescents with autism
were taught to order fast food interacting with staff
unfamiliar to them
 0-25% of manual sign requests were understood
 80-100% of graphic symbol requests were understood
Gestures
 Gestures: body movements or sequences of
coordinated body movements to represent an object,
idea, action, or relationship without the linguistic
features of manual signs
 Examples: pointing or yes-no headshakes
 One of the earliest developing non-linguistic forms of
unaided communication (Loncke & Bos, 1997)
 Individuals with autism, however, rarely use gestures
as an alternative communication strategy, even if they
have difficulty speaking (Loveland, Landry, Hughes,
Hall, & McEvoy, 1988)
Gestures:
Empirical Evidence
 Two studies focused on teaching gestural
communication skills
 Buffington, Krantz, McClannahan, and Poulson
(1998) taught gestures in combination with oral
speech, measured frequency of correctly
produced gestural and verbal responses: PND
scores of “highly effective” for all four participants
 Carr and Kemp (1989) provided training in
communicative pointing (e.g., to obtain toy),
observed frequency pointing occurred: again PND
scores of “highly effective” for all four participants
CARD Conference 2011
Manual Signs Conclusions
 Future research implications:
 Lack of studies comparing manual signing or gestures
against an aided mode of communication such as graphic
symbols  More comparative efficacy studies are needed
to clarify if learners with autism actually do better and/or
have a preference for one communication modality over
another
 How to use manual signs as part of a multi-modal
communication system consisting also of graphic
symbols, communication boards, SGDs, and
vocalizations (when available)  need research into
effective strategies for teaching the conditional use of
manual signs
Why Choose Gestures?
 Use of gestures serves as a precursor to later
development of language skills (Morford & Goldin-
Meadow, 1992)
 Gestural behavior also important for establishment and
maintenance of social interaction and social reciprocity
(Garfin & Lord, 1986; Koegel & Frea, 1993)
 Appropriate for early AAC intervention to facilitate
symbolic development
 Motor demands not as much of an issue as with manual
signs
Gestures: Empirical
Evidence Summary
 Summary:
 Appears to be very effective communication
option but limited amount of studies at this time
 Compared to manual signs it seems that gestures
are underrepresented and not well researched in
this population
 Surprising, because of its correlation with vocal use
and preceding speech development
 More research needed to build up the empirical
support for gestural communication
 Also need more comparative efficacy studies
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Wendt: Evidence AAC in Autism CARD Conference 2011

Graphic Symbol Sets

and Systems
 Graphic symbols: relatively new AAC mode for
children with ASD in practice as well as in the
development of a research base
 As early as the 1980s authors have drawn attention
to the potential benefits of graphic symbols due to
their non-transient nature (e.g., Schuler & Baldwin,
1981)
AAC in Autism: What Does the Research Say?  Graphic symbols are part of sets or systems
 Sets are collections of symbols that do not have
SELECTION-BASED clear rules for their creation
 Systems are rule-governed (see Lloyd et al., 1997)
GRAPHIC SYMBOL SETS  Iconicity hypothesis: symbols having a strong
resemblance to their referents are easier to learn
AND SYSTEMS (Fuller, Lloyd, & Stratton, 1997)

Why Choose Graphic Intervention Outcomes:

Symbols? Line Drawings
 Basic Rebus  Pictogram Ideogram
 Good fit with visuo-perceptual strength in ASD
 Can be highly iconic and easy to learn
 Can be combined with verbal model for
augmented input self bicycle sad

 Easily understood by unfamiliar communication

partners
 Often used across various activities and middle big small

environments (e.g., visual schedules, story book

reading, etc., in addition to communication
board)
nurse apple eat
 Easy to produce and cost-efficient low
technology strategy

Intervention Outcomes: Intervention Outcomes:

Line Drawings (cont.) Orthographic Symbols
 Line drawings (also including basic rebus and  Hebrew Orthography
pictograms ideogram communication):
Study Participant (Age) Outcome variable PND
Dettmer et al., Jeff (7-0) Decrease in latency to begin 100
2000 Josh (5-0) new activity 100
Reichle & Subject 1 (23-0) Object labeling 78
Brown, 1986 Locating symbols 81
Reichle et al., Al (27-0) Correct requests 100
1991
Sigafoos, 1998 Larry (6-0) Touching symbols for requests 83
Sigafoos et al., Cleo (17-0) 29
1996 Karen (12-0) 8

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Intervention Outcomes: Intervention Outcomes: Picture

Orthographic Symbols (cont.) Communication Symbols (PCS)
 Orthographic symbols:  Picture Communication Symbols (PCS)
 Hetzroni and Shalem (2005) combined orthographic
symbols from Hebrew alphabet with food item logos in
computer-based intervention to teach the meaning of
orthographic symbols; mixed results of effectiveness:

Participant (Age) Speech/Language Outcome variable PND

Max (11) 1-word utterances Number of correct 67
Bob (11) no speech responses 70
Gina (13) not verbal 88
Lara (10) no vocalizations 60
Sara (10) echolalia 82
Al (10) echolalia 50

Intervention Outcomes: Picture Intervention Outcomes: PCS in

Communication Symbols (PCS) Aided Language Stimulation
 Picture Communication Symbols (PCS)  PCS as part of Aided Language Stimulation
(cont.): (AiLS):
Study Participant Outcome variable PND  Instructional approach: Communication partner
(Age) provides a verbal model supported by AAC use
Hamilton & Snell, Carl (15) Correct responses using 95 (Goossens’, Crain, & Elder, 1992)
1993 communication book
 Graphic symbols can be one option for
Spillane, 1999 John (1) Correct responses: discrete trial 18
30
delivering this additional input
Corr. responses Incidental teach.
Johnston et al., Brad (4-3) Correct use of symbolic 59  Spoken language input in return may contribute
2003 Alex (5-3) communication (graphic symbol 53 to learning the meaning associated with a
or verbal response)
Billy (5-1) 45 graphic symbol

Intervention Outcomes: PCS in Intervention Outcomes:

AiLS (cont.) Photographs
 PCS as part of AiLS:  Photographs
 Dexter (1998) study on joint storybook reading
 Explored effects of AiLS including PCS
 Measured frequency of symbol use
Participant (Age) Speech/Language Outcome variable PND
Andre (8-1) Limited verbal Number of PCS 74
Tony (9-2) output pointed to 100
Peter (9-3) 100
Carl (9) 84
Sam (7-2) 0
Brad (6-5) 90

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Wendt: Evidence AAC in Autism CARD Conference 2011

Intervention Outcomes: Intervention Outcomes: Various

Photographs (cont.) Graphic Symbols
 Photographs:  Blissymbol  Premack Symbol
 PND scores “highly effective” in Spencer (2002)
study; mixed results in Stiebel (1999) study
Study Participant Outcome PND
(Age) variable
Spencer, 2002 Tom (7) Number of 100  Colored Photograph  Rebus Symbol
requests
Nathan (7) 100
Donald (7) 100
Chase (9) 100
Stiebel, 1999 Steven (4-2) Spontaneous 100
Tommy (6-8)
picture card use
67  Orthography
to communicate
Jose (4-6) 71
APPLE

Intervention Outcomes: Various Intervention Outcomes: Final

Graphic Symbols (cont.)
 Various graphic symbol-based interventions:
 Kozleski (1991) compared acquisition rates of
Blissymbolics, colored photographs, orthography,
Premack symbols, and rebus across four individuals:
fewer sessions were needed for highly iconic symbols;
PND “highly effective” in each case
 Reichle et al. (2005) taught use of a colored graphic
symbol (unspecified, PCS?) to a 40 yr old subject: PND
score of “questionable effectiveness”
 Sigafoos et al. (1996) trained two girls (7 and 15 yrs)
with Rett syndrome to request food items using a
“WANT” symbol with a food item logo: “highly effective”
for one, too difficult for other girl
Results
 Summary:
 Heterogeneity of studies on graphic symbol
acquisition and use makes judgment about most
effective intervention(s) difficult
 Interventions (participants) associated with
highest range of PND scores (90% - 100%):
 Photographs (5)
 PCS-based (using PCS solely or as part of
materials) (4)
 Line drawings (3)

Intervention Outcomes: Final Intervention Outcomes: Final

Results (cont.)
 Summary (cont.):
 Most solid empirical evidence: use of graphic
symbols for the teaching of requesting skills
 In addition to requesting, the evidence in support
of using graphic symbols as part of visual
schedules is suggestive (but 1 study only)
 Children with ASD seem to be able to match
graphic symbols to orthographic symbols, but it is
yet to be examined whether this matching could
lead to enhanced communication
Results (cont.)
 Summary (cont.):
 Bottom line: research has not yet reached a level
and critical mass that it could productively inform
choices of one graphic symbol set/system over
others
 Future research: study the type of graphic symbol
set/system or even characteristics of symbols
and/or in relation to referents (e.g., iconicity)
prospectively as independent variables while
keeping the instructional method constant

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Wendt: Evidence AAC in Autism CARD Conference 2011

Picture Exchange
Communication System (PECS)
 Structured behavioral intervention program to teach
use of visual-graphic symbols for communication
(Bondy & Frost, 1994)
 Teaches to make requests by handing/ exchanging
symbols for desired items

AAC in Autism: What Does the Research Say?

EXCHANGE-BASED
GRAPHIC SYMBOL SETS

Picture Exchange
Communication System (PECS) Why Choose PECS?
 Picture Exchange Communication System  Requires very few prerequisites
(PECS) protocol (Bondy & Frost,1994)  Only prerequisite individual can clearly indicate wants
and needs
 Phase I: Physical Exchange
 First skill taught in PECS is requesting
 Phase II: Expanding Spontaneity  Often targeted in early instruction of individuals with
 Phase III: Picture Discrimination developmental disabilities due to motivational
 Phase IV: Sentence Structure considerations (Reichle & Sigafoos, 1991)
 Phase V: Responding to “What do you want?”  Systematically targets spontaneous
communication acts, a particular deficit in autism
 Phase VI: Responsive and Spontaneous
Commenting  PECS graphic symbols are highly iconic
 Can be easily recognized by the learner and are more
recognizable by communicative partners

Study N Phases DV PND- PND Apprai- Study N Phases DV PND- PND- Appraisal
Mean Range sal Mean Range
Ander- 6 I-III Requesting-PECS 67(Q) 29-100 Con-
son clusive Ganz 3 I-IV Words imitation 4 (I) 0-8 Suggestive
(2001) Requesting-Signing 0 (I) 0-0 (2007) Word approximation 4 (I) 0-8
imitation
Tincani 1 IV Word vocalizations 0 (I) 0 Con-
(2006-2) clusive Marckel 2 IV Requesting 100 (H) 100 Suggestive
(2006) generalization
Word approximations 100 (H) 100 (untrained items)
Anger- 4 I-II(III) Requesting-high iconic 67 (Q) 67 Con- Tincani 2 I-II/IV Requesting 100 (H) 100 Suggestive
meier 47 (I) 0-72 clusive
(2006-1) Word vocalizations 0 (I) 0
(2007) 0 (I) 0
Word approximation 6 (I) 0-11
Requesting-low iconic 100 (H) 100
72 (F) Charlop- 3 I-IV Eye contact, joint 100 (H) 100 Suggestive
Christy attention or play
31 (Q)
(2002) Requests and 87(F) 60-100
Tincani I (II as Requesting-PECS 92 (H) 83-100
initiations
(2004) best Requesting-Signing 75 (F) 72-78
Elicited vocalizations 44 (I) 25-90
2 treatm.) Words/approximations 100 (H) 100 Pre- Speech imitation 34 (I) 25-50
elicitation-PECS ponderant
MLU 31 (I) 17-50
Words/appr.-Signing 100 (H) 100

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Study; Phases DV: # of OUTCOMES STATISTICAL AP-

Study N Phases DV PND- PND- Appraisal N; CA RESULTS PRAISAL
Mean Range A Mean B Mean Coh. d Hedges’
(SD) (SD) d L (H) g (p)
Lund 3 I-III, I-II, Requesting 60 (Q) 54-71 Suggestive
(Independent) Yoder & 1 PECS - non- 1T2a: 2T2: -1.53 Conclusive
(2007) I 42 (I) 23-60 3.6 (4.8) 0.6 (4.8) .63 (2.91) .61(.03)
Stone (I-IV if imitative
100 (H) 100 (2006a); within 6 spoken 1T3: 2T3: -1.41
5.5 (3.2) 5.4 (3.2) .03 (1.55) .03 (.96)
38 months) acts
subjects 2 RPMT
33 mo different 1T2: 2T2: -1.12
non- 2.4 (3.6) 0.6 (3.6) .50 (2.21) .49 (.04)
imitative 1T3: 2T3: -1.00
3.1 (2.4) 2.9 (2.4) .08 (1.22) .08 (.93)
words

Yoder & 1 PECS - Genera- 1T2: 2T2: .97 .22 .92 Conclusive
Stone (I-IV if lized 4.0 (.81) 7.1 (.81) (4.29) (.019)
(2006b); within 6 turn-
38 months) taking
subjects 2 RPMT

33 mo Genera- Pretreatment joint attention skills predict

lized response to treatment:
joint > 7 initiating joint attention acts: greater benefit
attention from RPMT
initiation Only 1 initiating joint attention act: greater
benefit from PECS (ΔR2=.36, p<.001)

Study; Phase DV OUTCOMES STATISTICAL RESULTS AP-

N; CA s PRAISAL
A Mean B Mean z p r PECS Summary
Carr & PECS Child-to- T2: T2:
Felce I-III (A) adult 61.4 10 5.3 < 0.83 r  Considerable empirical support for using PECS as a
.00003 0.69 r2
(2007a); vs. initiations beginning communication strategy
41 control
subjects (B)  Overall shows strong effectiveness for teaching initial
Elemen- Child-to- T2: T2: requesting skills
tary age adult 50.8 1.3 6.93 < 1r
linguistic .00003 1 r2  Some evidence to indicate: more effective than
initiations manual signing in terms of requesting
Child-to- T2:
96.7
T2:
76.9 2.8 < .0026 0.44 r
Suggestive  Effect is less clear for other outcome variables such as
adult
initiations w 0.19 r2 speech production, social or challenging behavior
adult
response
 When treatment goals is speech production  no
Adult-to- T2: T2: sufficient evidence to inform practice in favor of PECS
child w no 13.3 21.1 -1.65 < .0495 -.26 r or manual signing
opportunity 0.07 r2
for child to  In general, mixed results on this outcome measure
respond

PECS Summary (cont.) PECS Summary (cont.)

 Another potential choice: use of Responsive
 Methodological issues in PECS studies Education and Prelinguistic Milieu Teaching (RPMT)
 Often lack investigation of maintenance relative to PECS
 Skill generalization sometimes reported, but what  Studies by Yoder and Stone (2006 a,b) offer
counts as generalization varies greatly conclusive evidence for decision-making
 Participant descriptions lack detail  PECS more effective than RPMT in terms of speech
 Sparse reports of treatment integrity production
 RPMT better choice in terms of generalized turn-taking and
initiating joint attention
 PECS appears as a promising intervention
 Depending on treatment goal the treatment choices may
that presents with emerging empirical support, differ
but critical questions are still to be answered  Also: important whether or not a child comes to the task with
pre-existing object exploration skills and/or joint attention
skills (low object exploration  RPMT better choice)

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Wendt: Evidence AAC in Autism CARD Conference 2011

PECS Future Directions

 Identifying predictors of successful PECS use by
itself and relative to other treatment choices
 Research into innovations of the PECS protocol
using rigorous methodologies
 Role of PECS for managing problem behavior still in
its infancy
 Future research needs to adhere to more rigorous AAC in Autism: What Does the Research Say?
designs
 Randomization of participants SPEECH-GENERATING
 Treatment integrity assessments
 Reliability of measures DEVICES
 Avoid vague measures that collapse multiple
behaviors

Speech-Generating Devices
SGDs (cont.)
(SGDs)
 Portable, computerized devices producing synthetic or
digitized speech output when activated
 Graphic symbols are used to represent messages,
activated by finger, switch, head stick, etc., selecting a
symbol from the display
 LightWRITER  BIGMack

SGDs (cont.) SGDs (cont.)

Fixed Display Dynamic Display Visual Scene Displays
 Graphic symbols • Selection from a • Language concepts are
located in separate display results in a new embedded into contextual
squares of a grid, array of graphic scenes
organized into rows symbols • Objects and events within
and columns
• Larger vocabulary sets the photograph are then
 Limited vocabulary used as symbols for
communication
• May be used in a dynamic
display system

12
Wendt: Evidence AAC in Autism
SGDs (cont.)
 Example of a child with ASD using an SGD:
 http://www.youtube.com/watch?v=s4GAX-
IXE_k&NR=1
 Example of synthetic speech output:
 http://www2.research.att.com/~ttsweb/tts/demo.ph
p#top
Why Choose SGDs? (cont.)
 iPads and other tablet devices are
 Lightweight and portable
 Cost-efficient compared to dedicated SGDs
 Easy to program
 Highly motivating to use
 Socially appealing (peer acceptance)
SGDs: Empirical Evidence
 Van der Meer, & Rispoli (2010), systematic
review:
 Found 23 studies with a total of 51 children aged 3-16
years
 Positive outcomes reported for 86% of studies, most
commonly targeting requesting skills
 Potentially effective option for teaching communication
skills in ASD
 Ganz et al. (2012), meta-analysis:
 Included 8 studies on SGDs, 9 studies on PECS, 7
other graphic symbols
 Effect size estimates were 99% each for SGDs and
PECS, 61% for others
 SGD or PECS use yields significantly higher effects
CARD Conference 2011
Why Choose SGDs?
 Allows composing more detailed messages
 Enable user to communicate very precise requests and
prevent communication breakdown
 Voice output (aka speech output) may facilitate
acquisition and maintenance of communication
skills
 Producing speech can be perceived as more
natural
 Better intelligibility
 Easier to get attention
 Higher likelihood of receiving a listener response
SGDs: Empirical Evidence
 Ganz, J. B., Earles-Vollrath, T. L., Heath, A. K.,
Parker, R. I., Rispoli, M. J., & Duran, J. B. (2012). A
meta-analysis of single case research studies on
aided augmentative and alternative communication
systems with individuals with autism spectrum
disorders. Journal of Autism and Developmental
Disorders, 42, 60-74.
 Van der Meer, L. A. J., & Rispoli, M. (2010).
Communication interventions involving speech-
generating devices for children with autism: A review
of the literature. Developmental Neurorehabilitation,
13, 294-306
SGDs: Empirical Evidence
(cont.)
 Schlosser et al. (2009): “…SGDs represent a
viable and effective AAC option for individuals
with ASD”
 Empirical evidence speaks a clear message,
effectiveness of SGDs no longer a question
important when applying for SGD funding from
insurance agencies
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Wendt: Evidence AAC in Autism CARD Conference 2011

Effects of Speech Feedback

Effects of Speech Feedback? (cont.)
 Hypothesis: synthetic speech more motivating for
children with autism because of essential  5 studies on SGDs investigated effects of
differences to natural speech (Schlosser & Blischak, speech output
2001)  In each study speech output was isolated as
 No prosodic variation  more “robotic speech” an independent variable to determine its
 No intonation changes that indicate the emotional specific impact when comparing the presence
state of the speaker (e.g., anger, fear, etc.) versus absence of speech
 This lack of variability in synthetic speech may
(a) help with auditory processing, and
(b) fit with the speech patterns of echolalia, repetitive
speech, and insistence on sameness observed in
individuals with autism

Effects of Speech Feedback Study

(Type of SGD)
Participant
(Age)
Outcome variable PND for Speech

[Design]
(cont.) ON OFF
Parsons & La Sorte, 1993 1 (4-8) Frequency of 83 0
(Apple II GS + software; spontaneous
 Outcome data for speech-on and speech-off synthetic speech)
2 (5-1)
utterances using
75 0
conditions were extrapolated [A-B-BC-B-BC/A-BC-B-BC] 3 (5-8) computer-assisted 100 9
instruction
 Four different outcome variables in this Variation design 4 (6-2) 100 0
sample: 5 (6-7) 50 0
1. Frequency of spontaneous utterances 6 (6-8) 92 0
2. Words spelled correctly Schlosser & Blischak, 2004 Scott (8-0) Words spelled 83 100
(LightWRITER SL35; synthetic correctly
3. Requesting speech)
Fred (12-0) 93 93

4. Number of vocalizations [AATD] Justin (9-0) 91 91

 For each outcome variable and for total Carl (12-0) 77 63

sample, a series of pair-wise Mann-Whitney Schlosser et al., 1998 Martin (10-0) Words spelled 100 84
(LightWRITER SL35; synthetic correctly
U tests were conducted to evaluate speech) [AATD]
significant differences between speech-on Continued on next slide
and speech-off

Study Participant Outcome variable PND for Speech

(Type of SGD)
[Design]
(Age)
ON OFF
Effects of Speech Feedback:
Schlosser et al., 2007
(Vantage; synthetic speech)
Avery (9) Requesting 65 2 Results
Greg (8) 32 30
[AATD]
Mathew (10) 31 3
Michael (8) 33 76  Overall effect of speech on vs. speech out
Zachary (10) 45 80  Speech on: Mdn PND = 63.0% (Mn = 50.83%,
Avery (9) Elicited vocalizations 0 0 SD = 38.07)
Greg (8) 0 0
 Speech off: Mdn PND = 3.0% (Mn = 30.80%,
Mathew (10) 0 0
SD = 38.97)
Michael (8) 19 5
Zachary (10) 0 0  No statistically significant difference, z = -1.901,
Sigafoos, Didden, & O’Reilly, Michael (13) Increase in number 0 0 p = .057
2003 (BIGMack; digitized Jason (4) of vocalizations 0 0
speech)[MBD]  Not a reasonable comparison, because of different
Michael (13) 63 63
Jason (4)
Requesting
86 71
outcome measures
Participants Total N=18; mean age: 8-3 Overall PND (Mn) 52.72 30.80  More detailed analysis by outcome variable reveals:

14
Wendt: Evidence AAC in Autism
Effects of Speech Feedback:
Results (cont.)
 Frequency of spontaneous utterances
 Speech on: Mdn PND = 87.5 % (Mn = 83.3%,
SD = 19.03)
 Speech off: Mdn PND = 0% (Mn = 1.5%, SD = 3.67)
 Statistically significant difference, z = -2.99, p <.01
 Words spelled correctly
 Speech on: Mdn PND = 91% (Mn = 88.8%, SD = 8.96)
 Speech off: Mdn PND = 91% (Mn = 86.2%, SD = 14.17)
 No difference between conditions, z = 0.00,
p = 1.00
Effects of Speech Feedback:
Results (cont.)
 For all comparisons, need to consider very
small sample of studies and small number of
data points
 Definitely need more data to clarify role of
speech output
 Should focus on one specific outcome variable
instead of several
SGDs Summary (cont.)
 Methodological Issues:
 No (quasi-)experimental group studies
 Need to incorporate maintenance and
generalization assessments
 Many studies limited to school setting
 Few studies report treatment integrity
 Narrow focus on requesting skills
 Need to target more advanced communication
using SGDs
CARD Conference 2011
Effects of Speech Feedback:
Results (cont.)
 Requesting
 Speech on: Mdn PND = 33.0% (Mn = 41.2%,
SD = 14.46)
 Speech off: Mdn PND = 30.0% (Mn = 38.2%,
SD = 38.06)
 No statistically significant difference, z = -.256,
p =.805
 Number of vocalizations (elicited plus regular)
 Speech on: Mdn PND = 0% (Mn = 2.71%, SD = 7.18)
 Speech off: Mdn PND = 0% (Mn = 0.71%, SD = 1.89)
 No difference between conditions, z = - 1.05,
p = 1.00
SGDs Summary
 Ample evidence of positive effects of SGDs, but
effectiveness may vary depending on targeted
outcome variables
 Most clearly effects for teaching requesting
 Variation in participants’ performances and responses
to SGDs
 Benefits of speech feedback not clear at this point
 Need for further replication studies
 Strong need for further data-based information on
effects of SGDs, especially tablet devices
Future Research
 Need for more predictor studies, identifying
participant characteristics that serve as predictors
of treatment outcomes
 Role of SGDs in facilitating speech production is
still in its infancy and needs further investigation
 Need for more comparative efficacy studies
comparing aided vs. unaided AAC strategies
 Studies with methodological weaknesses need
replication
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Wendt: Evidence AAC in Autism CARD Conference 2011

SGD Advantages
 Additional provision of speech output presented
as (a) antecedent auditory stimuli (a.k.a.
“augmented input”), and/or (b) consequence
auditory stimuli (a.k.a. “feedback”) may benefit
learners with developmental disabilities
 Gains in receptive and expressive language
AAC in Autism: What Does the Research Say? skills in adolescents with intellectual disabilities
using SGDs (Romski & Sevcik, 1993, 1996)
MOVING FROM PECS TO  SGD may allow more independent form of
SPEECH-GENERATING communication (voice output understood by
variety of familiar and unfamiliar comm.
DEVICES partners)

Research Questions Experimental Design

 Practitioners/parents: after successful mastery of (initial) PECS
phases, can the child move on to a SGD? (Grether, 2007)
 “…research into innovations to the PECS protocol is a
laudable direction and should be continued using rigorous
methodologies” (Schlosser & Wendt, 2008)
 Project goals:
- Modify traditional PECS protocol for implementation and
transition to an SGD
- Evaluate the effects of such a modified PECS protocol on
increasing requesting skills, social-communicative behaviors,
and emerging speech
- Evaluate effectiveness of a particular device for such purpose
that is built upon PECS principles
 Multiple Baseline Design across participants
(Baer, Wolf, & Risley, 1968)
 Intervention phase split into PECS phases and SGD
phases, followed by maintenance phase
 3 children, 9-11 yrs., severe autism and non-verbal
 Dependent measures:
 Requesting skills: number of correct requests during
20-trials session
 Social-communicative behavior: number of responses
including eye contact, physical orientation towards
comm. partner, positive affect via smiling/laughter
 Emerging speech: word vocalizations or word approx.

Materials and Setting

 Traditional PECS book with PCS symbols for
desired items
 Proxtalker -“sentence strip that actually speaks”:
picture card is put on ProxTalker display  speak out the
symbol referent in form of prerecorded digitized speech
- several picture cards can be
combined to speak sentences
- symbols used were identical to
PECS symbols
 Departmental Speech Clinic,
3 sessions per week

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Wendt: Evidence AAC in Autism CARD Conference 2011

Modified PECS Protocol Baseline Video Clip

(Preference Assessment)
 Phase I: Physical Exchange
 Phase II: Expanding Spontaneity
SGD Implementation
 Phase III: Picture Discrimination
 Phase IV: Sentence Structure
 Phase V: Responding to “What do you want?”
 Phase VI: Responsive and Spontaneous
Commenting
(Original PECS protocol by Bondy & Frost, 1994)

PECS Phase I Video Clip PECS Phase II Video Clip

End End

ProxTalker Phase II Video Clip ProxTalker Phase V

Beginning End

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Wendt: Evidence AAC in Autism CARD Conference 2011

Ipad Phase
Effects on
End
Requesting
 Moving from Mid-Technology (ProxTalker) to High- Skills
Technology (iPad)

Effects on Effects on
Social- Emerging
Communi- Speech
cative
Behavior

SpeakAll!
 The purpose is to help teach the process of
constructing sentences
 Customizable to each child’s specific needs
 Allows the instructor to use recorded audio and custom
images
 Seamlessly connects with PECS or ProxTalker intervention
 Selection Area on top replaces
PECS book
 Sentence Strip at bottom speaks
selected graphic symbols
 “Shuffle button" randomly regroups
graphic symbols
 DOWNLOADABLE ON ITUNES (free app)
Appstore>Education>Purdue>SPEAKall!

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Wendt: Evidence AAC in Autism CARD Conference 2011

Current iPad-SpeakAll
Participant 1 - Requesting
Research
 Multiple Baseline Design across settings (Baer, Home
1 attr.
Wolf, & Risley, 1968) 2 attr.

 Intervention repeated across clinic, home, and school iPad fade out

environments following PECS instructional phases

School
 iPad with SpeakAll replaces ProxTalker, intervention
starts immediately with iPad
 Dependent measures:
 Requesting skills: number of correct requests during Clinics
20-trials session
1 attr. 2 attr.
 Emerging speech: word vocalizations or word approx.

Baseline Ph 3 Ph 4 Ph 5

Participant 2 – Requesting Participant 3 - Requesting Clinic

20

15
2 attr. Speech only 1 smbl
iPad gone
10 2+ smbl
1 attr.
1 attribute iPad fade out
5

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

School

iPad gone
Speech only
1 attr. iPad fade out

Home

2 attr. iPad gone Speech only

1 attr.
iPad fade out

Baseline Ph 3 Ph 4 Ph 5 Baseline Ph 3 Ph 4 Ph 5

Participant 4 - Requesting Ipad and SpeakAll!

20

15
Ph 3 School
Participant 2 - Beginning
10 1 smbl
5 2+smbl
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

20

15

10 Home
5

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
20

15 Clinics
10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Baseline Ph 1 Ph 2 Ph 3

19
Wendt: Evidence AAC in Autism CARD Conference 2011

Ipad and SpeakAll! Ipad and SpeakAll!

Participant 2 – End Participant 3 - Baseline

Ipad and SpeakAll! Ipad and SpeakAll!

Participant 3 – Middle Stages Participant 3 – End

SpeakAll! in the News

 Journal and Courier
WLFI News Channel 18
 Indianapolis Star Report
 Inside INdiana Business  Go to
 Case In Point Healthcare http://www.wlfi.com/dpp/news/local/app-
Newsletter helps-autistic-children-communicate
 WLFI News Channel 18
 WTHR 13 Eye Witness News Indianapolis
 Part of CNN documentary on apps for autism
(producer: Supraja Seshadri)
 Over 4,250 downloads since Nov. 2011

20
Wendt: Evidence AAC in Autism
Acknowledgements
 This project is supported by a Project
Development Team within the ICTSI
NIH/NCRR Grant Number RR025761
 Thanks to ProxTalker.com, LLC for providing
devices
 Thanks to the families who agreed to
participate in our research
Contact Information
Oliver Wendt, Ph.D.
Purdue University
Dept. of Speech, Language, and Hearing Sciences
West Lafayette, IN 47907-2038, USA
Phone: 765-494-2462
E-mail: olli@purdue.edu
References (cont.)
 Fuller, D. R., Lloyd, L. L., & Stratton, M. M. (1997). Aided AAC symbols. In
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and alternative communication to support receptive and expressive
communication for people with autism. Journal of Communication
Disorders, 31, 153-180.
CARD Conference 2011
Questions ???
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Wendt: Evidence AAC in Autism
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CARD Conference 2011
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Wendt: Evidence AAC in Autism
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CARD Conference 2011
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Wendt: Evidence AAC in Autism
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CARD Conference 2011
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