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Case Study

Read an actual scenario and apply your learning. Use the guiding questions in discussion.

Background
Strategies
Intervention
Outcome
Questions

Background

Tommy Johnson is a 5-year-old boy with autism. He has difficulty communicating with his peers and frequently fails to respond when people speak to him. Tommy never initiates conversations and rarely makes eye contact with other individuals. Periodically, Tommy becomes upset and loses his temper throughout the school day. Tommy is not the only person with autism in his family. His older brother, Matthew, exhibits some signs of autism, including certain repetitive behaviors, difficulty with social skills, and behavioral problems. Despite these barriers, Mathew has been successfully integrated into a general education classroom.

Tommy was placed in a special education class at Springfield Elementary School at the beginning of September. Mrs. Penny, Tommy’s teacher, has been unable to find effective teaching strategies to work with Tommy. He rarely listens to Mrs. Penny and has difficulty interacting with the six other students in his class. At home, Mr. and Mrs. Johnson have noticed that Tommy loses his temper more frequently since their move to Springfield last year. They have learned that the methods that helped Matthew change his behavior do not seem to be effective with Tommy. In order to reassess the strategies for working with Tommy, Mrs. Penny scheduled an IEP team meeting.

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Strategies

At the IEP team meeting, Mr. and Mrs. Johnson explained how their son Matthew once had a teacher who used social stories to help decrease Matthew’s anxiety and tantrums during recess. Although the Johnsons were impressed with this strategy, they were unsure whether social stories could help Tommy change his behavior in the classroom. Mrs. Penny agreed that social stories would not be the appropriate approach, since Tommy has not yet developed the appropriate language skills for social stories to be effective. Although Tommy occasionally repeats words from a story, he never seems to understand the story.

Mrs. Penny suggested using Ivar Lovaas’s intensive behavioral treatment as an intervention strategy. The Johnsons had heard of the Lovaas method but expressed some reservations about using this approach with their son. Although the Lovaas method provides intensive one-on-one contact with a therapist, this strategy seemed to provide little interaction with peers. The Johnsons felt that Tommy needed to develop better social skills to relate to other young people. They were primarily concerned with Tommy’s socialization.

The IEP team decided that the primary goal was to help Tommy learn to communicate better. Over the past year, the Johnsons had tried sign language with Tommy, but this strategy did not seem to be any more effective than teaching him direct speech. Tommy was capable of imitating signs, but never initiated signed speech on his own. The Johnsons were also concerned that even if Tommy did learn signs, his peers would not necessarily understand these signs. Imitation strategies also seemed to be relatively ineffective for Tommy. Although Tommy was capable of repeating language, he never did this consistently. He rarely looked at his trainer’s face and usually could not sit still long enough to focus on language skills. The Johnsons also felt that teaching Tommy to communicate by using imitation would take a very long time. They hoped for an approach that would help Tommy communicate better immediately.

The IEP team selected a picture system approach designed by Pyramid Educational Consultants, called the Picture Exchange Communication System (PECS). This approach seemed most appropriate for Tommy because it encourages children to be the communication initiators. PECS concentrates on each child’s interests, instead of forcing a child to focus on objects that do not appeal to him. The Johnsons also liked the idea of using pictures to help Tommy communicate, since both his brothers and his peers would be able to understand these signs. The Johnsons hoped that PECS would allow Jamie, their third son, to have a more important role in communicating with his younger brother. In addition, PECS seemed suitable for Tommy because he would be able to begin using pictures immediately to help him communicate. When the Johnsons learned that PECS did not require an extensive training period, they were ready to begin using PECS with Tommy immediately.

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Intervention

The main goal was for Tommy to begin initiating communication on his own so that he could establish better relationships with his peers and feel less frustrated during daily interactions with other people. Mr. and Mrs. Johnson both decided to receive PECS training. The plan was to have Tommy work initially with a PECS specialist for several days after school, and then to encourage Tommy to use PECS at school during the day and at home at night. During Tommy’s first few training sessions, Mrs. Johnson observed the training so that she would feel more comfortable working with Tommy. Mr. and Mrs. Johnson planned to familiarize their two older sons, Matthew and Jamie with this approach so that they could both begin using PECS with Tommy as well.

The two specialists working with Tommy spent most of the first session determining Tommy’s "likes and dislikes." Before the next session, they made pictures of these desired objects on little squares backed with Velcro. During the next few training sessions, they worked with Tommy on Phase 1 of PECS, which they called the Physical Exchange. Mrs. Johnson watched as one of the specialists, who called herself the communicative partner, tried to attract Tommy’s attention with a cup of water (one of Tommy’s desired objects). When Tommy reached for the cup, the second specialist, the physical prompter, helped Tommy pick up the picture of the cup of water and hand this picture to the communicative partner. When the communicative partner received the picture from Tommy, she gave him the cup and said to him: "Oh, you want the cup." Once Tommy became familiar with this routine, the two specialists switched roles and worked with Tommy in different environments to introduce some variety to the training.

After one week, Tommy was ready for Phase 2 of the training, Expanding Spontaneity. During these sessions, one of the specialists placed herself farther away from Tommy. She encouraged Tommy to move toward her to give her the picture of a desired object (a ball in one session). When Tommy handed her the picture of the ball, she praised him by saying, "Great job, Tommy. You want the ball!" and quickly gave him the ball to play with. At first, the physical prompter helped Tommy move toward the communicative partner. However, over time, the physical prompter was phased out of the training. As Tommy progressed through the training, one of the specialists gave him his own communication book. During each session, the specialist would place one picture with velcro on the outside of the book and wait for Tommy to peel off the picture and hand it to her before giving him the desired object.

Last month, Tommy complete Phase 3 of PECS, called discrimination training. This phase was most difficult for Tommy. He needed to learn to choose between pictures of different objects. At first, the specialist started with one picture of a desired object and one picture of a non-preferred object. When Tommy handed her a picture, she would give him the object he requested. Initially, Tommy had a hard time distinguishing between the two pictures. The specialist made the pictures slightly bigger with brighter colors to enhance the visual components. Eventually Tommy was able to distinguish between the pictures. Presently, Tommy is working on Phase 4 of PECS, Sentence Structure, at home and at Springfield Elementary School. He is learning to use simple sequences of pictures on Velcro sentence strips to make requests.

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Outcome

The Johnsons are very pleased with Tommy’s progress with PECS. Tommy now has a way to communicate with and to request things from other people. The Johnsons feel that their two older sons are beginning to establish better relationships with Tommy. Even Jamie seems to enjoy using the PECS communication book with his younger brother. Mrs. Penny reported that Tommy throws fewer tantrums and seems calmer during the school day. She also noticed that Tommy has started to use the communication book with the other six students in his class. Tommy is slowly learning to use some speech with his PECS training. Mrs. Penny feels that she has more time to work with the other children now that she does not have to constantly focus on Tommy’s tantrums. Although Tommy has a long way to go, the Johnsons feel that he has made huge strides with PECS.

The IEP team plans to meet again in another month to discuss Tommy’s progress and to establish new goals for him. In the future, Mrs. Penny hopes to begin implementing the University of North Carolina at Chapel Hill’s TEACCH strategies into her classroom. She already uses several of these classroom strategies, which seem to work well with Tommy. In particular, she has established a very structured environment in her classroom, where Tommy is familiar with his daily routine. Mrs. Penny tries to focus on visual aspects of each lesson when she is working with Tommy, since he has not fully developed his verbal skills. Tommy seems to be most successful when he has to focus on only one topic at a time. Mrs. Penny plans to work collaboratively with the Johnsons to help Tommy continue to develop his social skills and speech.

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Questions

  1. Why might the IEP team choose to improve Tommy’s communication skills, rather than focusing on his social/behavioral skills as their primary goal?

  2. What else can be done to help Tommy develop his communication skills?

  3. How were Tommy’s brothers, Jamie and Matthew, affected by the Johnson’s choice of PECS as the appropriate intervention method?

  4. Now that Tommy has a means of communicating his needs to others, what should the IEP team establish as Tommy’s next goal?

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