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American Sign Language
vs.
Picture Exchange Communication System
in the Development of Verbal Language
in Children with Autism:
A Review

Every parent eagerly awaits their child's first words.  Each of us, as parents, wants our child to speak and communicate normally.  Unfortunately, these things do not always happen.  When a child does not begin speaking at the typical time there are any number of possible reasons.  Immediate and professional assessment of the reasons is always indicated.  No one should accept the answer "Well, lets just wait and see if he catches up." or "Boys just develop more slowly than girls." from any professional - those are excuses not answers.  If your child's language is not developing in the manner you believe is typical then an evaluation to determine why is essential - not optional.  

Language development is critical for almost all other forms of development in children and the sooner any delays or deficits are addressed the better for the long-term development of the child.  A diagnosis of Autism or an Autism Spectrum Disorder is only one of a wide range of possible reasons for delays in spoken language.  There are a variety of other possible reasons, from a hearing impairment to more serious issues.  Adequate and immediate evaluation by a qualified professional who takes the issue seriously is absolutely essential.  This article is intended to address issues around the development of spoken language in children with an Autism Spectrum Disorder and the relative value of using either Sign Language or PECS as tools to assist in the development of typical language for the child.

Estimates are fairly consistent that fifty percent of children with autism are nonvocal (Frankel, Leary & Kilman, 1987). Currently the most widely used augmentative communication systems  with this population are sign language and the Picture Exchange Communication System (PECS; Bondy & Frost, 1994).  Large individual differences in performance have been noted in both modalities (Bondy & Frost, 1994; Kiernan, 1983).  Research indicates that augmentative systems are typically  chosen for children with autism based on what their caregivers prefer or what their teachers know how to use (Kiernan, Reid & Jones, 1982). Recent research on neural plasticity in the brains of very young children has demonstrated the importance of individualizing early treatment (Chugani, Phelps & Mazziotta, 1987).  

The development of spoken language in children with Autism is the ultimate goal of a vast array of interventions designed to address this fundamental deficit central to the diagnosis of Autism.  A variety of procedures and packages have been offered to facilitate this development.  The overriding goal, of nearly all programs and policies in this area, is the development of "normal speech".  However, Autistic children require supports and often intensive programs in order to make significant progress toward meeting that goal.  A vast industry of interventions from a variety of professions and theoretical orientations have sprung up in the past decade in an effort to meet this need.  For the majority of these approaches there exists little or no evidence that they are effective.  For even more of these interventions there exists no evidence that they are superior to the known treatments which are already supported by a research base in the literature such as Applied Behavior Analysis (ABA) and Verbal Behavior Analysis (VBA).  Some of the approaches that are popular currently have their origin in ABA or VBA and draw their credibility from that body of research.  In many instances, where a purely verbal program is not producing significant improvements in spoken language, two alternative support options are considered: American Sign Language (ASL) and Picture Exchange Communication System (PECS).

For many years there have been people that opposed the use of sign language and ASL with Autistic people.  Many of these advocates have argued that ASL somehow impedes the development of spoken language.  Others have argued that there is not a natural group of listeners for sign language thereby isolating the autistic child.  Many have argued that PECS is superior to ASL because naive listeners (readers) can understand the communication efforts of the autistic child more readily and that PECS is superior to ASL in development of spoken language.  As in many areas there are zealots who have entered this arena with their preconceived notions and who propose a one-size-fits all answer.  If there is one thing that we should have learned in working with children, let alone children with Autism, it is that one-size definitely does not fit all.  Such an approach has repeatedly been demonstrated to be harmful to the child reaching their own fullest potential.

So, is there any evidence in the scientific literature on these issues?  Does our science have anything to say about whether ASL delays the development of typical spoken language?  Is PECS definitely better?  Is ASL as outdated as a horse and buggy or does it continue to have a role to play in the treatment of children with autism?  These are very important questions that all too many have offered opinions on uninformed by the research literature.  There are answers to these questions available, but like most areas academics write for each other and not for parents, teachers, and practicing professionals working and living day-to-day with children with autism.  This makes actually accessing this information difficult for the parent trying to live their life and raise their children.  It is not particularly easy for the working clinical professional who does not have graduate students to run to the huge university library and search the achieves for them to know either.

First, lets address the issue of whether or not sign language delays the development of spoken language.  This is an old assertion made by many advocates, educators, and others regarding sign that really needs to be addressed.  Fortunately, the National Academy of Science in its landmark report Educating Children with Autism does address this issue very directly.  The NAS report says unequivocally:

There is no evidence to suggest that sign language interferes with the development of speech. (p. 58)

The report also states that:

There is evidence that sign language enhances the use of speech for some children. (p. 58)

The NAS report goes on to say that children with poor verbal imitation skills are the best candidates for an AAC system, such as sign language, because they are likely to make poor progress in speech acquisition without AAC.  So, the conclusions are pretty clear - the preeminent science organization has firmly and very clearly stated that a comprehensive review of the research says several things: 1) Sign Language does not delay the acquisition of spoken language, 2) there is evidence that some children's spoken language is enhanced by the use of sign language, and 3) children with poor verbal imitation skills are the ones most likely to need one form or another of augmentative communication system like ASL to develop spoken language.

Sign language, or any Alternative or Augmentative Communication System (AAC), is not intended to be the end-point in the development of language for children with autism.  Seal and Bonvillian (1997) analyzed sign language formation of 14 children with autism and found that the size of the sign vocabulary and accuracy of sign formation were highly correlated with measures of fine motor abilities. These findings point to the role of a motor impairment in the level of competence attained in sign language and speech acquisition for children with autism.  It is important to note that simple signs may be a support for children learning to speak or an additional mode of communication for children who have no speech or limited speech. However, it is very rare to find a child with autism who learns to sign fluently (in sentences) and flexibly - nor is it intended to be a substitute for fluid natural speech.

So, if ASL does not delay speech acquisition and in fact accelerates it for some children with autism; why is the assertion put forth that learning sign is somehow condemning the child to having no one to communicate with in the community?  First, how many young children with autism are truly roaming the community or their neighborhood without a caregiver?   True, caregivers and service providers need to learn some sign language if it is to be used as a meaningful form of communication for the student.  Remember that ASL is not intended to be the stopping point but rather to help generate more spoken language as soon as possible.  Typically, signs are taught in sets and the adults need to stay ahead of the child in their learning of more signs.  Our experience is that adults who are dedicated to working with the child can readily learn the elementary signs needed with limited effort and time.  Additionally, we have seen over and over again typical children be fascinated by the use of sign language and work to learn it without adult supports.  So, the child with autism is not going to be expected to wander the wide-world signing at strangers and people who care for the child can easily learn the sign needed.  Another benefit of sign is that it does not require an extensive technological base - you don't need color printers, laminators, Velcro, computers, etc. to use it.

PECS is a system using pictures to communicate that was developed by Bondy & Frost in the last 1980s.  Typically, 1 to 3 inch square icons are printed on paper and laminated to form the PECS cards and they are Velcroed to books, boards, items, etc.  PECS has better research support than other icon based visual systems principally because PECS requires the child to exchange the card with the listener thereby generating a social interaction, when other systems only expect the child to touch the icon and not to directly interact with the listener.  Additionally, over the past few years Bondy & Frost have incorporated the idea of starting by teaching Mands to children using the PECS system which appears to have improved the effectiveness of this AAC intervention.  PECS includes protocols for expanding communication from single to multiple words and for increasing communicative function from requesting to labeling and commenting. 

In 1994, Bondy and Frost  reported a case review of a group of preschoolers with autism who were taught PECS.  Of 19 children who used PECS for less than 1 year, only two (10%) acquired independent speech as their sole communication. Of 66 children using PECS for 2 years, 39 (59%) developed independent speech. Thus, for most preschoolers introduced to PECS, it took more than 1 year after initiating PECS to observe independent speech, and many continued to have very limited spontaneous use of language. Speech tended to develop once the children were able to use 30100 symbols to communicate. Another factor that appeared to have a strong correlation with the development of independent speech was the overall level of intellectual functioning of the child at the outset of training.

Aimee Anderson, in her dissertation research in 2002 (sadly it is apparently unpublished), studied 6 children with autism, ages 2 to 4, who received training in both sign language and PECS. The study  investigated differences in child performance between the sign language and PECS conditions in rates of acquisition, spontaneous use, maintenance, behavior (e.g., self-stimulation, positive affect), generalization, eye-contact and vocalization.  In addition, the study sought to identify child characteristics (e.g., joint attention, imitation) that may be related to performance in each modality. 

Children in the study appeared to prefer one modality of communicating over the other.  There was a main effect of PECS acquisition, benefits of the PECS modality included success with a broader range of children, faster rates of acquisition, and better generalization to novel items.  Signing resulted in more vocalizations during correct responding at post treatment than PECS.  Vocalizations during and after treatment were associated with initial vocal imitation levels, but signing overall resulted in more mastered items than did PECS.  For example, John mastered 3 items with speech during signing and 1 item during PECS intervention and Ryan mastered one item with speech in signing and none in PECS.  The benefits of sign language included higher levels of initiation, eye-contact, and vocalization following the end of treatment.  Rates of acquisition of sign language were associated with levels of protodeclarative joint attention comprehension before treatment.  A preference for sign language was associated with high levels of functional play.  Vocalization during and after treatment was associated with imitation levels and language age-equivalents before treatment.

Matt Tincani, as his doctoral dissertation, compared the effects of Picture Exchange Communication System (PECS) and sign language training on the acquisition of Mands (requests for preferred items) of students with autism.   Mands, or requests, are the fundamental starting point in Verbal Behavior Analysis programs designed to develop functional language in children with language delays.  The research support for ABA/VBA approaches to language development is strong, however the question of alternative and augmentative systems to facilitate the use by the child of spoken language with an ABA/VBA program remains relatively under researched.  This initial study is an important step in addressing the questions regarding ASL & PECS in teaching language to children on the Autism Spectrum of Disorders.

The study, which appeared in the journal Focus on Autism and Other Developmental Disabilities in 2004, examined the differential effects of ASL vs. PECS on students' acquisition of vocal behavior. Students were two elementary school students with autism enrolled in a suburban public school. Training sessions involved presentations of preferred items, prompting and prompt fading procedures. Probes were conducted to evaluate the generalization of learned Mands to classroom teachers. For one participant, sign language training produced a higher percentage of independent Mands. PECS training produced a higher percentage of independent Mands for the other participant.  For both children, sign language training produced a higher percentage of vocalizations during training.  Mands learned with the experimenter generalized to the classroom teachers. The results of the study suggest that acquisition of picture exchange and sign language may vary as a function of individual student characteristics, specifically, motor imitation skills prior to intervention. However, further research is needed to determine the optimal procedures for teaching both modalities to students with communication difficulties.

The bottom line on this issue is simple - there are options that may assist the child with serious language delays in developing spoken language.  Sign and PECS are two of those options that have research supporting their effectiveness.  There is NO literature support for the often heard assertions that ASL delays the development of spoken language in anyone - let alone children with autism.  Why would you select one option over another?  If one has been tried consistently and competently and has failed to facilitate the development of language is a good reason to try the other.  Another reason might be motor planning and fine motor skills because PECS generally requires less motor planning and skill to use than does ASL.  However, all other things being equal there are good arguments for trying old fashioned low-tech sign language first.  Sometimes being old and low-tech is not a bad thing.

 

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