Let There Be PECS

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R using PECS to request a cookie

Recently we have been having some pretty exciting success with PECS!  PECS stands for Picture Exchange Communication System, and it is a picture-based alternative form of communication.

Therapists have been trying to introduce PECS to R ever since he was first diagnosed at 18 months.  They start very simple- introducing just one picture card of a highly preferred item.  Back when they first started trying PECS with R, the card was a screenshot of his favorite Baby Einstein video.  Therapist A would play the video for a few minutes then pause it.  When R fussed for more, therapist B, standing quietly behind him, would take his hand and hand-over-hand have him pull the video card off a velcro strip and hand it to therapist A.  Therapist A would announce “video!” and press play.  The idea was that he would eventually make the connection that his video was played every time he grabbed the video card, and then he would begin grabbing it spontaneously without help or prompting from therapist B.

When we initially tried PECS, this never happened.  A few months later when we tried again and he did progress to grabbing the card himself, but was unable to discriminate between cards, despite the exact-photo images on them.  Meaning that as long as there was only one card on the strip he could and would pull it off.  But as soon as you added a second card option, for example “apple,” he would grab one or both cards indiscriminately.  The idea was to teach him to choose the right one- so if he grabs “apple,” he is given an apple, and if he grabs “video,” his video is played for him.  However, despite exhaustive attempts we were not able to get him to discriminate between cards, and he soon began refusing  to do anything more than grab and mouth the cards.  So we put them away again.  PECS were tried once or twice more and with the same result.  About 6 months ago I asked his therapists to put them away semi-permanently and focus on ASL signs.  While we did see some receptive language success with ASL, R was not able to form signs expressively.

A few weeks ago I noticed that R had learned what “no” means and was showing consistent understanding of the word.  That same week he made faces to himself in the mirror for the first time- a cognitive milestone that typically developing children achieve around 6 months of age, but which R had been missing.  Previously he did not appear to realize that the face in the mirror was his own.  We had seen one or two other cognitive developments recently, and it occurred to me that with these developments maybe it would be a good time to try PECS again.

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R’s current food strip.

We started with food items, since that is such a concrete thing, easy to make exact photo images of, and something which he interacts with multiple times per day.  Every time I brought him something to eat I showed him the card picture of the item.  He only eats the same 3-5 food items, so I kept those 4 or 5 picture cards hanging on a velcro strip next to the kitchen when the cards were not being used.  I noticed him looking at them on the wall throughout the week, and looking at them when I presented them with his food.  After one week of this, R independently went to the strip on the wall and pulled off the “cookie” card to request a cookie spontaneously for the first time!  Over the course of the next week he also spontaneously requested “chicken” and “chips” several times.  He was really doing it!  Watch R request a cookie here.

In our initial excitement over the communication we did allow R to choose “cookie” about 15x per day.  But after a few days it became evident we were going to have to deny him or “cookie” was all he was going to ask for and eat.  At first I tried removing the “cookie” card from his strip at times when it was not going to be an option.  This didn’t quite sit right with me- you wouldn’t remove words from a child’s spoken vocabulary just because the answer is going to be “no”- but I didn’t know what else to do.  This did not help or work however, as R simply searched for the card and then had a tantrum that he couldn’t find it.  It broke my heart because he was working so hard to communicate with us and didn’t understand why he was being ignored/denied.

At a loss of what to do, I reached out to an AAC (alternative augmentative communication) group on Facebook that is home to a number of helpful SLPs.  They all had the same advice- create a “no” symbol that can be imposed over the card so that R can still see the cookie card, but sees the “no” symbol on top, denoting that it is not a choice right now.  I made a clear pocket with the “no” symbol on it, and placed the cookie card in the pocket.

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The “no” pocket.

To further help him understand, I also paired it with the “no” and “all done” cards that his school uses in the classroom, and with which his teacher said he is slowly growing familiar.  At first he was resistant.  He tried to grab the card despite the “no” sign, but I would run his finger over the “no” sign and show him the “no,” “all done” cards and use the ASL sign for “all done” (which he understands) as well.

His next move was to remove the cookie card from the “no” pocket.  My husband greatly appreciated this!  If the pocket made the cookies off limits, surely just removing it from there would make them available again!  We responded by intervening and putting the card back in the “no” pocket and reminding him again that it was “no” and “all done.”  At this point I decided to move “cookie” off the wall strip, and onto a separate sentence strip paired with “no” and “all done.”

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The sentence strip showing “no cookie, all done.”

Then when it was time that he was allowed to choose “cookie,” I brought him over and had him watch as I removed “no” and “all done” and took “cookie” out of the “no” pocket.  I placed the “yes” card down next to the “cookie” card and kept them on the same separate sentence strip.

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The sentence strip showing “yes cookie!”

This arrangement seemed to make more sense to him.  He began checking the strip to see if it said “yes” or “no/all done,” and his attempts to remove the cookie from the “no” pocket reduced dramatically.

As of this morning we are introducing cards for a few non-food items.  For example the strip below is mounted on his spinning chair so he can request to be spun by me or his dad.

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I’m really proud of him and excited that we are slowly getting some communication!  Hopefully we will have more PECS progress to share in a few weeks or months as we continue to work on this.

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