Back in March 2017, Naprika, attended a PECS Level 1 workshop as she wanted to begin implementing PECS with her son Eli. In August 2018 Naprika contacted us as she wanted some PECS support at home, she felt that Eli was very reliant on an adult prompting him to use PECS when he wanted to communicate. She also wanted some help with increasing his vocabulary beyond food and drink items and encouraging spontaneity.

Although Eli was very reliant on prompting, we discovered that he had excellent discrimination skills and was using attributes (eg size, colour) so was working at Phase V of the PECS protocol.

Pyramid Clinical Director, Louise Maggs, advised Naprika to make sure that Eli had enough practice using PECS so that his communication could be extended. She should be aiming for him to complete a minimum of 40 exchanges per day, and that to facilitate this number she should hold back key items, or reinforcers so that Eli had to ask for them. After the session we sent Naprika a written report with recommendations and a list of the next steps to take.

Fast forward 4 years
Naprika contacted us again to request some further PECS support at home as Eli’s PECS use had reduced considerably over time. This is probably an all too familiar story to some parents, and was likely exacerbated by the pandemic.

Naprika said “We have fallen into a pattern of saying ‘What does Eli want?’ and then saying the two choices e.g., Ribena or grapefruit juice. When giving Eli the two choices, I wait and give Eli time to respond, which he can do verbally. But there is a downfall to this because he has echolalia which now seems to switch between the first or second choice offered, which means we must switch the choices around to check which one he really wants. I am also sensing that there is sometimes possible growing anxiety when he knows that we are waiting for him to verbalise his choice.

“Other ways to encourage Eli to respond have been by me signing ‘I want’ and then pausing and waiting for Eli to say what he wants. I think that Eli is back at Phase I because, when we give him options I have to gesture to him to use his book or to get it from another room. He is not independently going to his book. This is again partly due to us at home slowing down on our usage of PECS and not keeping up the momentum with it. I guess we also pre-empt that he is wanting our attention, and what he is wanting to get or choose.

“At a recent EHCP review meeting all those present agreed that there were still a lot of areas where Eli was unable to communicate his needs, thoughts, or answers to questions with extended family,  friends and those who don’t know him well. Recently he was unwell and unable to communicate if he felt bad and where his pain might have been. It was agreed that PECS should stay on Eli’s EHCP”

Pyramid Consultant Andy Yates visited Naprika, Eli and Eli’s Grandmother Margaret, to help them get PECS back on track. Andy takes up the story, “After several minutes of initial discussion about Eli’s skills he stood up, made a noise and pointed to a corner. Naprika told me that he wanted the iPad. Eli was continually looking at mum and then the iPad, appearing to be seeking approval for him to get it. I put a symbol of an iPad on his communication book and paired it with a symbol of Lego, which was in the same corner, asked Naprika not to say anything but to simply push the book closer to Eli. Eli tapped the iPad symbol, I prompted him to exchange the symbol with Naprika, and whilst he gave the symbol he also said, “I want iPad please Mummy”. Naprika, Margaret and I were really surprised, we all showed our joy by telling Eli how good he was and giving him the iPad!

What a difference a picture can make…

“Using this as a starting point, we continued to assess Eli’s skills whilst focusing on removing any kind of vocal, gestural or facial prompts. We swapped between Naprika and Margaret being the communication partner to build Eli’s ability to generalise his skills, whilst I remained the prompter, prompting Eli from behind to exchange the symbol.

“After four correct trials using a correspondence check, Eli quickly demonstrated that he could discriminate between two, three, four and five symbols of items that he found reinforcing. With only minimal prompting from me to remind him to exchange the symbol on the first 2 trials, as he simply tapped the symbols whilst they were still on the book. After that Eli was able to exchange the symbol independently and reach out to take the corresponding item.

“I then introduced the Sentence Strip and reminded Eli of all four steps needed to construct a sentence. He required only minimal prompting to begin with and after three trials, not only was Eli constructing a two-symbol sentence and exchanging it with Naprika and then tapping the symbols, but he also started to put the symbols back whilst waiting for the requested item! I encouraged everyone to give Eli lots of social praise and to let him have the item for longer, as this was better than before!

“Naprika and Margaret were both amazed at not only how quickly Eli was remembering how to construct and exchange the Sentence Strip, but at the increased frequency that he was initiating vocalisations! We all agreed that using the Sentence Strip to initiate communication appeared to support Eli’s confidence in spontaneously vocalising his intentions – without the need for either Naprika or Margaret to ask first.

“We moved onto adding in some attributes such as colour and doing correspondence checks to assess the accuracy of Eli’s requests. When Eli made an error, I demonstrated the four-step error correction procedure, on step four Eli showed correct correspondence!

“At this point I reminded Naprika and Margaret about Phase II – Distance and Persistence. Over the next five trails, Margaret became the communication partner and gradually moved further away from Eli, using the teaching strategy of shaping to encourage him to travel and to get her attention. Margaret was brilliant at slowly turning her back towards Eli and not giving him her full attention!  We discussed the need to continually remind Eli about Phase II skills as they would not always be able to give him their undivided attention as we were all doing at present.

“Finally we briefly touched upon teaching the nine critical communication skills (help, wait, break and so forth). Naprika said that teaching Eli to ask for help would be very useful for everyone! I also explained how to use the I am Working For cards as a teaching strategy to increase Eli’s motivation to participate in activities that were less appealing to him.”

Progress
After the session we sent Naprika a report and some recommendations and next steps. She wrote to Andy saying “We are so grateful for the work that you did with us on the home visit with Eli. He has been using PECS, just the other day after he finished eating dinner, he independently made a sentence strip that said: ‘I want pudding’ and handed it to me, he has also been more specific and requested yogurt.

“Eli has also taken the PECS book with him to his drama sessions. I explained to his drama leader that he had it with him, and at the end of the session she let me know that Eli had used PECS to request a drink, which was fantastic!! He has also done well using the sentence strip, when choosing breakfast he built a sentence that said, “I want toast, butter and jam”, Eli had a big smile whilst he was verbally reading it out to me!

“He has also been sat, relaxed, pondering through the pages of his PECS book. Watching him made me think that I need to add more pictures to his book to enable him to have a bit more choice and to extend his vocabulary. I also thought that if I have more PECS symbols that Eli will be able to use PECS in more situations. This will also give me more opportunity for sabotage, (a teaching strategy to create more opportunities for Eli to be motivated to communicate) as sabotage has been around the dinner table with leaving a knife or fork missing or a drinking glass.”

Virtual Follow Up Sessions
As well as some PECS support at home, Naprika had also booked two short online follow-up sessions to take place three and six weeks later. They were used to check on progress and for Andy to demonstrate anything Naprika was unsure about. During the first follow up session Naprika commented that she could see the difference in the frequency with which Eli was initiating communication. Andy and Naprika agreed that this was due to Naprika being able to reduce the occasions that she was communicating for Eli, hence increasing the need for Eli to initiate communication when he wanted to and not when he was asked to. Naprika agreed to continue to support Eli in this way.

At the second follow up session Naprika said that Eli’s ability to communicate in a more functional way using PECS was increasing, and with this increase in communication there was decrease in the guess work to find out what Eli really wanted to communicate. Andy recommended that Naprika and Margaret should begin to eliminate any vocal or gestural prompting (we know it is easier said than done…) and increase the opportunities for Eli to spontaneously communicate. Andy also suggested that Naprika should collect more data to share with the school to promote a more consistent approach to support Eli in the future.

A huge thank you to Naprika for allowing us to share her experience of PECS In-Home Support

If you are interested in having some PECS support at home take a look at the different options for parents, we also have several options for professionals requiring support in their setting too. Don’t forget to visit the PECS User Support Group on Facebook where you will find can find the answers to lots of questions, discuss tips and tactics with other parents and hear about any news and developments.

By Louise Hotchkiss & Andy Yates

© Pyramid Educational Consultants