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Evaluation of the Effects of the Picture Exchange Communication System™ Protocol on Problematic Behavior across the School Day

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Title: Evaluation of the Effects of the Picture Exchange Communication System™ Protocol on Problematic Behavior across the School Day
Language: English
Authors: Tyler-Curtis C. Elliott (ORCID 0000-0001-6826-4449), Chloe N. Wise (ORCID 0000-0002-2539-5059), Krystin A. Abt (ORCID 0009-0009-5345-4157), Madeline G. Drives (ORCID 0009-0006-4685-3510), Rachel R. Cagliani (ORCID 0000-0001-8031-295X), Kevin M. Ayres (ORCID 0000-0002-7166-5742)
Source: Journal of Developmental and Physical Disabilities. 2025 37(6):981-1006.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 26
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Augmentative and Alternative Communication, Pictorial Stimuli, Behavior Problems, Preschool Children, Autism Spectrum Disorders
DOI: 10.1007/s10882-024-09999-9
ISSN: 1056-263X
1573-3580
Abstract: The Picture Exchange Communication System (PECS) helps build a functional communicative repertoire, including requesting, thus acquisition of picture exchange may result in reductions in operationally defined problematic behavior if the requests act as a replacement behavior. Current research provides inconclusive data regarding the impact of acquisition of picture exchange on problem behavior. In addition, these studies collected behavior data for only 5-15 min sessions during or after PECS training. We taught four preschool students with autism to communicate with picture exchange using the PECS Phase I-IIIB protocol and collected data on their problem behavior across the day for at least 2 days a week for 4 months. The results suggest that the acquisition of picture exchange through Phase IIIB did not consistently diminish problem behavior for our participants. We discuss these results in relation to spontaneous picture exchange use.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1495388
Database: ERIC
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  Value: <anid>AN0189290419;jdp01dec.25;2025Nov17.04:32;v2.2.500</anid> <title id="AN0189290419-1">Evaluation of the Effects of the Picture Exchange Communication System™ Protocol on Problematic Behavior across the School Day </title> <p>The Picture Exchange Communication System (PECS) helps build a functional communicative repertoire, including requesting, thus acquisition of picture exchange may result in reductions in operationally defined problematic behavior if the requests act as a replacement behavior. Current research provides inconclusive data regarding the impact of acquisition of picture exchange on problem behavior. In addition, these studies collected behavior data for only 5–15 min sessions during or after PECS training. We taught four preschool students with autism to communicate with picture exchange using the PECS Phase I-IIIB protocol and collected data on their problem behavior across the day for at least 2 days a week for 4 months. The results suggest that the acquisition of picture exchange through Phase IIIB did not consistently diminish problem behavior for our participants. We discuss these results in relation to spontaneous picture exchange use.</p> <p>Keywords: Picture exchange communication system; PECS; Problem behavior; Functional communication; School</p> <p>Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10882-024-09999-9.</p> <p>Children without a functional means of communication are more likely to engage in problematic behavior (Chiang, [<reflink idref="bib13" id="ref1">13</reflink>]). Children who engage in problem behaviors experience fewer inclusive opportunities (Murphy, [<reflink idref="bib55" id="ref2">55</reflink>]), are more likely to be treated with pharmacotherapy (Matson & Dempsey, [<reflink idref="bib52" id="ref3">52</reflink>]), and their caregivers experience greater stress (Hastings et al., [<reflink idref="bib33" id="ref4">33</reflink>]). Although developmentally young children frequently engage in challenging behaviors, including tantrums and aggression, most children grow out of these behaviors as their communication develops (Neil, [<reflink idref="bib57" id="ref5">57</reflink>]). Approximately 31% of children with autism spectrum disorder (ASD) also have an intellectual disability (Christensen et al., [<reflink idref="bib14" id="ref6">14</reflink>]) making them more likely to have substantial difficulty communicating through spoken language (Simpson, [<reflink idref="bib69" id="ref7">69</reflink>]). Should these children who do not develop speech get left behind, they would miss out on what some consider to be a right (see Communication Bill of Rights; Brady et al., [<reflink idref="bib7" id="ref8">7</reflink>]). Thankfully, augmentative and alternative communication (AAC) can provide children with ASD and limited communication a form of functional communication that may prevent or decrease problem behavior and can be used without hindering future speech development (White et al., [<reflink idref="bib79" id="ref9">79</reflink>]).</p> <p>AAC means "all of the ways that someone communicates besides talking" (American Speech-Language-Hearing Association, n.d.) and can be used to compensate for impairments of both speech comprehension and production (Mirenda, [<reflink idref="bib54" id="ref10">54</reflink>]). If students do not develop speech, AAC intervention should begin as soon as possible since individuals with developmental disabilities may require more time and practice on a skill and given that communication development begins at birth (Beukelman & Light, [<reflink idref="bib4" id="ref11">4</reflink>]; pp. 322). Overall, meta analyses suggest AAC interventions are effective for individuals with ASD at increasing requests (Iacono et al., [<reflink idref="bib39" id="ref12">39</reflink>]). Aided AAC uses materials or devices for communication, whereas unaided AAC does not rely on external mediums (Gilroy et al., [<reflink idref="bib30" id="ref13">30</reflink>]). There are two types of aided AAC devices: high tech devices use electronic devices for communication, whereas low tech AAC does not require technology such as sign language or picture exchange (O'Brien et al., [<reflink idref="bib58" id="ref14">58</reflink>]). The technology for AAC devices (e.g., iPad) is now accepted in the mainstream, minimizing how much an individual using high-tech AAC may stand out from their peers (McNaughton & Light, [<reflink idref="bib53" id="ref15">53</reflink>]). However, there is little technical and professional support that is available to assist with high tech AAC devices when problems arise (McNaughton & Light, [<reflink idref="bib53" id="ref16">53</reflink>]). When comparing both high and low tech AAC, there is no clear evidence that one modality is better over the other (Gilroy et al., [<reflink idref="bib30" id="ref17">30</reflink>]).</p> <p>One approach to teaching AAC use that systematically develops communication skills through explicit training phases is the Picture Exchange Communication System (PECS; Frost & Bondy, [<reflink idref="bib24" id="ref18">24</reflink>]). PECS is an intervention that teaches individuals to use picture exchange (an aided, low-tech AAC modality for communication) and is a logical first choice for teaching students with ASD functional communication since it systematically teaches prerequisite skills (Weiss & Zane, [<reflink idref="bib77" id="ref19">77</reflink>]). With the PECS protocol, trained instructors teach skills sequentially and build upon other skills, such that the only prerequisite the student needs is to have identified reinforcers. PECS first teaches the student to exchange a picture with a communication partner (CP), focusing on initiation. Then, Phase II teaches the student to independently move their body to find the PECS book, the CP, and to persist with the bid for communication even when the CP is not ready to accept the picture. Phase III focuses on teaching the student to discriminate between pictures. Phases IV, V, and VI focus on teaching sentence building, responding to questions, and socially commenting. A more detailed description of PECS can be found in the manual (Frost & Bondy, [<reflink idref="bib24" id="ref20">24</reflink>]).</p> <p>Several meta-analyses and reviews conducted by different researchers all found that PECS has a positive effect on communicative outcomes (e.g., Preston & Carter, [<reflink idref="bib61" id="ref21">61</reflink>]; Hart & Banda, [<reflink idref="bib32" id="ref22">32</reflink>]). Because the dynamic effects of PECS on communication are well documented (Sulzer-Azaroff et al., [<reflink idref="bib72" id="ref23">72</reflink>]), we will focus the rest of this paper on the ancillary effects of picture exchange acquisition, with a primary focus on problem behavior. Some researchers have demonstrated that PECS may impact vocalizations (Cagliani et al., [<reflink idref="bib8" id="ref24">8</reflink>]; Charlop-Christy et al., [<reflink idref="bib11" id="ref25">11</reflink>]; Ganz & Simpson, [<reflink idref="bib25" id="ref26">25</reflink>]; Tincani, [<reflink idref="bib75" id="ref27">75</reflink>]), social interactions (Carr & Felce, [<reflink idref="bib9" id="ref28">9</reflink>]), play skills (Johnston et al., [<reflink idref="bib41" id="ref29">41</reflink>]), and spontaneous requesting (Marckel et al., [<reflink idref="bib51" id="ref30">51</reflink>]).</p> <p>A few researchers have investigated the concomitant effect of PECS on operationally defined off-task behavior (Conklin & Mayer, [<reflink idref="bib17" id="ref31">17</reflink>]), tantrums (Conklin & Mayer, [<reflink idref="bib17" id="ref32">17</reflink>]; Charlop-Christy et al., [<reflink idref="bib11" id="ref33">11</reflink>]), object grabbing (Charlop-Christy et al., [<reflink idref="bib11" id="ref34">11</reflink>]), leaving seat/area (Charlop-Christy et al., [<reflink idref="bib11" id="ref35">11</reflink>]; Ganz et al., [<reflink idref="bib26" id="ref36">26</reflink>]), disruption (Charlop-Christy et al., [<reflink idref="bib11" id="ref37">11</reflink>]), aggression (Frea et al., [<reflink idref="bib23" id="ref38">23</reflink>]; Ganz et al., [<reflink idref="bib26" id="ref39">26</reflink>]; Hu & Le, [<reflink idref="bib38" id="ref40">38</reflink>]), and self-injury (Ganz et al., [<reflink idref="bib26" id="ref41">26</reflink>]). Although each researcher operationally defined these behaviors unique to the individual, each represents a behavior that the researchers (and other relevant stakeholders) targeted for decrease. Thus, we refer to this class of behavior as problem behavior (behaviors that stakeholders report as impacting the student and those around the student due to the frequency, duration, intensity, or context of the behavior). Although these studies represent a large body of literature evaluating the effects of PECS on problem behavior, the results of these studies are mixed and some of the designs do not allow for causal conclusions.</p> <p>For example, Ganz et al. ([<reflink idref="bib26" id="ref42">26</reflink>]) found that picture exchange acquisition had no accompanying effect on problem behavior. On the contrary, Charlop-Christy et al. ([<reflink idref="bib11" id="ref43">11</reflink>]), Conklin and Mayer ([<reflink idref="bib17" id="ref44">17</reflink>]), Frea et al. ([<reflink idref="bib23" id="ref45">23</reflink>]), and Hu and Lee ([<reflink idref="bib38" id="ref46">38</reflink>]) all reported concomitant reductions in problem behavior following picture exchange acquisition. Although these results are promising, there are a few features of the studies that should be considered. For example, Frea et al. used an adapted version of the PECS protocol that included verbal prompts, and the design only allowed for limited demonstrations of effect (i.e., only two tiers), making it hard to draw clear conclusions between the PECS protocol and the reduction in problem behavior. Additionally, one participant from Hu and Lee engaged in decreasing trends of problem behavior during baseline, making it hard to draw conclusions about if picture exchange acquisition caused the decrease. Lastly, Charlop-Christy et al. ([<reflink idref="bib11" id="ref47">11</reflink>]), Conlkin and Mayer (2011), and Hu and Lee ([<reflink idref="bib38" id="ref48">38</reflink>]) found reductions in behavior across tiers at different time points after the introduction of PECS. This staggered effect across time suggests the possibility that some other factor was responsible for the reduction in problem behavior, or that specific phases of PECS may result in these collateral reductions. In other words, more research should be conducted to determine the specific contextual factors that lead (or do not lead) to reductions in problem behavior.</p> <p>A logical assumption is that socially mediated problem behavior (where the reinforcers are delivered by another person) can be interpreted as communication given that the problem behavior evokes people's responding behavior. Thus, a logical extension is that teaching communication through PECS could replace socially mediated problem behaviors by providing an alternative communicative option. Unfortunately, this may not hold true for two reasons. Firstly, the main purpose of PECS is to teach communication skills, and this protocol succeeds in that goal (Gilroy et al., [<reflink idref="bib29" id="ref49">29</reflink>]; Sulzer-Azaroff et al., [<reflink idref="bib72" id="ref50">72</reflink>]). In other words, Frost and Bondy ([<reflink idref="bib24" id="ref51">24</reflink>]) simply did not design the PECS protocol to reduce problem behavior. Secondly, although PECS teaches communication and is functional, it is not the procedure known as functional communication training (FCT). In PECS, the items for requesting are based on how well they motivate the child (and are often tangible in nature). With FCT, the functional communicative response is selected to functionally match the problematic behavior (Tiger et al., [<reflink idref="bib74" id="ref52">74</reflink>]). Thus, this process requires conducting some form of functional behavior assessment (FBA) to identify why the behavior occurs. But when teaching PECS, the practitioner does not conduct an FBA because the protocol is not intended to reduce problem behavior but rather to increase communication overall.</p> <p>FCT is one of the most researched methods for replacing problem behavior with a functional replacement within the individual's communicative repertoire (Tiger et al., [<reflink idref="bib74" id="ref53">74</reflink>]). Relatedly, LaBelle et al. ([<reflink idref="bib44" id="ref54">44</reflink>]) found that FCT in combination with PECS was more effective at reducing problem behavior than PECS alone. However, FCT may not always be a feasible <emph>first</emph> choice for intervention with young children in a classroom. First, FCT requires an FBA (which may include a functional analysis), which can be resource intensive. For example, in a preschool classroom with eight students, each who engage in two topographies of problem behavior, immediately prescribing FCT would result in conducting a FBA for 16 topographies of problem behavior, which is not feasible for teachers (Roscoe et al., [<reflink idref="bib65" id="ref55">65</reflink>]; Young & Martinez, [<reflink idref="bib81" id="ref56">81</reflink>]). Related, Chezan et al. ([<reflink idref="bib12" id="ref57">12</reflink>]) conducted a systematic review of FCT research conducted in schools and found the ecological validity of the procedure in this context to be low.</p> <p>One approach to ensuring student's needs are met without wasting resources would be to apply a tiered intervention model (e.g., Response to Intervention) by providing less resource-intensive, evidence-based, environmental support to everyone in the classroom (Tier 1), developing more specific interventions for students who need them (Tier 2), and providing individualized, functionally matched support (Tier 3) for those for whom the previous Tier 2 and Tier 1 interventions were ineffective. In this parallel, FCT can be conceptualized as a Tier 3 intervention (most resource intensive) while PECS would be a Tier 2 intervention (only those who need to develop a communicative repertoire and engage in problem behavior). Naturalistic Developmental Behavioral Interventions (NDBI) might be considered a Tier 1 intervention.</p> <p>Further, for young children who enter the educational setting with no functional means of communication, without vocal imitation, and who are unable to make requests via speech after an empirically validated intervention was implemented by trained professionals, AAC instruction should begin immediately (Sundberg, [<reflink idref="bib73" id="ref58">73</reflink>]). Students who enter preschool without a functional means of communication are already behind their peers, as students at this age typically begin using decontextualized language (i.e., meaning beyond the current environment) and use emerging literacy skills (Pence Turnbull & Justice, [<reflink idref="bib60" id="ref59">60</reflink>], pp. 238). Immediate, systematic instruction in communicative behaviors (beyond the one request limitation of FCT) is critical given a student's ability to acquire language begins to decrease at around three years old (Pence Turnbull & Justice, [<reflink idref="bib60" id="ref60">60</reflink>], pp. 147). Those students who miss these critical years and do not develop language may be forced to rely on grimaces, crying, or problematic behavior as their primary source of communicating with others (Dell et al., [<reflink idref="bib20" id="ref61">20</reflink>], pp. 263).</p> <hd id="AN0189290419-2">Purpose</hd> <p>Given that PECS training results in a communicative repertoire that is generalizable (beyond one request as used in FCT procedures), is developmentally appropriate, and is less resource intensive than FCT, future research should continue to expand and replicate the aforementioned findings related to picture exchange acquisition and its effect on problem behavior. Additionally, we could not identify any studies that evaluated the effects of PECS on problem behavior across an entire school day. If PECS results in a reduction in problematic behavior, researchers should evaluate whether those effects maintain throughout the entire day, rather than just small segments surrounding the PECS training sessions. We designed this study to answer the following: Does teaching PECS have any collateral, detectable reductions on problem behavior within the classroom across an entire school day for preschool students with ASD?</p> <hd id="AN0189290419-3">Method</hd> <p></p> <hd id="AN0189290419-4">Participants</hd> <p>This study included four male participants (referred to as "student" throughout the manuscript) with ASD eligibility under the Individuals with Disabilities Education Act who received special education services in a public, university-affiliated pre-kindergarten classroom. The students were between the ages of 4 and 6 and did not have an established formal functional communication (i.e., system that they could use fluently and that could be consistently understood by others). Researchers received parental permission for each student to participate in the study prior to any data collection, and the study was approved by the affiliated university's institutional review board. We recruited and selected the four students to participate because their parents had each expressed to the teacher that improving communication was a priority. If any students engaged in severe problem behavior for which they needed an immediate, functionally matched, individualized intervention, they were excluded from the study so we could prioritize those needs. The research team and lead teacher determined together that none of the four new students to the classroom engaged in a problem behavior severe enough to warrant an immediate functionally matched intervention and thus all four were included in the study.</p> <p>Henry was a 4-year-old Latino student with eligibility for special education through ASD and speech language impairment. His family spoke primarily Spanish in the home. His preschool special education teacher conducted the cognitive domain of the Developmental Profile, Third Edition (DP-3) 1 year before the start of this study and Henry scored 47 (-3.53 SD). He scored a zero on the Early Echoic Skills Assessment (ESSA; Esch, [<reflink idref="bib21" id="ref62">21</reflink>]) meaning that he did not vocally imitate any sounds or words presented to him. He scored a six on the Motor Imitation Scale (MIS; Stone et al., [<reflink idref="bib71" id="ref63">71</reflink>]) meaning he demonstrated some basic object imitation. At the onset of the study, Henry did not have an identifiable edible reinforcer due to a limited diet (e.g., sugar-free, gluten-free, dairy-free). Thus, his reinforcers for the classroom were primarily toys, which he used to engage in motor stereotypy. Throughout the duration of this study, his classroom teachers focused on increasing his duration of time he sat at the table without demonstrating avoidance behaviors (e.g., crying and leaving the work table).</p> <p>Jordan was a 4-year-old Latino male with an eligibility for special education through ASD and speech language impairment. His family spoke primarily Spanish at home. He communicated by pointing and pulling his teachers over to his desired reinforcers. He scored < 50 (<-3.33 SD) on the DP-3 conducted 1 year and 6 months prior to this study. He scored a zero on the ESSA meaning he did not vocally imitate any sounds. He scored an eight on the MIS suggesting he could complete some object imitation. Within the classroom, he followed two-step directions and sat at the work table for 15-min sessions two times a day with teacher support. During designated work times, he worked on receptively identifying colors and shapes and matching letters. He also had goals related to greetings, attending to his name, washing hands, and dressing.</p> <p>Jerry was a 5-year-old Latino student with eligibility for special education through ASD and speech language impairment. His family primarily spoke Spanish in his home. His DP-3 performance resulted in a standard score of < 50 (<-3.33 SD) and was conducted by the special education team leader a year prior to this study. He scored a three on the ESSA meaning she imitated approximately three echoics from the 0–18 month developmental range and a 17 on the MIS suggesting he could imitate various object and motor movements. At the start of the study, he communicated by pointing, bringing teachers to his preferred items, making some vocalizations including vocal stereotypy, babbling, and echoics. During his set work time in the classroom, Jerry's goals included labeling items, colors, letters, body parts, and shape identification as well as goals related to social-emotional development and daily living.</p> <p>Rock was a 5-year-old multi-racial male with eligibility for special education through ASD and speech language impairment. His parents primarily spoke English in the home. On the Preschool Language Scales, 5th Edition (PLS-5), he obtained a standard score of 50 across expressive, receptive, and total language portions indicating a severe language delay. On the Adaptive Behavior Assessment System, Third Edition (ABAS-3) he had a standard score of 55 and on the DP-3 he scored less than 50. He scored a zero on the ESSA meaning he did not vocally imitate any sounds presented to him and a two on the MIS suggesting minimal object imitation skills. Throughout the study, Rock had goals related to attending to materials during work time, expanding his play behaviors, sitting during group activities/instruction, performing activities for daily living (e.g., dressing), and attending to his name.</p> <hd id="AN0189290419-5">Setting</hd> <p>All students attended an elementary school in an urban district with 244 students enrolled. The classroom included eight pre-kindergarten students, with six to eight educational staff members daily (staff each worked three days a week in the classroom). The classroom environment included two play centers, a kidney-shaped table in the middle of the classroom primarily used for group activities (e.g., puzzles, crafts, etc.), two child-size tables for 1:1 instruction, and a carpeted area with cube chairs for whole group activities. In this classroom, we used evidence-based teaching methods including, but not limited to, visual activity schedules (Knight et al., [<reflink idref="bib43" id="ref64">43</reflink>]), discrete trial training (Lerman et al., [<reflink idref="bib48" id="ref65">48</reflink>]), prompting (Collins et al., [<reflink idref="bib16" id="ref66">16</reflink>]), antecedent-based interventions (Sam & AFIRM, [<reflink idref="bib66" id="ref67">66</reflink>]), differential reinforcement (Savage & AFIRM, [<reflink idref="bib67" id="ref68">67</reflink>]), time delay (Walker, [<reflink idref="bib76" id="ref69">76</reflink>]), naturalistic interventions (Schreibman et al., [<reflink idref="bib68" id="ref70">68</reflink>]), and reciprocal imitation training (Ingersoll, [<reflink idref="bib40" id="ref71">40</reflink>]).</p> <hd id="AN0189290419-6">Implementers</hd> <p>PECS sessions were implemented by the classroom staff. The classroom staff were practicum students obtaining their Master of Science in Applied Behavior Analysis or Master of Education in Special Education and were aware of the purpose of the study (i.e., not masked). Given that the implementers for the study were also the classroom teachers, these implementers all had established rapport with the students. The first and second author trained all implementers to run PECS sessions using behavior skills training (Homlitas et al., [<reflink idref="bib35" id="ref72">35</reflink>]). The first and second authors supervised all sessions and provided in situ feedback to staff as needed. The first author attended a PECS Level 1 (Howlin et al., [<reflink idref="bib37" id="ref73">37</reflink>]) and PECS Level 2 training and had 5 years of experience implementing PECS. The second author was the classroom teacher who had 4 years of experience implementing PECS and had used PECS in her previous practicum coursework under supervision of the first author and fifth author, who also completed the PECS Level 1 training.</p> <hd id="AN0189290419-7">Materials</hd> <p>We used a PECS communication notebook (7.25–10.25 cm by 6.25–9.25 cm) with strips of velcro placed horizontally on the front and inside cover of the book. All pictures were actual photographs taken in the classroom or downloaded from an internet search engine. We removed the background from the photos and typed the label of the item below the picture (in English), and were printed in full color (3.81 cm x 3.81 cm) and laminated. Edible reinforcers included M&Ms, Oreos, Skittles, and other candies cut up to be one-fourth of the full size. Various toys available included Legos, magnet letters, balls, stuffed animals, trains, and an iPad with YouTube kids. For Phase IIIa, distractor items included a spoon, t-shirt, jacket, and a train piece.</p> <hd id="AN0189290419-8">Response Definitions and Measurement</hd> <p>Definitions for PECS communication skills (travel, discriminate, grab, travel, reach, release) can be found via Supplemental Materials 1. In order to evaluate problem behavior throughout the day, the researchers used partial-interval recording (PIR; Cooper et al., [<reflink idref="bib18" id="ref74">18</reflink>]). Researchers divided the 6 h school day into 36 total 10 min intervals. If any target problem behaviors occurred during the interval, the data collector scored an occurrence for that behavior during the interval. When observing problem behavior we collected data on <emph>aggression</emph>, <emph>furniture climbing</emph>, <emph>elopement/dropping</emph>, <emph>self-injurious behavior</emph>, <emph>disruption</emph>, and <emph>screaming/crying</emph>. We selected these topographies of behavior based on behaviors the lead teacher or previous lead teachers of the classroom had targeted for reduction for prior students. We agreed that these topographies of behavior reasonably represented behaviors that would be dangerous or disruptive to classroom learning. The lead teacher of the classroom approved the behaviors and behavior definitions prior to the start of data collection. Full-behavior definitions are available in Table 1. Each definition captures the occurrence of the behavior, but may not capture intensity. When conducting PIR, we also coded <emph>picture exchanges</emph>, which were defined as any instance where the student handed a picture card from their book to a person without prompting. We trained select veteran staff (those who had worked in this classroom before and had availability in their schedule to collect data) in the classroom on the definitions prior to the sessions, and they collected all of the problem behavior data, including interobserver agreement.</p> <p>Table 1 Specific operational behavior definitions used</p> <p> <ephtml> <table rules="groups"><thead><tr><th align="left"><p>Problem Behavior</p></th><th align="left"><p>Definition</p></th></tr></thead><tbody><tr><td align="left"><p>Aggression</p></td><td align="left"><p><italic>Hitting</italic> - any instance or attempt in which the student's hand (open or closed fist) comes into contact with another person from a distance of 6 in or more (each hand is one instance).</p><p><italic>Kicking</italic> - any instance or attempt in which the student's foot comes into contact with another person from a distance of 6 in or more (each foot is one instance).</p><p><italic>Biting</italic> - any instance or attempt in which the student's mouth, while open, contacts another person.</p><p><italic>Grabbing</italic> - any instance or attempt in which one or two open hands closing on skin or clothes (each hand is one instance).</p><p><italic>Pinching</italic> - any instance or attempt in which the student's fingertips grab another person's skin; rotates in a circular position; or squeezes.</p><p><italic>Pushing</italic> - any instance in which the student's hands, arms, shoulders, or torso come into contact with another person from 6 inches away and applies force which alters the original standing of that person.</p><p><italic>Scratching</italic> - any instance or attempt in which the student's fingernails drag down or across on another person and leave a red mark</p><p><italic>Hair pulls</italic> - any instance or attempt in which the student gathers another person's hair between his fingers and pulls away from their scalp (each pull is one instance).</p></td></tr><tr><td align="left"><p>Furniture Climbing</p></td><td align="left"><p><italic>Furniture Climbing</italic> - any instance in which the student stands/climbs or attempts to stand/climb on furniture.</p></td></tr><tr><td align="left"><p>Disruption</p></td><td align="left"><p><italic>Throwing/Swiping items</italic> - any instance or attempt in which the student holds an item in one or both hands and releases the item through the air a distance of 6 in or greater so that it lands greater than 12 in from another person (each item is one instance), outside of appropriate toy play.</p><p><italic>Furniture</italic> - knocking over furniture or attempting to knock over furniture. (furniture needs to be in a different position than before s/he touched it. If the furniture leaves the ground at any time that is included).</p></td></tr><tr><td align="left"><p>Elopement</p><p>Dropping</p></td><td align="left"><p><italic>Elopement</italic> - any instance in which the student moves more than an arm's reach from his seat or designated area or more than an adult's arm's reach (when transitioning).</p><p><italic>Dropping</italic> - when the student's body goes from a standing or seated position to the floor when not instructed to do so.</p></td></tr><tr><td align="left"><p>Self-injurious Behavior</p></td><td align="left"><p><italic>Head to surface/body</italic> - any instance in which the student's head comes into contact with a surface or another person's body from a distance of at least 3 in.</p><p><italic>Hand to hand</italic> - any instance in which the student's wrists (palm facing palm) come into contact with one another where an audible sound is heard.</p><p><italic>Arm to chest</italic> - any instance in which the student's arm comes into contact with torso/chest from at least 6 in (arm crosses torso/chest like a seatbelt).</p><p><italic>Knee to surface</italic> - any instance in which the student's knee comes into contact with a surface from a distance of at least 3 in.</p><p><italic>Hand to leg</italic> - any instance in which the student's hand (open palm facing the body) comes into contact with their leg from a distance of 2" or more with an audible sound.</p></td></tr><tr><td align="left"><p>Screaming</p><p>Crying</p></td><td align="left"><p><italic>Screaming-</italic> any instance in which a student's vocal volume increases louder than conversational volume, does not contain intelligible speech, and lasts for a duration of 3 s or longer (may or may not be accompanied by crying).</p></td></tr></tbody></table> </ephtml> </p> <p>Table 2 Teaching sessions to meet "mastery" criterion for each PECS phase</p> <p> <ephtml> <table rules="groups"><thead><tr><th align="left" /><th align="left" colspan="4"><p>Sessions to "mastery" criterion</p></th><th align="left" colspan="3"><p>Total number trained with</p></th></tr></thead><tbody><tr><td align="left" /><td align="left"><p>I</p></td><td align="left"><p>II</p></td><td align="left"><p>IIIa</p></td><td align="left"><p>IIIb^</p></td><td align="left"><p>CP</p></td><td align="left"><p>Toys</p></td><td align="left"><p>Edibles</p></td></tr><tr><td align="left"><p>Henry</p></td><td align="left"><p>8</p></td><td align="left"><p>8</p></td><td align="left"><p>4</p></td><td align="left"><p>24</p></td><td align="left"><p>17</p></td><td align="left"><p>16</p></td><td align="left"><p>8</p></td></tr><tr><td align="left"><p>Jordan</p></td><td align="left"><p>9</p></td><td align="left"><p>5</p></td><td align="left"><p>6</p></td><td align="left"><p>28</p></td><td align="left"><p>14</p></td><td align="left"><p>16</p></td><td align="left"><p>4</p></td></tr><tr><td align="left"><p>Jerry</p></td><td align="left"><p>3</p></td><td align="left"><p>5</p></td><td align="left"><p>3</p></td><td align="left"><p>19</p></td><td align="left"><p>14</p></td><td align="left"><p>17</p></td><td align="left"><p>7</p></td></tr><tr><td align="left"><p>Rock</p></td><td align="left"><p>9</p></td><td align="left"><p>6</p></td><td align="left"><p>*26</p></td><td align="left"><p>-</p></td><td align="left"><p>15</p></td><td align="left"><p>1</p></td><td align="left"><p>13</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph> *=incomplete. ^=Phase IIIb includes building from 2 pictures to 5 + pictures placed inside the book</p> <hd id="AN0189290419-9">Interobserver Agreement (IOA)</hd> <p>When two data collectors were available at the same time, they both separately collected data to calculate interobserver agreement. Data collectors could serve as both primary or secondary data collectors depending on availability (i.e., the staff member available for the entire school day served as primary). To calculate IOA on problem behavior, we compared the data collected by the primary data collector and the secondary data collector for each interval using exact agreement per interval across all behaviors (Ledford et al., [<reflink idref="bib47" id="ref75">47</reflink>]). For example, if the primary data collector wrote <emph>A</emph> (<emph>Aggression)</emph>, <emph>E</emph> (<emph>Elopement)</emph>, and <emph>SC</emph> (<emph>Screaming/Crying)</emph> in an interval, and the secondary only wrote <emph>A</emph> and <emph>SC</emph> for that interval, we would score that interval as a disagreement. If both the primary data collector and secondary data collector both marked the same behaviors, such as both marking <emph>A</emph> and <emph>D</emph>, then that would be marked as an agreement. We then took the total number of agreements and divided it by the total number of agreements and disagreements and multiplied it by 100% to get a percentage of agreement. We calculated IOA for at least 29% of intervals for each student across all phases. For Henry, we obtained an average of 93% agreement, for Jordan an average of 95% agreement, for Jerry an average of 94% agreement, and for Rock we obtained 91% average agreement. Specific IOA results can be found via Supplemental Materials 2.</p> <hd id="AN0189290419-10">Experimental Design</hd> <p>We used a concurrent multiple probe design (Gast et al., [<reflink idref="bib28" id="ref76">28</reflink>]) in order to stagger the introduction of PECS for each student. We made design decisions (such as moving to the next PECS phase) based on responding during PECS sessions, but we also evaluated the effects on problem behavior and initiated PECS exchanges throughout the entire school day. We looked for demonstrations of effects on problem behavior using visual analysis (changes in trend, level, and variability during condition changes; Horner & Odom, [<reflink idref="bib36" id="ref77">36</reflink>]).</p> <hd id="AN0189290419-11">Procedures</hd> <p></p> <hd id="AN0189290419-12">General Procedures</hd> <p>The procedures described are specific to the PECS training sessions. Data collection on problem behavior occurred throughout the study. At the beginning of the year, teachers used a multiple stimulus without replacement preference assessment (DeLeon et al., [<reflink idref="bib19" id="ref78">19</reflink>]) to determine a rank of preferred edible and leisure items. However, since preferences change over time (due to the environmental events during that time; MacNaul et al., [<reflink idref="bib50" id="ref79">50</reflink>]), the CP conducted an in-the-moment reinforcer analysis (see Alcalay et al., [<reflink idref="bib1" id="ref80">1</reflink>]; Leaf et al., [<reflink idref="bib45" id="ref81">45</reflink>]) prior to conducting the first trial of each session. This method relies on selecting potentially reinforcing stimuli based on what the student was playing with prior, what served as a reinforcer previously, student affect, student indicator responses, presenting options informally. For example, sometimes the CP selected a stimulus the student was previously playing with to include in the PECS session and other times they informally presented a few preferred items from the classroom and allowed the student to select. The trial began once the student demonstrated motivation for the reinforcer by reaching for it, reaching for the card, staring at the reinforcer for more than 5 s, or any other behavior that demonstrated the student wanted the preferred item. Thus, if the stimulus did not serve as a reinforcer for that child in that moment, they would not reach for the item (or reach for a picture or stare at the item), and the trial would not begin. After enticing with the item for more than 30 s with no response from the student, the staff member would begin the process of selecting a potential reinforcer again. Likewise, the trial ended once the CP delivered the reinforcer following the corresponding picture exchange. We attempted to complete 10 trials per session, but ended early if we ran out of time due to a school transition (e.g., recess, lunch) or if there was no motivation for any of the preferred toys or food items in the classroom (i.e., satiation). All PECS training sessions lasted for 3–20 min, depending on how long it took to complete the trials. We conducted one session a day for each day the student was at school. For Rock, starting on session 60 (during Phase IIIa), we began conducting three sessions a day to increase the number of practice trials because he was not making progress with one session a day.</p> <p>Once we provided students their own PECS book (upon mastery of Phase 1), they had access to it the entire day. Students could request (and obtain access to) edibles during snack times, meal times, and work times (approximately 27% of the day). Students could request and have access to toys during morning table and center time (approximately 29% of the day). During PECS sessions (approximately 4% of the day), the student had access to all reinforcers. The classroom was set up this way to model after a typical preschool classroom (e.g., Students in preschool classrooms are not allowed to eat goldfish at all parts of the day; this reinforcer is restricted to certain times, like snack). If a student requested for an item that was not available at a certain time, we responded by saying "[Item] is not available right now but you can ask for it at [time available]." Note that the students had access to their communication book and pictures as described in the phase specific procedures below. We restricted the availability of reinforcers (i.e., how we responded) not the availability of communication books and pictures.</p> <hd id="AN0189290419-13">Baseline</hd> <p>Baseline permitted evaluation of problem behavior in the absence of PECS training. During baseline, the CP held out one hand with the target item and one hand with nothing in it. The student had the option to grab the picture and place it in the CP's open hand, grab the item out of their hand, vocalize, sign, or engage in problem behavior. Regardless of the behavior the student engaged in, the CP labeled the item and gave it to the student. Consequently, the baseline condition represented a concurrent schedule arrangement in which all behaviors were reinforced with direct access to the target item or food. We selected this baseline because it has been used in prior research (White et al., [<reflink idref="bib80" id="ref82">80</reflink>]).</p> <hd id="AN0189290419-14">PECS Training</hd> <p>The structure of PECS is such that skills are taught in a sequential format. Therefore, although the end goal is for students to have the entire PECS sequence, the steps are taught a few at a time. Prior to training, we gave the students a personalized PECS book with an image of the target/preferred stimulus, withheld the target stimulus, and held our hand out. In this concurrent schedule arrangement, the student could either hand us the picture, grab the item, engage in problem behavior, or vocalize. This arrangement allowed us to determine that the students did not have the picture exchange initiation skill prior to training. During Phase I, we taught the students to exchange a picture to receive a preferred item. In Phase II, we taught the student to find their book, find a CP, and find the CP's hand to place the picture into. In Phase IIIa, we taught the student to discriminate between a picture of a preferred item and a non preferred item. During Phase IIIb, we taught the student to discriminate between multiple pictures of preferred items. In addition, we systematically introduce pictures during IIIb until the student is distinguishing between 5 or more pictures and searches inside the communication book for those pictures.</p> <p>We conducted Phases I, II, IIIa, and IIIb exactly as described in the PECS manual (Frost & Bondy, [<reflink idref="bib24" id="ref83">24</reflink>]). Readers interested in an abbreviated version of these procedures should see Bondy and Frost ([<reflink idref="bib6" id="ref84">6</reflink>]). During training phases (all except baseline), the CP required a picture exchange regardless of other communicative behaviors (vocalization, signs, etc.). For each phase, the student needed to demonstrate the target steps with 80% accuracy for three sessions in a row, with at least three different reinforcers, and at least three different people before moving on to the next PECS phase.</p> <hd id="AN0189290419-15">Staff Training & Self-Monitoring</hd> <p>Upon analysis of the data, we found that students were rarely (if ever) using picture exchange outside of PECS teaching sessions. Because this impeded our ability to draw conclusions about the effects of PECS on problem behavior, we conducted a staff training on how to create opportunities for students to communicate throughout the day, rather than only during PECS training sessions. This procedure is one common feature of NDBIs, environmental arrangement. Environmental arrangement involves promoting communication by limiting access to preferred materials so the child has to interact with someone or initiate communication to access the preferred item (Schreibman et al., [<reflink idref="bib68" id="ref85">68</reflink>]). This strategy is often referred to as "create and wait," meaning creating an opportunity for the learner to communicate for something in their environment and wait for the learner to initiate (Frost & Bondy, [<reflink idref="bib24" id="ref86">24</reflink>]). All staff were taught to use this strategy in their original training and as part of their university coursework and practicum supervision. We conducted this booster training to re-orient staff to the expectations of the classroom and to introduce the new classwide self-monitoring component. Thus, we presented no new information nor expectations to the staff. We retrained everyone so no staff could claim incompetence with the expectations as a reason for not meeting the classwide-self monitoring goal (described below). In addition, while the researchers had the staff convened, they talked through the steps for responding to an initiation error and a discrimination error. This information also served as a review and did not contain new expectations.</p> <p>We conducted this booster training following mastery of Phase IIIb for all students except Rock, who was still learning in Phase IIIa. If the student did not initiate in a situation where access to specific materials was being restricted, we trained staff to use a secondary prompter to prompt the student to exchange a picture from their PECS notebook. If the student handed the wrong picture, we trained staff to use 4-step error correction in which they prompted a model to correct the exchange, practice, switch, and repeat the trial. We used a PowerPoint presentation and active student responding to conduct this training to clarify expectations of "create and wait" and how to respond to different errors.</p> <p>After we conducted staff training on how to "create and wait," staff implemented a class-wide self-monitoring procedure in which they tracked the number of times the staff did a "create and wait" with the student. At the beginning of the day, the lead teacher reviewed the "create and wait" procedure and provided a class goal of total number of opportunities. Staff then listed each student's name on the board and after each opportunity to "create and wait" the staff marked a tally by that student's name. When staff met the goal for a student, a lead staff member provided group-wise verbal praise. We gave the staff the goal to do 10 "create and wait" opportunities a day for each student. Intermittently through the day, a lead staff member would remind staff of each student's goal of created opportunities.</p> <hd id="AN0189290419-16">Procedural Fidelity</hd> <p>During sessions, we had a second observer evaluate procedural fidelity for at least 20% of sessions in each PECS phase and at least 50% of the sessions overall. For each phase, we used a thorough checklist to collect the procedural fidelity data. If the step was followed with fidelity throughout the entire session, the observer would mark a "+" for the corresponding step. If the CP failed to complete a step of a trial or multiple trials, then the observer would document a "-" for that specific step. Procedural fidelity was calculated by dividing the total correct steps by the total steps measured (correct and incorrect), then multiplying the total by 100%. During Henry's sessions, on average, staff followed the steps with 98% (range 83–100%) accuracy, with Jordan 99% (range 90–100%) accuracy, with Jerry 96% (range 60–100%) accuracy, and with Rock 99% (range 90–100%) accuracy. For Jerry, procedural fidelity only dropped below 80% on two occasions and for both sessions feedback was provided during the session by the first or second author. We collected procedural fidelity for the staff training with 100% fidelity. Additionally, we collected procedural fidelity on the staff self-monitoring system for 100% of data collection days with 100% of procedural steps followed correctly. The procedural fidelity checklists we used are available via Supplemental Materials 3.</p> <hd id="AN0189290419-17">Results</hd> <p>Although not the research question, Fig. 1 depicts acquisition of the target communication skills across the PECS phases. These data were used for making decisions of starting/switching phases. To supplement this graph, Table 2 contains information on how long it took the students to master each phase and how many reinforcers/teachers the student practiced with. Visual analysis of Supplemental Materials 5 (the same graphed student performance, but separated by which implementor served as the CP) suggests consistent performance across implementers.</p> <p>Graph: Fig. 1 Acquisition of communication steps (travel, discriminate, grab, travel, reach, release). Note. The dashed vertical lines depict the addition of an additional picture into the array (or moving the pictures to inside the book)</p> <p>Figure 2 contains the data on problem behavior and spontaneous communication usage for all participants. During baseline for Henry, we saw an average of 40.0% of intervals with problem behavior, moderate variability (range: 24.7–51.5%) and a slight increasing trend (slope: 2.1x%). Once we began teaching Phase I, we saw an increase in level (average: 53.6%) and an increase in variability (range: 36.6–70.5%). We could not determine trend because this condition only included two data points. Once we began teaching Phase II, we saw minimal increase in level (average: 48.3%), a decrease in variability (range: 32.4–55.9%), and the behavior began a decreasing trend (slope: -1.1x%). Henry initiated picture exchange outside of teaching sessions for an average of 1.66% of intervals during this phase. During Phase IIIa, Henry's engagement in problem behavior reduced in level (average: 28.6%) and variability (range: 22.9–34.3%), however he did not initiate any picture exchange outside of sessions (average: 0%). During Phase IIIb, we saw minimal change in level (average: 32.9%), with an increase in variability (range: 11.8–65.5%), and minimal trend (slope: -0.1x%). During this phase, he did not initiate picture exchange outside of PECS teaching sessions (average 0.00%). Once we re-trained staff on the create and wait procedures, we saw further reduction in problem behavior (average: 22.6%), a reduction in variability (range: 16.1–30.0%), and minimal trend (slope: -0.4x%). During this time, Henry engaged in spontaneous picture exchange outside of teaching sessions for 3.91% of intervals.</p> <p>Graph: Fig. 2 Effects of acquisition of PECS on problem behavior throughout the school day</p> <p>For Jordan in baseline, he engaged in problem behavior for an average of 28.8% of intervals with a slight increasing trend (range: 0.7x%) and almost no variability (range: 8.3–8.10%). Once we began teaching PECS Phase I, we saw a small decrease in level (average: 22.4%), a decreasing trend (slope: -1.4x%), and an increase in variability (range: 11.4–41.2%). During Phase II, Jordan returned to baseline levels of problem behavior (average: 28.8%) with a continued decreasing trend (slope: -1.1x%), and a decrease in variability (range: 20.6–41.9%). Once we began Phase IIIa, we saw levels of problem behavior return to Phase I levels (average: 22.2%) and a reduction in variability (range: 18.8–25.7%). During Phase IIIb, we saw a drop in problem behavior (average: 12.4%) with near zero trend (slope: 0.03x%), and an increase in variability (range: 5.8–27.2%). This drop in problem behavior did not correlate with an increase in spontaneous picture exchange usage (average: 0.0%). Last, once we retrained staff on the create and wait procedures and introduced the self-monitoring expectations, we saw almost no change in level of problem behavior (average: 14.3%) or trend (slope: 0.1x%) but did see an increase in variability (range: 8.82–21.2%). After this change, Jordan began initiating picture exchange for an average of 9.7% of intervals.</p> <p>During baseline Jerry engaged in problem behavior for an average of 28.2% of intervals, with a small increasing trend (slope: 0.4x%), and large variability (range: 14.1–47.1%). Once we began teaching PECS, problem behavior continued at a similar level (average: 32.9%) and variability decreased (range: 31.4–34.3%). Once we began teaching Phase II, his behavior maintained at similar levels (average: 31.3%), took a slight increasing trend (slope: 3.1x%), and increased in variability (range: 18.2–38.2%). During this phase, he initiated picture exchange on average 1.0% of intervals. Once we began Phase III, we saw a decrease in problem behavior (average: 23.5%). During this phase, Jerry did not initiate picture exchange outside of PECS teaching sessions (average: 0.0%). Once we began teaching Phase IIIb, his problem behavior maintained at similar levels (average: 24.6%) with a decreasing trend (slope: -4.9x%) and large variability (range: 12.1–45.5%). Finally, once we introduced the self-monitoring for staff use of create and wait, Jerry's problem behavior reduced to an average of 11.9% intervals, took a decreasing trend (slope: -2.7x%), and reduced in variability (range: 8.6–15.2%). During this phase, he initiated using picture exchange outside of teaching sessions for an average of 7.11% of intervals.</p> <p>Rock engaged in high levels of problem behavior (average: 61.9%) with large variability (range: 44.2–82.9%) and minimal trend (slope: 0.5x%). Upon introduction of Phase 1, we saw nearly no change in levels (average: 61.8%) or trend of problem behavior (slope: -0.6x%), but did see a reduction in variability (range: 55.9–68.8%). When we began teaching Phase II, on average his behavior reduced to 55.9% of intervals with a continued decreasing trend (slope: -1.5x%), and increased in variability (range: 41.2–67.7%). During this phase, he did not initiate any picture exchange usage outside of teaching sessions (average: 0.0%). Once we began Phase IIIa with Rock, we saw continued levels of problem behavior (average: 55.6%) with a continued decreasing trend (slope: -0.5%) and reductions in variability (range: 54.5–57.6%). Rock did not initiate picture exchange outside of teaching sessions during this phase. Once we added the self-monitoring and training for create and wait, his behavior continued at steady levels (average: 52.9%) with a slight increasing trend (slope: 0.18x%), and moderate variability (range: 45.5–61.8%). During this Phase, Rock began initiating picture exchange for an average of 8.4% of intervals. Supplemental Materials 4 contains individual graphs for each behavior for each student.</p> <hd id="AN0189290419-18">Discussion</hd> <p>Some prior researchers found that PECS training did not result in reductions in problem behavior (Ganz et al., [<reflink idref="bib26" id="ref87">26</reflink>]) while others (Frea et al., [<reflink idref="bib23" id="ref88">23</reflink>]; Hu & Lee, [<reflink idref="bib38" id="ref89">38</reflink>]; Conklin & Mayer, [<reflink idref="bib17" id="ref90">17</reflink>]; Charlop-Christy et al., [<reflink idref="bib11" id="ref91">11</reflink>]) found that clients engaged in less problem behavior following PECS training. However, these previous studies only considered small windows of time (e.g. 5–15 min during or after PECS training). PECS training could have an effect on problem behavior during PECS training sessions, but not across the entire day (which may not be socially significant). Thus, we evaluated the effects of the PECS protocol on problem behavior throughout the school day (6 h) for four preschool children with ASD. Although three of the four children learned PECS through Phase IIIb and one child learned Phases I and II, the effects on problem behavior for participants was either high variable (i.e., difficult to detect visual analysis), idiosyncratic to the student (i.e., effects are not replicated across participants), or unaccompanied by picture exchange usage.</p> <p>For example, we did not see Henry's problem behavior below baseline levels until the middle of Phase IIIb. However, two sessions later (in the same phase), his problem behavior levels were higher than what had occurred in baseline (extreme variability). In addition, Henry never initiated picture exchange outside of teaching sessions during this phase. Similarly, Jordan only had two school days with problem behavior lower than in baseline and he did not initiate with picture exchange outside of teaching sessions on either of these school days. For Jerry, the lowest levels of problem behavior were at the end of the study (following the create and wait self monitoring). Since this effect was not replicated across other participants (and three replicated demonstrations of effect are suggested for ruling out threats to internal validity in single case design; Gast & Ledford, [<reflink idref="bib27" id="ref92">27</reflink>]), this effect could be due to some other factors (i.e., history threat). Similarly, Rock's problem behavior began trending downward in Phase 1, however, Rock did not have access to the communication book throughout the day in this phase. In addition, since this effect was not replicated across participants, we cannot be sure that this change in behavior is due to the experimental manipulation (rather than some other variables).</p> <p>The lack of replication across participants could be due to differences in function of behavior. Each of the students in this study engaged in eight different topographical classes of problem behavior with four different students. Although we did not conduct an FBA, the functions of these behaviors likely spanned the full spectrum, including all of the social functions (attention, tangible, escape) as well as automatic functions. Although PECS can teach functional replacements for nearly all behavior maintained by access to tangibles, attention, and escape, the first three phases generally focus on teaching requesting of items, which would only functionally match a tangible function. Thus, if the problem behavior was maintained by any environmental variables other than access to tangible items and edibles, picture exchange would not be a replacement for those behaviors.</p> <p>Second, even if the student's problem behavior was maintained by positive reinforcement in the form of access to tangibles, and picture exchange resulted in access to tangibles, that does not mean that this replacement would have resulted in the reduction of problem behavior. The matching law framework (Herrnstein, [<reflink idref="bib34" id="ref93">34</reflink>]) suggests that there are many variables that affect which response the student will allocate, including rate, quality, effort, and learning history (Reed & Kaplan, [<reflink idref="bib62" id="ref94">62</reflink>]; Ringdahl et al., [<reflink idref="bib64" id="ref95">64</reflink>]). Consequently, it is possible that although we taught the students how to use pictures to communicate, the picture exchange was not equal based on these reinforcement and response parameters. The fact that students rarely allocated to picture exchange may indicate that they had a preference for either problem behavior or another prelinguistic modality (reaching, pointing) and used it throughout the day. Previous research has demonstrated that modality preference may affect the usage and persistence of requesting behaviors (Ringdahl et al., [<reflink idref="bib63" id="ref96">63</reflink>], [<reflink idref="bib64" id="ref97">64</reflink>]). Future research should evaluate the effects of communication modality preference and experience on problematic behavior for individuals with limited communication.</p> <p>Potentially contributing to the lack of picture exchange usage is that these students began school without a functional communicative repertoire. This lack of early intervention services could be due to a variety of challenges including family readiness, lack of fundings, and/or lack of knowledge about services (Westling et al., [<reflink idref="bib78" id="ref98">78</reflink>], pp. 347). Regardless, these students did not learn basic communication skills with a modality that could be understood (i.e., reinforced) by anyone in their community until <emph>after</emph> they entered school. At this same time, other preschoolers are using decontextualized language and emerging literacy skills (Pence Turnbull & Justice, [<reflink idref="bib60" id="ref99">60</reflink>], pp. 238). Thus, the students in our sample were already significantly behind their peers and had years of learning history with using problem behavior or prelinguistic communication (e.g., facial grimaces) as their primary modality of communication. Related, given the decrease in innate language ability beginning around three years old (Pence Turnbull & Justice, [<reflink idref="bib60" id="ref100">60</reflink>], pp. 147), these students entering without a functional means of communication have already missed several formative years of language development.</p> <p>Last, three of the four participants lived with family who spoke Spanish in the home. One benefit of picture exchange modality is that the pictures can be understood by anyone regardless of the language spoken. However, there is some evidence that language type (e.g., English or Spanish) can impact FCT outcomes (Neely et al., [<reflink idref="bib56" id="ref101">56</reflink>]; Padilla Dalmau et al., [<reflink idref="bib59" id="ref102">59</reflink>]). Potentially, clients preferred or were more fluent in Spanish and this could have impacted their problem behavior or rate picture exchange. Future research could evaluate how difference in language type impacts PECS usage and allocation.</p> <p>Overall, the results suggest that for this cohort of children, teaching functional communication repertoire, such as that established through the PECS protocol, did not consistently reduce problem behavior throughout the school day. Although there is ample evidence that teaching a functional communicative response reduces problem behavior (Tiger et al., [<reflink idref="bib74" id="ref103">74</reflink>]), this process is inherently different from teaching using PECS. FCT is function based, targeted, and taught under the specific motivations that were previously identified to evoke problem behavior. PECS, not necessarily function based, was designed to expand the students language repertoire, and is taught under the motivation for the target item. Accordingly, as first suggested by Hu and Lee ([<reflink idref="bib38" id="ref104">38</reflink>]), teaching using PECS does not have the same process or outcomes as FCT.</p> <hd id="AN0189290419-19">Limitations</hd> <p>Given the lack of replication across participants, we cannot contribute the potential changes in problem behavior (e.g., Jerry) to the acquisition of PECS (i.e., history threat). Challenging behavior and communication are products of interactions with the environment (Dell et al., [<reflink idref="bib20" id="ref105">20</reflink>], pp. 262–263), thus as time passes, and students receive 8 hours of special education services a day, we are likely to see changes in behavior. The multiple baseline design is highly susceptible to a history threat when condition lengths are long (Gast et al., [<reflink idref="bib28" id="ref106">28</reflink>]). We used visual analysis to detect this history threat (e.g., changes in behavior that do not correspond with experimental changes), but this design did not allow us to control for the threat beyond "continue condition until data are stable" (Gast et al., [<reflink idref="bib28" id="ref107">28</reflink>], pp. 242). Note that with this particular study, we made phase changes based on accuracy with PECS exchanges (which were stable) not on problem behavior (which were more variable and often trending). Given the limitations of a multiple baseline design for this specific research question, future researchers may consider utilizing pre-post evaluation with a control group. This design would allow for a history threat to be detected (by comparing the pretest and posttest scores of the control group) and controlled for (by comparing post-test scores of the intervention and control groups).</p> <p>In addition, interval recording systems are known to result in measurement artifacts that may or may not fully represent the behavior (Cooper et al., [<reflink idref="bib18" id="ref108">18</reflink>]). In our study, this measurement system was sensitive enough to identify a range of occurrences of problem behavior (e.g., 11.8% of intervals to 70.5% of intervals for Henry), however this still represents a measurement artifact and adds a limitation to the study. Future researchers with resource limitation should use smaller intervals to increase the sensitivity of the measurement system (Fiske & Delmolino, [<reflink idref="bib22" id="ref109">22</reflink>]; Ledford et al., [<reflink idref="bib46" id="ref110">46</reflink>]). Those with access to the resources to do so should use event recording to establish a rate of problem behavior across the school day.</p> <p>The lack of FBA represents a limitation to the study, as knowing the function of students' problem behavior could help contextualize these findings. We did not include an FBA because teachers are unlikely to have time to conduct an FBA on every behavior for every student that joins the classroom (Roscoe et al., [<reflink idref="bib65" id="ref111">65</reflink>]; Young & Martinez, [<reflink idref="bib81" id="ref112">81</reflink>]). Many problematic behaviors in the classroom first receive less-intrusive "best practices" before conducting an FBA. However, without this information in the study, we do not know how the function of behavior might moderate the effects of PECS on problem behavior (e.g., automatically maintained behaviors not impacted; tangible maintained behaviors reduced).</p> <p>Despite availability of their AAC and prompting and reinforcement from staff, the students rarely independently used picture exchange outside of direct teaching sessions, making it difficult to draw conclusions about the effects on problem behavior. In other words, when students were engaged in other activities such as play they rarely requested using picture exchange. One explanation is that direct teaching sessions incorporated other stimuli that may have signaled to the participant that reinforcers were available. For example, before each session the researcher gathered highly preferred food items and toys and brought the participant to an area of the classroom with fewer distractions than play or group instructional settings. The salient antecedents incorporated across all direct teaching sessions, may have hindered picture exchange initiations outside of the direct teaching sessions. Thus, it is possible that idiosyncratic variables of the learning trial (e.g., seeing the reinforcer) may have signaled for the student to exchange a picture. Researchers programmed for generalization in other ways such exploiting current functional contingencies (e.g., reinforcing occurrences of generalization in settings outside of the direct teaching sessions, training diversely (e.g., sufficient stimulus exemplars by incorporating as many reinforcers as possible), and incorporating functional mediators (e.g., multiple communication partners; Stokes & Osnes, [<reflink idref="bib70" id="ref113">70</reflink>]).</p> <p>However, these generalization strategies may have been insufficient to promote generalized responding. This finding is curious given that in previous research, this approach is sometimes effective to promote generalized picture exchange usage (e.g., Greenberg et al., [<reflink idref="bib31" id="ref114">31</reflink>]) and for other participants insufficient (e.g., Carrê et al., [<reflink idref="bib10" id="ref115">10</reflink>]; Jurgens et al., [<reflink idref="bib42" id="ref116">42</reflink>]). Researchers should consider evaluating how variables within the control of the teacher promote generalized picture exchange use. For example, Chua and Poon ([<reflink idref="bib15" id="ref117">15</reflink>]) used a multiple regression analysis on various PECS variables and found that teacher reported spontaneous use of picture exchange was primarily predicted by teachers reported intentional planning of PECS, the context, PECS phase, and time spent learning PECS.</p> <p>Potentially, the students in this study needed more systematic exposure to PECS in other settings (e.g., the home). We did not systematically conduct PECS training in the home environment. Although we conducted PECS training in the classroom (i.e., a natural environment), we used outside services (e.g., speech therapy, applied behavior analysis) to provide this support to parents in the home. Given the barriers that parents face accessing outside services (Binns et al., [<reflink idref="bib5" id="ref118">5</reflink>]; Littman et al., [<reflink idref="bib49" id="ref119">49</reflink>]), comprehensive implementation of PECS across all environments will require systems level changes. Perhaps, providing teachers the flexibility to train parents and families in PECS without having to work extra hours (e.g., scheduled teacher time away from the classroom) would provide benefits that outweigh the costs (e.g., family can provide additional training opportunities at home).</p> <p>One other explanation is that there were not enough motivating opportunities throughout the day to promote picture exchange usage. There were natural motivating opportunities to communicate throughout the day (not all toys were in centers, other kids were playing with a toy the student wanted, etc.). However, these opportunities may not have been enough (i.e., the student just chose to play with a different toy). This second explanation is highly likely because once self-monitoring extra communication opportunities throughout the day (i.e.,"create and wait"), we saw an increase in picture exchange usage for all students (to an average of about 13.04% of their day; based on the last 3 data points per student). Assuming the student only exchanged once in each interval, this underestimation would suggest that Henry used picture exchange at least 0.27 times per hour, Jordan 1.00 per hour, Jerry for 0.55 an hour, and Rock at least 0.833 per hour. This can be compared with Andzik et al. ([<reflink idref="bib3" id="ref120">3</reflink>]) who conducted an observational study of students who used various AAC devices (including picture based) and found that across all the students initiated using their AAC about 2.47 times an hour (range, 0–9; SD, 2.80, CI [1.27, -3.68]). In addition, 21.74% of the students did not use their AAC device at all. Regardless, in our study, even after the additional "create and wait" opportunities increased student initiations, we saw no change in problem behavior. Potentially, had the staff provided this high rate of create and wait opportunities from the start of the study, the effects on problem behavior would be different.</p> <p>Only three of the four students in this study made it through Phase IIIb. Hence, it is unclear if Rock would have experienced a further reduction in problem behavior had he successfully completed IIIb, when the communication truly becomes functional (because the student learns to discriminate between pictures to make specific requests).[<reflink idref="bib1" id="ref121">1</reflink>] It is also unknown if all four students completing Phase IV or higher would have had an effect on problematic behavior throughout the day. This is unlikely, given that Phase IV increases the response effort required to make the exchange, and we did not see an effect upon introduction of Phase IIIb. Still, future research could replicate and extend these findings by continuing to evaluate PECS throughout all phases.</p> <hd id="AN0189290419-20">Conclusions and Implications for Research and Practice</hd> <p>We did not observe consistent co-occurring reductions in problem behavior when we began using PECS to teach four students to communicate using picture exchange. This does not negate the need to teach students with severe disabilities a functional communicative repertoire, rather additional components may be necessary to simultaneously reduce problem behavior. We still recommend using PECS as a way to develop communication skills. However, our results provide some evidence that learning to communicate with picture exchange will not guarantee reductions in problem behavior; ongoing problem behaviors may need to be reduced using established methods such as conducting an FBA and developing a functionally matched intervention (e.g., FCT). As we discussed in our introduction, the PECS protocol is designed to build broad-based communicative repertoires that provide students with socially appropriate ways to express their wants and needs. However, practitioners should note that additional modifications (self-monitoring the "create and wait" procedure) were necessary to occasion usage throughout the school day.</p> <hd id="AN0189290419-21">Acknowledgements</hd> <p>We would like to acknowledge the people who helped with this project including Nadya Logan, Nestle Butler, Maddie Grosoff, Hannah Foster, Farin Allen, Jazmynn Flewellen, Sydney Miller, Natalie Morris, Sara Kathryn Synder, Sierra Stillwell, Amani Shukukani, Mackenzie Riley, Caity Schaefer, Olivia Burley, Leah Idichandy, Renalie Labarda, and Christina Novelli.</p> <hd id="AN0189290419-22">Author contributions</hd> <p>All authors contributed to the conceptualization, implementation and/or writing of this study.</p> <hd id="AN0189290419-23">Funding</hd> <p>No funds, grants, or other support was received.</p> <hd id="AN0189290419-24">Data availability</hd> <p>Some data are available via supplementary materials and all other data can be accessed by the first author upon request.</p> <hd id="AN0189290419-25">Declarations</hd> <p></p> <hd id="AN0189290419-26">Ethics approval and consent to participate</hd> <p>Researchers received approval from the University IRB and parents of all participants provided informed consent to conduct and publish the study and all aspects of the study were in accordance with the Declaration of Helsinki.</p> <hd id="AN0189290419-27">Conflict of Interest</hd> <p>The authors have no relevant financial or non-financial competing interests to disclose.</p> <hd id="AN0189290419-28">Electronic supplementary material</hd> <p>Below is the link to the electronic supplementary material.</p> <p>Graph: Supplementary Material 1</p> <p>Graph: Supplementary Material 2</p> <p>Graph: Supplementary Material 3</p> <p>Graph: Supplementary Material 4</p> <p>Graph: Supplementary Material 5</p> <hd id="AN0189290419-29">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0189290419-30"> <title> References </title> <blist> <bibl id="bib1" idref="ref80" type="bt">1</bibl> <bibtext> Alcalay A, Ferguson JL, Cihon JH, Torres N, Leaf JB, Leaf R, McEachin J, Schulze KA, Rudrud EH. 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Wise; Krystin A. Abt; Madeline G. Drives; Rachel R. Cagliani and Kevin M. 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  Data: Evaluation of the Effects of the Picture Exchange Communication System™ Protocol on Problematic Behavior across the School Day
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  Data: <searchLink fieldCode="AR" term="%22Tyler-Curtis+C%2E+Elliott%22">Tyler-Curtis C. Elliott</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-6826-4449">0000-0001-6826-4449</externalLink>)<br /><searchLink fieldCode="AR" term="%22Chloe+N%2E+Wise%22">Chloe N. Wise</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-2539-5059">0000-0002-2539-5059</externalLink>)<br /><searchLink fieldCode="AR" term="%22Krystin+A%2E+Abt%22">Krystin A. Abt</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0009-5345-4157">0009-0009-5345-4157</externalLink>)<br /><searchLink fieldCode="AR" term="%22Madeline+G%2E+Drives%22">Madeline G. Drives</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0006-4685-3510">0009-0006-4685-3510</externalLink>)<br /><searchLink fieldCode="AR" term="%22Rachel+R%2E+Cagliani%22">Rachel R. Cagliani</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-8031-295X">0000-0001-8031-295X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Kevin+M%2E+Ayres%22">Kevin M. Ayres</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-7166-5742">0000-0002-7166-5742</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Developmental+and+Physical+Disabilities%22"><i>Journal of Developmental and Physical Disabilities</i></searchLink>. 2025 37(6):981-1006.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: 26
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  Data: Journal Articles<br />Reports - Research
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  Data: <searchLink fieldCode="DE" term="%22Augmentative+and+Alternative+Communication%22">Augmentative and Alternative Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Pictorial+Stimuli%22">Pictorial Stimuli</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Preschool+Children%22">Preschool Children</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink>
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  Data: 10.1007/s10882-024-09999-9
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  Data: 1056-263X<br />1573-3580
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  Data: The Picture Exchange Communication System (PECS) helps build a functional communicative repertoire, including requesting, thus acquisition of picture exchange may result in reductions in operationally defined problematic behavior if the requests act as a replacement behavior. Current research provides inconclusive data regarding the impact of acquisition of picture exchange on problem behavior. In addition, these studies collected behavior data for only 5-15 min sessions during or after PECS training. We taught four preschool students with autism to communicate with picture exchange using the PECS Phase I-IIIB protocol and collected data on their problem behavior across the day for at least 2 days a week for 4 months. The results suggest that the acquisition of picture exchange through Phase IIIB did not consistently diminish problem behavior for our participants. We discuss these results in relation to spontaneous picture exchange use.
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