Asprin essays

Asprin essays The discovery of aspirin dates back to the 5th century B.C., when Hippocrates used a powder from the bark of a willow tree to ease minor pains, reduce fevers and to help with childbirth. The willow tree powder was actually salicin, the pharmacological ancestor to the family of drugs known as salicylates. The best known of which is aspirin. Later efforts where made to neutralize salicin with sodium, but unfortunately turned out to be useless. In 1853 a French chemist named Charles Fredric Gerhardt tried to improve sodium salicylate in 1853. He combined it with acetyl chloride, which proved to be less irritating to the stomach. After a few years of hard work, Gerhardt didnt see any future with this concoction and soon abandoned it. In 1899 a German chemist, Felix Hoffmann set out to find a formulation to relieve his fathers arthritis pain. Hoffman used Gerhardts research to synthesize acetylsalicylic acid (ASA), a compound that appeared to lower fever, reduce pain and at high doses relieved arthritis. Hoffmann, who worked for Bayer, took his research to his superiors. They, however, doubted the commercial success of ASA. This was because ASA commonly caused shortness of breath and very high heart rates when taken in large doses. Fredrick Bayer in is the common drug ending of that time. When Bayer marketed the drug in 1897, they had no idea that it would turn out to be the most commonly used pain reliever in history. Aspirin works by inhibiting the production of prostaglandins, which are hormone-like substances that influence the elasticity of blood vessels, control urine contractions, and the direct functioning of blood platelets. Blood platelets cause blood clots and regulate numerous body functions. John Vane, Ph....

Free Essays on Malcolm X

On May 19, 1925 in Omaha, Nebraska, Louise Little gave birth to a son, Malcom. Both she and Malcom's father, a Baptist preacher named Earl, were members of Marcus Garvey's Universal Negro Improvement. Including Malcom, there were eight children in the Little family. When Malcolm was an infant, his family was forced to move to Lansing, Michigan after being driven from Omaha by the Ku Klux Klan. Once in Lansing, their house was burned down by a white hate group called the Black Legionnaires. Earl Little died when Malcolm was six years old. After his father died, Malcom's mother had a mental breakdown. With no one to care for them, all eight children were sent to foster homes. Malcolm dropped out of school after the 8th grade. Soon after, he became involved in hustling, drug dealing, and burglaries. This criminal lifestyle landed him in the penitentiary where he spent six years, from 1946 to 1952. During his prison term, Malcolm turned to religion for answers. When he was re leased he became a minister for the nation of Islam. He was the national spokesman for Elijah Muhammed. The Nation of Islam grew from several hundred members to hundreds of thousands of members under Malcolm's leadership. The organization built 40 temples in the and bought 30 radio stations nationwide. The Nation of Islam recruited members from ghetto poor communities, people from the prisons, hustlers, drug dealers, pimps, prostitutes, and thieves. These people were believed to be, â€Å"ethically impoverished by white racist neglect of their fundamental needs.† These fundamental needs were "self-respect, social dignity, to understand their royal black history, and to worship and serve a black god." The Nation of Islam also believed women were a â€Å"lethal source of deception and seduction from within.† The women had to wear a modest dress, they were under close supervision of men, and they were relegated to the background. In March of 1964 Malcolm left... Free Essays on Malcolm X Free Essays on Malcolm X Malcolm X was probably one of the most controversial elements in the civil rights movement. Malcolm X had become a member of the Nation of Islam in his earlier years. The Islamic faith borrows basic ideas from the orthodox teachings of Islam and combines them with the very racist views regarding whites taught by Elijah Mohammed. Malcolm was a very influential priest for the Nation of Islam. Malcolm X questioned some of the views and beliefs of the Nation of Islam, which made Mr. Mohammed and the rest of the Nation angry. This forced Malcolm to travel on a journey overseas to find out what his true beliefs were. When he reached Arabia, he found that it was a different society than that of which Elijah Mohammed had described it. Malcolm discovered that race played no role in determining a person's status in society. Viewing this made a positive change in Malcolm X's beliefs and views. This unity of human kind made Malcolm think and change his ideas about the solution to the racial prob lem in America. This was the most influential turning point in his life. Malcolm first adopted his views and beliefs of the Nation of Islam while he was serving time in prison. By the time he had gotten out of prison, he had undergone a transformation from a drug-dealing thief to a religious priest for his newfound faith, the Nation of Islam. Malcolm had taken on in full Mr. Mohammed's racist teachings. It was through these teachings that Malcolm X developed his radical views about race in America. Under the guidance and teachings of Elijah Mohammed, Malcolm had targeted all whites and blamed them for position of African Americans in society. He referred to the whites as devils, which tried making the standards of blacks even lower then they already were. Malcolm X believed that complete segregation was the only way to end racial problems in America. He also said that all actions committed against blacks in history were due to the white race as a whole... Free Essays on Malcolm X They were black men who had a dream, but never lived to see it fulfilled. One was a man who spoke out to all humanity, but the world was not yet ready for his peaceful words, " I have a dream, a dream that one day this nation will rise up and live out the true meaning of it's creed†¦ that all men are created equal." (Martin Luther King). The other, a man who spoke of a violent revolution, which would bring about radical change for the black race. " Anything you can think of that you want to change right now, the only way you can do it is with a ballot or a bullet. And if you're not ready to get involved with either only of those, you are satisfied with the status quo. That means we'll have to change." (Malcolm X) While Martin Luther King promoted non-violence, Civil Rights, and the end to racial segregation, a man of the name Malcom X dreamed of a separate nation. Malcom Little was born on May 19, 1925 and came from an underprivileged home. He was a self-taught man who received little schooling and rose to greatness on his own intelligence and determination. The early background of Malcolm X was a large factor responsible for the distinct different responses to American racism. During his childhood, He was raised in a harsh atmosphere consisting of fear and anger where the seeds of bitterness were planted resulting in his attitude effecting his decisions later in live. Malcolm X suffered not only from abuse by whites, but also from domestic violence. His father beat his mother and both of them abused their children. His mother was forced to raise 8 children during the depression. After his mother had a nervous breakdown his family was spilt up. The children were all placed in foster homes. And the burning of his house by the Klu Klux Klan resulted in the murder of his father. Malcolm's resentment was increased as he suffered through these hard ships, and he was haunted by this early nightmare for most of his life. From then on, he w... Free Essays on Malcolm X Autobiography of Malcolm X The hardest part of this story is trying to capture the significance to every word and detail that’s written. The only idea that could flow the reader’s mind is, â€Å"Where exactly is this story going?† and it is as though the writer understands this pondering and answers, â€Å"I would not spend one hour in the preparation of a book which had the ambition to perhaps titillate some readers. But I am spending many hours because the full story is the best way that I know to have seen, and understood, that I had sunk to the very bottom of the American white man’s society†¦Ã¢â‚¬  (153). While making sense and finally putting the wandering mind out of its misery; it grabs the reader and pushes it to move on throughout the book. If the author wanted to titillate, writing this realistic experience was the way to do so. Malcolm Little was born on May 19, 1925 and came from an underprivileged home. He was a self-taught man who received little schooling and rose to greatness on his own intelligence and determination. The early background of Malcolm X was a large factor responsible for the distinct different responses to American racism. During his childhood, he was raised in a harsh atmosphere consisting of fear and anger where the seeds of bitterness were planted resulting in his attitude effecting his decisions later in life. Malcolm X suffered not only from abuse by whites, but also from domestic violence. His father beat his mother and both of them abused their children. His mother was forced to raise 8 children during the depression. After his mother had a nervous breakdown his family was spilt up. The children were all placed in foster homes. The burning of his house by the Ku Klux Klan resulted in the murder of his father. Malcolm’s resentment was increased as he suffered through these hardships, and he was haunted by this early nightmare for most of his life. From then on, hatred and desire for revenge... Free Essays on Malcolm X On May 19, 1925 in Omaha, Nebraska, Louise Little gave birth to a son, Malcom. Both she and Malcom's father, a Baptist preacher named Earl, were members of Marcus Garvey's Universal Negro Improvement. Including Malcom, there were eight children in the Little family. When Malcolm was an infant, his family was forced to move to Lansing, Michigan after being driven from Omaha by the Ku Klux Klan. Once in Lansing, their house was burned down by a white hate group called the Black Legionnaires. Earl Little died when Malcolm was six years old. After his father died, Malcom's mother had a mental breakdown. With no one to care for them, all eight children were sent to foster homes. Malcolm dropped out of school after the 8th grade. Soon after, he became involved in hustling, drug dealing, and burglaries. This criminal lifestyle landed him in the penitentiary where he spent six years, from 1946 to 1952. During his prison term, Malcolm turned to religion for answers. When he was re leased he became a minister for the nation of Islam. He was the national spokesman for Elijah Muhammed. The Nation of Islam grew from several hundred members to hundreds of thousands of members under Malcolm's leadership. The organization built 40 temples in the and bought 30 radio stations nationwide. The Nation of Islam recruited members from ghetto poor communities, people from the prisons, hustlers, drug dealers, pimps, prostitutes, and thieves. These people were believed to be, â€Å"ethically impoverished by white racist neglect of their fundamental needs.† These fundamental needs were "self-respect, social dignity, to understand their royal black history, and to worship and serve a black god." The Nation of Islam also believed women were a â€Å"lethal source of deception and seduction from within.† The women had to wear a modest dress, they were under close supervision of men, and they were relegated to the background. In March of 1964 Malcolm left... Free Essays on Malcolm X Early Life On May 19, 1925 in Omaha, Nebraska, Malcolm Little was born to Reverend Earl and Louise Little. Rev. Little, who believed in self-determination and worked for the unity of black people. Malcolm was raised in a background of ethnic awareness and dignity, but violence was sparked by white racists trying to stop black people such as Rev. Little from preaching the black cause. The history of Malcolm's dedication to black people, like that of his father, may have been motivated by a long history of oppression of his family. As a young child, Malcolm, his parents, brothers, and sisters were shot at, burned out of their home, harassed, and threatened. This culminated in the murder of his father by white racists when Malcolm was six. Malcolm became a drop-out from school at the age of fifteen. Learning the ways of the streets, Malcolm became acquainted with hoodlums, thieves, dope peddlers, and pimps. Convicted of burglary at twenty, he remained in prison until the age of twenty-seven. During his prison stay he attempted to educate himself. In addition, during his period in prison he learned about and joined the Nation of Islam, studying the teachings of Elijah Muhammed fully. He was released, a changed man, in 1952. The Nation of Islam Upon his release, Malcolm went to Detroit, joined the daily activities of the sect, and was given instruction by Elijah Muhammad himself. Malcolm's personal commitment helped build the organization nation-wide, while making him an international figure. He was interviewed on major television programs and by magazines, and spoke across the country at various universities and other forums. His power was in his words, which so vividly described the plight of blacks and vehemently incriminated whites. When a white person referred to the fact that some Southern university had enrolled black freshmen without bay... Free Essays on Malcolm X Malcolm Little, also known as Malcolm X was born on May 19, 1925, in Omaha, Nebraska. His mother, Louise Little was born in Grenada, a city in the British West Indies. His father, Earl Little was a very dark skinned man from Reynolds, Georgia who married Louise just after the birth of young Malcolm. Earl Little was a Baptist minister and organizer for Marcus Garvey. Marcus Garvey wanted and believed that all African-Americans should go back to the â€Å"home land†, Africa. Earl’s teachings of Garvey’s movement caused the whole family to be terrorized by the Ku Klux Klan. To avoid any more harassment be the group, Earl Little moved his family to Lansing, Michigan. Earl’s dreams of getting away from the white racists didn’t come true. Michigan’s chapter of the group beat Earl Little brutally with a hammer and left him for dead on a railroad track. Alone with no money, Louise Little was left to provide for her children, but the task proved too difficult and she had a nervous breakdown. The white authorities sent her to a mental institution. The Little children were forced to separate. Malcolm Little lived with a number of deferent families. All of Malcolm’s family was separated and he attended school until eighth grade. He was the only colored person in his school. He achieved the highest grades in his class, but his peers still didn’t accept him because of his color. When his teacher stopped him from trying to become a lawyer because the job was accessible only for whites, Malcolm dropped out of school and went to his older half sister, Ella, who lived in Boston. There, he took a job as a shoeshine boy at the Roseland Ballroom. Malcolm was described as a hard worker, but he didn’t make a lot of money. A career as a hustler seemed a more tempting option. He saw the hustlers around and saw their clothes, women, and money. Soon Malcolm Little started selling drugs. He slipped into the role of a black hustler. He m... Free Essays on Malcolm X Malcolm X was born Malcolm Little on May 19, 1925 in Omaha, Nebraska. His mother Louis Norton Little was a homemaker taking care of the family's eight children. His father, Earl Little, was a Baptist minister and supporter of Black Nationalist leader Marcus Garvey. There Michigan home was burned to the ground, and two years later Earl's mutilated body was found lying across the town's trolley tracks. Police ruled both accidents, but the Little's knew that members of the Black Legion did it. Louise had a breakdown several years after the death of her husband and was committed to a mental institution. Her children were split up in foster homes and orphanages. Malcolm was a smart, focused student and graduated from junior high at the top of his class. However, when a favorite teacher told Malcolm his dream of becoming a lawyer was "no realistic goal for a nigger," Malcolm lost interest in school. He dropped out, spent some time in Boston, Massachusetts working diferent jobs, and then wnet to Harlem, New York where he caused troble. Eventually Malcolm and his buddy, Malcolm "Shorty" Jarvis, moved back to Boston, where they were arrested and convicted for burglary in 1946. Malcolm It was during this time that Malcolm's brother Reginald visited and discussed his converson to the Muslim religious organization the Nation of Islam. Then Malcolm studie the Islam leader Elijah Muhammad. Among other things, the Nation of Islam fought for a state of their own, separate from one where white people lived. By the time he was paroled in 1952, Malcolm was a devoted follower with the new surname "X." He considered "Little" a slave name and chose the "X" to signify his lost tribal name.... Free Essays on Malcolm X Humans are shaped through interactions and experiences with other individuals. What happened to us in the childhood directly forms our identity, character and morality. Malcolm Little, also known as Malcolm X experienced childhood full of hurdles. He had to face them only because of the dark color of his skin. One of those hurdles was the murder of his father, who as Baptist minister fought for improvement of life of black community. Wrongful death of a head of the family bestowed intensive psychological pressures and financial difficulties on Malcolm and his family. An unstable situation in the family forced very young Malcolm to steal, starve and to look desperately for food. Under these demoralizing circumstances at young age, he was pressured to violate the law to fulfill the very basic need for food. As soon as Malcolm's mother unfairly lost her job because of her skin color, welfare state people ate away family's pride and dignity. Their forced visits and conversations disintegrated the family by telling them lies against each other. Welfare people finally brought family to its knees and separated its members from each other. Thus Malcolm was forced to leave behind the closest people to his heart. That left him naked to racist acts, opinions and judgments of white individuals who underestimated his abilities and skills. Because of the absence of his parents, it became difficult for Malcolm to talk to someone about his problems. Things that he experienced in school changed his life substantially. It's known that a teacher can play special role in the life of every student. However, one teacher that young Malcolm seemed to trust discouraged and humiliated his talent despite excellent performance in school. Malcolm naturally expected his abilities to be reaffirmed by his teacher, but instead he was discouraged to pursue his dream. It's important to mention that Malcolm was never considered equal to any white student even though he...

The History of Human Resources Management Research Paper

The History of Human Resources Management - Research Paper Example Industrial relations and organizational behavior are much the same paving the way for HRM as the ideal management model responsive to the pressures of intensive competitive forces. By definition, HRM simply refers to a system of operational management designed to ensure effective and efficient use of human talents in accomplishing organizational objectives (Mathis & Jackson, 2007). The function of HRM in the business enterprise has a long history, with roots right in the rise of modern industry in the nineteenth century. This article endeavors to put into perspective the history and development of the subject matter at hand, providing in part its progressive nature into the modern status. The Genesis and Early Development of HRM A generic thought that involves the management of labor services in production, human resource management (HRM) has its origin in the establishment of formal enterprises during the course of human history. Though recent in its use within the academic circles and/or in industrial developments [barely two decades old], the ideas engendered in "human resource management" are old and goes back to the dawn of human history. It [human resource management] has, thus, only undergone social and economic makeovers from earlier forms of administration through history, necessitating name changes a couple of times to accommodate the various productivity optimization add-ons. HRM as practiced today has two distinct antecedents: the emergence of industrial welfare in the 1800s and the creation of separate recruitment and selection offices/departments in the 1900s. The 1800s, particularly in the 1830s onwards, quite a number of companies begun the provision of various workplace and family amenities that included medical cover, housing, libraries , recreational programs, among other free services deemed important for effective and efficient production (Gospel, 1992). The inclusion of these extra services, reportedly pioneered by the German industries, f requently called for the creation of temporary departments hitherto known as welfare departments out of humanitarian concerns. From temporary positions created out of necessity to handle immediate tasks regarding employees’ wellbeing, separate employment offices, often staffed by one or a limited number of lower-level clerks, emerged to centralize and standardize functions such as recruitments and the general record-keeping of employee-related issues. The enactment of civil service legislations across Europe solidified the importance of employment departments, contributing to phasing out of the temporary nature of these departments into permanent offices. Farnham (1921) report of a German steel company Krupp having had an established Personnelburo as an independent office handling staff related functions since the late 1800s. As similar bureaus became widespread, the term ‘employment management’ quickly became the accepted description of the new management functi on with wide cross border managerial support. Routing employment management to HRM as ordered today was the emergence of the doctrine of scientific management (SM) authored

Education Essay Example | Topics and Well Written Essays - 500 words - 11

Education - Essay Example Student activism is observed as the crucial force for social change especially in times of political turmoil (â€Å"Student Activism,† 2002). The history is replete with many examples such as China’s May Fourth Movement which happened in 1919 and the Youth Pledge in Indonesia which occurred in 1928. These events have shown the immense sympathy of the youth population toward their respective country. The May Fourth Movement in China had gathered more or less three thousand Chinese students in Tianasquare to protest against its government’s weak response to imperialism and feudalism (Tse-tung, as cited in â€Å"Selected Works,† 2004). On the other hand, the Youth Pledge in Indonesia had helped the Indonesian youths to voice out their concerns with regard to colonialism. The pledge actually provided that the youths of Indonesia will â€Å"build a new and independent nation which was later on achieved in 1945† (McTique, 2009). In other cases, student de monstrations â€Å"have toppled powerful dictatorship, military juntas† and even ended wars (â€Å"Student Activism,† 2002). Truly, student movements have the capacity to effect political change by gathering support from the rest of the community. It serves as the conscience of nations (â€Å"Student Activism,† 2002). Moreover, it reminds the people â€Å"of the founding ideals of their countries† and the aim for dignity, justice and equality in times of political turmoil (â€Å"Student Activism,† 2002). Nonetheless, despite the aforementioned historical accounts on the significance of student activists in a society, there are those who vehemently oppose it. One of which is the government. It is a contention that governments are generally against any activist movements especially those from the youth sector. This is plausible since a government must always protect and defend its honor before its constituents. It looks forward to prevent any f orm of

Discuss the role of multinationals in the globalisation of innovation Essay

Discuss the role of multinationals in the globalisation of innovation - Essay Example With such economic power, the dominance of multinationals as leaders in technological innovation and this can be seen by the fact that 98% of the expenditure on Research and Development (R&D) by the 700 top R&D spenders, is done by the multinationals (Castellani and Zanfei 2005); the magnitude of the statistics can be fully comprehended when we see that the R&D expenditure of few major multinationals is more than the expenditure of some countries. This paper will attempt to show the positive role multinationals have played in the globalization of innovation with more focus on the emerging economies. Section 1 of the paper will deal with how innovation activities take place in a multinational. Section 2 looks over the research conducted by Jasjit Singh in his paper ‘Multinational Firms and International Knowledge Diffusion: Evidence using Patent Citation Data†. ... a positive light, as companies that bring in much needed technology and technical support that allows the host country’s’ citizen to able to improve their standard of living. Section 4 of the paper deals how technological innovations have also caused a dramatic rise in international trade especially in sectors which have close link to technology. In the conclusion we sum up the arguments of how multinationals have caused innovations, moreover, many of these innovations are not just technological but also supply chain process. Section 1 Innovations carried out by Multinationals fall under the second category of global generation of innovation. Since these companies operate on such large scales they usually have their own internal innovative network units based in different host countries as well as the home country. One of the many reasons for this is that, it allows the company not only to effectively and efficiently provide innovative ideas to the subsidiary unit but a lso it allows the main unit to understand the practical application process of these strategies on the local market of the host country and impart the reason for success or failure of a subsidiary to the other units. The three main strategies many multinationals use to organize their internal innovative system as stated by Archibugi and Iammarino. Centre-for-global This strategy is more commonly known in the business world as the â€Å"octopus view† of the multinational organization. As the word octopus suggest. The head of the octopus symbolizes the headquarters of the company where the entire R&D takes place. It is also the place where the top management is located thus the entire strategic planning and ideas takes place here too. It distributes its technical expertise and plans to the subsidiary

Definition Of Critical Review

Definition Of Critical Review To Critique research articles mean careful and critical appraisal of strength and limitations of a piece of research, rather than hunting for and exposing mistake (Polit and Beck 2008). A research critique is not a summary of the article but find scope and limitation and balance of the validity and significance. Definition of critical review You need to put your heading in bold and separate to your paragraph :A critical review is an evaluation of an academic article or essay. It requested to make judgments, positive or negative, about the text using various criteria. It is an overall critical appraisal, which mainly focuses on the reliability, validity, strengths and weakness, rather than the faults or weakness of the research (New South Wales University, learning Centre date?). The review supposes to be objective, balance discussion and evaluation of the strengths and weakness. (New South Wales University, learning Centre date?). It is the summarization and evaluation of the ideas and information in an article. It expresses the writers point of view in the light of what you already know on the subject and what is acquired from related texts. Purpose of the essay- The aim of this assignment is to develop a solid understanding of the experiences of residents in nursing home care by critiquing a published qualitative health research. Say who wrote the article, give article title and details. It helps to find out participants belief about their own role and the role of nurses in controlling and managing their condition. Potential benefit from conducting critical review of article is increase share control with health care staff in residential care facilities as well as increase awareness in health care staff, employer and in public. In this article critical thinking frame work is based on critical review guideline for qualitative studies by Beck, C 2009, Critiquing Qualitative Research, Aorn Journal, vol. 90, no.4, pp. 543-545. This article reviewed due to its design and contribution to health care facility;? A bit unclear to read in addition it also increases nursing knowledge and provide awareness in society. Reason behind to use this frame is provides specific guideline and cover all most question of critique such as how to do critique on title, phenomenon, structure, research design analysis data, findings and other prospective of the article. Title: please give exact study details here -otherwise it is hard to read and mark. I presume from your references you are critiquing: Nakrem, S, Vinsnes, A. G, Seim, A, 2011. Residents experiences of interpersonal factors in nursing home care: A qualitative study, International Journal of Nursing Studies vol .48 no.11, pp. 1357-1366. Title of the study is well-described and self-explanatory. It describes residents experience of factors while living in a nursing home. The article title find out age of participants, their experiences of interpersonal relationship factors in nursing home care Title is already indicate it is a qualitative study and title match with context of article. The objective of study is clearly stated in article. Abstract: The abstract part: aim was finding out the experiences of the residents with direct nursing care in relation to interpersonal aspects of quality of care. Background stating as life expectancy rate is lengthening the number of those needing care in nursing home will also increase dramatically over the period of next 20 years (Huber et al., 2009) Quality of care across developed countries mainly focuses on patient safety, excellence in care and patient satisfaction (Nakrem et al., 2009) Method: phenomenological methodology had been used. Findings were divided into category and then sub categories. Conclusion quality of nursing care depends upon individual approach to medical, physical and psychosocial care, including interpersonal aspects of care. Researcher used a short sentence to cover all aspect of research, also describes well information of data analysis and result. Overall, the abstract clearly and concisely summarized. Introduction: Statement of problem; the problem statement is unequivocally and easily located in the first paragraph of the article. The researcher focus on how nursing home quality can be understands from resident point of view. The problem certainly has significance for nursing because the life expectancy and number of resident will increase in the next 20 years. The problem statement convinced clearly and having an ability to persuade because the study is a greater understanding of interpersonal factors which is very important for improving the quality of patient nurse relationship in nursing homes. This is a bit confusing to read This statement of a problem does build a cogent and persuasive argument for the new study as the consideration of interpersonal relationship factors and quality of nursing care could be difference from nurses and residents perspective. It has a great significance in nursing as people who were the owners of the house is now the residents of the nursing home. So they believe their integrity is at risk in nurse patient interaction and care. They feel more dependent and sometime helpless. So its very important to study those aspects and find out the drawbacks, so that they can be rectified and the residents feel safer, secure and live their life happily in nursing home. The match between the research problem and the qu alitative paradigm and tradition used in the study is good. The researcher used the phenomenological methods in order to explain the life experience of people in nursing home in regards to quality of care and their expectations. Research questions: In this article author did not clearly state the researcher question, the open ended questions were used and these research questions were further divided in to sub categories for more understanding of problems. Research questions are related with the study. Qualitative method of data collection fits the research question by using phenomenological theory, in residents with lived experience (Polit, Beck Hungler 2001, p.214). Literature review: The reporter adequately summarized research that had been conducted on the phenomenon of interpersonal aspects of nursing care. The author clearly stated the gaps in the knowledge, in previous study it was identified that to provide good quality of care and to understand interpersonal aspect of care is essential and residents are primary source to find out the interpersonal factor and outcomes of care, on other hand recent study provide better understanding of interpersonal factor by taking depth interviews of the residence in order to improve the relationship of the residents with their nurses and also in the improvement of the quality of nursing. Conceptual underpinnings: the researcher provided a conceptual definition of the key concept of interpersonal aspects of quality care. This helps the reader to understand what interpersonal aspects of nursing referred to, and it includes not only medical care but also physical and psychological care, to protect their integrity and to recognize their individuali psychosocial needs. Be careful of odd capitals in sentences. The researcher did not state philosophical basis of this study in introduction. the author didnt make any conceptual framework for this study, he just compare and contrast the content on one research theory to compare the content of the study but he did consider the ethical aspect of study, took approval from regional committee for medical and health research either for maintaining privacy and confidentiality of the information collected from the study. Methods:- Protecting the participants rights: Approval was obtained from regional committee for medical and health research. However, according to Minichiello et al (2004), the ethical components not just ethics committee and follow-up support but also the informed consent, keeping patients information confidently and the right of withdrew the study. Ethical issues related to the research include informed consent, the identity of the researcher, the purpose and nature of the study, the right to refuse and to participate and other such as responsibilities of researcher and possible study benefits, side effects, privacy, autonomy, confidentiality, anonymity etc. these all aspects were taken into consideration by regional committee of medical and health research ethics. For data collection, confidentiality and right to refuse and withdrawal and written consent in addition to oral consent was taken from residents. Leave a line between sections Research design and research tradition: Appropriate methods of data gathering and analysis for this study are based on in-depth interviews.This is a qualitative study and the author has used a descriptive and exploratory research design. A phenomenological method is used in which the idea is taken from of the individuals who have actually experienced the situation. (Taylor, Roberts. 2007, p. 336 incorrect in text reference- always leave author initial out of body of text) The researchers used the phenomenological study to describe the life experiences of people in nursing home in regards to quality of care and their expectations (Vivilaki Johnson 2008). An adequate time was spent with participants, each interview was lasted for one hour and author find that the long-term residents are individuals with individual background but they also have a shared meaning of experience living in nursing home, so by comparing and contrasting the interpretations of meanings to combine and put toge ther them in general account. Sample and setting: Participants were selected on based of condition and on the eligible criteria completed by the researchers. This is the plus point for the research (Rawlinson ?1999, p.859) Initially 24 participants between the ages of 45 to 100 years were chosen from four municipal public nursing homes in Norway. Sample is taken from small, medium and large public nursing homes in rural and urban areas. But only 15 participants chosen with 9 women, 75 92 years old and 6 men 80- 96 years old, gave interview, there was a well described site and recruitment of participants which shows that sample size was not adequate. The inclusion criteria was set on the basis that they were mentally sound residents in the nursing home for minimum of a month and longer and had physical and mental capacity to participate. Individuals those are selected to participate in qualitative research is based on their first-hand experience with a culture social or phenomenon of interest (this is not an author surname. You really need some tutoring from the Student Learning Centre to help you to write correct in text references et.al 2011,p-28) sample decision were made and the sample framed according to the purpose of the study, there is no hard and fast rule rules about numbers, Sample size was not adequate to make a general statement should take at least 50 or 60 sample to make a general statement. For qualitative study it could be 10 -100 but minimum 30 should be when looking for evidence or trying to achieve maximum variation (Tuckett 2004, p.2). Data collection: The data was collected by in-depth interviews with the residents. One researcher, to assist the residents an interview guide with open-ended questions, conducted all interviews and probes were used. Three experts reviewed it. A narrative approach was used to encourage the resident to freely speak about their experience. The interviewer repeated and summarised during the interviews to check whether it was correct. Procedure: The procedure used to collect and record data were adequately described and were appropriate for phenomenological study. Because resident tell their views to the researcher in interviews and bias were minimised. How ? The author did not discussed about staff training for data collection. Enhancement and rigor: The rigour in qualitative research is demonstrated through researchers, attention to and confirmation of information discovered. The goal of rigor in qualitative research is to accurately represent study participant experienced (p.41) different methods was used to enhance the trustworthiness of the data and analysis, to enhance rigour in data analysis the authors of the article were all involved in discussions about development of analytical concepts. Researcher documented researcher procedures and decision process sufficiently to confirm that the finding is suitable and confirmable, the author himself and two other interviewers coded interview separately and compared with the coding done by main author and discussed for abstraction in categories and subgroups in meeting. Data analysis: Data was analysed by recording and transcribed the data by verbally, the data analytical approach was consisted of coding with categorization, and Interviewer took notes and summarized them. Moreover, interviewer also listened the tape recording carefully and meaningful entities in the transcript were also identified and interviewees expressions were sorted into more specific categories and finally each category was synthesized by comparing and contrasting with the already existing theory and literature. An electronic tool was used for mind mapping as well. To enhancing the rigour of the study all authors were involved in discussion about the development of analytical concepts. The main author coded all interview and all study was discussed the abstractions into categories and subgroups by the authors.(Ryan Nichollas Will 2009). Good Findings: Finding from the qualitative studies may be a show constructive format of phenomena (Polit, Beck Hungler 2001, p.313). The findings of this research highlight and acknowledge the importance of nurses in general and specialized (holistic) care, prevention of complications and prioritizing the individual needs. Findings also expressed the quality of care according to residents point of view to optimize and fulfil their medical, physical and psychosocial needs whilst protecting their integrity, dignity and social status. Findings mainly regard quality of care by building up long-term relationship between nurses and residents to enhance psychosocial wellbeing. Findings were all expressed in the article under separate subheadings for easy review and understanding. Interpretation of the findings: Finding is interpreted within an appropriate frame. Author focused on finding related to interpersonal factor of direct nursing care. ?the finding interpreted and discussed within the context of previous studies. The author compares the study with the previous study. In previous study (author, date) it was identified that to provide good quality of care to the residents, to understand interpersonal aspect of care is essential and residents are primary source to find out the interpersonal factors and outcomes of care while recent study provides better understanding of interpersonal factors by taking depth interviews of the residents in order to improve the relationship of the residents with their nurses and also in the improvement of the quality of nursing care. Both studies focus on the interpersonal aspect of care so that nurses can provide better quality of care to residents because residents have long term relationship with nurses in nursing homes. And also author mention about li mitation of this study nurse as representative of the health care took interview from the residents might be reluctant to criticize the nursing home quality and author did not put many efforts to understand cultural of the interviewees. Author did not address the issue of transferability of the finding due to small sample consisting of mentally lucid residents from four nursing homes. Implication and recommendation: Presentation: The report was well written, flowed logically, and was written in enough detail for critical analysis .the description of finding was rich and powerful. Researcher credibility: The researcher qualification enhanced confidence in the finding. Researcher was member of Norway College of Nursing facility. Summary assessment: The study result appears trustworthy. Trustworthiness is at the heart of a qualitative research critique (Beck 2009) This study provide some evidence that can be used in nursing practice in help in improving interpersonal relationship and quality of care in nursing homes. Appear to be trustworthy but author could take more sample/ participants in this study to make finding more general.? does this apply to qualitative work? Conclusion: This is critiquing and qualitative study about a quality of nursing care in nursing home .This qualitative study is to understand the real needs of the residents and how these needs can be fulfilled by the nurses. Nurses are required to understand the individual needs of the patient through their knowledge and skills in order to provide the holistic care to the residents. Nurses need to maintain the residents autonomy and dignity in order to improve the quality of nursing care. Overall, this was a good qualitative article. The researcher used a qualitative research design to explore the experience of residents those who live in the nursing home and providing the evidence for the practice for the healthcare to fulfill the individual needs through interpersonal relationship. The strength of this article would be great purpose, right methodology, and strong rigor. As mentioned previously, strong rigor was the most important part of qualitative study. However, study sample ta ken was small and the interview was taken by one of the nurse of the nursing may be this affect the views of the resident (Galvin et.al 2005, p-92). References: Beck, C 2009, Critiquing Qualitative Research, Aorn Journal, vol. 90, no.4, pp. 543-545. Leave a line between each one, no need to number them Galvin, Cathy, Roiste first name? and Aine first name?2005, Living in care: older person experience of nursing homes, Irish Journal of applied social studies, vol. 6, issue.1. Hilarie, Surrena 2011, Qualitative research in nursing,5th edn, China Minichiello, V Sullivan, G Greenwood, K and Axford, R 2004, Handbook of research methods for nursing and health science, 2nd Pearson Education Australia, Australia. Nakrem, S, Vinsnes, A. G, Seim, A, 2011. Residents experiences of interpersonal factors in nursing home care: A qualitative study, International Journal of Nursing Studies vol .48 no.11, pp. 1357-1366. New South Wales University Learning Centre n.d., Writing a Critical Review, viewed 21 Oct 2011 Polit, D.F Beck, C.T, 2008, Nursing research : generating and assessing evidence for nursing practice, 8thedn, pp.105-138, Lippincott Williams and Wilkins, Philadelphia, USA. Polit, DF, Beck, CT Hungler, BP 2001, Essential of nursing research methods, appraisal, and utilization, 5th edn, Lippincott Williams and Wilkins, Philadelphia, USA. Ryan-Nicholls, KD Will, CI 2009, Rigour in qualitative research: mechanisms for control, Nurse Researcher, vol. 16, no. 3, viewed 9 September 2012, (online Bell Howell/ProQuest). Taylor, B Roberts, K 2007, Research in nursing and health care: evidence for practice, 3rd edn, Thomson, South Melbourne. Thomas, Sp Pollio, HR 2002, Listening to patients: a phenomenological approach to nursing research and practice, Springer, New York. Tuckett, A, 2009,Qualitative research sampling -The very real complexties nursing research,vol.12, no.1,P.2. Vivilaki, V Johnson, M 2008, Research philosophy and Socrates: rediscovering the birth of phenomenology, Nurse Researcher, vol. 16, no. 1, viewed 9 September 2012, (online Bell Howell/ProQuest). Appendix A Critiquing Qualitative Research put author details here also Basic Questions for Critiquing Title Introduction in Qualitative Reports Title Was the title a good one, suggesting the key phenomenon and the group or community under study? Introduction Statement of the problem Is the problem stated unambiguously and is it easy to identify? Does the problem statement build a cogent and persuasive argument for the new study? Does the problem have significance for nursing? Is there a good match between the research problem on the one hand and the paradigm, tradition, and methods on the other? Research questions Are research questions explicitly stated? If not, is their absence justified? Are the questions consistent with the studys philosophical basis, underlying tradition, conceptual framework, or ideological orientation? Literature review Does the report adequately summarize the existing body of knowledge related to the problem or phenomenon of interest? Does the literature review provide a solid basis for the new study? Conceptual underpinnings Are key concepts adequately defined conceptually? Is the philosophical basis, underlying tradition, conceptual framework, or ideological orientation made explicit and is it appropriate for the problem? Basic Questions for Critiquing Results in Qualitative Reports Results Data analysis Were the data management (e.g., coding) and data analysis methods sufficiently described? Was the data analysis strategy compatible with the research tradition and with the nature and type of data gathered? Did the analysis yield an appropriate product (e.g., a theory, taxonomy, thematic pattern, etc.)? Did the analytic procedures suggest the possibility of biases? Findings Were the findings effectively summarized, with good use of excerpts and supporting arguments? Do the temes adequately capture the meaning of the data? Does it appear that the research satisfactorily conceptualized the themes or patterns in the data? Did the analysis yield an insightful, provocative, and meaningful picture of the phenomenon under investigation? Theoretical integration Are the themes or patterns logically connected to each other to form a convincing and integrated whole? Were the figures, maps, or models used effectively to summarize conceptualizations? If a conceptual framework or ideological orientation guided the study, are the themes or patterns linked to it in a cogent manner? Basic Questions for Critiquing Discussion in Qualitative Reports Discussion Interpretation of the findings Are the findings interpreted within an appropriate frame of reference? Are major findings interpreted and discussed within the context of prior studies? Are the interpretations consistent with the studys limitations? Does the report address the issue of the transferability of the findings? Implications and recommendations Do the researchers discuss the implications of the study for clinical practice or further inquiry, and are those implications reasonable and complete? Basic Questions for Critiquing Methods in Qualitative Reports Methods Protection of participants rights Were appropriate procedures used to safeguard the rights of study participants? Was the study subject to external review? Was the study designed to minimize risks and maximize benefits to participants? Research design and research tradition Is the identified research tradition (if any) congruent with the methods used to collect and analyze data? Was an adequate amount of time spent in the field or with study participants? Did the design unfold in the field, giving researchers opportunities to capitalize on early understandings? Was there evidence of reflexivity in the design? Was there an adequate number of contacts with study participants? Sample and setting Was the group or population of interest adequately described? Were the setting and sample described in sufficient detail? Was the approach used to gain access to the site or to recruit participants appropriate? Was the best possible method of sampling used to enhance information richness and address the needs of the study? Was the sample size adequate? Was saturation achieved? Data collection Were the methods of gathering data appropriate? Were data gathered through two or more methods to achieve triangulation? Did the researcher ask the right questions or make the right observations, and were they recorded in an appropriate fashion? Was a sufficient amount of data gathered? Was the data of sufficient depth and richness? Procedures Were data collection and recording procedures adequately described and do they appear appropriate? Was data collected in a manner that minimized bias or behavioral distortions? Were the staff who collected data appropriately trained? Enhancement of rigor Were methods used to enhance the trustworthiness of the data (and analysis), and was the description of those methods adequate? Were the methods used to enhance credibility appropriate and sufficient? Did the researcher document research procedures and decision processes sufficiently that findings are auditable and confirmable? Basic Questions for Critiquing Global Issues in Qualitative Reports Global Issues Presentation Was the report well written, well organized, and sufficiently detailed for critical analysis? Were the descriptions of the methods, findings, and interpretations sufficiently rich and vivid? Researcher(s) credibility Do the researchers clinical, substantive, or methodological qualifications and experience enhance confidence in the findings and their interpretation? Summary assessment Do the study findings appear to be trustworthy and do you have confidence in the truth value of the results? Does the study contribute any meaningful evidence that can be used in nursing practice or that is useful to the nursing discipline? Please add rubric FU logo L mono Faculty of Health Sciences School of Nursing Midwifery NURS2107/NURS2107A Evidence for Health Care Practice 2 Content marking guide for assignment 3 Introduction (20%) Grade HD D C P F Purpose of essay clearly stated (2.5%) x No stated purpose A critical review explained/defined (2.5%) x No explanation/definition Potential benefits of conducting critical reviews clearly explained (5%) x Potential benefits of conducting critical reviews not stated Article to be reviewed introduced and context set (2.5%) x No introduction of article to be reviewed or context set Critical thinking framework(s) clearly outlined and rationale for using them explained (5%) x No explanation of critical thinking framework(s) Structure/headings of essay clearly stated (2.5%) x Structure/headings of essay not clear Critical review: quantitative study (40%) Grade HD D C P F Critique of title, authors and journal (2.5%) No critique of title, authors and journal Critique of abstract (2.5%) No critique of abstract Critique of introduction/literature review /background (10%) No critique of literature review Critique of research design/methodology/methods (10%) No critique of research design/methodology/methods Critique of validity and reliability (2.5%) No critique of validity and reliability Critique of ethical issues (2.5%) No critique of ethical issues Critique of findings (5%) No critique of findings Critique of discussion, conclusions, implications, limitations and recommendations (5%) No critique of discussion, conclusions, implications, limitations and recommendations Conclusions: quantitative study (10%) Grade HD D C P F Effective and succinct summary of main findings of critical review (5%) No summary of main findings of critique process Established significance of studys findings relating to evidence-based practice (5%) Significance of studys findings relating to evidence-based practice not stated Critical review: qualitative study (40%) Grade HD D C P F Critique of title, authors and journal (2.5%) x No critique of title, authors and journal Critique of abstract (2.5%) x No critique of abstract Critique of introduction/literature review /background (10%) x No critique of literature review Critique of research design/methodology/methods (10%) x No critique of research design/methodology/methods Critique of study rigour (2.5%) x No critique of validity and reliability or rigour Critique of ethical issues (2.5%) x No critique of ethical issues Critique of findings (5%) x No critique of findings Critique of discussion, conclusions, implications, limitations and recommendations (5%) x No critique of discussion, conclusions, implications, limitations and recommendations Conclusions: qualitative study (10%) Effective and succinct summary of main findings of critical review (5%) x No summary of main findings of the critique process Establishing significance of studys findings relating to evidence-based practice (5%) x Significance of study

The Last Samurai :: essays research papers

My Place of Refuge For a number of people visiting places of significance can be the channel for changing one’s point of view on life, recharging one’s emotional battery, or growing closer to one’s family and friends. These favorite places could have characteristics such as captivating beauty, sentimental value or a refuge of serenity. My favorite place where I find refuge is at Pomme De Terre Lake near Bolivar, Missouri. This is where I find a connection with my family and friends. The lake is a place to reflect on times spent growing up and now a place to make new memories with my family and friends. A place to find refuge from normal day-to-day life and take in the beauty of such a splendid area that God created. 1.  Ã‚  Ã‚  Ã‚  Ã‚  The smells surround me in an irresistible craving for the lake. A. The smell of the dew in the morning B. Smells of the campfires C. Waking up by the aroma of the bacon frying. 2. As I think of the aroma of the bacon frying it brings my to the sensational tastes created at the lake. A. The flavor of the bacon in your mouth. B. I take delight in the taste of the smoked turkey on July 4. C. The taste of a cold beer while spending a hot day on the lake or enjoying a late night game of cards. 3. The magnificent sights created at the lake. A. Blazing orange and red colors created by the flames of the campfire. B. The marvelous scene of an evening sunset. C. The view of our family enjoying time together at the lake. 4.  Ã‚  Ã‚  Ã‚  Ã‚   The sounds of the lake create a refuge from the normal day-to-day life. A.  Ã‚  Ã‚  Ã‚  Ã‚  The voices of my family talking and laughing B.  Ã‚  Ã‚  Ã‚  Ã‚   The roaring of the engines of the boats racing up and down the water. C.  Ã‚  Ã‚  Ã‚  Ã‚   While laying in the tent taking in the peaceful sounds of the night 5.  Ã‚  Ã‚  Ã‚  Ã‚   The lake makes me feel such an enjoyment. A. The feel of the salmon ski under my feet B. The control I feel while in the driver’s seat of the boat C. The feel of the dew under my feet People need to find a place that can cause a renewing to their body and their inner self. People need time to create significant memories with their family and friends. They need a place to reflect back on the beauty of our magnificent world that God created. We all need to find a way to recharge our emotional battery and grow closer to the ones we love.

Review of the Efficacy of the Picture Exchange Communication

J Autism Dev Disord (2009) 39:1471–1486 DOI 10. 1007/s10803-009-0763-y ORIGINAL PAPER A Review of the Ef? cacy of the Picture Exchange Communication System Intervention Deborah Preston ? Mark Carter Published online: 3 June 2009 O Springer Science+Business Media, LLC 2009 Abstract The Picture Exchange Communication System (PECS) is a communication program that has become widely used, especially with children with autism. This paper reports the results of a review of the empirical literature on PECS. A descriptive review is provided of the 27 studies identi? d, which included randomized controlled trials (RCTs), other group designs and single subject studies. For 10 appropriate single subject designs the percentage of nonoverlapping data (PND) and percentage exceeding median (PEM) metrics were examined. While there are few RCTs, on balance, available research provides preliminary evidence that PECS is readily learned by most participants and provides a means of communication fo r individuals with little or no functional speech. Very limited data suggest some positive effect on both socialcommunicative and challenging behaviors, while effects on speech development remain unclear.Directions for future research are discussed including the priority need for further well-conducted RCTs. Keywords Picture exchange communication system A Augmentative and alternative communication A Autism Introduction Serious de? cits in communication form part of the primary diagnostic criteria for autism (American Psychiatric Association 2000). It has been estimated that around D. Preston A M. Carter (&) Macquarie University Special Education Centre, Macquarie University, Sydney, NSW 2109, Australia e-mail: mark. [email  protected] edu. au one-third to one-half of children and adults with autism do not have unctional speech (Mirenda 2003). Such individuals may show only pre-intentional communication, such as reaching for a desired item, or communication may demonstrate intent through behaviors such as alternating eye gaze, and conventional gestures such as pointing (Yoder et al. 2001). Communication may also take the form of challenging behaviors (Mirenda 1997). When speech does develop it may be limited mainly to unusual or echolalic verbalizations (Paul 2005). Individuals with serious developmental disabilities other than autism may also fail to develop speech and language skills (Westling and Fox 2004).In order to help develop communication skills, various forms of augmentative and alternative communication (AAC) have been developed. These include the use of manual signs (e. g. , Layton 1988; Yoder and Layton 1988), voice output communication devices (VOCAs) (reviewed by Lancioni et al. 2001), and various picture-based systems (Keen et al. 2001; Sigafoos et al. 1996). The Picture Exchange Communication System (PECS) is a picturebased system developed by Bondy and Frost (1993, 1994) to help young children with autism acquire functional communication sk ills. PECS appears promising for several reasons.First, it avoids dif? culties inherent in other systems by requiring very few prerequisites; in fact the only prerequisite is that the individual can clearly indicate (e. g. , by reaching for an item) what he or she wants, in a way that can be shaped into exchanging a physical symbol such as a picture (Bondy and Frost 2002). Other skills such as eye contact, motor or verbal imitation skills, the ability to sit quietly in a chair, match-to-sample skills, picture discrimination, or the ability to follow verbal prompts are not necessary (Bondy and Frost 1994, 2002), at least at the earliest program stage. 23 1472 J Autism Dev Disord (2009) 39:1471–1486 Second, the ? rst skill taught in PECS is requesting. Requesting has often been targeted in early instruction of individuals with developmental disabilities due to motivational considerations (Reichle and Sigafoos 1991). In relation to PECS, it is argued that individuals with autism in particular are less likely to be motivated by the social consequences of labeling or commenting (Bondy and Frost 1995) and more likely to be motivated by requesting and immediately obtaining a speci? c, typically concrete, desired item (Bondy and Frost 1994).Third, PECS systematically addresses the issue of spontaneity, which has often been reported as problematic in individuals with autism spectrum disorders (ASD) (Chiang and Carter 2008; Koegel 2000). Rather than being dependent on a partner to establish a communicative exchange, or requiring a partner to watch for the learner to point to a picture board or generate a manual sign, which could easily be missed, PECS speci? cally teaches the individual to approach the partner and gain their attention by putting a picture symbol into their hand.Fourth, picture symbols can be highly iconic, closely resembling their referents (Ganz and Simpson 2004; Mirenda 2003). Consequently, they may be easily recognized by the learner (Ganz and Simpson 2004) and are more recognizable by communicative partners than some other systems, such as manual signs (Lancioni et al. 2007). The PECS protocol begins with a reinforcer assessment through which the trainer determines an ordered list of reinforcers for the individual (Bondy and Frost 1998). This is followed by six phases, which are brie? overviewed in Table 1. For each phase, the criterion for successful completion is 80% or more trials successful without prompting in a 10-trial block (Charlop-Christy and Jones 2006). The randomized control trial (RCT) is recognized as providing the gold standard for evaluating clinical interventions in areas such as medicine and education (Evidence-Based Medicine Working Group 1992; What Works Clearinghouse 2006) and ideally evaluations would be limited to such evidence (Carter and Wheldall 2008).Such designs, however, are relatively rare in educationrelated areas (Carter and Wheldall 2008) for a variety of reasons and clinicians must oft en look to a second line of evidence to inform decision-making. Single subject quasiexperimental designs employ repeated measures of the dependent variable over time with a single or small number of participants. Although not offering the standard of evidence of RCTs, the best of these designs are considered capable of effectively controlling major threats to internal validity and strong conclusions about causal inference can be drawn (Campbell and Stanley 1963; Horner et al. 005). Similarly, high quality quasi-experimental group designs, speci? cally those involving non-equivalent groups with pre-test matching, are generally considered to be interpretable (Flay et al. 2004). The weakest level of evidence is provided by pre-experimental designs, such as single group pre-test—post-test studies, where few threats to internal validity are controlled and causal inference cannot be inferred with any degree of con? dence (Campbell and Stanley 1963). Early papers on PECS were largel y descriptive with limited data (e. . , Bondy and Frost 1993, 1994, 1995, 1998), or presented outcome data without control (e. g. , Schwartz et al. 1998). In recent years, however, a number of interpretable group studies (e. g. , Yoder and Stone 2006b) and single subject studies (e. g. , Charlop-Christy et al. 2002; Tincani 2004) have been published. Lancioni et al. (2007) reviewed the use of PECS and VOCA (voice output communication aids) for request making in individuals with developmental disabilities. In addition to studies following the PECS protocols of Frost and BondyTable 1 Summary PECS stages Phase Teaching target I II Make requests through picture exchange Persistence in initiating communication Discrimination between symbols Introduction of sentence structure Answering question with a request Commenting Description Second person acts as a prompter from behind learner; when learner reaches for the desired item, physically prompts to exchange picture; prompts faded as quick ly as possible Communicative partner moves gradually further away; picture is also gradually moved further away; number of communicative partners increased; ‘‘Communication book’’ is introduced; range of items requested is increased, but only one picture and item is available at a time Initially, two pictures are presented (highly preferred and neutral or disliked); more pictures are added; later, more than one preferred item is offered at a time; periodic correspondence checks are carried out to check accuracy at discrimination Taught to use a sentence strip, placing an ‘‘I want’’ as well as the symbol; requests can also be expanded with attributes such as color or size, e. g. ‘‘I want red playdough’’ Taught to answer question ‘‘What do you want? ’’ Taught to respond to other simple questions such as ‘‘What do you see? ’’; gradually, more spontaneous com menting is developed III IV V VI 123 J Autism Dev Disord (2009) 39:1471–1486 1473 (1994, 2002), they also included studies employing ‘‘any conventional use of pictorial material as a way of making requests for preferred items’’ (p. 4).Thus, studies that did not follow PECS protocols, and in which the participants pointed to a picture rather than actually exchanging it, were included (e. g. , Dyches et al. 2002; Keen et al. 2001). In addition, no attempt was made to quantify the data obtained from the studies to evaluate either the overall ef? cacy or effectiveness of the approach or the effect of relevant variables on outcomes. To date, no comprehensive review of empirical literature speci? cally examining the PECS approach of Frost and Bondy (1994, 2002) appears to have been published. The present paper looks speci? cally at studies of PECS intervention as described by Frost and Bondy (1994, 2002).In the absence of a substantial number of gold-stand ard RCT studies that would allow a conventional meta-analysis, a broader approach to evaluation of the research was undertaken. This review is intended to examine the extant empirical research on PECS, with speci? c consideration of the research designs employed and, consequently, the strength of conclusions that can be drawn. excluded (e. g. , Son et al. 2006). One article in which previously taught communication using the PECS program was compared to facilitated communication (Simon et al. 1996) was excluded because there was no PECS intervention during the study. The study of Rosales and Rehfeldt (2007), in which the ? rst three phases of PECS was taught prior to the experiment, was lso excluded because no data on the results of the PECS training was provided. Analysis A summary of each study was prepared including participants, research design, treatment and duration of study, outcomes investigated, setting, PECS version and phases implemented, and a summary of the outcomes, as well as inter-observer and procedural reliability, social validity, maintenance and generalization data. Ages of participants were coded into 5, 5–8, 9–17, or over 18 years. Four categories of dependent variable were identi? ed: PECS exchanges (number or percentage of independent exchanges), speech or vocalization, social-communicative behaviors, and undesirable behaviors.As the majority of studies employed single subject designs, they were coded for quality using an adaptation of the guidelines for single subject research presented by Horner et al. (2005). These indicators addressed several areas: adequacy of participant and setting descriptions; dependent variables; independent variables; baseline; experimental control/internal validity; external validity; and social validity. A total of 10 points were allocated to each area with the exception of external validity, which was allocated 5 points in recognition of the inherent limitations of single subject designs in th is regard. Thus, studies were rated on a scale from 0 to 65, with higher scores indicating greater quality.Details of the criteria are included in the Appendix. Traditionally, single subject studies have been interpreted by visual inspection of graphed data (Reynhout and Carter 2006). More recently, attempts have been made to quantify results of these studies objectively, and to provide reliable data summaries for evaluating evidence-based interventions (Parker et al. 2007). The most commonly used of the resulting statistical indices is the percentage of non-overlapping data (PND) (Scruggs et al. 1987). The PND is the percentage of treatment data points that are above (or below when behavior decrease is targeted) the highest (or lowest) baseline data point.Scruggs and Mastropieri (1998) provided guidelines for the interpretation of PND: scores between 91 and 100 indicate highly effective interventions, between 71 and 90 effective interventions, between 51 and 70 questionable interve ntions, and 50 or below ineffective interventions. Whilst PND has been criticized on a number of grounds (e. g. , Allison and Method Search Strategy Empirical studies using PECS were identi? ed through computerized searches of A? Education, British Education Index, ERIC, Expanded Academic ASAP, Linguistic and Language Behavior Abstracts, PsycINFO, PubMed and ScienceDirect, using the descriptors ‘‘PECS’’ or ‘‘Picture Exchange Communication System’’. In addition, manual searches of the reference lists of articles identi? ed were carried out to locate further studies.Studies were included if they: (1) (2) were journal articles in English from 1992 to July 2007; used PECS (Bondy and Frost 1994; Frost and Bondy 1994, 2002) as whole or part of an intervention strategy as indicated by reference to program documentation and description of implementation; presented group or individual data on the results of the intervention. (3) Articles th at referred to PECS but did not follow Frost and Bondy’s protocol were excluded. For example, Dooley et al. (2001) used a ‘‘PECS-based schedule board’’ (p. 58) but no actual picture exchange. In addition, articles that used a picture exchange system but did not speci? cally stated that the PECS protocols (Bondy and Frost 1994; Frost and Bondy 1994, 2002) were employed were 123 1474 J Autism Dev Disord (2009) 39:1471–1486 Gorman 1993; Salzberg et al. 1987; White 1987), it is nevertheless the most widely used statistic for quantifying data from single subject studies (e. g. Bellini and Akullian 2007; Erion 2006; Lee et al. 2007; Reynhout and Carter 2006; Xin et al. 2005). A particular disadvantage of PND is that if any baseline data point has reached the ceiling or ? oor level of the measurement scale, the calculated PND is 0%, even if visual inspection indicates a treatment effect (Ma 2006). Ma (2006) has suggested an alternative, the percentag e of data points exceeding the median (PEM). The PEM is the percentage of treatment data points that are above (or below when behavior decrease is targeted) the median baseline data point. There is also evidence that PEM may correlate better with author judgments of program ef? cacy than PND (Ma 2006).Nevertheless, PND is by far the most widely used metric for summarizing single subject studies and comparative data are available on a range of interventions. The application of the PEM statistic is very limited to date but, given its potential advantages, it was decided to calculate both PEM and PND values in the current review. It has also been argued that con? dence in ? ndings from analysis of single subject studies may be strengthened if multiple approaches to synthesis converge on similar conclusions (Smoot et al. 1990). PND and PEM statistics were calculated for all single subject studies with graphed data including a baseline and intervention phase. Changing conditions (i. e. , PECS phase changes), were coded as part of the ‘‘intervention’’ phase.Metrics were initially calculated for treatment data only and then for all intervention data, including treatment, maintenance and generalization phases. The PND statistic was calculated for each study using the pooled number of non-overlapping data points across all subjects and categories of dependent variable (PECS exchanges, speech/ vocalization, social-communicative behaviors, undesirable behaviors). In addition, a PND statistic was calculated for each participant and for each category of dependent variable within relevant studies. Similarly, PEM statistics were calculated using the pooled number of data points exceeding, or below when appropriate, (i. e. , for undesirable behavior) the baseline median.In cases where the exact value of data points on a graph was dif? cult to determine, a copy of the graph was obtained from a Portable Document Format copy of the article or a good qua lity digital scan. Subsequently, numeric data were extracted using the Digitizelt (Bormann 2003) computer software. Inter-Rater Reliability PND and PEM values were independently calculated by the ? rst and second authors for ? ve randomly selected single subject studies (50% of studies for which calculation was possible). Values were calculated for each graph that included a baseline and time-series data. Where more than one panel was shown on the same graph (e. g. multiple baseline, alternating treatments), a value was calculated for each panel. For each panel, reliability was calculated by dividing the lower percentage value by the higher percentage value and multiplying by 100 (i. e. , if both raters agreed on the percentage value, the reliability was 100%). The same ? ve studies were independently rated for quality indicators by the ? rst and second authors. Inter-rater reliability was calculated by dividing the number of agreements by the total of agreements and disagreements, and multiplying by 100. Inter-rater reliability for both PND and PEM was 100% for 54 panels and over 90% for the remaining three panels with an overall mean agreement of 99. 8%.There were discrepancies in only three graphs; the majority of these related to determining how many data points were present in very small ? gures. Inter-rater reliability for quality indicators was 97. 5%. Results A summary of the participants, research design, inclusion of maintenance or generalization data, PECS phases taught, and outcomes examined is presented in Table 2. Research Design The early studies (Bondy and Frost 1993, 1994, 1998; Schwartz et al. 1998) were all reports or program evaluation data without adequate experimental control, as were two later studies (Liddle 2001; Webb 2000). Malandraki and Okalidou (2007) used a case study.Magiati and Howlin (2003), in their pilot study, used a pre-PECS treatment measure plus three measures over time, with data mainly from teacher ratings. All of these studies can be considered pre-experimental. Of the 14 single subject studies, 4 used alternating treatments. Adkins and Axelrod (2001), Chambers and Rehfeldt (2003) and Tincani (2004) compared PECS and manual signing, while Bock et al. (2005) compared PECS and VOCA (voice output communication aid). Four studies (Charlop-Christy et al. 2002; Rehfeldt and Root 2005; Tincani et al. 2006, Study 1; Yokoyama et al. 2006) used a multiple baseline across participants, while two (Frea et al. 2001; Kravits et al. 2002) used a multiple baseline across settings, one (Marckel et al. 006) used a multiple baseline across descriptors taught, and one (Cummings and Williams 2000) used a multiple baseline across activities. Two studies (Stoner et al. 2006; Tincani et al. 2006, Study 2) used an ABAB design, while one (Ganz and Simpson 123 Table 2 Summary of Studies Ages Dependent variable Research design Maintenance (M) PECS or generalization (G) Phases data I–III I–III I–III Iâ⠂¬â€œIV I–III I–III I–III I–VI III Picture exchange, sign Picture exchange, VOCA Picture exchange Picture exchange, speech Picture exchange, speech Speech Social/communicative Picture exchange, sign language Speech, social, behavior (variation) Authors Participants DiagnosisAdkins and Axelrod (2001) – 35 Autism Autism Autism Autism Autism 1 ‘‘autistic characteristics’’ Autism 2 autism, 3 PDD 3–5 years Single-subject (multiple baseline) – 3–12 years Single-subject (multiple baseline) M,G 19–40 years Single-subject (alternating treatment) G 3–7 years 3–7 years Non-equivalent control group Non-equivalent control group – G 32 months Program evaluation – 6 years Program evaluation – 6 years– adult Program evaluation – 4 years Single-subject (alternating treatment) G 1 PDD 7 years Single-subject (alternating treatment) G Bock et al. (2005) 6 Bondy and F rost (1993) 74 Bondy and Frost (1994) 85 Bondy and Frost (1998) 1 J Autism Dev Disord (2009) 39:1471–1486 Carr and Felce (2007a) Carr and Felce (2007b) 10 41 Chambers and Rehfeldt (2003) 4 Charlop-Christy et al. (2002) 3Cummings and Williams (2000) Autism Autism Autism Autism 14 ASD Autism or ASD Autism Autism – 16 autism/PDD-NOS – 3–6 years 22–31 years 20–34 years 4–5 years 10 years Case study Single-subject (multiple baseline) Single-subject (multiple probe) Program evaluation Single-subject (ABAB) Single-subject (alternating treatment) 9–11 years Single-subject (multiple baseline, ABAB) 5–12 years Single group School Program evaluation 6 years Single-subject (multiple baseline) 3–7 years 4–11 years Single-subject (changing criterion RCT G M – – G M G – G G G G 4 years Single-subject (multiple baseline) – 5 Picture exchange, other I–III I–IV I–VI I–I II I–VI I–VI I–VI Extension I–III I–IV I–IV I–III I–IV Picture exchange, behavior Picture exchange, speech Picture exchange, speech, ADOS-G Picture exchange, speech, social Picture exchange Picture exchange, speech, other Picture exchange Picture exchange (improvised requests) Picture exchange, other Picture exchange, speech, other Picture exchange Picture exchange Picture exchange, sign, speech PECS, speech 1475 Frea et al. (2001) 1 Ganz and Simpson (2004) Howlin et al. (2007) 3 84 Kravits et al. (2002) 1 Liddle (2001) 21 Magiati and Howlin (2003) 34Malandraki and Okalidou (2007) 1 Marckel et al. (2006) 2 Rehfeldt and Root (2005) 3 Schwartz et al. (1998) 31 Stoner et al. (2006) 5 Tincani (2004) Autism 2 1 autism, 1 PDD-NOS 5–6 years 123 Tincani et al. (2006) 3 1476 J Autism Dev Disord (2009) 39:1471–1486 Maintenance (M) or generalization (G) data M,G 2004) used a within subjects changing criterion design. In seve ral studies, a changing criterion was included, re? ecting the PECS phase changes but it was secondary to the main design (Bock et al. 2005; Chambers and Rehfeldt 2003; Cummings and Williams 2000; Rehfeldt and Root 2005; Stoner et al. 2006; Tincani 2004; Tincani et al. 2006; Yokoyama et al. 2006).Comparative group designs were employed in ? ve papers. Yoder and Stone (2006a, b) used random assignment to PECS or Responsive Education and Prelinguistic Milieu Teaching (RPMT) intervention groups, while Howlin et al. (2007) used random assignment of classes to immediate treatment, delayed treatment or no treatment with PECS groups. Carr and Felce (2007a, b) used a quasiexperimental group design whereby PECS intervention and control groups were chosen by geographical location, and included both within subjects and between group measures. Pre-test equivalence of the groups was established. Participants Picture exchange, speech PECS Phases I–VI I–VI G I–VI G –Sin gle-subject (multiple baseline)) I–IV Picture exchange, speech Dependent variable Speech Social In total, there were 456 participants in the 27 studies; of these, 394 (86%) received PECS intervention and 62 (14%) were in non- or alternative-intervention groups. Of the total, 377 (83%) were described as having ASD. Ages of participants ranged from 20 months to 40 years and there were 198 males (43%) and 38 (8%) females with the gender of 220 (48%) of participants unstated. Where the same or a subgroup of participants were reported in multiple studies (Carr and Felce 2007a, b; Yoder and Stone 2006a, b), they were counted only once. The group experimental (Howlin et al. 007; Yoder and Stone 2006a, b) or quasi-experimental (Carr and Felce 2007a, b) studies involved a total of 161 participants (35% of the total sample): 98 in PECS intervention groups and 92 in control or other treatment groups. The Delayed Treatment Group in the Howlin et al. (2007) study was used as both control and intervention at different times. All these children were described as having autism or PDD-NOS and little or no speech. They ranged in age from 20 months to 11 years at study commencement. These studies all provided information on the initial abilities of the participants based on standardized tests. The single subject studies involved a total of 42 participants (9% of the total sample) and all provided information on diagnosis, age and gender.Only a minority provided information on the diagnostic instrument or protocol used to identify ASD (Ganz and Simpson 2004; Marckel et al. 2006; Yokoyama et al. 2006), described the degree of autism or provided standardized assessment data or a description of general ability for all participants (Chambers and Rehfeldt 2003; Frea et al. 2001; Kravits et al. 2002; Rehfeldt and Root 2005; Stoner et al. 2006; Research design Program evaluation 55–70 months RCT 21–54 months Autism/PDD 36 Yoder and Stone (2006a) 20–53 months Autism/PDD Yoder and Stone (2006b) 36 RCT Diagnosis Participants 6 Table 2 Summary of Studies 123 Yokoyama et al. (2006) Authors Webb (2000) 3 Autism 5 ASD 5–7 years Ages J Autism Dev Disord (2009) 39:1471–1486 1477 Yokoyama et al. 2006).Most researchers did document initial communication skills, either using standardized test results or a description of functional skills, although some descriptions were minimal. Participants were almost entirely described as non-verbal or having little or no functional speech, or in some cases no functional communication. The participants in the Marckel et al. (2006) study were able to use PECS independently to make requests at the start of the research. Participants in three studies were explicitly identi? ed by researchers as having challenging behavior (Adkins and Axelrod 2001; CharlopChristy et al. 2002; Frea et al. 2001). Interobserver and Procedural Reliability Interobserver reliability was reported for 20 of the 27 papers revie wed. Papers in which interobserver reliability was not reported included ? e earlier program evaluations (Bondy and Frost 1993, 1994, 1998; Liddle 2001; Webb 2000) and one single subject study (Adkins and Axelrod 2001). Reliability ranged from 80. 3 to 100% calculated on between 10 and 100% of data. Three studies (Howlin et al. 2007; Kravits et al. 2002; Malandraki and Okalidou 2007) estimated reliability on less than a minimum standard of 20% of total sessions. In contrast, procedural reliability was reported for only 7 of the 27 studies (Bock et al. 2005; Cummings and Williams 2000; Marckel et al. 2006; Tincani 2004; Tincani et al. 2006; Yoder and Stone 2006a, b) and discussed but not formally calculated in one other (Stoner et al. 2006). Where reported, procedural reliability ranged from 96 to 100%.In two papers (Yoder and Stone 2006a, b) less than 20% of sessions were used for the estimate. Social Validity Formal measures of social validity were reported in only four papers (Mag iati and Howlin 2003; Marckel et al. 2006; Tincani 2004; Yoder and Stone 2006a). Settings Fourteen studies were conducted in a special school, special preschool or special classroom setting. Remaining studies were conducted in a variety of settings including an integrated preschool, regular classroom, homes, clinics, day treatment facilities, and combinations of these settings. Ef? cacy and Effectiveness of PECS Of the total group of 394 individuals who received PECS intervention, only one child was reported as being nsuccessful at mastering at least phase I (Liddle 2001), and one adult had dif? culty with the motor and cognitive demands of the training and failed to progress past phase I (‘‘Mike’’, Stoner et al. 2006). ‘‘Carl’’, from Tincani’s (2004) study, was more successful with manual signs than PECS, but, the great majority successfully mastered at least some phases of PECS. Outcome data will now be considered further, initially focusing on pre-experimental designs, then single subject designs, quasi-experimental group designs and ? nally RCTs. This will be followed by a more detailed consideration of maintenance and generalization. Pre-Experimental Studies Several studies used pre-experimental designs.Bondy and Frost (1993) reported data on the implementation of PECS and found increased communicative initiations and use of pictures. Bondy and Frost (1994, 1998), Schwartz et al. (1998), Webb (2000), and Liddle (2001) also presented data on PECS implementation and reported increases in spoken language following PECS training. Schwartz et al. found that children were able to acquire communication with PECS training and there was evidence of generalization across pragmatic function. These studies, however, lacked adequate experimental control, and especially given the young age of the children involved in at least four studies, it is unknown how communication would have developed without the interve ntion.In their pilot study, Magiati and Howlin (2003) used a pre-treatment measure and three teacher ratings over time. They found signi? cant increases in PECS level (d = 2. 91),1 frequency of spontaneous use (d = 1. 75), and number of symbols used (d = 3. 01) over the 6 months following teacher training in PECS and its subsequent introduction. These are very large effect sizes by educational standards. They also found smaller but still statistically signi? cant increases in the number of signs (d = 0. 31), words (d = 0. 32) and phrases (d = 0. 30) used, and in the overall level of spontaneous communication (d = 0. 83). Outcomes were, however, measured mainly through teacher rating scales.The results must be treated with caution as they are likely to have been in? uenced by expectations and the research design was very weak. 1 For pre-test post-test designs, effect sizes were calculated by subtracting the pretest mean from the post-test mean and dividing by the pooled standard devi ation. For studies involving a comparison group, effect sizes were calculated by subtracting the mean of the control or alternate treatment group from the mean of the PECS intervention group and dividing by the pooled standard deviation. 123 1478 J Autism Dev Disord (2009) 39:1471–1486 Single Subject Studies PND and PEM statistics were calculated for the 10 single subject studies that provided baseline and intervention data.Initially, calculations were conducted on treatment data alone and then on all intervention data, including treatment, maintenance and generalization. When compared, the overall mean differences in favor of the treatment alone data were very small, only 0. 4% in the case of PND and 0. 8% for PEM. It was considered that the inclusion of all intervention data provided the best indicator of the ef? cacy of the overall package and these data were used for the remaining analysis. Results are provided in Table 3. Calculations were not possible for the four addit ional single subject studies (Adkins and Axelrod 2001; Cummings and Williams 2000; Ganz and Simpson 2004; Rehfeldt and Root 2005). These studies either lacked baseline data (e. g. alternating treatment design without baseline) or lacked baseline data that corresponded directly to that collected in intervention. The overall mean PND was 78. 5% (range 50– 100), placing the PECS intervention in the effective range (Scruggs and Mastropieri 1998). The overall mean PEM was 89. 1% (range 72. 3–100). Quality indicator scores are also presented in Table 3, and ranged from 30. 6 to 55. 7 out of a possible 65 points. Correlation between Quality Indicator scores for each study and their associated study PND was not signi? cant (rs = -0. 05, p = 0. 87). For PEM there was a trend toward weaker studies producing higher effect sizes but this did not reach signi? cance (rs = -0. 44, p = 0. 19).Mann–Whitney U tests or Kruskal–Wallis one-way ANOVAs were used to compare PND and PEM values across participant and study characteristics and these data are presented in Tables 4 and 5. No signi? cant difference in PND was found for age, gender, setting, inclusion of maintenance or generalization data, or research design. A signi? cant difference was found for PND scores for outcome variables, with studies addressing picture exchange only having a higher mean PND than those that included other dependent variables (i. e. , speech, social, behavioral, with or without picture exchange). A signi? cant difference was also found between PND values for participant diagnosis.Post hoc comparison showed that PND for children identi? ed with autism (i. e. , autistic disorder) were signi? cantly lower than for the other two groups, but these groups were not signi? cantly different from each other. No signi? cant difference was found between PEM values for any of the study or participant characteristics although participant diagnosis approached signi? cance (p = . 06). Fo ur of the single subject studies included data speci? cally relating to speech development from which PND and PEM values could be calculated (Charlop-Christy et al. 2002; Tincani 2004; Tincani et al. 2006; Yokoyama et al. 2006). The mean calculated PND was 49. % (range 19. 5– 100) and PEM 54. 2% (range 25. 0–100). These values are in the non-effective or at best very mildly effective range but with wide variation. Charlop-Christy et al. (2004) found increases in speech during PECS training. Tincani (2004) examined independent word vocalizations during PECS and sign language training. The addition of a Table 3 Single subject studies: PND and PEM results; study quality results Study PND PEM Study quality (Maximum 65) Picture Speech Social Behavior Overall Picture Speech Social Behavior Overall exchange exchange Adkins and Axelrod (2001) Bock et al. (2005) Chambers and Rehfeldt (2003) Charlop-Christy et al. 2002) Cummings and Williams (2000) Frea et al. (2001) Ganz and Si mpson (2004) Kravits et al. (2002) Marckel et al. (2006) Rehfeldt and Root (2005) Stoner et al. (2006) Tincani (2004) Tincani et al. (2006) Yokoyama et al. (2006) Mean SD – 92. 1 100. 0 – – 100. 0 – 87. 7 97. 3 – 77. 5 90. 6 98. 6 68. 7 90. 0 10. 9 – – – 59. 8 – – – – – – – 100. 0 20. 0 19. 5 49. 8 38. 4 – – – 86. 8 – – – – – – – – – – 86. 8 n/a – – – 26. 0 – 0 – – – – – – – – 13. 0 18. 4 – 92. 1 100. 0 55. 6 – 50. 0 – 87. 7 97. 3 – 77. 5 95. 3 70. 5 58. 6 78. 5 18. 8 – 92. 1 100. 0 – – 100. 0 – 87. 7 100. 0 – 90. 1 90. 6 98. 6 89. 9 94. 3 5. 2 – – – 65. 7 – – – – – – – 100. 0 25. 0 26. 0 54. 2 36. 0 – – – 95. – – – – – – – – – – 95. 6 n/a – – – 85. 0 – 100. 0 – – – – – – – – 92. 5 10. 6 90. 1 95. 3 72. 3 76. 7 89. 1 10. 6 – 92. 1 100. 0 76. 3 – 100. 0 – 87. 7 100. 0 30. 6 55. 7 43. 8 52. 4 32. 9 42. 4 35. 3 50. 4 49. 6 43. 8 50. 3 48. 2 45. 7 50. 3 45. 1 7. 6 123 J Autism Dev Disord (2009) 39:1471–1486 Table 4 Means, standard deviations and Mann–Whitney U test results for PND and PEM scores of study and participant characteristics Variable N PND M (SD) Quality indicators C50 50 PECS only Includes other Yes No 5 74. 3 (16. 6) 5 82. 6 (21. 7) 5 90. 9 (8. 9) 5 66. 0 (18. 0) 3. 0 0. 94 84. 6 (7. 5) 93. 5 (12. 0) 3. 0 1. 98* 94. 0 (5. 7) 84. 1 (12. 6) 7. 0 1. 14 5. 0 1. 6 U z PEM M (SD) U z Research design Multiple baseline Alternating treatments ABAB A ge Under 5 5–8 2. 0 1. 56 76. 5 (0. 3) 92. 2 (9. 4) 4. 0 1. 04 87. 9 (11. 2) 93. 9 (8. 7) 6. 0 1. 27 89. 9 (12. 2) 11. 0 0. 21 88. 5 (10. 5) 88. 5 (12. 5) 52. 0 0. 46 92. 5 (11. 2) 6. 0 0. 52 2. 0 1. 56 9–17 18? Diagnosis Autism PDD-NOS/autistic characteristics Other Setting Special school/ preschool Clinic Integrated preschool Home Combination 10 1 1 9 8 90. 1 (12. 5) 3. 87 79. 3 (n/a) 50. 0 (n/a) 74. 3 (30. 4) 82. 3 (21. 8) 2 57. 1 (2. 1) 8 83. 8 (17. 0) 9 8 3 9 13 85. 0 (17. 0) 2. 58 73. 1 (31. 2) 72. 2 (21. 4) 87. 9 (18. 5) 69. 8 (25. 9) 7. 68* 93. 8 (7. 3) 84. 4 (11. 4) 75. 4 (18. 8) 93. 5 (11. 1) 6 3 1 70. 0 (19. 0) 3. 82 95. 8 (4. 0) 77. 5 (n/a) 479 Table 5 Descriptive statistics and Kruskal–Wallis One-Way ANOVA results of PND and PEM scores of study and participant characteristics Variable N PND M (SD) H PEM M (SD) H 85. 5 (12. 3) 1. 62 95. 8 (4. 0) 90. 1 (n/a) 6. 74 Outcome variables Maintenance data included Generalization data included Yes 8 80. 9 (17 . 8) No Yes No Gender Male Female 2 68. 9 (26. 7) 4 88. 8 (12. 4) 6 71. 6 (20. 0) Procedural reliability data 83. 7 (13. 2) 5. 59 100. 0 (0) 92. 8 (9. 8) 90. 4 (11. 8) 2. 29 79. 3 (n/a) 100. 0 (n/a) 87. 8 (13. 1) 89. 2 (13. 4) 2 100. 0 (0) 14 89. 2 (15. 2) 25 78. 9 (23. 9) 40. 5 1. 12 5 92. 5 (11. 2) Note: * Indicates signi? cant result at 0. 05 level for two-tailed test reinforcer delay in phase IIIb resulted in increased in word vocalizations. Tincani et al. 2006) examined word vocalizations and vocal approximations during PECS training, and found a decrease during phases I-III before dramatic increases in phase IV. In a second experiment, looking at phase IV only, a higher percentage of word vocalizations was found with the reinforcement delay procedure than without. Yokoyama et al. (2006) examined frequency and intelligibility of vocalization during PECS training in phases I-IV; these authors also found an increase with the time delay procedure. Several other studies provided da ta on speech development, which was not suitable for calculation of PND or PEM values. Kravits et al. (2002) found an increase in frequency of intelligible speech but not in range of spoken vocabulary.Ganz and Simpson (2004) found that words per trial increased noticeably during phase IV or phases III and IV of PECS training, in particular, simultaneously with delayed word modeling. Charlop-Christy et al. (2002) provided the only appropriate data for calculation of PND and PEM values for social outcomes. From this very small amount of data, the PND of 86. 8% and PEM of 95. 6% suggest an effective or highly effective intervention. Variables that increased in this study were eye contact, joint attention, cooperative play, and frequency of initiations and requests including but not limited to PECS requests. Initiations and requests Note: * Indicates signi? cant result at 0. 05 level for two-tailed test ncreased the most, and joint attention also increased in all three children. It has been suggested that a direct positive relationship exists between joint attention and communication in children with autism, with improvement in one potentially stimulating an increase in the other (CharlopChristy et al. 2002). Kravits and colleagues (2002) reported some increase in duration of social interaction with peers although these data were not suitable for calculation of PND or PEM as only the mean level in each phase was presented. PND and PEM scores were calculated for data from only two studies for behavioral variables (CharlopChristy et al. 2002; Frea et al. 2001). The mean PND was 13. 0% while the mean PEM was 92. %, but, examination of graphed data showed treatment effects, indicating that decreased problem behaviors occurred in conjunction with increased communication skills through PECS training. Two studies compared sign language to PECS interventions (Chambers and Rehfeldt 2003; Tincani 2004) and one compared a VOCA to PECS (Bock et al. 2005). For each of these st udies PND and PEM were equal, and a higher value was found for PECS than for the alternative intervention. For Tincani (2004) calculated values were 95. 3% for PECS and 92. 3% for sign, for Chambers and 123 1480 J Autism Dev Disord (2009) 39:1471–1486 Rehfeldt (2003) values were 100% for PECS, and 65. 7% for sign, and for Bock et al. 2005) values were 92. 1% for PECS and 79. 7% for VOCA. Quasi-Experimental Group Studies Carr and Felce (2007b) found signi? cant improvement in several aspects of communicative interaction between children and staff following 15 h of PECS training (Phases I-III). Signi? cant increases were found for total child-toadult initiations, linguistic initiations, the percentage of adult response, the percentage of child response, and signi? cant decrease in adult-to-child interactions with no opportunity for child response. These differences were found in comparison to both a pre-intervention measure over time and to a non-intervention and non-equivalent control group.Examining a subset of this group, who used at least one word during observations, Carr and Felce (2007a) reported that over 6 weeks training in PECS phases I-III, 3 of the 24 children in the PECS group increased their spoken words. A further 2 who did not speak at pretesting did so at post-testing, while there was a marginal increase in speech for one child in the control group. RCTs Only three RCT studies were located. Yoder and Stone (2006a) conducted an experimental study of 36 children with autism, aged 21–54 months, who were randomly assigned to PECS or RPMT intervention groups. They found that the PECS group showed a signi? cantly greater increase in frequency of speech (d = 0. 3) and in number of different words used (d = 0. 50) after 6 months of intervention, but by 6 months post-intervention the difference was no longer evident. Interestingly, they also found differing effects according to pretreatment characteristics: children who were low in initial object exploration bene? ted more from the RPMT intervention, while those who were higher bene? ted more from PECS, these effects being evident 6 months post-intervention. Overall, there was a signi? cant increase in non-imitative spoken acts over 1 year. The actual increases were from a mean of 0. 25 nonimitative spoken acts in a 15-min session to a mean of 5. 5, and from a mean of 0. 7 different non-imitative words to a mean of 3. Given the young age of the children, the fact that their initial verbal mental age averaged 11. 9 months (range 7–19 months), just at the stage when verbal language is likely to develop naturally, it seems quite possible that this increase could be attributed to maturation. In a second article, Yoder and Stone (2006b) examined the effect of the interventions on the three major types of intentional communication used prior to speech development, (i. e. initiating joint attention, requesting, and turn-taking). They found that, overall all three comm unicative functions increased signi? cantly, but RPMT increased turn-taking more than PECS.Children who were higher in initiating joint attention before treatment had greater increases in both initiating joint attention and requesting following RPMT intervention, while those who were initially lower in initiating joint attention had greater increases following PECS intervention. Howlin et al. (2007) conducted a group RCT of 84 children with autism, examining the effect of teacher training and consultancy in PECS. It should be stressed that this study examined the effectiveness of a consultancy model to deliver PECS, rather than the ef? cacy of PECS per se. Thus, the study was noteworthy in that it appears to be the only research to examine effectiveness (i. e. , outcomes under clinical rather than optimal conditions). Howlin et al. ound that rates of communicative initiations and PECS usage were signi? cantly increased immediately following intervention, but that these effects were not maintained once the intervention ceased. They found no signi? cant increase in frequency of speech. Howlin et al. also examined ADOS-G (Lord et al. 2000) domain scores for communication and reciprocal social interaction. They found no increase in most ADOS-G ratings, with the exception of a decrease in the severity score for the Reciprocal Social Interaction domain at the 10 month followup. Unfortunately, no data was provided on the ? delity of implementation of the PECS program, or indeed on the ? delity of the teacher training.Maintenance and Generalization Only ? ve studies provided data on maintenance. Two of the RCT studies included long-term follow-up. Yoder and Stone (2006a) found that differences in speech variables were not maintained 6 months post-intervention, while Howlin et al. (2007) found that for the 26 children assessed at a 10-month follow-up, the increased rate of communicative initiations and PECS usage found immediately post-intervention was not maintained. Two single subject studies and one case study measured maintenance of skills 6–10 months postintervention (Charlop-Christy et al. 2002; Malandraki and Okalidou 2007; Yokoyama et al. 2006). Charlop-Christy et al. ound that speech and socio-communicative behaviors had been maintained or continued to increase for one participant followed up 10 months post-training. Yokoyama et al. found maintenance of PECS skills both in the training room and at home, 6–8 months after training for the three participants in their study. Malandraki and Okalidou in their study of one child found maintenance of skills 6 months after the main intervention. While the difference was not signi? cant and the number of studies was low, for the single 123 J Autism Dev Disord (2009) 39:1471–1486 1481 subject studies both PND and PEM were lower for studies that included maintenance data (Table 4).Fifteen of the 27 studies included some data on generalization of PECS skills. The great majority o f these were positive, with skills generalizing to different settings, people and stimuli. For some studies, generalization was an integral part of the way data were collected (CharlopChristy et al. 2002; Yoder and Stone 2006a, b). For others, generalization to untrained situations was speci? cally probed (e. g. , participants in Stoner et al. ’s (2006) study generalized their skills to use in fast food restaurants). Several studies demonstrated generalization to the classroom teacher or to home. In a small number of instances, generalization was unimpressive or absent.For example, in the Adkins and Axelrod (2001) study, tests for ‘‘generalization’’ simply required the child to mand for an object without immediately prior prompted trials. ‘‘Carl’’, from Tincani’s (2004) study, failed to generalize PECS skills to classroom teachers, preferring to use sign language. Discussion The PECS program was originally designed to provide a method of communication for children with autism, particularly those who do not use functional speech. PECS appears to be a popular intervention (Howlin et al. 2007) but, unfortunately, popularity of a given treatment does not necessarily re? ect actual ef? cacy (Green et al. 2006; Reynhout and Carter 2006). Only three RCTs have been reported to date. The studies of Yoder and Stone (2006a, b) compared PECS to RMPT.PECS was superior for some children but the study was designed to compare two treatments and, consequently, did not include a control arm. Thus, no conclusions can be drawn about the relative superiority of either intervention to a non-treatment control. Howlin et al. (2007) provided the only effectiveness study conducted. They found signi? cant effects on communicative initiations but this was not maintained once the intervention ceased. Thus, further examination of approaches to the delivery of PECS in clinical settings is needed. Con? dence in the Howlin et a l. study is somewhat weakened by the lack of any data on treatment ? delity, which is a critical feature in study quality (Gersten et al. 2005).The nature and quantity of data arising from RCTs at this point in time is insuf? cient to draw ? rm conclusions regarding the PECS interventions. Thus, probably the highest priority for research in this area is the conduct of further RCTs examining both ef? cacy and effectiveness in applied settings. In the absence of an adequate body of RCTs, clinicians still need to make informed decisions regarding interventions and may need to look to the second line of evidence. Evidence supporting the PECS intervention was provided by the well-designed quasi-experimental studies of Carr and Felce (2007a, b), which incorporated a non-equivalent control group with demonstration of pre-test equivalence between groups.Arguably, the bulk of interpretable data on PECS comes from single subject studies. For the relevant studies, the overall, mean PND (78. 5% ) and PEM (89. 1%) ? gures support the preliminary conclusion that PECS may be an effective intervention, at least when implemented under research conditions. There was a signi? cant difference between the PND results for studies that only looked at picture exchange outcome variables and those that included other collateral variables, such as speech, social, or challenging behavior. This indicates that, unsurprisingly, PECS training appears to be most effective in providing a successful means of communication through picture exchange.Nevertheless, it should be acknowledged that the number of studies remains relatively low and single subject designs have several limitations, including low external validity. While these studies contribute to our knowledge and give us a preliminary indication of the ef? cacy of PECS, they are not a substitute for well-conducted large scale RCTs. A substantial number of the extant studies were preexperimental in nature, particularly the early research. As such, they are not able to provide convincing demonstrations of experimental control. Hence, these studies offer no interpretable evidence on the ef? cacy of PECS. The effect of PECS training on speech development remains unclear.Research into various forms of AAC suggests they may have the potential to enhance speech development (Cress and Marvin 2003; Millar et al. 2006; Romski and Sevcik 2005) although results have sometimes been inconsistent (Carter 1999; Millar et al. 2006). Several of the studies reviewed in this paper reported increases in speech following PECS training, but others, including Howlin et al. (2007), reported little or no effect. Where speech increased, this has often occurred concurrently with phase III or IV of PECS, and in particular when a time delay was introduced. A related question, for which there is as yet no empirical evidence, is whether PECS training affects comprehension.Brady (2000) found increased comprehension skills with the use of VOCAs and it would be worth investigating whether PECS would have a similar effect. In comparison with other AAC systems, better overall results were obtained with PECS in the studies reviewed here (Adkins and Axelrod 2001; Bock et al. 2005; Chambers and Rehfeldt 2003; Tincani 2004). Nevertheless, there was variability in the results depending on initial imitation skills and, possibly, participant preference. It has been argued that individuals with ASD may bene? t from visually cued instruction (Quill 1997) and further examination of this issue would seem warranted. In addition, existing 123 1482 J Autism Dev Disord (2009) 39:1471–1486 application of PECS appears to have been exclusively limited to graphic symbols.There are distinct advantages to the use of three-dimensional tangible symbols, including decreased cognitive load and high iconicity (Rowland and Schweigert 1989, 1990; Turnell and Carter 1994). The exploration of the use of PECS with tangible symbols, especially with indiv iduals who are low functioning, would seem warranted. Only 5 of the 27 studies provided data on maintenance of PECS skills or other dependent variables. It is worthy of note that maintenance was problematic in both RCTs (Howlin et al. 2007; Yoder and Stone 2006a) that examined the issue. Overall, available evidence is mixed but there is certainly suf? cient doubt to indicate that maintenance should be formally and systematically monitored in the clinical application of PECS programs.Fifteen studies provided data on generalization of skills, the vast majority of these found that generalization did occur, but what was described as ‘‘generalization’’ varied greatly. There were several methodological limitations and issues in the research examined that warrant comment. In general, participant descriptions were poor, making it dif? cult to assess whether the intervention is best suited to individuals with particular characteristics. While nearly all studies prov ided a diagnosis, few speci? ed the diagnostic protocol or criteria. Further, when participants were diagnosed with ASD, few researches attempted to quantify the degree of autism.Noting the range of behaviors and symptom severity possible within individuals presenting with autistic disorder, and even greater variation in the broader autism spectrum, this would seem to be relevant, if not critical, information. Few researchers provided standardized assessment data or a detailed functional description of general ability, but probably re? ecting the aim of the intervention, most did provide some description of initial communication skills. While the number of studies was clearly insuf? cient to reach ? rm conclusions, PND data suggest that individuals with PDD-NOS or showing autistic traits made more progress with PECS than those with autistic disorder.It is unclear whether this is because the PECS protocol is better suited to them, or because they would do better with any treatment. W ithout further clear and consistent quanti? cation of the degree of autistic symptomatology, it is impossible to evaluate further this variable in relation to the ef? cacy of the PECS intervention. In addition, there was insuf? cient data on intellectual functioning to enable analysis of any relationship to PND or PEM. It is recommended that, in future studies, standardized psychometric data, standardized functional assessment of adaptive behavior, and clear information on initial communicative abilities should be provided.In addition, where a diagnosis of autism is provided the level of autistic symptomatology should be quanti? ed. Procedural reliability data were very limited, with data only meeting the conventional minimum standard in 5 of the 27 studies. Because of the absence of this data, it is not possible to determine in many cases whether what was being implemented was in fact the PECS program as designed. PECS is a complex and multi-component intervention making the veri? cation of treatment integrity even more critical. The absence of such information in research studies is somewhat dif? cult to understand given that the PECS manual (Frost and Bondy 2002) gives explicit and speci? criteria for assessing the integrity of training during each phase. Nevertheless, research on PECS is not alone in this regard and lack of procedural reliability data has been reported as a problem in other recent intervention reviews in the area of autism (e. g. , Bellini and Akullian 2007; Reynhout and Carter 2006). The calculated PND (88. 8%) and PEM (89. 9%) ? gures for studies that did meet the standard for reporting procedural reliability, are at the high end of the effective intervention range (Ma 2006; Scruggs and Mastropieri 1998), suggesting that monitoring of procedural integrity should be a key feature in research as well as clinical applications of PECS. A signi? ant component of the present review was the application of PND and PEM metrics to the relevant dat a. PND and PEM values were in most cases very similar, with lower variability for PEM (see Table 4). An exception was found for data relating to behavioral variables (CharlopChristy et al. 2002; Frea et al. 2001), where high baseline variability and ‘‘? oor’’ effects occurred, often causing the calculated PND for affected graphs to be low, while the PEM was high. For example, visual inspection of the graphed data in Frea et al. (2001) shows a clear treatment effect of the PECS intervention on disruptive behavior. Nevertheless, the calculated PND for these data was 0%, while the PEM was 100%.The discrepancy between the clear treatment effect seen in the graphed data and the PND value indicates that PEM may be a more appropriate metric for challenging behavior, where variability is likely to be high. Further, the advantages of using multiple methods of calculating effect sizes for single subject research are highlighted. As previously noted, PECS is a complex multi-component intervention program. Consequently, the question arises as to which of the components are most critical to its ef? cacy. For example, reinforcer assessment is formally and systematically incorporated into PECS and this may well be a salient factor in program ef? cacy. The use of picture exchange with a partner (rather than touching or pointing to a symbol) is a key distinguishing feature of PECS, but it is unclear whether exchange per se is essential to ef? cacy.The issue of developing spontaneity is addressed in an unusually systematic way in the PECS program (Chiang and Carter 2008) but extant research 123 J Autism Dev Disord (2009) 39:1471–1486 1483 provides only limited information on the circumstances under which communication occurs. Thus, there would appear to be considerable scope for examination of how speci? c components contribute to the overall ef? cacy of PECS. In addition, there has been only limited comparison of PECS to alternative interventio ns and this stands as a priority for future research. Several limitations of the current review must be acknowledged. Many of the earlier studies were descriptive and clear experimental control was not established.While later studies were of higher quality, only a limited number of RCTs have been conducted and much of the available interpretable data comes from second line of evidence single subject studies. Analysis of PND and PEM was only possible for a subset of the relevant single subject studies examined and analysis of speci? c study and participant characteristics were based on low numbers. In addition, very few studies provided adequate procedural reliability data so the extent to which PECS was appropriately implemented often remained unknown. Conclusion On balance, the studies reviewed provide preliminary evidence that PECS may be ef? cacious for children and adults with ASD and other developmental disabilities, who have little or no speech. Primary bene? s appear to be ev ident in communication by picture exchange. Identi? cation of the core aspects of the program that are important to its success, the individuals to whom it is best suited, and its relationship to other interventions remain to be substantively investigated. PECS stands as a promising intervention with some empirical support but many questions remain. The conduct of further RCTs into the ef? cacy and effectiveness of PECS stands as a high research priority. Appendix See Table 6. Table 6 Quality criteria for single subject research adapted from Horner et al. (2005) Area Indicator Description of participants Participants are described with suf? ient detail to allow others to select individuals with similar characteristics and settings (e. g. , age, gender, disability, diagnosis). One point awarded for each of the following (maximum of 5): 1. Statement of diagnosis such as autism, ASD, Asperger syndrome, intellectual disability (with or without indicating diagnostic source), age and gend er 2. Diagnostic instrument speci? ed (e. g. , WISC, AAMR diagnostic criteria, DSM-IV criteria, ADOS). Must provide if ASD or 0 awarded 3. If ASD, degree of autism speci? ed either with reference to symptoms (DSM-IV) or instrument like CARS. If not ASD, award point 4. Standardized assessment data (e. g. IQ, developmental scale, adaptive behavior) OR detailed functional description of general ability. Disability range (e. g. , moderate) acceptable for intellectual disability 5. Communication skills documented by means of standardized test results OR description of functional skills The process for selecting participants is described with replicable precision. MUST describe the process used to select participants, not just describe the participants or their needs. This would generally include the criteria the participants must meet (e. g. , 3–5 years, less than 5 spoken words, diagnosis of autistic disorder) and or the process of selecting participants (e. g. , the ? rst 5 chil dren on the waiting list).Essentially, authors must explicitly state HOW/WHY participants were selected Critical features of the physical setting are described with suf? cient precision to allow replication Dependent variables All dependent variables are described with operational precision Each dependent variable is measured with a procedure that generates a quanti? able index The measurement process is described with replicable precision Dependent variables are measured repeatedly over time Data are collected on the reliability or inter-observer agreement (IOA) associated with each dependent variable, and IOA levels meet minimal standards (i. e. , IOA = 80%; Kappa = 0. 60).Must be on minimum of 20% of sessions to be acceptable Independent variables Independent variable is described with replicable precision Independent variable is systematically manipulated and under the control of the experimenter Overt measurement of the ? delity of implementation for the independent variable. M UST be measured on a minimum of 20% of sessions to be acceptable 123 1484 Table 6 continued Area Baseline Indicator J Autism Dev Disord (2009) 39:1471–1486 A baseline phase provides repeated measurement of a dependent variable and establishes a pattern of responding that can be used to predict the pattern of future performance if introduction or manipulation of the independent variable did not occur. Should include a minimum of 3 stable data points.High variability is acceptable if intervention effects are unambiguous The procedural characteristics of the baseline conditions should be described operationally Experimental control/internal The design provides at least three demonstrations of experimental effect at different points in time. Effects of validity alternating treatments may be added, as main comparison is not with baseline. AB designs may not be added as they do not demonstrate intervention at different times when comparing to baseline The design controls for common threats to internal validity (e. g. , permits elimination of rival hypotheses). Acceptable designs include multiple baseline, ABAB and alternating treatment with counterbalancing.Unacceptable designs include: AB, ABA, and changing criterion External validity Social validity Experimental effects are replicated across participants, settings, or materials to establish external validity. At least three participants, settings or materials must be apparent The dependent variable is socially important Implementation of the independent variable is practical and cost effective (must be measured) Social validity is enhanced by implementation of the independent variable over extended time periods, by typical intervention agents, in typical ph