Adaptações Do Sistema De Comunicação Por Troca De Figuras No ...
Pró-Fono Revista de Atualização Científica, v. 17, n. 2, maio-ago. 2005
Adaptações do sistema de comunicação por troca de figuras no
contexto escolar****
Adaptation of the picture exchange communication system in a
school context
Maria Amélia Almeida* (ameliama@terra.com.br)
Maria Helena Machado Piza**
Dionísia Aparecida Cusin Lamônica***
*Psicóloga. Pós-Doutorado em
Abstract
Educação Especial pela Universidade
Federal de São Carlos. Professora do
Background: alternative communication. Aim: to evaluate the efficacy of the adapted Pecs
Curso de Pós-Graduação em Educação
and Picture Communication Symbols (PCS) in the communication of a child with cerebral
Especial da Universidade Federal de
palsy. Method: the participant of this study was a 9 year and 10 months old girl, with
São Carlos.
athetoid quadriplegia. All stages of the adapted Pecs were applied (Walter, 2000), using the
**Fonoaudióloga. Mestre em Educação
PCS pictures (Johnson, 1998), associated with the functional curriculum proposed by
Especial pela Universidade Federal de
São Carlos. Professora do Curso de
LeBlanc (1991). An experimental AB Design was used in order to test the procedures.
Pedagogia da Universidade Vale do
Results: the subject was able to pass through all of the adapted Pecs phases and to use her
Itajaí.
communication board in school activities. Conclusion: the adapted Pecs proved to be
***Fonoaudióloga. Doutora em
effective in improving the subject’s communication abilities.
Distúrbios da Comunicação pela
Key Words: Cerebral Palsy; Alternative Communication; Communication Barriers; Speech
Universidade Federal de São Paulo -
Escola Paulista de Medicina.
Language Pathology.
Professora Doutora do Curso de
Fonoaudiologia da Faculdade de
Odontologia de Bauru da Universidade
Resumo
de São Paulo.
Tema: comunicação alternativa. Objetivo: avaliar a eficácia do Sistema de Comunicação por
****Trabalho Realizado na
Intercâmbio de Figuras (Pecs-Adaptado) e do Picture Communication Symbols (PCS) na
Universidade Federal de São Carlos
comunicação de paralítico cerebral. Método: participou uma menina de 9a e 10m, com
com Apoio Financeiro da Fapesp
quadriplegia atetóide. Aplicou-se todas as fases do Pecs-Adaptado (Walter, 2000), usando
Processo Número 99/08415-6.
figuras do PCS (Johnson, 1998), tendo como programa o currículo funcional (LeBlanc,
1991). Utilizou-se o delineamento experimental AB, tendo "o sujeito como seu próprio
Artigo de Relato de Caso
controle". Resultados: a participante passou por todas as fases propostas e usou sua
Artigo Submetido a Avaliação por Pares
prancha de comunicação nas atividades curriculares escolares. Conclusão: o Pecs-Adaptado
Conflito de Interesse: não
mostrou-se efetivo para melhorar as habilidades comunicativas e escolares da participante.
Palavras-Chave: Paralisia Cerebral; Comunicação Alternativa; Barreiras de Comunicação;
Patologia da Fala e Linguagem.
Recebido em 15.01.2004.
Revisado em 26.03.2004; 18.08.2004;
28.09.2004; 03.03.2005; 14.04.2005.
Aceito para Publicação em 29.04.2005.
ALMEIDA, M. A.; PIZA, M. H. M.; LAMÔNICA, D. A. C. Adaptation of the picture exchange communication system in a school context (original title: Adaptações
do sistema de comunicação por troca de figuras no contexto escolar). Pró-Fono Revista de Atualização Científica, Barueri (SP), v. 17, n. 2, p. 233-240, maio-ago.
2005.
Adaptações do sistema de comunicação por troca de figuras no contexto escolar
233
Pró-Fono Revista de Atualização Científica, v. 17, n. 2, maio-ago. 2005
Introduction
Alternative communication is a clinical
symbols with simple designs whose meanings are
approach which proposes to compensate
easily recognized, being divided into categories
temporarily or permanently for the difficulties of
denominated: social, persons, verbs, descriptors,
individuals with severe communication problems
nouns and miscellaneous. These categories are
due to incapacity or disability (Jensen, 2000; Clarke
based on the function of each word and purpose
et al., 2001; Downey & Hurting, 2003). Many
of ordering the words appropriately (Johnson,
studies have presented the efficacy of the use of
1980; 1998). The Pecs system uses the figures
alternative communication to improve the
proposed by PCS.
communication of persons with special needs
In Brazil, Pecs was described, adapted and
(Basil et al., 1994; Watson, 1995; Boose & Stinett,
standardized by Walter (1998; 2000) and obtained
1999; Bondy and Frost, 2001; Liddle, 2001; Sanchis,
positive results. In the 1998 study, Walter carried
2001; Vasconcelos, 2001; Charlop-Christy et al.,
out procedures for the adaptation of the Pecs
2002; Kravits et al., 2002; Pires & Limongi, 2002;
system for Brazil. The study presented by Walter
Santos & Marquezine, 2003).
(2000) had the objective of evaluating the effects
The Picture Exchange Communication System
of the adapted Pecs with the PCS figures applied
is an alternative that was described by Frost &
to the context of the natural functional curriculum.
Bondy (1996) as a training manual for alternative
In this study the author made adaptations for the
communication for the progressive increase of
utilization of Pecs and applied the procedure to
interpersonal communication skills, principally for
four autistic individuals, with training sessions and
persons with severe communication difficulties. It
data collection being accompanied for two years.
was developed at the Delaware Autistic Program
The application involved two phases, baseline and
and initially utilized with autistic children who did
intervention, with an AB Design. The results show
not communicate orally (Bondy & Frost, 1994).
the effectiveness of these procedures in the process
This system of figure exchange is applied by the
of communication, which may have favored the
presentation of phases, each of which is composed
inclusion of the participants in the school
of specific objectives, environmental arrangement,
environment, family and community.
training instructions and procedures (Frost &
Cerebral Palsy is defined as an encephalitic
Bondy, 1996), which can be used individually or in
lesion sequel, which is characterized as a permanent
groups, in various places such as at home, the
condition affecting, but not invariably, muscle tone,
classroom or in the community. Its principal
posture and movement, which appears in early
advantage is with respect to its low cost (Bondy &
childhood and is not only a directly secondary to
Frost, 1994;; Frost & Bondy, 1996).
this non-evaluative encephalitic lesion, but also
The Picture Communication Symbols System
influences neurological maturation (Badawi et al.;
(PCS) proposed by Johnson (1980; 1998), is
1998; Miller, 2002).
composed of 3000 figures that express a great
The basic symptoms of cerebral palsy are
variety of words used in daily activity situations
characterized by motor difficulties, which develop
and practices. It was created to address the needs
over time, causing delays or interruption of sensory
of individuals with communication alterations. For
motor development, insufficient postural reaction
its utilization, visual acuity as much as visual
mechanism, the presence of reflexes in epochs at
perception must be taken into consideration,
which they should have already been inhibited,
because these both these skills enable the verbally
alterations in muscle tone and inability to make
disabled to identify the desired symbol, as well as
movements (Lepage et al.; 1998). The clinical
being of fundamental importance to the existence
condition of cerebral palsy is as variable as the
of communication partners as facilitators who
individuals with cerebral palsy because it is related
create, maintain and organize communication
to innumerous variables, notable among which are:
situations.
the anatomical site of the cerebral lesion, the part
The speech skills that the individual may have
of the body affected and the influence on
or come to present are not inhibited, because this
neurological maturation.
system fosters the elimination of possible existing
In athedoid cerebral palsy, the sequel is related
tension in the act of communication, making oral
to the involvement of the extra-pyramidal system
emission possible accompanied by the indication
that favors the appearance of involuntary
of the symbol desired. This system possesses
movements, muscle tone fluctuation and delayed
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psychoneuromotor development with the retention
developed by LeBlanc (1991). This article
of primitive reflexes. In athetosis, the involuntary
discusses the Adapted-Pecs procedure and not
movements are slow, smooth and contorted which
the functional curriculum.
compromises the distal muscles by dysynergy with
The data collection occurred during the school
the opposite muscle groups (Badawi et al., 1998;
day period of routine daily activities, which are
Miller, 2002). The face musculature is also
part of the program offered by the Association of
compromised by involuntary movements, causing
Parents and Friends of Exceptional Children
difficulties in oral expression and oropharynx
(APAE). The intervention sessions were planned
disorders (Miller, 2002). As to the development of
to occur during mealtimes, speech therapy and
language and cognition, the expectation is that this
classroom activities.
patient will not present great alterations, but these
The participant was submitted to an initial
alterations, however, may occur in various degrees
evaluation correspondent to the baseline sessions.
(Badawi et al., 1998).
Following this, training of the Adapted-Pecs
Considering that cerebral palsy sequel cause
(Walter, 2000) was structured to address the
primary motor alterations, which interfere in speech
necessities of the child with cerebral palsy.
communication, the utilization of alternative
The 24 cm x 35 cm communication board was
communication methods is fundamental. For this
made of wood with velcro glued to the boards and
reason, this study was designed to evaluate the
the figure cards. The figures were initially 8 x 8 cm
efficacy of the use of Adapted Pecs and PCS in the
in size and were later reduced to 4 x 4 cm.
communication of a girl with athetoid cerebral palsy
The communication trials (1 to 10) were
in terms of functional curriculum.
registered for each figure card, signifying the
number of trials needed to train each figure. Each
Method
time the figure was exchanged for the desired item,
the participant received points from 0 to 3 in
The project was approved by the Research
accordance with the level of assistance received.
Ethics Committee of the Federal University of São
At the end of the session, total points were
Carlos under Protocol No. 021/2002. After the
registered, and total trials and total successful trials
parents had agreed to give to allow their daughter
were converted into percentages to obtain the
to participate in this study, and had signed a Free
performance of the participant for that session.
and Informed Consent form, they were invited to
The point scheme followed the criteria below
participate in the Functional Vocabulary Selection
for all phases:
that would be utilized during the procedures. They
were to choose five items of preference or interest
. unsuccessful trials = zero (0) points;
for each of the following categories: food
. trials with physical assistance = one (01) point;
preferences; beverages; toys or objects of interest;
. trials with verbal assistance = two (02) points;
games and play; places and known persons.
. trials with no assistance = three (03) points.
The participant in this study was a nine year
and ten month old female child enrolled in a special
The answers were noted in accord with the
school maintained by the Association of Parents
assistance received and summed at the end of the
and Friends of Exceptional Children.
day for a descriptive analysis in absolute and
The participant had been given a diagnosis of
relative numbers.
quadriplegic athetoid cerebral palsy on the
The data were noted during the intervention
institution’s medical chart and did not communicate
activity and all sessions were filmed to be used for
by speech. The following evaluations were done:
the inter observer reliability indices. The videos
complete hearing test: presenting normalcy; vision
were watched by two observers (rehabilitation
testing which claimed estropia and a psychological
professionals) and the calculation of reliability was
evaluation which scored 58 on the Columbia,
done. The index of reliability was analyzed by the
classifying her as presenting moderate mental
point-by-point technique, or that is, the points for
disability. However, the psychologist’s report
each observation were verified for each trial in 25%
stressed the difficulty the participant had in doing
of the sessions, chosen randomly and respecting
the test due to motor alterations.
the characteristics of each step of the procedure.
The Adapted-Pecs (Walter, 1998) was utilized
The indice of reliability was calculated by dividing
in association with the PCS figures relating
the number of agreements with the sum of
alternative communication to functional curriculum
disagreements and agreements and multiplying the
Adaptações do sistema de comunicação por troca de figuras no contexto escolar
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result by 100 following the formula proposed by
work of discriminating between two figures
Hersen and Barlow (1982). Data considered to have
measuring 8 x 8cm was begun, one figure being of
reliable validity were those with a minimum of 75%
great interest and the other irrelevant. The
agreement. The mean percentage of the registers
participant should look at and perceive the
of the participant was 95%.
difference in the figures to make her request. After
The observations of the procedures, materials
obtaining 100% recognition, Phase 3b was begun,
and academic content, physical context of the
offering the figures in the 4 x 4cm size, again one
classroom and informative content transmitted by
being of great interest and the other irrelevant, to
means of the motor responses made with the figure
certify that the smaller figure had been recognized.
cards were the object of a general synthesis for all
In this phase the family was oriented to collaborate
registered sessions.
in the process by taking the communication board
An AB research design in which “the subject
home and taking on a role of great importance by
himself is the control” was used and consists of
continuing the training at home. It must be noted
two phases: baseline and intervention. (Sidman,
that this data was not collected in a standard
1960; Tawney & Gast, 1984). This design does not
manner, that is, an accompaniment was not made
require statistical analysis, only visual inspection,
of the use of the communication board at home,
that is, a visual analysis by means of graphs which
because this was not the principal intention at that
show the effects of the intervention, when
time. However it was observed that the family
compared to the performance of the participant in
presented interest in the process and this form of
the baseline phase.
communication. To improve visualization, the board
In the baseline phase, the figure card was
was positioned vertically at a 45 degree angle and
matched to the corresponding object and without
attached to the participant’s wheelchair.
offering any type of assistance, the participant was
asked individually if this is what she wanted. In
Phase 4: Forming sentences. In this phase, began
this phase, the objective was to verify whether the
the use of the figure denominated “I want” + the
participant could use the exchange procedure to
desired figure, requiring the use of a resource called
communicate. Once the baseline was established,
“Phrase-Frame” (Walter, 1998). This adaptation was
the intervention phase was initiated.
made utilizing a wooden board measuring 5cm wide
The intervention was divided into five (5) sub-
by 40cm long with velcro strips glued to both sides.
phases of Adapted PECS proposed by Walter
In this instance, the participant should remove the
(2000), with specific adaptations to facilitate the
desired figures from the communication board and
utilization of the cards by the participant. The
place them on the "Phrase-Frame", forming the
phases are described as follows:
phrase "I want" + the desired stimulus. Verbal
assistance was given when necessary. With a
Phase 1: Learning to make the exchange. In this
phrase formed, the participant should submit the
phase, each participant should take, push or point
phrase-frame showing their desire. As the process
to the figure, indicating the item of interest and
evolved, the verbal help was withheld to make the
can receive physical assistance to point to the
participant formulate their phrase spontaneously.
desired item (figure card). This phase extended until
Lastly, figures such as, "I like", "I have", "I see",
no physical assistance was necessary to indicate
etc. were utilized.
the figure. The participant could receive social
reinforcement such as: “Very good, I understand
Phase 5: Increase vocabulary. In this phase, the
what you want!”. In training, each figure was used
figures that contained concepts such as, for
once.
example, notions of color, shape, size, etc., figures
that expressed feelings and figures for concepts
Phase 2: Increase the spontaneity. In this phase,
from the academic curriculum were introduced.
using an auditory stimulus (a rattle, for example)
as a aid, the participant should get the attention of
The sessions to register the performance of the
the interlocutor to initiate the communicative
participant in the phases of the Adapted-Pecs
interaction and make their request by exchanging
(Walter, 2000) were carried out during the school
the desired figure to indicate their need.
week, in accordance with the frequency of the
participant’s school attendance during the school
Phase 3: Discrimination of the figures and reduction
year. In the third phase, the sessions recorded and
of their size. In this phase, denominated 3a, the
use of the Adapted-Pecs moved to other activities
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and environments in the school, in accordance
In Figure 2 the type of assistance given to the
with the daily planning for the classroom, such as
participant during the baseline and intervention
help with pedagogic activities set by the teacher
phases are described.
and in other areas of the school, in physical
As can be verified in the baseline, no type of
education classes, in interactions which took place
response that demonstrated a communicative
in the park and music activities. The data collection
intention was observed (sessions one, two and
had duration of nine months. Note that the criteria
three).
for moving on to a new phase was linked to
At the beginning of the intervention phase
obtaining 100% correct responses. However, if
(sessions four to ten) the participant was oriented
there had been absences during the week, the
orally about the manner in which the exchange
procedure was reapplied at the same phase.
should be made, that is, she could take the card,
remove it and give it. The presence of unsuccessful
Results
responses and appropriate responses with
physical assistance can be verified. The baseline
The performance of the participant in the
sessions through to the seventh session (of phase
training phases of the Adapted-Pecs, the level of
one) were conducted by the researcher.
assistance given to allow the request to be made
From the 5th through 8th sessions, it was possible
in an independent manner, the observations and
to verify the presence of verbal assistance, which
the reports about the communicative changes that
became a permanent form of assistance. In the 8th
occurred through use of the alternative
session, the teacher was oriented and solicited to
communication procedures utilized will be
carry out the training.
presented.
In the 9th session 100% of independent
Figure 1 shows the performance in the baseline
responses were presented. There was then a 15-
phase and in each of the intervention phases that
day recess period. The indices of successful
the participant managed to achieve through use of
responses was stable in the session subsequent
the Adapted Pecs.
to the return to classes and the option was made
In the baseline phase (sessions one, two and
to move on to the 2nd phase.
three), the participant was unable to make any
In phase 2 of the Adapted-Pecs (sessions 11 to
solicitation, merely looked at the figure and took it,
16), there was a physical distancing between the
but did not present any use of the figure to manifest
teacher and the participant and the participant was
her desire as a communicative function. From these
orally oriented to use the rattle when she desired
behaviors with the figures, the responses can be
to solicit something.
observed to be unsuccessful as the objective was
In the 12th session, the participant obtained
to verify if the picture exchange as a form of
100% of responses with independence; however,
communication could be performed. In the
in the following session, alterations in behavior
subsequent phases, it was possible to observe the
were presented, such as armcrossing, movement
effective utilization of the alternative
of the head to indicate “no” as well as hiding the
communication resource in each of the phases.
card in her lap.
FIGURE 1. Performance in the baseline phase and in each of the intervention phases that the participant managed to achieve through
use of the Adapted Pecs.
LB Fase1 Fase 2 Fase 3 Fase 4 Fase 5
100%
80%
60%
40%
20%
0%
porcentagem de respostas
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
sessões consecutivas
Adaptações do sistema de comunicação por troca de figuras no contexto escolar
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FIGURE 2. Assistance given to the participant during the baseline and intervention phases are described.
participante 1
30
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
independência
auxílio verbal
auxílio físico
sem êxito
In the 14th session, guttural sounds and
participant was oriented orally about how the
screams to call attention were presented, together
picture exchange should be done, that is, in this
with the shaking of the rattle. In the 17th session of
phase the participant should utilize the figures “I
the intervention, phase 3a was begun, where the
am” and Ï want” to form phrases to solicit what
participant was oriented to make a choice between
was desired.
two distinct figures that were on the board: shake
In the 33rd session, 100% independent
the rattle to call the adult and make the
responses were presented; meeting the criteria to
communicative exchange. In this session, initially
move on to phase five. At the beginning of the
difficulties were presented (unsuccessful
phase five, in the 34th session, the participant was
responses) such as giving the teacher two figures.
oriented orally on the way the exchange should be
In the 19th session, the participant presented
made, that it should be made as in phase four, with
behaviors of refusal to do the communication
the difference that the figures which were still
training ( unsuccessful responses), because she
unfamiliar would be utilized. In this phase, new
wanted to change activities, did not respond to
categories of vocabulary were presented and the
the teacher’s solicitations, necessitating verbal
use of alternative communication for other
assistance. In the 22nd session, she performed
activities by the participant in school and at home.
100% of successful responses ,permitting her to
move on to phase 3b.
Discussion
Phase 3b began in the 23rd session. The
participant was oriented that the figures would be
The participant managed to achieve all of the
reduced in size and new options would be added
phases of the Adapted-Pecs system successfully:
to the communication board. It was clarified that
The experimental design proposed in this study,
she should choose the figures on the board and
having the subject as her own control, served as a
shake the rattle to make the communication
parameter for evaluating the possibilities of the
exchange. It must be noted that it was also
use of alternative communication and academic
considered appropriate to call the teacher by
learning proposed by the school, since the
producing the guttural sounds that the participant
participant responded to the curricular questioning
was able to make. Phase 3b refers to sessions 23
solicited by the teacher, through use of the
through 30 and despite having achieved the indice
Adapted-Pecs. Sidman (1960); Tawney & Gast
for the next phase in session 28, there was a school
(1984); describe this methodology and the
recess and the participant was absent, and for this
importance of its use for the acquisition of
reason sessions were done to guarantee the criteria
knowledge on the part of the participants, for
met, in this phase.
having themselves as their own control.
In the 30th session, the participant presented
In phase one, with the placement of the
100% independent responses and after this
communication board positioned vertically, the
performance, the fourth phase was begun. In the
participant did not demonstrate any difficulty in
31st session, phase 4 was initiated, in which the
doing the communication training. For the
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elaboration of the communicative resource, it is
to successfully develop academic content. The
important that all necessary adaptations are made
functional curriculum of Le Blanc (1991) favors the
to facilitate the development of communicative
exchange of information in different situations,
activities by the user (Jensen 2000; Liddle, 2001;
valuing the student when the student is observed
Downey & Hurting, 2003; Santos & Marquezine,
to be capable of responding appropriately to
2003).
demands of the environment and collaborate with
In phase two, the rattle was used as a resource
their social insertion. Basil et al. (1994); Watson
to get the attention of the interlocutor, the
(1995); Sanchis (2001); Santos & Marquezine (2003)
participant made use of it without demonstrating
also point to the importance of the use of alternative
difficulty with the inclusion of this new rule. It was
communication for the full development of the user,
observed that, from this procedure on, the
so that these strategies can favor interaction in all
participant began to use her oral possibilities to
the environments that this individual may frequent.
get the attention of the interlocutor, as in, for
Finally, it was verified that the participant with
example, produce guttural sounds. It is important
cerebral palsy responded in an appropriate manner
to note this aspect because the use of alternative
to the stimuli provided by the Adapted-Pecs and
communication does not impede the development
PCS systems in the communicative activities. Other
of oral communication and the authors, Watson
relevant aspects were the participation of the
(1995); Frost & Bondy, (1996); Walter (1998); Boose
teacher who was active in the educational process
& Stinnet, (1999); Bondy & Frost (2001); Clarke et
by providing conditions for use of the procedures
al. (2001), also call attention to this fact.
in academic activities and the participation of the
In phase 3a it was possible to verify that the
parents in the process, which despite having been
participant managed to make the exchange of two
asked only to choose the functional vocabulary
or more figures available on the communication
for the organization of the board, involved
board, and in phase 3b, the quantity of figures
themselves completely in the process and
utilized for communicative exchange increased and
participated by actively stimulating their daughter
the figures were reduced in size. The importance is
in the use of alternative communication at home.
to increase the communication possibilities of the
users and in some cases, this means optimizing
Conclusion
the surface on which the symbols will be placed,
as in the case of the use of the communication
The Adapted-Pecs System (Walter, 1998),
board. (Charlop-Christy et al., 2002; Kravits, et al.,
associated with the PCS figures was effective in
2002).
assisting the communication skills of a child with a
In phase four, the participant, initially utilized
diagnosis of athetoid cerebral palsy. The emission
short phrases to solicit her desires. After three
of sounds whose purpose was to call attention to
sessions, it is possible to verify that the participant
her, initiates communicative interactions, and
managed to form phrases to solicit her desires. The
request something desired, maintain a simple dialog
objective of the proposal by Walter for the use of
and transmit messages.
Adapted-Pecs (1998; 2000) was to broaden the
Considering it of extreme importance that other
communicative repertoire of the users. The studies
studies be carried out with the intention of utilizing
by Bondy & Frost (2001); Liddle (2001); Charlop-
the methodology presented with other persons
Christy et al. (2002); Kravits et al. (2002);
with cerebral palsy or individuals who present
demonstrate that the use of Pecs fostered the
serious alterations in oral communication. Note that
broadening of the communicative repertoires of
the need to analyze the variables involved in this
the individuals who used this system.
methodology in order to make the necessary
In phase five, the communication training was
adaptations in its application, in order to obtain
extended to other daily school and home activities.
positive results.
Beyond this, the teacher could use these resources
Adaptações do sistema de comunicação por troca de figuras no contexto escolar
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Endereço para correspondência:
Maria Amélia Almeida
R. Episcopal, 2474, apto. 72, Bloco 1 - São Carlos - São Paulo - CEP: 13560-480.
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