Treszl, A. T., Koudys, J., & O’Neill, P. (2022). Evaluating the effects of Picture Exchange Communication System® mediator training via telehealth using behavioral skills training and general case training. Behavioral Interventions, 37(2), 290-305.https://doi.org/10.1002/bin.1835

Reviewed by:
Kate McKenna, MEd, MSEd, MS, BCBA and Seirra Mitchell, BS, RBT, SLC
Association for Science in Autism Treatment

Why research this topic?

Procedures to teach specific skills for individuals with autismAccording to the National Institute on Deafness and Other Communication Disorders, individuals on the autism spectrum often struggle with communication. Augmentative and Alternative Communication (AAC) systems such as the Picture Exchange Communication System (PECS) can aid in effective communication for individuals diagnosed with autism. PECS involves the child exchanging a picture or series of pictures with their communication partner to access a preferred item, activity, or outcome. It is crucial to provide parents with the necessary PECS implementation training to support their child’s communicative efforts at home and in other settings. When parents are not trained to implement PECS effectively at home, they may inadvertently misuse it or abandon the communication system altogether, thus jeopardizing their child’s ability to communicate (Moorcroft et al., 2019). Further, there is an increasing need to evaluate training interventions that are delivered via telehealth as this has become a more common modality for service delivery. The present study uses telehealth and teaches parents how to implement PECS through the combination of behavior skills training (BST) and general case training (GCT). BST is an evidence-based approach for training individuals to implement behavior change and related procedures (Parsons et al., 2012). GCT is a method of teaching concepts or skills using a variety of related materials and items. The goal of GCT is to increase the range of circumstances under which the child can perform a skill in the natural environment (Steere et al., 1989).

What did the researchers do?

The researchers examined the efficacy of BST and GCT through telehealth to teach parents to use PECS with their child in their home. The study focused on a 4-year-old boy named Noah, his father (Jeffery) and his mother (Kate). Noah has an autism diagnosis and was in the initial stages of using PECS as a mode of communication. Because Noah was making errors in differentiating between picture icons to ask for preferred items, it was recommended that Noah’s parents learn how to implement PECS at home as Noah would benefit from the additional picture discrimination training to help him become more accurate in his requests. In this study, the researchers trained the parents on successful implementation of discrimination training with Noah. Jeffery and Kate participated in training sessions where Jeffrey received direct training and Kate served as the confederate parent who acted as the child. The researchers targeted three key skills: Skill 1 was to set up opportunities for the child to communicate, such as presenting preferred items and activities that the child must use communication to gain access. Skill 2 was to conduct a correspondence check which ensures that the correct picture is being used to request the preferred item. Skill 3 was to implement the PECS four step error correction procedure (i.e., model, practice, switch, and repeat) to correct a potential picture discrimination error (i.e., when child exchanged an icon for juice but reached for a cookie).

A web video application called Life Size was used and sessions took place virtually with participants at the kitchen table or in the basement recreation room. The intervention package included BST and GCT. BST involved providing instructions, modeling of the target skills, opportunities for practice, and feedback on the practice sessions. GCT involved a process of general case analysis to identify variations in steps in parent responses for each of the three skills, possible responses by Noah that could be influenced by lack of interest or change in motivation, variations in the type, size, and magnitude of reinforcers, and potential variations in the location of the binder and response effort needed to locate and use the icons. Possible scenarios were created to be used in training.

During training, written instructions and video models were provided for the parents to follow to ensure correct PECS implementation and data were collected on their ability to follow those procedures. The parents viewed short videos (1 – 2 minutes) of the skills being performed. Additionally, researchers demonstrated the skills through telehealth so Noah’s parents could watch them. Jeffery then performed the skills with Kate acting as Noah. Jeffrey was provided with corrective feedback. Kate’s performance was monitored, and feedback was provided to ensure correct implementation. Data collection of Kate’s performance was important because it assisted the researchers in determining if she could implement PECS with Noah at home in the absence of direct training.

What did the researchers find?

Data collected on Jeffrey’s performance indicated that BST and GCT training resulted mastery of Skill 1 (creating opportunities) and Skill 2 (correspondence check). Jeffrey was not observed to meet criteria for mastery for Skill 3 (error correction). This may have been because there were limited opportunities to practice due to Noah’s high level of PECS accuracy. Through indirect training, Kate was also observed to master Skills 1 and 2 but did not meet criterion for Skill 3. Data taken on Noah’s use of PECS showed a high level of PECS accuracy. Before training began Noah demonstrated consistent errors in picture with a mean correct of 85%. That score did not change after parent training. During follow-up, Noah’s accuracy was variable, with a 76% accuracy at 2-weeks and 85% at 6-weeks. Additional research would need to be conducted to explore the relationship of PECS acceptance and use by individuals with autism and the PECS implementation skill level of caregivers. Social validity data were collected from Jeffrey only, who reported that the training had improved his PECS skills. The use of Kate as the confederate parent was beneficial.

What are the strengths and limitations of the study?

This study adds to the research base in its use of telehealth to teach the implementation of PECS using both BST and GCT in the child’s home. This study also examined the effectiveness of training one parent while the other participated as a confederate who did not receive direct training. Development of an effective teaching procedure in which one participant receives direct training and the other learns through observation is worthy of further study as it would reduce teaching time and could possibly increase the number of caregivers who could participate as observers. Further research would be needed on the efficaciousness of participants observing teaching sessions remotely.

There are a few limitations in this study that must be mentioned and suggest caution when interpreting its results. This study used one family, which makes it difficult to generalize results to other families that do not match the age, educational background, proficiency in English, and economic status of the participant family. The authors note also that Noah’s parents were aware they were being observed using PECS with him which may have influenced their behavior. Noah already possessed prerequisite skills using PECS. Additional research with participants with limited or no previous PECS experience is necessary before generalizing these results to the other PECS levels. Additionally, social validity measures were only completed with Jeffrey and not with Kate. More information about Kate’s experience could have been gleaned through social validity measurement or a survey which captured details of her perspective of the training procedures.

What do the results mean?

Results indicate that the combination of BST and GCT was effective when teaching parents to implement the PECS discrimination training with their child. Skill improvement was seen in the kitchen and the basement playroom, two places in which Noah was likely to want to request items. This shows that skills Noah learned in a clinical setting can transfer to the home environment when parents gain competency in the PECS protocol. Kate’s implementation of PECS improved even though she did not receive direct training. These results show promise, and further research is needed on the variables that effect observational learning. This study also demonstrates the strength of telehealth as a teaching medium. Parents observed both videos and live modeling of the skills. More research is needed to investigate the benefits of video and live models used in combination and separately.

References

Frost, L., & Bondy, A. (2006). The Picture Exchange Communication System training manual (2nd ed.). Pyramid Educational Products Inc. https://pecsusa.com/shop/pecs-training-manual-second-edition/#tab-description

Moorcroft, A., Scarinci, N., & Meyer, C. (2018). A systematic review of the barriers and facilitators to the provision and use of low-tech and unaided AAC systems for people with complex communication needs and their families. Disability and Rehabilitation: Assistive Technology, 14(7), 710-731. https://doi.org/10.1080/17483107.2018.1499135

National Institute on Deafness and Other Communication Disorders. (2020). Autism Spectrum Disorder: Communication Problems in Children. NIDCD. https://www.nidcd.nih.gov/health/autism-spectrum-disorder-communication-problems-children

Parsons, M. B., Rollyson, J. H., & Reid, D. H. (2012). Evidence-based staff training: A guide for practitioners. Behavior Analysis in Practice, 5(2), 2-11. https://doi.org/10.1007/bf03391819

Steere, D. E., Pancsofar, E. L., Powell, T. H., & Butterworth, J. (1989). Enhancing Instruction through General Case Programming. TEACHING Exceptional Children, 22(1), 22-24. https://doi.org/10.1177/004005998902200105

Treszl, A., Koudys, J., & O’Neill, P. (2021). Evaluating the effects of Picture Exchange Communication System ® mediator training via telehealth using behavioral skills training and general case training. Behavioral Interventions, 37(2). https://doi.org/10.1002/bin.1835

Citation for this article:

McKenna, K. & Mitchell, S. (2024). Research Synopsis: Evaluating the effects of Picture Exchange Communication System® mediator training via telehealth using behavioral skills training and general case training. Science in Autism Treatment, 21(10).

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