There are various visually based ways to help communication in people with autism. Visual means can be used to accompany or augment the spoken word to help the person with autism understand spoken information. They can also be used to help the pre-verbal person learn to express their needs by requesting what they want.
Object, photograph or symbol?
Objects, photographs, picture symbols and written words can all be helpful to accompany speech and the choice will depend on the needs of the individual. Traditionally, the use of objects of reference was considered most suitable for an early developmental stage, followed by the use of photographs and only later that of symbols.
Picture symbols (line drawings which are usually accompanied by the written word) are one way of enhancing (or augmenting) the spoken word to help visual learners communicate. However, as with many aspects of development, in autism the normally developing progression from object to photo to symbol may not be appropriate indeed, sometimes the person with autism finds a symbol line drawing less confusing than a detailed photograph. People with autism tend to perceive details more powerfully than the whole (they may be unable to see the wood for the trees) and they can become confused or distressed if the photograph used (e.g. that of a particular brand of sweet or of a certain playground) does not exactly match the real life object or place to which it refers.
Some people with autism are able to recognise written words more easily than spoken words (hyperlexia) so it advisable to always use picture symbols with an accompanying (lower-case) written word. This may assist the person with autism and will also help other people to understand the symbol. Picture symbols are easily understood by the general public (especially if used in association with the written word) and are becoming more easily available with the advent of computer generated systems in addition to the master picture sets available from educational suppliers.
Labelling: understanding names for things and places
Picture symbols should first be associated with the thing that they represent by labelling: attaching a symbol to the object or place that it represents (eg biscuit or toilet). Once the person with autism has begun to associate the symbol with the real thing (or place), then an identical symbol can be introduced a little distance away from the actual thing, allowing the parent or carer to show the symbol whilst telling the person with autism what to get, or where to go. Thus the symbol becomes portable and can be used away from the thing that it represents.
The rate at which new symbols can be introduced will vary from person to person but it will be important to use symbols first to refer to things which are motivating for the person with autism and to wait for clear signs of understanding before introducing a new symbol.
Learning to request: to exchange a symbol for a desired object
People with autism have difficulty in learning how communication works. Their mind-blindness increases their problems in figuring out how communication works. If you lack the understanding that another person may not know what you want, why make the effort to communicate that want? To help the person with autism learn how communication works, it can be very helpful to teach them to exchange a symbol for a desired object.
The Picture Exchange Communication System (PECS) was developed by Bondy and Frost to help young children with autism learn to initiate requests and communicate their needs. PECS uses a behaviourally based programme to teach the child to exchange a picture card for something the child likes and wants. Objects, pictures or symbols may be used, according to the childs developmental level but many young children with autism find the less detailed line drawing of a symbol easier to understand, especially if this is accompanied by the written word. A picture cut out from a certain packet of crisps may be refused by the child with autism for use with any other type (or brand!), whereas the more general outline of a symbol will be accepted as referring to all crisps.
PECS first assesses the childs preferences, for a small number of food items and some toys. The child is then taught, in a carefully graded pattern of small steps, to exchange a symbol representing one of these wanted items for the item itself. At first, two adults are needed so that the child can be physically (but not verbally) prompted to exchange the symbol, rather than grab the wanted item. One item (and its symbol) is worked on at a time. No verbal prompts are given the first speech the child hears will be the name of the item, said by the adult offering it, as the exchange is made. The second adult stands behind the child, offering a physical prompt to encourage the child to exchange the symbol, but never speaking. Once the child learns to give the symbol, this second adult is no longer needed.
The six phases of PECS are carefully structured to enable the child to:
- learn the picture exchange
- actively find someone to give a symbol to as a request
- discriminate between several symbols
- use a portable communication book
- construct simple sentences, both requests and comments.
The child gradually becomes independent of adult prompting and learns that communication is a two-way process which can achieve desired needs.
PECS has been shown to facilitate the development of spoken words, and establishes the basics of communication in advance of the hoped-for emergence of speech. Children learn to communicate with PECS because they are highly motivated to request a wanted item and because PECS teaches visually explicit skills, using only physical prompts which can be gradually faded, thus avoiding the child becoming prompt dependent. PECS is easy to use and does not involve expensive equipment, testing or training although training courses for professionals are available, together with a video.
Making choices
Picture symbols can also be used to introduce the idea of choices for instance with food. If the understanding (and exchange) of symbols for a variety of foods has been established then these symbols can be used to show the choices available and the person with autism can be encouraged to communicate their preferred choice. Choice boards can also be used for play or leisure activities, encouraging the person with autism to choose an available activity (rather than remaining passive or persisting in one activity repetitively).
Visual structure
People with autism, whether non-verbal or verbal, may also benefit from the use of picture symbols on timetables (or schedules) showing the sequence of daily routines. Using picture symbols in this way can avoid tantrums or a build up of anxiety and encourages the development of independence in skills such as dressing. Symbol timetables can be adapted for use at home, at school, in the workplace, or in an independent living environment. This use of visual structure helps the person with autism understand the world around them, and develop independence skills. Picture symbols can help make their environment organised and predictable, encouraging calm behaviour.
Symbols can also be used to help the person with autism understand available choices of activity, or to reinforce the concept that something is finished and show the person with autism what will happen next. When one activity has been selected and completed the person with autism can (if desired) be taught to place the symbol for the completed activity in a container labelled finished and to move on to another activity.
This use of visual structure is part of the TEACCH approach and can be modified for use throughout the life of the person with autism, if necessary.
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