Running head: PECS EFFECTIVENESS FOR CHILDREN WITH ASD 1

An Evidence-Based Review of the Effectiveness of Picture Exchange Communication System

(PECS) compared to other forms of Augmentative and Alternative Communication (AAC) for

children with Autism Spectrum Disorder

Kari Olsen and Krystle Mitchell

University of Utah

Division of Occupational Therapy

PECS EFFECTIVENESS FOR CHILDREN WITH ASD 2

An Evidence-Based Review of the Effectiveness of Picture Exchange Communication System

(PECS) compared to other forms of Augmentative and Alternative Communication (AAC) for

children with Autism Spectrum Disorder (ASD)

Introduction

According to Christensen et al. (2016), one in every sixty-eight children are born with

autistic spectrum disorder (ASD). Though there is no single cause, an increase in understanding,

awareness, and early intervention can increase the functioning and overall outcome of these

individuals lives. Within the diagnosis of ASD, there are possibilities of learning delays with

language, lack of eye contact and conversation skills, executive functioning problems, deficits in

motor skills, and sensitivity to sensory stimuli (Autism Society, 2016). Although ASD is a

lifelong diagnosis, early intervention and therapy can increase the developmental progression.

Therefore, determining the most effective form of intervention and communication aid can

address the needs of these individuals.

It has been estimated that the cost to care for a child with ASD throughout their lifetime

is over $2 million. This is further broken down into a $90 billion cost for the United States every

year. One of the largest contributors to the cost of ASD needs is through the school system in

providing special education. The cost of education for those with ASD is approximately $8600

more than the average student. There is an enormous burden to provide the children with

necessary education and tools to support their needs for the future (Lavelle, T. et al., 2014).

Of those who are diagnosed as having ASD, over half will have some level of

communication difficulty that will affect their ability to communicate verbally (The Center for

AAC and Autism). The delay in spoken language can have a detrimental and everlasting effect

on a childs learning process and school experience. The ability to communicate is necessary for
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 3

the proper development of cognitive, social, and life skills. It is because of the need for

assistance in communication for those with autistic spectrum disorder that the use of

augmentative and alternative communication (AAC) has been continually utilized and

progressively enhanced.

Augmentative and alternative communication is the term that refers to the different forms

of communication outside of oral speech. This can be as simple as gestures and facial

expressions, but it can also be more sophisticated symbols and technology. There are multiple

forms of AAC implemented in therapy of those with ASD. However, there are some systems that

are used more regularly than others (American Speech-Language Hearing Association, 2016).

Types of AAC devices that have been utilized for children with ASD include Picture Exchange

Communication System (PECS), Voice Output Communication Aids (VOCA), Speech

Generating Devices (SGD), sign language, and facilitated communication (Research Autism,

2016). Though there are many options available to those with communication aid needs, it is

important to know which type of AAC is going to be the most efficient and ultimately beneficial.

The sooner an appropriate communication intervention is chosen, the more likely the child will

be able to interact in social situations, participate in the educational settings, and communicate

biological and personal wants and needs.

There are many professionals involved in the therapy and intervention of those with ASD

and consequent verbal disorders. Of these professional, an occupational therapist provides a vital

part in the childs participation in necessary life roles. Occupational therapists working with

children with ASD strive to help children learn the communicational, functional, and social skills

necessary to meet their needs. As a part of this purpose, therapists must be able to determine and

employ the type of AAC that fits the childs needs and ability level.
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 4

There are many types of AAC available, research is unclear as to which type of AAC is

most beneficial for children with ASD. A bias towards PECS has been seen through multiple

education and therapy settings. It is vital to understand if this form of intervention is the most

effective for this population. An understanding of the AAC that is most effective will more

readily allow a child to be involved in their everyday purposeful activities. As a part of this

search to find the most appropriate form of AAC for those with ASD, a systematic review has

been conducted to compare PECS to other commonly used forms of AAC to determine if this is

the most effective type of communication intervention.

Methods

Literature Search

A search for applicable literature on the use of Augmentative and Alternative

Communication for children with disabilities was initially conducted. Databases including

CINAHL, PubMed, Google Scholar, and ERIC were searched using text available online or

through the University of Utah Eccles Health Science Library. Keywords used for this initial

search included augmentative and alternative communication, autism, ASD, PECS, children,

adolescents, learning disability, communication disorder, and VOCA. Only literature published

between 2006 and 2016 were considered for inclusion. Researchers also searched references of

selected articles to find additional related studies.

Selection Criteria

Only studies that examined the effect of PECS on children with ASD were included in

the selection process. From the initial literature search, approximately 50 articles were obtained.

The researchers then narrowed the search criteria to the following keywords: augmentative and

alternative communication, children, autism, picture exchange communication system, and

PECS EFFECTIVENESS FOR CHILDREN WITH ASD 5

PECS. Two researchers then selected and reviewed articles from the search findings to those

studies that met the specified criteria. Inclusion criteria was specified to only studies involving

the use of the picture exchange communication system (PECS) with children (specifically 3-12

years) diagnosed with autism spectrum disorder (ASD) and similar developmental disabilities.

Studies were included that involved research on the effectiveness of the PECS system in the

increase of communication behaviors in children with ASD. Studies that compared the use of

PECS to other AAC methods were also included. Articles with higher levels of evidence were

given more consideration than lower levels of evidence. For the purpose of this article, meta-

analyses were viewed but not included. Eight articles were analyzed and met criteria for

inclusion in this research review.

Data Extraction

Data was obtained from each study based on the type of study performed, participant

information and characteristics, explanation of the experiment or intervention, measurements,

results, and limitations. Researchers allowed all five levels of evidence from the modified

Sackett scale for the purpose of this study to provide an all encompassing view of PECS

effectiveness. Each study was analyzed and the overall strength was observed.

Results

For this systematic review, eight articles were chosen to formally analyze, review, and

discuss. The selected articles include five single-subject designs and three pre-test/post-test

designs, two of which were randomized. Six studies observed the effectiveness of PECS in

comparison to other forms of AAC. Two studies followed the effectiveness of PECS in regards

to appropriate training of the intervention. All studies were included in Level III and IV of the

level of evidence scale.

PECS EFFECTIVENESS FOR CHILDREN WITH ASD 6

PECS Training

Cummings, Carr, and LeBlanc (2012) conducted a study to evaluate the effectiveness of

the PECS training protocol for children with developmental or language disorders. The

researchers also hoped to test the truthfulness of the claims that PECS can be effectively taught

in a relatively short period of time and requires few prerequisite skills to be able to utilize it. The

seven participants were trained and assessed for each of the six training phases of PECS. The

researchers found that there was an increase in the percentage of correct communication

exchanges after phases one through four. All participants demonstrated an increase in correct

exchanges following phases five and six. For most of the participants, training was effectively

conducted within a relatively smaller number of trials. Most participants were also able to master

the PECS system with no prior training or prerequisite skills. However, some participants

required visual discrimination training and modifications to the training protocol in order to

successfully master the program. The researchers concluded from this study, as well as other

published studies, that the PECS protocol is an effective training method for the system. Some

training in prerequisite skills, as well as modification to the training protocol may be needed to

be made on an individual basis based on the needs of individual children.

Ganz, Simpson, and Corbin-Newsome (2007) studied the effectiveness of PECS on

increasing the number of independent picture exchanges, intelligible word utterances, and word

approximations. The researchers trained three preschool-aged children with ASD in each of the

first four phases of PECS training, using the PECS training protocol. Although two of the

children were able to master the PECS technique quickly, one of the participants was unable to

master PECS according to the protocol. Most of the participants increased in functional

communication, although few improved in spoken communication. Although more research is

PECS EFFECTIVENESS FOR CHILDREN WITH ASD 7

needed, the researchers believed that individual characteristics, such as the presence of echolalia

prior to PECS training and the individuals ability to understand pictures as representations of

actual objects, may have a substantial effect on the effectiveness of PECS to help increase

spoken language. The researchers concluded that PECS can be an effective method for

facilitating communication in children with ASD. However, they recommend that assessments

be conducted prior to using PECS in order to determine which style of visual representation is

most understandable to the individual child.

PECS and SGD

Agius and Vance (2016) conducted a study to determine the effectiveness of PECS

compared with the use of an iPad as a speech generating device (SGD) for preschool-age

children ASD. The researchers used three independent measurements. These measurements

included the number of independent requests made by each child, the number of trials necessary

to reach the mastery criterion for each of three phases, and modality preference data. The

findings of the study support the claim that preschoolers with ASD can be taught to request

desired items through the use of PECS and an iPad/SGD. The children were able to learn how to

use both methods and reached the mastery criterion within a similar time frame, which the

researchers believe shows that both methods of requesting are equally effective. However, the

rate at which the children were able to use the PECS system with minimal errors was faster than

the iPad/SGD. The level of maintenance for using the device during follow-up sessions was

higher for PECS than for the iPad/SGD. The results of the modality preference assessments

showed high levels of variability, which led the researchers to suggest that children with ASD

should be provided with multiple forms of AAC until they reach proficiency, to help them be

able to find a preferred device.

PECS EFFECTIVENESS FOR CHILDREN WITH ASD 8

Boesch, Wendt, Subramanian, and Hsu (2013) studied the difference between PECS and

SGD using a ProxTalker communication device to promote an increase in requesting skills of

three students with the diagnosis of ASD. Their intention was to compare the use of these AAC

modalities in regards to social, communicative, and natural speech. The study included three

elementary school aged children with severe Autism. The study was observed over 63 sessions,

through 2-4 sessions every week at 15 minutes each. Each child first was assessed to decide the

food items they prefer the most. These items were used as reinforcers for each AAC device. Each

child underwent baseline, three phases, a follow-up, and maintenance portion of the study. At

baseline, the observers measured each participants level of skill. Phase I included the client

learning to request the intended reinforcer through PECS or choosing the picture card on the

SGD. In Phase II, the distance of the reinforcer as well as the SGD and PECS were varied. In

Phase III, the participant was expected to decide between multiple picture card options to request

reinforcer. The follow-up phase consisted of access to the AAC devices. After about 8 weeks,

three maintenance sessions were administered. No clear results came from this study. Both AAC

devices were deemed similar in their effects on requesting behavior. They combined and

reported multiple parts of social communication as one product instead of indicating each

individual occurrence. Also, it was deemed to re-evaluate established protocol to see if any other

teaching skills could facilitate an increase in preferred skills.

Flores et al. (2012) compared the effectiveness of the iPad as a speech generating device

(SGD) to PECS as an AAC method. This study included participants who were of elementary

school age who had autism spectrum disorders and developmental disabilities. The participants

were selected from summer special education programs. All participants had experience using

PECS while none of them had used an iPad. The study was conducted in a classroom setting
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 9

during snack time. Prior to instructing the children to use the iPad for requesting items, the

researchers conducted a pretest by giving each child access to the iPad during opportunities to

request food items. Following the pretest, the students were instructed to use the iPad to request

items. A post-test was conducted after the instruction. The students were also given opportunities

to request items using PECS. The results of this study were mixed. One student showed

increased frequency of communication behaviors during the iPad sessions as compared to the

PECS sessions. However, most of the students had a similar frequency of communication

behaviors during both the iPad and PECS sessions.

PECS and VOCA

Beck, Stoner, Bock, and Parton (2008) compared the effectiveness of the PECS with the

Voice Output Communication Aid (VOCA) for children who do not speak or have limited

speech. The study attempted to distinguish which Augmentative and Alternative Device would

yield greater preference amongst preschool aged children with autism. Four children of

preschool age participated in both PECS and VOCA interventions. The treatment consisted of

four sessions a week for four weeks. All participants were obtained from an Autism Summer

School. Three of these participants were boys, and one of the participants was a girl. The PECS

intervention intended to guide the participant to use the picture exchange for a desired item. The

VOCA intervention was for the participant to hold the VOCA in the right way and find the

correct picture to produce the specific digitized speech for a particular item. Each session

consisted of ten opportunities or fifteen minutes of requesting items for one intervention

followed by the other. Participants were randomly assigned to one intervention first, and the next

day the order of interventions was reversed. The study consisted of a reinforcement inventory,

baseline, phase I, phase II, phase III, and generalization probes. The findings showed that the
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 10

first phases of PECS could be learned in a quick amount of time. It seems that the use of VOCA

is more difficult for the participants to learn. Part of the limitations of the VOCA interventions

was due to physical difficulty in operating the device. The study also had a limited sample size

and limited time span.

PECS and PRT

Schreibman and Stahmer (2014) conducted a randomized trial in order to compare the

effects of the PECS with Pivotal Response Training (PRT) in children with autism. The intention

of the study was to indicate which language device facilitates a greater increase in spoken

language. Thirty-nine children with autism and an age range within 20 and 45 months

participated in this study. The children were placed in either the PRT or PECS group through

stratified randomization. Assessments were performed at the beginning of the program, after the

intervention, and after 3 months following treatment. Treatment consisted of a scheduled 258

hours with the assigned intervention. As a part of the initial 15 weeks, parents attended 2-hour

biweekly sessions with their children in the lab. Children also participated in five, 2-hour

sessions every week of treatment in the home. The following eight weeks consisted of two, 2-

hour sessions in lab and two, 2-hour sessions in home. The study showed no greater

effectiveness of one intervention over the other. Both PECS and PRT made a similar increase in

verbal communication. This treatment did not include a control group, and therefore cannot

prove that treatment caused the measured gains.

PECS and RPMT

Yoder and Stone (2006) compared the overall effect of the PECS and Responsive

Education and Prelinguistic Milieu Teaching (RPMT) for increasing spoken communication in

children with Autism Spectrum Disorder. This study consisted of a randomized group treatment
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 11

with a pretreatment, post-treatment, and a follow-up. Thirty-six preschoolers with autism

spectrum disorder were randomly assigned to either the PECS or RPMT intervention groups.

Each participant underwent semi structured free-play with examiner (SFPE) for 15-minute

sessions. During these intervention times, the amount of spoken language was transcribed from

video recordings and then analyzed. Overall, both interventions increased spoken

communication. However, without a control group, the study is unable to prove against the

possible growth effects of maturation. PECS had a greater production of non-imitative spoken

acts and non-imitative words in comparison to RPMT. The RPMT intervention produced a

greater analogous slope for the participants who started the experiment with lower object

exploration. Examiners and coders were not blinded from the assigned treatment.

Discussion

In this review of PECS as an intervention for children with ASD, eight studies fulfilled

the inclusion criteria. Two of these studies established the effectiveness of PECS in regards to

appropriate and accurate training. One study assessed the preference of children with ASD for

PECS or VOCA as an AAC tool. Three studies compared the effectiveness of PECS to that of

SGD using an ipad or a ProxTalker communication device. One study compared the use of PECS

to PRT to facilitate a greater increase in spoken language. One study was analyzed that evaluated

the difference in effectiveness between PECS and RPMT for spoken language.

PECS Effectiveness

Through the compilation of our studies, we have observed a wide range of effectiveness

of PECS for those with ASD. A majority of the studies found an increase in language through

both methods of AAC. Flores et al. (2012), Boesch et al. (2013), and Schreibman and Stahmer

(2014) all had mixed results where children had an increase in communication through both
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 12

methods. Flores et al. (2012) and Boesch (2013), while comparing PECS and SGD, were unable

to state that one intervention had greater effectiveness than the other. This was also true for the

comparison of PECS and PRT in the study by Schreibman & Stahmer (2014). Both interventions

provided an increase in spoken language skills. This does not show that PECS is ineffective, but

that both interventions provided a significant increase in language ability.

Beck et al. (2008) revealed that PECS can be learned in a shorter amount of time when

compared to VOCA. This reveals the ease that participants were able to utilize PECS for

communication needs. The differences in results was also seen due to the physical demands of

communicating through VOCA. Agius and Vance (2016) stated that not only could PECS be

learned in a short amount of time, but also that the speed of use with minimal errors is

significantly higher for PECS. Continued speed and accuracy of PECS was maintained through

future sessions compared to SGD. A faster and easier means of communication provides those

with ASD a more immediate form of communication. This immediate form of communication

provides the opportunity to more readily learn in other areas of their education.

Limitations

There were some limitations observed in the creation of this systematic review. Although

the effectiveness of PECS was compared to other AAC interventions, this study did not observe

the effectiveness of other AAC means such as sign language or facilitated communication.

Studies indicating these comparisons were not available to the researchers and therefore were not

included in the analysis. However, it is important for further research to be done to decide if

these are adequate interventions to use for children with ASD. Within this limitation is also the

fact that this review had a greater focus on PECS compared to SGD due to the progress towards
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 13

this form of AAC. A review that not only included alternate forms of AAC, but also included

multiple studies would create a more informative determination.

Another limitation is the study of different modifications to the PECS intervention.

Because those with ASD may have a wide variety of physical, cognitive, and visual deficits, the

PECS intervention may need to be adapted further to the childs needs. An analysis of the

different modifications to the PECS intervention needs to be explored in order to provide a more

conclusive intervention for the specific needs of each child. For some children, PECS may be

seen as ineffective do to low vision or inability to manipulate the pictures. This may be a factor

that indicates a lesser effectiveness, but PECS can also be altered in order to better suit each

child.

Also, the availability of RCT studies was lacking for the realm of comparing AAC

devices for those with ASD. There is no comparison to the natural growth in speaking ability in

children without an AAC intervention. This is seen due to the unethical nature of not providing

children with a means to communicate. Therefore, the data analyzed was not compared to a

controlled group. The use of convenience samples provides situational based data, however, the

ability to minimize the effect of outside variables is not available.

PECS in Clinical Practice

According to the American Heart Associations classification of recommendation and

level of evidence chart, using PECS as a method of AAC has a recommendation level of IIa.

This means that is is reasonable to use this intervention method. Based on the research found,

PECS has been shown to be effective as an AAC method. The research has not shown PECS to

be significantly more effective than other AAC methods. More research should be conducted on
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 14

the subject. However, the benefits of using PECS outweigh the risks. Therefore, the researchers

have concluded that the use of PECS is more beneficial than not using any form of AAC.

There is great variability among individuals on the autism spectrum. Because it is a

spectrum, each individual will have unique characteristics, deficits, needs, and communication

styles. Considering this fact, it is important that clinicians understand the need to adapt AAC to

meet the unique needs of each individual. PECS can be an effective communication method for

individuals with ASD, but the system may need to be modified to meet the users needs.

Modifications may be made to the materials, such as enlarging pictures or using more durable

materials. Modifications may also be applied to the procedural aspects of the system, involving

the way the individual interacts with the materials.

When necessary modifications are made to PECS, the system can better fit the

communication needs of the user. In a clinical setting or in other practice areas, such as schools

and early intervention, PECS can be used to enable children with ASD to be able to

communicate. Depending on the unique skills and needs of the child, PECS may or may not be

the most appropriate AAC method. Considering the research found, PECS is shown to be a

useful method of AAC that can help children with ASD be able to better communicate with

others. This increased communication can enable children with ASD to meet their needs and be

able to more fully participate in everyday life.

PECS EFFECTIVENESS FOR CHILDREN WITH ASD 15

References

About Autism | Autism Society. (n.d.). Retrieved April 07, 2016, from http://www.autism-

society.org/what-is/

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), 58-68. doi: 10.3109/07434618.2015.1108363

American Speech-Language Hearing Association. (n.d.). Augmentative and Alternative

Communication (AAC). Retrieved April 07, 2016, from

http://www.asha.org/public/speech/disorders/AAC/

Beck, A. R., Stoner, J. B., Bock, S., & Parton, T. (2008). Comparison of PECS and the use of a

VOCA: A replication. Education and Training in Developmental Disabilities, 43, 198

216.

Boesch, M. C., Wendt, O., Subramanian, A., & Hsu, N. (2013). Comparative Efficacy of the

Picture Exchange Communication System (PECS) versus a Speech-Generating Device:

Effects on Social-communicative Skills and Speech Development. AAC: Augmentative &

Alternative Communication, 29(3), 197-209 13p. doi:10.3109/07434618.2013.818059

Christensen, D. L., Baio, J., Braun, K. V., Bilder, D., Charles, J., Constantino, J. N., . . .

Yeargin-Allsopp, M. (2016). Prevalence and Characteristics of Autism Spectrum

Disorder Among Children Aged 8 Years Autism and Developmental Disabilities

Monitoring Network, 11 Sites, United States, 2012. MMWR. Surveillance Summaries

MMWR Surveill. Summ., 65(3), 1-23.

PECS EFFECTIVENESS FOR CHILDREN WITH ASD 16

Cummings, A. R., 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, 32-45. doi:10.1016/j.rasd.2011.08.006

Data & Statistics. (2016). Retrieved April 02, 2016, from

http://www.cdc.gov/ncbddd/autism/data.html

Flores, M., Musgrove, K., Renner, S., Hinton, V., Strozier, S., Franklin, S., & Hil, D.

(2012). A comparison of communication using the Apple iPad and a picture-based

system. Augmentative and Alternative Communication, 28(2), 74-84. doi:

10.3109/07434618.2011.644579

Ganz, J. B., Simpson, R. L., & Corbin-Newsome, J. (2007). The impact of the picture

exchange communication system on requesting and speech development in preschoolers

with autism spectrum disorders and similar characteristics. Research in Autism Spectrum

Disorders, 2(1), 157-169. doi:10.1016/j.rasd.2007.04.005

Lavelle, T. A., Weinstein, M. C., Newhouse, J. P., Munir, K., Kuhlthau, K. A., & Prosser,

L. A. (2014). Economic Burden of Childhood Autism Spectrum Disorders. Pediatrics,

133(3).

Research Autism. (n.d.). Picture Exchange Communication System (PECS) and Autism.

Retrieved April 07, 2016, from http://researchautism.net/autism-

interventions/types/alternative-and-augmentative-communication/picture-exchange-

communication-system-and-autism

Schreibman, L., & Stahmer, A. (2014). A Randomized Trial Comparison of the Effects of
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 17

Verbal and Pictorial Naturalistic Communication Strategies on Spoken Language for

Young Children with Autism. Journal Of Autism & Developmental Disorders, 44(5),

1244-1251 8p. doi:10.1007/s10803-013-1972-y

Yoder, P., & Stone, W. (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 & Hearing Research, 49(4), 698-

711 14p.
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 18

EBP CHARTS

Author/ Design/ Variables

Measures/ Findings Limitations
Date Sample

Data Collection

Agius & 3 children, Quantitative- Three Children with ASD

Vance preschool age Single-subject design independent can be taught to
(2016). Multiple baseline design measures: 1) use PECS and an
All had autism with a adapted number of iPad/SGD.
spectrum disorder alternating treatment independent Skill acquisition is
and limited design requests, 2) similar for both
functional speech DV = requesting number of trials methods.
reinforcers to criterion, 3) Faster phase 1
All lived in Malta IV = use of PECS or modality skills acquisition
iPad preference data and fewer errors
for PECS.
3 Phases must Higher retention
meet mastery for PECS in follow-
criteria before up.
moving to next
phase

Modality
preference
assessment at
the beginning of
each baseline,
intervention, and
post-intervention
session

Beck, A. 4 preschool Alternating 10 PECS was Limited

R., children treatment single opportunities or acquired at a sample size
Stoner, Central Illinois subject design 15 min higher rate than Limited time
J. B., & Non-speaking DV (PECS) sessions VOCA span
Bock, S., 3 males, 1 correct response- (whichever Supports use of
(2008) female exchanging a picture came first) a systematic,
for desired item 4 days a behaviorally-
DV (VOCA) week for 4 based program
accessing a picture to weeks for teaching
produce digitized Transcribed children to
speech for a desired vocalization initiate
item recordings communication
IV VOCA and utilizing either
PECS pictures
Randomly selected
to VOCA/PECS or
PECS/VOCA

Boesch, 3 elementary Experimental Sessions 2-4 Results for Combined

M. C., school aged A single subject times a week social- communicat
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 19

Wendt, students Multiple baseline (15 min) communicative ion into one
O., ASD (severe design 5 months behavior were product
Subrama childhood range) Alternating treatment 3 stage mixed ignoring
nian, A., design preference Little difference individual
& Hsu, IV Picture assessment was observed parts
N. Exchange (before) between PECS
(2013) Communication Event and SGD
System (PECS) and recording of conditions
speech-generating AAC success
device (SGD) were Baseline,
compared Phase I, II, II,
DV Social Follow-up, and
Communicative maintenance
behavior and natural MacArthur-
speech production; Bates CDI
requesting skills questionnaire

Cummin 7 children Multiple baseline design Data collected for PECS exchanges
gs et al. All males Single Subject Design 6 phases of only increased
(2012) Developmental or training after training was
language disorders DV = percentage of completed for
independent exchanges Prior to phases 1-4.
per 10-trial session intervention: All participants
IV = following the Behavioral demonstrated an
training protocol for Language increase in correct
each of 6 phases of Assessment exchanges during
PECS Form used to phases 5-6.
assess language Responses were
skills, correct for What
Assessment of do you want?
Basic Learning questions rather
Abilities used to than What do you
assess visual see?
discrimination PECS can be
skills effectively taught
in a relatively short
IOA ranged length of time.
between 94- Modifications in
100% training may need
to be made for
Stimulus individual children.
preference The PECS
assessments protocol is
PECS testing at effective for
each phase training.

Author/ Design/ Variables

Measures/ Findings Limitations
Date Sample

Data Collection
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 20

5 children, Quasi-experimental, Recorded the Results were Students

Flores et
Elementary school Pre-test, post-test frequency of mixed. Some had previous
al.
age design communication children showed a experience
(2012)
DV = frequency of behaviors higher frequency with PECS
All had ASD and communicating of communication and not with
developmental behaviors Cognition behaviors when the iPad
disabilities IV = use of PECS or assessed using using the iPad.
iPad the Leitner Most children had
All had previous International approximately
experience using Performance equal rates of
PECS, no previous Scale Revised communication
use of iPad behaviors while
Spoken language using either
assessed using method.
the TOLD P-4

Ganz et 3 children Single-subject design, 1-10 PECS Did not Did not use
al. 3-5 years old multiple baselines sessions per significantly a pre-
(2007) participant/wk, 10 increase assessment
Participants had DV = percentage of trials per session expressive
ASD, independent phrases speech.
developmental IV = PECS use, Recorded Individual levels of
delays, and modeling of percentage of cognition can
characteristics of verbalizations, training independent affect the
ASD guidelines phrases, effectiveness of
Average number PECS.
of words spoken 2 out of 3
per session, mastered the
Number of system.
intelligible words Need to assess
and word each childs
approximations preferred style of
visual
representation.

Schreib Age between Experimental pre-post Dependent Children in both No control

man, L., 20 and 45 or repeated measures measures at intervention group
& months design program entry, groups
Stahmer 39 families (39 Randomly assigned to post demonstrated
, A. kids) PRT or PECS using a intervention, increases in
(2014) 34 male, 5 stratified and 3-month spoken language
female randomization follow up skills
Absence of procedure 15 weeks of 5, No significant
prior PECS or IV PRT or PECS 2-hr sessions in difference
PRT use DV Overall home (2, 2 hr between the two
Diagnosis of communication, sessions in lab) conditions
Autistic Disorder expressive 8 weeks of 2, 2-
vocabulary, pictorial hr sessions in
communication and home
parent satisfaction
20 in PRT; 19 in
PECS

Yoder, 36 Randomized group 6 month Both treatments Coders and

P., preschoolers experiment period had strong examiners
& Stone, Autism Pre-post 24 hour growth of spoken were not
W. spectrum experiment; 6-month maximum total language blinded to
PECS EFFECTIVENESS FOR CHILDREN WITH ASD 21

(2006) disorders or follow up Semi- PECS treatment

pervasive IV PECS or structured free- increased non
developmental RPMT (Responsive play with imitative
disorder Education and Pre- examiner language more
Age 18-60 linguistic Milieu (SFPE) Analogous
months Teaching) 15 minute slopes were
DV spoken session more in RPMT
communication/non Coding for those starting
imitative word use transcribed with low object
from exploration
videotaped
recording