Updated by Lisa Tereshko, PhD, BCBA-D
Endicott College

Description:

Sensory Integrative TherapyThe Picture Exchange Communication System (PECS®) is a type of alternative augmentative communication system that was originally developed in 1985 by Andy Bondy, Ph.D., and Lori Frost, MS, CCC-SLP for use with preschool students with autism spectrum disorder (ASD) and has since been expanded across ages and disabilities (Battaglia & McDonald, 2015; Hughes-Lika & Chiesa, 2021). The procedure was originally used, and continues to be implemented, with learners who have a limited vocal repertoire for communication. Given the high percentage of non-vocal or minimally vocally communicative individuals with autism, the existence of an effective alternative approach is essential.

PECS® is based on Applied Behavior Analysis (Bondy & Frost, n.d.), and is built on the Verbal Behavior classification system originally proposed by Skinner. It embeds a systematic progression of independence and persistence strategies. Additionally, the protocol utilizes distinct prompting and reinforcement techniques throughout the six phases of the protocol in combination with systematic error correction procedures. Using individual pictures of items stored in a PECS® Communication Book or on an Activity Board, a child is taught to engage in functional communication by exchanging a picture or a sequence of pictures with their communication partner to receive the intended outcome. For example, a child selects a picture of a cracker and hands it to the communication partner who then gives the child a cracker.

PECS® is also based on Skinner’s conceptualization of Verbal Behavior (Bondy & Frost, n.d.), and (as noted above) is aligned with Skinner’s view that the function of communication is the most important feature of it. In other words, what the person is communicating (e.g., a request, a comment) is more important than the modality (e.g., vocal communication, sign language, picture exchange) of their communication. The PECS® phases focus on crucial component skills of effective communication, and include teaching the individual how to communicate, how to engage in communication from a distance and with persistence, how to develop picture discrimination skills, how to engage in appropriate sentence structure, how to use attributes and other mechanisms to expand language abilities, and how to engage in requesting and commenting (Bondy & Frost, n.d.).

The protocol to implement PECS® has been manualized and was updated in 2002 (Frost & Bondy, 2002). It is important to note that PECS® is a distinct and comprehensive communication system. The term PECS® should not be used for any picture-based communication system that does not use the procedures and phases of PECS®. PECS® is reserved for the Picture Exchange Communication System only, which includes systematic teaching procedures, a phase-based instructional model, and a joint focus on communication and social skills. Phase I of PECS® includes teaching the individual how to initiate communication. Phase II teaches the individual to generalize their communication across environments by traveling to communicate and teaches persistence in their communication attempts. Phase III teaches the individual to identify the picture of the item they want from an array of pictures. Phase IV teaches sentence structure which is followed by increasing language to include attributes, adjectives, verbs, and prepositions. Phase V teaches the individual to answer questions and Phase VI teaches the individual to respond to the question, “What do you want?” and comment on things in their environment (e.g., what they see, hear, or feel). PECS® capitalizes on social communication, emphasizing communication with a partner. For more information, please visit the PECS® website.

Research Review:

PECS® is supported by an extensive growing body of research that endorses its use to teach functional communication to individuals with ASD. According to the National Standards Project: Phase 2 (2015), PECS® was found to have an “emerging” level of evidence for individuals under the age of 22, implying that the intervention may produce favorable outcomes for those individuals but that it needed more evidence to be labeled an “established” intervention. Since its publication, many more high-quality single subject design research studies have been implemented that further support the effectiveness of PECS® with individuals with ASD (Battaglia & McDonald, 2015), suggesting that the intervention should be classified as an established intervention to increase functional communication skills (Battalia & McDonald, 2015; Hughes-Lika & Chiesa, 2021; McCoy & McNaughton, 2019). Furthermore, Autism New Jersey has created a framework to assist those in understanding what treatments are evidence-based for individuals with autism by using a stoplight analogy with red signifying treatments that research identifies as harmful or ineffective, yellow signifying treatments that research identifies as not enough (or any) research conducted yet to categorize, and green signifying treatments to be most effective. Through this analogy, Autism New Jersey identifies PECS® as a green light treatment as research demonstrates it to be highly effective for individuals with ASD (Autism New Jersey, 2022).

Importantly, the benefits of PECS® seem to extend beyond communication. PECS® has also been associated with an increase in vocal requests and reductions in challenging behaviors (e.g., aggression, Hu & Lee, 2019; tantrums, Charlop-Christy et al., 2002). Following implementation of the PECS® protocol, some individuals demonstrate an increase in vocal behavior which has been demonstrated to occur following the training at Phase IV (Alzrayer, 2020; Charlop-Christy et al., 2002) but has also been reported to occur following training at Phase III (Hu & Lee, 2019). A randomized control trial conducted by Schreibman and Stahmer (2014) examined the use of PECS® compared with Pivotal Response Training (a speech-orientated approach) and found both methods successful in increasing speech production at 6- and 9-month follow-ups but the PECS® group demonstrated slightly higher levels with an average of 90 spoken words at the 6-month follow-up and 130 spoken words at the 9-month follow-up. These findings suggest that the use of PECS® does not inhibit spoken language and may be as successful as naturalistic vocal language training programs. Furthermore, the review article by Battaglia and McDonald (2015) suggests that there appears to be an inverse relationship between the implementation of PECS® (functional communication) and aggression and tantrum behavior as it noted three studies in the review that demonstrated an increase in PECS® use, a reduction of aggression and tantrum behavior was observed.

Generalization and maintenance of a skill is essential for an intervention to be considered successful. Research has demonstrated that the use of PECS® can be generalized across settings such as clinics, homes, and communities (Hu & Lee, 2019). Family involvement during PECS® intervention is recommended, as it has been associated with increased child performance (Alsayedhassan et al., 2020; Olivatti et al., 2021). Throughout the longitudinal study conducted by Olivatti et al., family members successfully were trained to implement PECS® with their child and the child’s performance demonstrated an increase in functional communication. This study highlights the importance of family engagement and acceptance of the intervention to assist with the generalization of PECS® use across people.

Maintenance has also been assessed in the research and suggests the importance of a motivating environment with opportunities for the individual to practice PECS® after training. This implies that the more families support the use of PECS® across environments (e.g., home and community), the more the individual will engage in functional communication with PECS®. Short-term maintenance of PECS® use has been observed following one to six months after direct training (Hughes-Lika & Chiesa, 2021; McCoy & McNaughton, 2019). Following a 3.5-year follow-up after the training of PECS® concluded for a child with ASD, a decrease in the use of PECS® was observed; however, vocal requesting increased for that child which may imply that vocal communication required less effort than PECS® at that point (Jurgens et al., 2019). This may represent a natural progression of the approach and may also support PECS® as a bridge to vocal communication.

Furthermore, the implementation of PECS® has resulted in high social validity scores from both parents/caregivers, and teachers (Hu & Lee, 2019; Magiati & Howlin, 2003). Following the implementation of PECS®, parents/caregivers and teachers identified PECS® as a feasible and effective intervention for their children and students (Hu & Lee, 2019). Another study that trained family members to implement PECS® with their children included a treatment acceptability form to assess the acceptability of goals, procedures, and outcomes of PECS® and found parents were satisfied with all aspects of the intervention (Alsayedhassan et al., 2020).

For PECS® to be a successful intervention, it is recommended that individuals implementing the intervention be specifically trained on the protocol (Bondy & Frost, n.d.; Lamb et al., 2018). The meta-analysis conducted by Lamb et al. examined the fidelity of implementation of PECS® and its effects on the success of the client’s performance. Results found that for every hour of training the individual received, the effectiveness of PECS® increased by three points, moving the effect size from small to large with increased training. Research also supports the use of behavioral skills training to train parents or teachers to accurately implement PECS® (Alsayedhassan et al., 2020) as video models and instructions alone may not be effective (Barnes et al., 2011).

Recommendations:

Aligned with the 2014 review from the National Professional Development Center on Autism Spectrum Disorders (2014) and following this review of recent literature, PECS® is an evidence-based practice for teaching individuals with ASD functional communication skills. Similarly, the review of evidence-based practices (Hume et al., 2021) found the use of PECS® with children, youths, and adults to have enough empirical evidence to classify it as an evidence-based intervention for this population. Although current research supports the use of PECS® with individuals with ASD, intervention decisions should be left to the team directly involved in the treatment of the individual. As with any intervention, assessing the match of the procedure to the learner is of paramount importance. Furthermore, it is important that providers who offer PECS® are practicing within their scope of competence and scope of practice. Not every behavior analyst is qualified to deliver this intervention.

Continued research is required to further evaluate the long-term effects and success of PECS® with individuals. Questions remain about when and how to transition individuals on PECS® to other augmentative systems. Additional questions exist about how to best use PECS® to spark more vocal communication. Finally, additional research designs might help add to the existing literature. Some research suggests that the implementation of many single-subject designs may inflate the success rate of PECS® (Lamb et al., 2018), so it is also recommended that group studies continue to further examine all aspects of the intervention. An additional important expansion of the PECS® database will be to increase the diversity of the participants within studies.

From a practice perspective, PECS® is highly effective and is an evidence-based procedure for building communication skills in learners with ASD for whom vocal communication is absent or weak. It is conceptually systematic, empirically supported, demonstrated to maintain and generalize, and has high levels of social validity. It facilitates communication expansion and the transfer to vocal or other augmentative means of expression. It is also associated with documented reductions in challenging behaviors and increases in social behaviors. Overall, PECS® has proven effectiveness for increasing communication in individuals with ASD, can be classified as an evidence-based intervention, and has been robustly supported in experimental studies.

References:

Alsayedhassan, B. T., Banda, D. R., & Griffin-Shirley, N. (2020). Training parents of children with autism to implement the Picture Exchange Communication intervention. Clinical Archives of Communication Disorders, 5(1), 31-41. https://doi.org/10.21849/cacd.2019.00171

Alzrayer, N. M. (2020). Transitioning from a low- to high-tech augmentative and alternative communication (AAC) system: Effects on augmented and vocal requesting. Augmentative and Alternative Communication, 36(3), 155-165. https://doi.org/10.1080/07434618.2020.1813196

Autism New Jersey (2022). Treatment: Making informed choices. Retrieved from https://www.autismnj.org/understanding-autism/treatment/

Barnes, C. S., Dunning, J. L., & Rehfeldt, R. A. (2011). An evaluation of strategies for training staff to implement the Picture Exchange Communication System. Research in Autism Spectrum Disorders, 5, 1574-1583.

Battaglia, D., & McDonald, M. E. (2015). Effects of the Picture Exchange Communication System (PECS®) on maladaptive behavior in children with autism spectrum disorders (ASD): A review of the literature. Journal of the American Academy of Special Education Professionals. Winter, 8-20.

Bondy, A., & Frost, L. (n.d.) Picture Exchange Communication System. Retrieved from https://PECS®usa.com/PECS®/

Charlop-Christy, M. H., Carpenter, M., Le., L., LeBlanc, L. A., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS®) with children with autism: Assessment of PECS® acquisition, speech, social-communication, and problem behavior. Journal of Applied Behavior Analysis, 35(2), 213-231. https://doi.org/10.1901/jaba.2002.35-213

Frost, L., & Bondy, A. (2002). The Picture Exchange Communication System Training Manual (2nd ed.). Pyramid Educational Products.

Hu, X., & Lee, G. (2019). Effects of PECS® on the emergence of vocal mands and the reduction of aggressive behavior across settings for a child with autism. Behavioral Disorders, 44(4), 215-226. https://doi.org/10.1177/0198742918806925

Hughes-Lika, J., & Chiesa, M. (2021). The Picture Exchange Communication System and adults lacking functional communication: A research review. European Journal of Behavior Analysis, 22(1), 40-58. https://doi.org/10.1080/15021149.2020.1815507

Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2021). Evidence-based practices for children, youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders 51, 4013-4031. https://doi.org/10.1007/s10803-020-04844-2

Lamb, R., Miller, D., Lamb, R., Akmal, T., & Hsiao, Y. J. (2018). Examination of the role of training and fidelity of implementation in the use of assistive communications for children with autism spectrum disorder: a meta-analysis of the Picture Exchange Communication System. British Journal of Special Education, 45(4), 454-472. https://doi.org/10.1111/1467-8578.12243

Magiati, I., & Howlin, P. (2003). A pilot evaluation study of the Picture Exchange Communication System (PECS®) for children with autistic spectrum disorders. Autism, 3, 297-320. https://doi.org/10.1177/13623613030073006

McCoy, A., & McNaughton, D. (2019). Training education professionals to use the Picture Exchange Communication System: A review of the literature. Behavior Analysis in Practice, 12, 667-676. https://doi.org/10.1007/s40617-018-00296-4

National Autism Center. (2015). Findings and conclusions: National Standards Project, Phase 2. Author.

National Professional Development Center on Autism Spectrum Disorders (2014). Picture Exchange Communication System (PECS®). Retrieved from https://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/imce/documents/PECS®_Complete.pdf

Olivatti, D. O., Sugahara, M. K., Camilo, S., Perissinoto, J., & Tamanaha, A. C. (2021). The relevance of family engagement in the implementation of the Picture Exchange Communication System (PECS®) in children with autism spectrum disorder. Speech, Language, Hearing Sciences and Education Journal, 23(5), e1-7. https://doi.org/10.1590/1982-0216/20212353121

Citation for this article:

Tereshko, L. (2022). Picture Exchange Communication Systems® (PECS®®): A treatment summary. Science in Autism Treatment, 19(10).

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