Picture Exchange Communication System and Autism Ranking:

The Picture Exchange Communication System (PECS) is a form of augmentative and alternative communication in which a child is taught to communicate with an adult by giving them a card with a picture on it.

PECS is based on the idea that children who are non-verbal or with limited functional speech can be taught to communicate using pictures.

The adult begins by teaching the child to exchange a picture of an item he wants. For example, if the child wants a drink, he will give a picture of a drink to the adult who will then give him a drink.

The adult will then teach the child progressively more difficult skills, such as using pictures to make whole sentences or to express preferences.

The Picture Exchange Communication System was originally designed to help non-verbal autistic children but it has also been used with adolescents and adults who have a wide range of communicative, cognitive and physical difficulties.

The Picture Exchange Communication System is a key element in many multi-component programmes and approaches - such as the SPELL approach and the TEACCH programme.

Our Opinion

There is a very small amount of high quality research evidence (five controlled trials) and a small amount of low quality research (19 single-case design studies with three or more participants) into the use of PECS for autistic individuals.

This research suggests that PECS may be an effective way to increase the social communication skills (particularly requesting) of some young autistic children who are non-verbal or who have limited functional speech.

There is insufficient evidence to determine if PECS provides any benefits in other areas (such as a reduction in challenging behaviours) to young autistic children.

There is insufficient evidence to determine if PECS provides any benefits to autistic adolescents and adults.

There is a need for more research into PECS which uses scientifically robust, experimental methodologies with larger numbers of more diverse participants. That research should investigate whether PECS is more or less effective than other interventions designed to improve social communication skills (in particular requesting and speech) and whether specific individuals are more likely to benefit from PECS than other individuals.

PECS is a straightforward and positive approach, cost effective and not overly time consuming to implement. There is, however, much confusion regarding the correct use of PECS and it should only be implemented by appropriately trained individuals.

Disclaimer

Please read our Disclaimer on Autism Interventions

Audience

The Picture Exchange Communication System was originally designed for young autistic children who are non-verbal or who have limited functional speech. However it has since been used with autistic individuals of all ages including adolescents and adults and it has also been used with individuals with a range of other disabilities.
For example, according to Bondy (2012), PECS has been used successfully with people with…”developmental disabilities and multiple disabilities, as well as conditions such as cerebral palsy, blindness and deafness.”

According to Preston and Carter (2009), PECS is suitable for a wide range of people because it does not require them to have many prerequisite skills or abilities.

“… 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. 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 at least at the earliest program stage.”

Aims and Claims

Aims

The aim of the Picture Exchange System is to teach individuals to initiate communication and express their needs more effectively. For example, according to Ganz et al (2012),

“The stated purpose of PECS is to increase functional communication in individuals whose current communication methods do not adequately meet their needs. However, PECS has also been investigated as a means to affect other, collateral – or ‘‘non-target’’ – outcomes. The most common collateral outcomes examined include speech production and problem or challenging behaviors. “

Claims

There have been various claims made for the use of PECS as an intervention for autistic people. For example, according to Bondy and Frost (1994),

“For the 66 children who used PECS for more than 1 year, 39 (59%) acquired speech as their sole communication system. Of the total group (i.e., children using PECS for more than 1 month), 25 (29%) currently use a combination of speech and pictures or use a complex printed word system, while 41 (48%) use solely speech. Twenty of the children in the mixed outcome group have spent less than 2 years within DAP. Overall, 76% of all the children placed on PECS have come to use speech either as their sole communication system or augmented by a picture-based system. Even within 1 year of starting on PECS, 2 of the 19 most recently identified students already used speech as their sole communication modality. The large majority of the children who continue to rely on PECS as their sole means of communication function in the profoundly handicapped range of intellectual abilities.”

Key Features

The adult begins by teaching the child to exchange a picture of an item he wants. For example, if the child wants a drink, he will give a picture of 'drink' to the adult who will then give him a drink.

The adult will then teach the child progressively more difficult skills, such as using pictures to make whole sentences or to express preferences.

The child's preferences for items like food and toys are assessed. The child is then taught to exchange picture cards (usually symbols) for the items he likes.

At first, two trainers are needed so that the child can be prompted to exchange the symbol for the items he wants. The first trainer sits or stands in front of the child, holding the desired item without speaking at all. The second trainer sits or stands behind the child and physically prompts him to pick up the picture and hand it to the first trainer, naming it as it is handed over. The first trainer then hands the desired item to the child. Once the child learns to make the exchange spontaneously, the second trainer is no longer needed.

PECS involves six distinct phases of training, during which the child gradually becomes independent of adult prompting and learns that communication is a two way process which can achieve desired needs.

Phase 1: Performs the basic exchange with a wide range of pictures
Phase 2: Persists in getting an adult's or peer's attention and in moving across increasing distances
Phase 3: Discriminates between a number of pictures in an array
Phase 4: Forms sentences using pictures
Phase 5: Answers questions using pictures
Phase 6: Expands on previously mastered interactions

Frost and Bondy recommend continuing training within each phase until the child has reached 80% or greater proficiency for a minimum of three days before moving onto the next phase.

They suggest that once an individual has mastered PECS and is able to spontaneously and successfully approach others, it may be appropriate to introduce a pointing system or a voice output communication device.

They recommend that, rather than attempting to force the individual to speak, adults should demonstrate appropriate speech. They also note that some individuals may start to speak spontaneously.

Picture symbols can also be used to introduce the idea of choice. For example a child may learn to choose between different symbols to show which food he wants to eat or what toys he would like to play with.

Picture symbols can also be used to make the environment seem more organised and predictable. For example, they can be used with timetables or schedules to show what is supposed to happen when during the day - which can reduce stress and anxiety.

Cost and Time

Cost

In theory, PECS can be undertaken for free by anyone who has learnt how to use it. In practice, there may be costs for any training that is undertaken (which may include travel and accommodation) and any equipment and materials used (which may include the creation or purchase of the picture cards).

According to the Pyramid Educational Consultants UK Ltd website, accessed on 20 June 2017,

The costs of a PECS Level 1 (Basic) 2 Day Workshop are: Professional £330 Student £ 297 Parent £185.
The PECS manual training manual costs £47.70 and picture sets cost between £23.50 and £69.60.

Time

The amount of time it takes to use the Picture Exchange Communication System will depend on a number of factors including the length of time it takes to progress through the 6 stages of the protocol and the amount of time spent using PECS each day.

Bondy and Frost (1994) have noted that most children take several months to progress from stage 1 to stage 5 of the protocol.

“Children typically progress through Phases 1 and 2 within a matter of days (Phase 1 has been mastered by many children in as few as six trials). Phase 3 training ordinarily lasts the longest for all students, but it progresses more rapidly for those students who, prior to PECS training, showed some interest in pictures. Actual time spent in Phase 3 training is extremely variable, ranging from several days to several months. Issues generally related to the acquisition of complex visual discrimination are involved with the rapid acquisition of this phase of training. Phases 4 and 5 usually are mastered within a few weeks. “

Bondy and Frost have recommended that a minimum of 30 training trials should take place throughout the day, rather than being grouped into one big trial period. They suggest that the training trials can easily be integrated into normal daily routines, such as mealtimes, trips to the park etc.

Risks and Safety

Hazards

There are no known hazards for the Picture Exchange Communication System.

Contraindications

There are no known contraindications (something which makes a particular treatment or procedure potentially inadvisable) for the Picture Exchange Communication System.

However, Tincani and Devis (2011) note that PECS requires proper and thorough training if it is to be implemented correctly.

“… the PECS protocol is a complex system requiring myriad teaching procedures, including most-to-least prompting, least-to-most prompting, shaping, chaining, and error correction*. Indeed, Howlin et al. (2007) found that teachers had difficulty maintaining communicative gains achieved with PECS when classroom consultation visits ended, perhaps in part because expert consultation did not fully establish complex teaching repertoires necessary to implement PECS without external support.”

*Please Note: these are behavioural techniques derived from applied behaviour analysis.

Suppliers and Availability

Suppliers

In theory, anybody can use the Picture Exchange Communication System as it was designed to be used by a wide variety of people, including parents, teachers and others.

In practice, there are a number of organisations which can provide training and materials.

Credentials

PECS does not require professional qualifications or credentials as it was designed to be used by a wide variety of people, including parents, teachers and others. However, according to Vicker (2010),

“Professional training regarding PECS is required in order to implement the program as designed. Generally the training is provided at a two-day workshop. While speech pathologists might be the primary PECS program coordinator for a specific child, it is helpful to have others also attend the two-day trainings since they too will play an important role. These others could include parents, the classroom teacher, and classroom assistants. They will be important in identifying new vocabulary and may help construct some of the picture display symbols as well as provide the nonverbal individual with opportunities to use/learn the new vocabulary. Although many people receive their initial training from a Pyramid Educational Consultant, others may receive their training through a train-the-trainer model from a local individual who has had training beyond the two-day orientation and is certified to train others.”

Related Suppliers and Availability

History

The Picture Exchange Communication System was first developed for use at the Delaware Autistic Program by Andrew Bondy and Lori Frost in 1985.

Bondy and Frost focused on building essential skills in very young autistic children, including teaching them how to communicate using picture symbols.

PECS was developed within a school setting rather than in a research-based environment and the protocol was adapted over time to meet the needs of different students.

Current Research

Study characteristics

We have identified more than 30* studies of the Picture Exchange Communication System used as an as an intervention for autistic people which were published in English-language, peer-reviewed journals and which included three or more participants.

These studies included a total of more than 400 autistic individuals aged from two years old to adult. The majority of these studies were on pre-school children or primary school children. There was only one study on secondary school children and only one study on adults.
The majority of the studies we identified included children who were non-verbal or with limited functional speech.
The majority of the studies investigated PECS to stage 3. Very few studies investigated PECS from stage 4 to stage 6.
Some of the studies compared PECS to other forms of augmentative and alternative communication (such as voice output communication aids).
Some of the studies compared PECS to combined, multi component interventions (such as pivotal response training or responsive education and prelinguistic milieu teaching).

* Please note:

Because there are so many studies on this topic we have not included those studies with fewer than three participants in this section. However, you can find details of some of those studies, and other publications on PECS, in our publications database.
Some of the studies appeared several times in different journals. For example, the following papers all report on the same study: McDuffie et al. (2012); Yoder and Stone(2006a); Yoder and Stone ( 2006b); Yoder and Lieberman (2010).

Study outcomes

The majority of studies reported that PECS lead to an increase in requesting, via the exchange of picture cards, in the majority of participants.
Some of the studies reported an increase in speech or other forms of social communication in many of the participants.
Only one of the studies (Charlop-Christy et al, 2002) reported decreases in problem behaviours.
The studies which compared PECS with voice output communication aids reported that both were equally effective but the results of these studies were limited and inconsistent.
The study which compared PECS to responsive education and prelinguistic milieu teaching (Yoder and Stone, 2016) reported that PECS was more effective in teaching young children to make requests than responsive education and prelinguistic milieu teaching.
The study which compared PECS to pivotal response training (Schreibman and Stahmer, 2014) reported that PECS was as effective as PRT in teaching young children to speak.

Status Research

There are a number of limitations to all of the research studies published to date. For example

The overwhelming majority of studies consisted of single-case designs with small numbers of participants (mostly three, four or five participants).
Some of these single-case design studies used extremely weak methodologies (such as descriptive case studies).
There were five group studies but only three of these were randomised and none of them was fully blinded. One of these studies (Lerna et al, 2012) only had 18 participants.
Some of the studies did not provide enough details about the participants, such as whether they had a formal diagnosis of autism, their level of intellectual ability, their ethnicity etc.
Most of the studies were limited to young autistic children, with very few looking at other groups (such as adults, females, individuals from ethnic minority groups).
Some of the studies included participants with a range of disabilities and did not provide separate assessment and outcome data for those participants who were autistic .
Some of the studies claimed to report positive results but sometimes the actual results were less positive. For example, the study by Carr and Felce (2007) showed that only five of the 24 children who received PECS actually made progress.
Some of the studies did not include measures for outcomes such as speech and other vocalisations.
Very few of the studies investigated the effects of PECS in other areas such as academic skills
Very few of the studies investigated all six phases of the PECS protocol and some did not report how well they followed the protocols established by Bondy and Frost.
Very few of the studies compared PECS with other techniques or interventions which are designed to achieve similar results, such as sign language or voice output communication aids.
Some of the studies did not state if PECS provided any beneficial effects which lasted in the medium to long term or in real world settings.
One of the studies (Bondy and Frost, 1994) was a retrospective case series and undertaken by the researchers who developed the approach.
Most of the studies did not involve autistic people or parents and carers in the design, development and evaluation of the research.

For a comprehensive list of potential flaws in research studies, please see ‘Why some autism research studies are flawed’

Ongoing Research

We have been unable to identify any studies into the Picture Exchange Communication System that are currently underway. If you know of any studies we should include in this section please email info@researchautism.net with the details.

Future Research

Summary of Existing Research

There is insufficient evidence to determine if PECS provides any benefits in other areas (such as a reduction in challenging behaviours) to young autistic children.

There is insufficient evidence to determine if PECS provides any benefits to autistic adolescents and adults.

Recommendations for Future Research

Future studies should

Use more scientifically robust, experimental methodologies with larger numbers of participants.
Involve a wider range of participants (such as adults, females, individuals from ethnic minority groups).
Provide more details about the participants, such as whether they had a formal diagnosis of autism, their level of intellectual ability, ethnicity etc.
Provide separate assessment and outcome data for those participants who were autistic where those studies include participants with a range of disabilities.
Identify if there any prerequisite abilities and skills (such as cognitive ability or linguistic skills) that may make some individuals more likely to benefit from PECS.
Include standardised measures for outcomes such as speech and other vocalisations.
Investigate the effects of PECS in other areas such as academic skills.
Identify which elements, if any, of the training protocol established by Bondy and Frost are the most effective for which groups of people.
Identify if PECS can be delivered successfully by a wider range of providers, such as parents and carers.
Compare PECS with other interventions which are designed to achieve similar results, such as sign language and voice output communication aids.
Determine if PECS can be used as one of the elements within comprehensive, multi-component, treatment models.
Identify if PECS provides any benefits in the medium to long term and in real world settings.
Involve autistic people and parents and carers in the design, development and evaluation of those studies.

Studies and Trials

This section provides details of scientific studies into the effectiveness of this intervention for people with autism which have been published in English-language, peer-reviewed journals.

If you know of any other publications we should list on this page please email info@informationautism.org

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Studies and Trials

Agius M. M., Vance M. (2016) A comparison of PECS and ipad to teach requesting to pre-schoolers with autistic spectrum disorders. Augmentative and Alternative Communication. 32(1), Read Abstract (New Window)
Boesch M. C. et al. (2013) Comparative efficacy of the Picture Exchange Communication System (PECS) versus a speech-generating device: Effects on requesting skills. Research in Autism Spectrum Disorders. 7(3), Read Abstract (New Window)
Boesch M. C. et al. (2013) Comparative efficacy of the Picture Exchange Communication System (PECS) versus a speech-generating device: Effects on social-communicative skills and speech development. Augmentative and Alternative Communication. 29(3), Read Abstract (New Window)
Bondy A., Frost L. (1994) The Picture Exchange Communication System. Focus on Autistic Behavior. 9(3), Read Abstract (New Window)
Carr D., Felce J. (2007) Brief report: Increase in production of spoken words in some children with autism after PECS teaching to phase III. Journal of Autism and Developmental Disorders. 37(4), Read Abstract (New Window)
Carr D., Felce J. (2007) The effects of PECS teaching to phase III on the communicative interactions between children with autism and their teachers. Journal of Autism and Developmental Disorders. 37(4), Read Abstract (New Window)
Carson L. et al. (2012) The collateral effects of PECS training on speech development in children with autism. Canadian Journal of Speech-Language Pathology and Audiology. 36(3), Read Abstract (New Window)
Chambers M., Rehfeldt A. (2003) Assessing the acquisition and generalization of two mand forms with adults with severe developmental disabilities. Research in Developmental Disabilities. 24(4), Read Abstract (New Window)
Charlop-Christy M. H. et al. (2002) Using the picture exchange communication system (PECS) with children with autism: assessment of PECS acquisition, speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior Analysis. 35(3), Read Abstract (New Window) Read Full (New Window)
Cummings A., Carr J. E., LeBlanc L. A. (2012) Experimental evaluation of the training structure of the Picture Exchange Communication System (PECS). Research in Autism Spectrum Disorders. 6(1), Read Abstract (New Window)
Ganz J. B., Simpson R. L. (2004) Effects on communicative requesting and speech development of the Picture Exchange Communication System in children with characteristics of autism. Journal of Autism and Developmental Disorders. 34(4), Read Abstract (New Window)
Ganz J. B. et al. (2008) Generalization of a pictorial alternative communication system across instructors and distance. Augmentative and Alternative Communication. 24(2), Read Abstract (New Window)
Ganz J. B., Parker R. I., Benson‌ J. (2009) Impact of the Picture Exchange Communication System: Effects on communication and collateral effects on maladaptive behaviors. Augmentative and Alternative Communication. 25(4), Read Abstract (New Window)
Greenberg A. L., Tomaino M. E., Charlop M. (2014) Adapting the picture exchange communication system to elicit vocalizations in children with autism. Journal of Developmental and Physical Disabilities. 26(1), Read Abstract (New Window)
Heneker S., Page L. (2003) Functional Communication: the impact of PECS. Speech and Language Therapy in Practice. Read Abstract (New Window)
Howlin P. et al. (2007) The effectiveness of Picture Exchange Communication System (PECS) training for teachers of children with autism: a pragmatic, group randomised controlled trial. Journal of Child Psychology and Psychiatry. 48(5), Read Abstract (New Window)
Lerna A. et al. (2009) The efficacy of the PECS for improving the communicative, relational and social skills in children with autistic disorder: Preliminary results. European Psychiatry. 24(1), Read Abstract (New Window)
Lerna A. et al. (2012) Social-communicative effects of the Picture Exchange Communication System (PECS) in autism spectrum disorders. International Journal of Language and Communication Disorders. Read Abstract (New Window)
Lerna A. et al. (2014) Long-term effects of PECS on social–communicative skills of children with autism spectrum disorders: A follow-up study. International Journal of Language and Communication Disorders. 49(1), Read Abstract (New Window)
Lund S. K., Troha J. M. (2008) Teaching young people who are blind and have autism to make requests using a variation on the Picture Exchange Communication System with tactile symbols: A preliminary investigation Journal of Autism and Developmental Disorders. 38(4), Read Abstract (New Window)
Magiati I., Howlin P. (2003) A pilot evaluation study of the Picture Exchange Communication System (PECS) for children with autistic spectrum disorders. Autism. 7(3), Read Abstract (New Window)
McDuffie A. S., Lieberman R. G., Yoder P. J. (2012) Object interest in autism spectrum disorder: A treatment comparison Autism. 16(4), Read Abstract (New Window)
Meer L. A. v. d. et al. (2012) A further comparison of manual signing, picture exchange, and speech-generating devices as communication modes for children with autism spectrum disorders. Research in Autism Spectrum Disorders. 6(4), Read Abstract (New Window)
Park J. H., Alber-Morgan S. R., Cannella-Malone H. (2011) Effects of mother-implemented Picture Exchange Communication System (PECS) training on independent communicative behaviors of young children with autism spectrum disorders. Topics in Early Childhood Special Education. 41(1), Read Abstract (New Window)
Schreibman L., Stahmer A. C. (2014) A randomized trial comparison of the effects of verbal and pictorial naturalistic communication strategies on spoken language for young children with autism. Journal of Autism and Developmental Disorders. 44(5), Read Abstract (New Window) Read Full (New Window)
Schwartz I. S., Garfinkle A. N., Bauer J. (1998) The Picture Exchange Communication System: Communication outcomes for young children with disabilities. Topics in Early Childhood Special Education. 18(3), Read Abstract (New Window)
Webb T. (2000) Can children with autism and severe learning difficulties be taught to communicate spontaneously and effectively using the Picture Exchange Communication System? Good Autism Practice. 1(1),
Yoder P. J., Stone W. L. (2006) Randomized comparison of two communication interventions for preschoolers with autism spectrum disorders. Journal of Consulting and Clinical Psychology. 74(3), Read Abstract (New Window)
Yoder P. J., Stone W. L. (2006) A randomized comparison of the effect of two prelinguistic communication interventions on the acquisition of spoken communication in preschoolers with ASD. Journal of Speech, Language, and Hearing Research. 49(4), Read Abstract (New Window)
Yoder P. J., Lieberman R. G. (2010) Brief report: Randomized test of the efficacy of Picture Exchange Communication System on highly generalized picture exchanges in children with ASD. Journal of Autism and Developmental Disorders. 40(5), Read Abstract (New Window)

Additional Information

Please note: It is important to understand that PECS is not simply the use of small laminated pictures. It is a complete system of augmentative and alternative communication based on the principles of applied behaviour analysis. It consists of six specific stages, each of which needs to be taught according to established protocols.

Related Additional Information

Picture Exchange Communication System

Updated: 17 Jun 2022
Last Review: 01 Sep 2017
Next Review: 01 Dec 2023

Picture Exchange Communication System and Autism Ranking:

Our Opinion

Disclaimer

Audience

Aims and Claims

Aims

Claims

Key Features

Cost and Time

Cost

Time

Risks and Safety

Hazards

Contraindications

Suppliers and Availability

Suppliers

Credentials

Related Suppliers and Availability

History

Current Research

Study characteristics

Study outcomes

Status Research

Ongoing Research

Future Research

Summary of Existing Research

Recommendations for Future Research

Studies and Trials

Related Studies and Trials

Other Reading

Related Other Reading

Additional Information

Related Additional Information