INT J LANG COMMUN DISORD, SEPTEMBER–OCTOBER 2012,

VOL. 47, NO. 5, 609–617

Short Report
Social–communicative effects of the Picture Exchange Communication
System (PECS) in Autism Spectrum Disorders
Anna Lerna†, Dalila Esposito†, Massimiliano Conson‡, Luigi Russo† and Angelo Massagli†
†Scientific Institute I.R.C.C.S. “Eugenio Medea" Regional Branch of Ostuni, Brindisi Department of Neurorehabilitation 2,
Child Psychiatry, Brindisi, Italy
‡Neuropsychology Laboratory, Department of Psychology, Second University of Naples, Caserta, Italy

(Received February 2012; accepted May 2012)

Abstract
Background: The Picture Exchange Communication System (PECS) is a common treatment choice for non-
verbal children with autism. However, little empirical evidence is available on the usefulness of PECS in treating
social–communication impairments in autism.
Aims: To test the effects of PECS on social–communicative skills in children with autism, concurrently taking
into account standardized psychometric data, standardized functional assessment of adaptive behaviour, and
information on social–communicative variables coded in an unstructured setting.
Methods & Procedures: Eighteen preschool children (mean age = 38.78 months) were assigned to two intervention
approaches, i.e. PECS and Conventional Language Therapy (CLT). Both PECS (Phases I–IV) and CLT were
delivered three times per week, in 30-min sessions, for 6 months. Outcome measures were the following: Autism
Diagnostic Observation Schedule (ADOS) domain scores for Communication and Reciprocal Social Interaction;
Language and Personal–Social subscales of the Griffiths’ Mental Developmental Scales (GMDS); Communication
and Social Abilities domains of the Vineland Adaptive Behavior Scales (VABS); and several social–communicative
variables coded in an unstructured setting.
Outcomes & Results: Results demonstrated that the two groups did not differ at Time 1 (pre-treatment assessment),
whereas at Time 2 (post-test) the PECS group showed a significant improvement with respect to the CLT group
on the VABS social domain score and on almost all the social–communicative abilities coded in the unstructured
setting (i.e. joint attention, request, initiation, cooperative play, but not eye contact).
Conclusions & Implications: These findings showed that PECS intervention (Phases I–IV) can improve social–
communicative skills in children with autism. This improvement is especially evident in standardized measures of
adaptive behaviour and measures derived from the observation of children in an unstructured setting.

Keywords: Picture Exchange Communication System (PECS), autism, intervention, social and communicative
skills.

What is already known on this subject

The Picture Exchange Communication System (PECS) is an augmentative communication system frequently used
with non-verbal children with autism. PECS can facilitate functional communication, improve severe impairments
of functional speech, decrease the behaviors problem. Only a small number of studies suggest positive effects in the
social domain.
What this study adds
This paper shows the possibility of using PECS for improving socio-communicative skills in autistic children.
An experimentally controlled group investigation was conducted using data collected with formalized measures of
communication and social functioning and with behaviour observation of participants in an unstructured setting.
Outcomes measures after PECS training suggest that this intervention (based on the “physical exchange” within an
interactive context) can represent an effective tool for promoting improvement of social-communicative skills.

Address correspondence to: Angelo Massagli, Department of Neurorehabilitation 2, Child Psychiatry Scientific Institute I.R.C.C.S.
‘Eugenio Medea’, Regional Branch of Ostuni–Brindisi, Di Summa Square, I-72100 Brindisi, Italy; e-mails: angelo.massagli@os.lnf.it and
angelo.massagli@tin.it
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  c 2012 Royal College of Speech and Language Therapists
DOI: 10.1111/j.1460-6984.2012.00172.x
610
Introduction
Communication and social impairments appearing
early in life and persisting into adulthood are core
features of Autism Spectrum Disorders (ASD; American
Psychiatric Association (APA) 2000, Howlin et al.
2004). In the past, rehabilitation interventions aimed
at improving language and communication in children
with ASD mainly focused on verbal production through
response training, while neglecting that, unlike non-
verbal training, this method did not influence communi-
cation skills (Howlin 1998). At present, successful
rehabilitation strategies of non-verbal autism are centred
on functional spontaneous communication. This has
favoured implementation of Alternative Augmentative
Communication (AAC) systems devoted to the develop-
ment of non-verbal communication by using signs,
pictures and symbols (Howlin 1998, Howlin et al. 2007,
Mirenda 2003, Schuler et al. 1997). Various forms
of AAC have been devised. These include the use of
manual signs, voice output communication devices and
various picture-based systems (for a recent meta-analysis
on AAC in ASD, see Ganz et al. 2011). The Picture
Exchange Communication System (PECS), originally
developed by Bondy and Frost (1994), is a picture-
based AAC system that was specifically designed for
non-verbal children with ASD (for recent reviews, see
Flippin et al. 2010, and Ganz et al. 2011). PECS
uses basic behavioural principles, particularly reinforce-
ment techniques, to teach children to use functional
communication in a social interaction context (Bondy
and Frost 1994, 1998).
The PECS protocol includes six instructional phases
(Bondy and Frost 1998): Phases I and II include teaching
the student to exchange pictures for preferred items
and activities (Phase II expands on Phase I by teaching
generalization across distance, communicative partners
and a variety of items and pictures); in Phase III
students learn to discriminate between preferred and
non-preferred pictures and eventually between a variety
of preferred items; in Phase IV students are taught
to make requests using complete sentences; Phase V
involves instruction in answering questions; and in the
final phase, Phase VI, students learn to make a variety of
comments. Thus, the first four phases focus on teaching
the child to use a symbol to make a request, while the
final two phases expand the range of communicative
functions used by the child.
Despite the fact that PECS is a popular
communication-training programme for non-verbal
children with autism (Flippin et al. 2010, Howlin et al.
2007), only a few empirical studies are available on its
efficacy in treating social–communication impairments
in autism. More precisely, while several investiga-
tions indicated that PECS can provide a viable means
to facilitate communication and to improve severe
Anna Lerna et al.
impairments of functional speech (Flippin et al. 2010),
only a small number of studies suggest positive effects
in the social domain (Preston and Carter 2009).
In a study on three individuals with autism,
Charlop-Christy et al. (2002) demonstrated positive
treatment-related increases in speech and different
social–communicative behaviours, especially initiations,
requests and joint attention. Accordingly, in a single case
study Kravits et al. (2002) reported some increase in
duration of social interaction with peers and provided a
demonstration of the effectiveness of PECS in increasing
spontaneous communication skills.
In a randomized control study, Yoder and Stone
(2006) compared the effect of PECS with that of
another communicative intervention (i.e. Responsive
Education and Prelinguistic Milieu Teaching—RPMT),
on initiating joint attention, requesting and turn-taking,
and found that RPMT facilitated the frequency of
generalized turn-taking and generalized initiating joint
attention more than the PECS did, whereas the PECS
had a superior effect to generalized request in children
with initially low rates of initiating joint attention. Carr
and Felce (2007) focused on spontaneous communica-
tive initiation following PECS training and found
significant increases in initiation and dyadic interac-
tion between children with autism and their teachers.
Analogously, in another randomized control study
Howlin et al. (2007) investigated potential effects
of PECS training on spontaneous communication of
children with ASD in a school setting and found that
rates of communicative initiations and PECS usage were
significantly increased immediately following interven-
tion (also Gordon et al. 2011). The authors also
examined ADOS-G (Lord et al. 2000) domain scores
for communication and reciprocal social interaction,
and only observed a specific decrease in the severity
score for reciprocal social interaction at the 10-month
follow-up.
This review shows that only three group studies
are available on social–communicative effects of PECS
training in ASD. In two studies a specific analysis
was performed on behavioural measures derived
from observation of participants in an unstructured
setting, without providing a systematic assessment with
standardized tests (Carr and Felce 2007, Yoder and
Stone 2006). In the third study, a less deep behavioural
observation has been combined with standardized tests
specifically assessing language and only one measure of
social–communicative abilities (i.e. ADOS Communi-
cation and Reciprocal Social Interaction domains;
Howlin et al. 2007). Recently, Preston and Carter (2009)
claimed that investigations on social–communicative
effects of PECS training should concurrently take
into account standardized psychometric data, standard-
ized functional assessment of adaptive behaviour, and
Social–communicative effects of PECS in ASD 611
information on social–communicative variables coded Table 1. Means and standard deviations (SD) of demographic
in an unstructured setting. On this basis, in the present variables, GMDS Non-verbal IQ and ADOS Total score,
separately for the two groups
study we conducted an experimentally controlled group
investigation to test the effects of the first four PECS PECS CLT
phases on social–communicative behaviours of children Variable Mean SD Mean SD
with ASD. To this aim, we collected psychometric
data and functional measures of adaptive behaviour Chronological age (months) 38.78 7.43 41.11 8.67
Mother’s education (years) 13.56 3.00 11.89 2.21
by means of standardized tasks, and evaluated social– Father’s education (years) 11.67 3.84 10.44 3.17
communicative skills in an unstructured setting through GMDS Non-verbal IQ 73.56 18.15 68.56 16.97
observation of children’s free-play interactions with an ADOS Total score 16.78 4.06 16.11 3.86
adult.

Methods tion, whereas the control group received a Conventional

Participants
The participants were all recruited from ‘Eugenio
Medea’ Scientific Institute, Regional Branch of Ostuni
(BR), Italy, an institute for diagnosis and rehabilita-
tion of developmental disorders. For inclusion in the
study each child was required: (1) to have a diagnosis of
autism; (2) to be aged between 18 and 60 months; (3) to
have little or no functional language (spontaneous use
of fewer than five words according to parent report,
defined on the basis of clinical observation and the
MacArthur Communicative Development Inventory;
Fenson et al. 1993), (4) not to be using PECS or
other ACC systems, and (5) to have no evidence of
severe sensory, motor deficits or of known co-morbid
medical conditions. Diagnosis of autism was based on
the following criteria: (a) a formal clinical diagnosis
made by a child psychiatrist and a clinical psychol-
ogist according to the criteria of the DSM-IV; and
(b) results from the Autism Diagnostic Observation
Schedule (ADOS; Lord et al. 1999) administered by
trained and certified examiners.
Thirty children were screened for participation in
the study between September 2010 and February 2011,
and 18 children fitted the inclusion criteria, so that
the total sample size was 18. All children were from
southern Italy; 17 male and one female. The mean
non-verbal IQ (based on level performance of Griffiths’
Mental Developmental Scales) was 71.1 (SD = 17.2)
and ranged from 44 to 98 points. Mean production
score on the MacArthur Communicative Development
Inventory was 1.72 (SD = 2.26), and total score on
the ADOS was 16.52 (SD = 3.76). The mean formal
educational level of the primary parent was 12.7 years
(SD = 2.7) for mother and 11.1 (SD = 3.5) for father.
Participants were assigned either to the experimen-
tal or to the control group after parents had provided
written informed consent. However, parents were
unaware of the precise goals of the study and of the
specific children’s skills that were targets of the interven-
tion. The experimental group received PECS interven-
Language Therapy (CLT). The two groups were defined
by territory, that is a 30–50-mile limit was set as a
viable distance for the parents to travel to reach the
‘Eugenio Medea’ Institute where PECS training was
implemented. Therefore, all the children in this area
who met the inclusion criteria for participation were
included in the intervention group, whereas children
outside the 30–50-mile limit who met inclusion criteria
were recruited for the control group. The control group
received CLT training in other rehabilitation structures
accredited with the Italian National Health System
placed within a short distance from their home.
All pre-test measurements were given to partici-
pants before the intervention sessions were initiated.
Table 1 presents descriptive information of the sample,
separately for the two groups.
Procedure
At entry into the study (Time 1), children received four
pre-treatment assessments (see the Outcome Measures
section below). The treatment phase lasted 6 months,
and at the end of this period the four pre-treatment
measures were repeated (Time 2). All assessment
procedures at both time points were conducted by
examiners who were blind to the purpose of the study
and to group assignment of the participants. Evaluation
took place in a building that was different from the
therapy building, and used materials and activities that
were not used in therapy sessions.
Outcome measures
The efficacy of treatment was assessed via a battery
of standardized assessments of social–communicative
abilities. In addition, several behavioural measures were
derived from observation of a free-play session with an
examiner. The following measures were included.
• Griffiths’ Mental Developmental Scales (GMDS;
Griffiths 1984): language subscale, assessing
612 Anna Lerna et al.
Table 2. Dependent measures and operational definitions for behaviours observed in the UFPE

Dependent measure Operational definition

Cooperative play Child engaged in the same activity (e.g. basketball, puzzles, board games) with the therapist for at least 10 s
Eye contact Child looked into therapist’s eyes for 2 s
Joint attention (a) Observing same object for 5 s
(b) Referential look between therapist and an object
(c) Established common attention focus with therapist
Requests Labelling object while pointing or reaching for it, handing the therapist PECS cards, verbal requests
Initiation Independent approach to therapist with vocal or non-vocal attempt to engage in conversation or play (e.g. pulling on
therapist’s shirt to get attention, play, handing therapist a toy)

receptive and expressive language, and personal–
social subscale, assessing proficiency in the
activities of daily living, level of independence and
interaction with other children, were employed as
outcome measures.
• Autism Diagnostic Observation Scale (ADOS; Lord
et al. 1999). Communication and Reciprocal
Social Interaction domain scores were used to
assess change over time.
• Vineland Adaptive Behavior Scales, Second Edition
(VABS; Sparrow et al. 2005). VABS were used to
gather parent report of child communication and
social abilities at home and in the community.
• Unstructured Free-Play with Examiner (UFPE).
Following previous studies on social–
communicative effects of PECS (Charlop-Christy
et al. 2002, Yoder and Stone 2006) a 15-min
session of UFPE was planned in order to collect
data on specific variables, i.e. cooperative play, eye
contact, joint attention, requests and initiation.
The operational definition of these variables was
based on Charlop-Christy et al.’s (2002) criteria
(table 2). UFPE was conducted in a room with
a variety of age appropriate toys or objects (i.e.
bubbles, balloons, stuffed and rubber animals,
female baby doll, building blocks, wind up car,
electronic toys, a small table and two chairs)
accessible to the children. The PECS book was
present in pre- and post-treatment and both
groups had the possibility to use it. The examiner
played with the same or similar toy as the child
by imitating the child’s play. If the child did not
attend to any toy for 10 s, then the examiner
selected an interesting object and used it in a way
that was suitable to the cognitive level of the child.
Examiners verbally commented on the child’s or
their own actions, but they were instructed not to
use any type of communication prompt, such as
time delays, questions or gestural prompts.
Social–communicative behaviours coded during the
UFPE session were derived from videotaped records
of the free-play session using the Observer Video Pro
(version XT.7; Noldus Information Technology 2007)
software package to transform a standard computer
keyboard into a point and state events recorder. The
point events were behaviours that only take an instant
in time, or whose duration was not important, i.e. joint
attention, requests and initiation; these variables were
coded in terms of frequency. The state events were
behaviours that take a period of time and therefore
have a duration, i.e. cooperative play, eye contact; these
variables were coded in seconds. The duration of the
session was exactly 15 min for all children; therefore
no correction for the length of the observation was
necessary.
Reliability of coded variables was analysed on
independently coded and randomly selected samples.
Two independent observers were trained to use the
coding system developed for the purposes of this study.
Each of the observers had a Master’s degree in clinical
or developmental psychology and received training by
an experienced clinician using video samples of children
not involved in the study. The observers (coders) were
blind to the purposes of the study and the treatment
assignment. Inter-rater reliability was determined by
double coding of 20% of the observations and was very
good (Kappa = 0.87).
Treatments
PECS and CLT were implemented within a psycho-
education rehabilitation programme based on the
TEACCH methodology (Mesibov et al. 2004).
All children followed a structured teaching for a
total 12 h a week; children were taught skills
including attention, basic discrimination, language and
spontaneous communication, daily living, socialization,
play, fine and gross motor control and pre-academics
(Watson et al. 1989). A semi-structured setting was
also implemented, using incidental teaching techniques,
to enhance generalization, increase motivation, develop
social skills and to decrease problem behaviours.
Treatments sessions took place in a therapeutic
room equipped with small desks, chairs, familiar and
unfamiliar objects and toys; children were offered 30-
Social–communicative effects of PECS in ASD 613
Table 3. Brief description of the PECS phases implemented in the study

Phase
I: Picture exchange
II: Increasing distance
III: Picture discrimination
IV: Sentence structure
Description
The child is taught to approach a communicative partner, give him or her a picture card, and receive a
preferred item
The child is taught to retrieve a picture from his PECS board, which had been moved away from him,
walk to a communicative partner and persist in handing the picture to the communicative partner,
who had moved across the room
The child is taught to discriminate among multiple pictures on the PECS board. At the end of this
phase the child can choose from six or more preferred and non-preferred items
The child creates a ‘sentence’ on the sentence strip by combining the ‘I want card’ and the card of a
desired item, seeks out the communicative partner, and gives him or her the sentence strip

min individual therapy sessions (PECS or CLT) three
times a week for 6 months (i.e. 72 sessions).
Experts leading both PECS and CLT were special-
ists in speech–language pathology with extensive
expertise with ASD. As specifically regards PECS,
the trainer attended two workshops about PECS
basic and advanced training provided by an expert
consultant of Pyramid Educational Consultants UK,
following the highly prescribed format of the training
manual (Frost and Bondy 2002), and received a
certificate of attendance at the conclusion of each
workshop.
Phases I–IV of PECS were implemented according
to the standard procedures devised by Bondy and Frost
(1998); table 3 provides a brief description of each the
four PECS phases. Before beginning of the training,
parents were required to record their children’s favourite
food and toys on a card in order to make picture cards
to be included in the communication book, according
to the standard procedure.
The percentage of correct requests per session and
the number of sessions per criterion were measured
for each of the four PECS phases. Observations were
carried out independently by two autism specialists,
speech-and-language therapists, one of which was the
PECS trainer. There was 100% agreement regarding the
PECS level between the two assessors. The criterion for
advancement within a phase was set at 80% independent
on symbol exchanges made during PECS instruction.
Training within each phase of PECS was continued until
all children were able to demonstrate independently a
correct response score of 80% or higher for a minimum
of three consecutive sessions, in accordance with the
criteria outlined in the PECS training manual (Bondy
and Frost 1994). The mean number of PECS sessions
for each phase was 6.3 (SD = 2.3); within these sessions,
children were provided with a mean number of 91
(SD = 38.9) individual trials.
Conventional Language Therapy (CLT) is a
language training based on a systematic, step-by-
step teaching technique using prompts and useful
reinforcements. In Italy it represents one of the
most widely employed methods to treat language and
communicative disorders in developmental disabili-
ties in accordance with the guidelines of the Italian
National Health System. CLT employs a variety of
largely operant approaches to language intervention
implemented in accordance with discrete trial training
formats (Goldstein 2002, Lovaas 1981, 2002): the child
is taught to attend to adults and respond to simple
instructions (receptive language training); she/he has to
first imitate manual, oral-motor and vocal behaviour,
and then to imitate speech. Association learning is
used for teaching increasingly sophisticated expressive
language skills, and motivation is favoured through use
of various external rewards. CLT uses didactic, adult-
directed instructions in a one-to-one interaction: each
session begins by presenting the child with his own
preferred items. If the child shows motivation to obtain
the item (e.g. reaching for it), the therapist waits for
a few seconds to provide the opportunity for the child
to say the word independently. If the child does not
produce the word, the therapist repeats the name of
the object three times with time delay. When the child
spontaneously names or imitates the name, or produces
a word approximation, she/he receives the desired
item.
Results
Standardized test assessment
We investigated group differences before treatment. To
this aim, a MANOVA was performed with demographic
characteristics and mean standard scores on formalized
tests at Time 1 (tables 1 and 4) as dependent variables
and group as independent variable. Results showed
that there were no significant group differences in
demographic data and Time 1 formalized tests scores (all
p > 0.05), thus demonstrating that the two groups were
well matched with respect to pre-treatment measures
and that no covariate was needed to analyse group
differences on Time 2 measures.
614 Anna Lerna et al.
Table 4. Means and standard deviations (SD) of standard scores on formalized outcome measures at Times 1 and 2 separately for the
two groups

Time 1 Time 2
PECS CLT PECS CLT
Variable Mean SD Mean SD Mean SD Mean SD
GMDS
Language 35.00 7.98 36.00 13.18 38.44 14.70 36.67 17.43
Social 61.78 8.00 53.56 12.03 63.00 8.41 55.22 11.17
ADOS
Communication 6.44 1.74 6.22 2.39 5.89 3.44 6.11 2.09
Reciprocal Social Interaction 10.11 3.02 10.22 1.99 9.56 2.40 9.89 1.76
VABS
Communication 56.33 13.20 55.67 10.79 64.89 8.64 60.56 17.08
Social 64.56 6.95 60.00 3.46 82.67 19.91 60.78 3.67

Table 5. Means and standard deviations (SD) of behavioural outcome measures coded during free-play at Times 1 and 2 separately
for the two groups

Time 1 Time 2
PECS CLT PECS CLT
Variable Measure Mean SD Mean SD Mean SD Mean SD
Cooperative play Duration 40.56 30.06 32.56 36.41 209.78 131.72 74.89 63.73
Eye contact Duration 4.00 4.18 9.11 16.21 19.22 21.22 26.00 39.46
Joint attention Frequency 1.00 1.12 1.11 2.03 4.11 3.86 0.44 0.53
Requests Frequency 1.78 2.22 3.44 2.35 6.44 4.72 2.67 2.12
Initiation Frequency 0.22 0.44 0.67 1.41 3.67 4.00 0 0

A MANOVA was performed with mean standard
scores on formalized outcome measures at Time 2
(table 4) as dependent variables and group as
independent variable. Results showed significant group
differences on VABS—Social, F (1, 16) = 10.519,
p = 0.005, η2 p = 0.397, but not on all the other Time
2 measures (all p > 0.05).
A within-group comparison between Times 1 and
2 scores was performed separately in PECS and CLT
group. As regards the PECS group, paired t-tests showed
a significant improvement of scores on both VABS—
Communication (t(8) = –2.484, p = 0.038) and
VABS—Social (t(8) = –3.331, p = 0.010) domains, but
not on the other measures (all p > 0.050). The same
analysis performed on the CLT group did not reveal
significant difference on any of the considered measures
(all p > 0.050).
(table 5) showed significant group differences in
cooperative play, F (1, 16) = 7.648, p = 0.014,
η2 p = 0.323, joint attention, F (1, 16) = 7.993,
p = 0.012, η2 p = 0.333, requests, F (1, 16) = 4.797,
p = 0.044, η2 p = 0.2312, and initiation, F (1,
16) = 7.562, p = 0.014, η2 p = 0.321, but not in eye
contact (p > 0.05).
A within group comparison between Times 1 and
2 scores was performed separately in PECS and CLT
group. As regards the PECS group, paired t-tests showed
a general improvement in all the five coded variables
(cooperative play, t(8) = –3.941, p = 0.004, eye contact,
t(8) = –2.369, p = 0.045, joint attention, t(8) = –
2.865, p = 0.021, requests, t(8) = –2.682, p = 0.028,
and initiation, t(8) = –2.486, p = 0.038). The same
analysis performed on the CLT group did not reveal
significant difference on any of the considered measures
(all p > 0.05).

Unstructured free-play session

A MANOVA was performed with behavioural
outcome measures coded during free-play at Time 1
(table 5) as dependent variables and group as indepen-
dent variable. Results showed that at Time 1 there
were no significant group differences in the behavioural
measures coded during free-play (all p > 0.05). In
contrast, the MANOVA performed on Time 2 measures
Discussion
The present study investigated the effects of PECS on
social–communicative abilities of children with ASD by
collecting data from formalized measures of communi-
cation and social functioning and from observation
of participants’ behaviour in an unstructured setting.
A group of children with ASD receiving PECS were
Social–communicative effects of PECS in ASD
compared with another group of children receiving CLT.
The two groups were well matched on demographic and
pre-treatment outcome measures, thus allowing to relate
post-treatment differences to the specificity of group
intervention. Between group comparisons performed on
formalized tests scores at Time 2 showed that children
receiving PECS gained significantly higher scores than
the CLT group on the VABS social domain. The
between group comparison on social–communicative
measures coded during free-play revealed that frequency
of joint attention, requests and initiation, and duration
of cooperative play but not of eye contact were signifi-
cantly higher in the PECS than the CLT group. These
results were confirmed by within-group comparisons
between Times 1 and 2 showing in the PECS group,
but not in the CLT group, significant improvements on
VABS communication and social domains, and in all the
measures coded during free-play. These results provide
support to the existence of a close relationship between
communication and social skills (Charlop-Christy et al.
2002).
Several lines of evidence suggest that improvement
in the frequency of requests might trigger an increase of
joint attention (Tomasello et al. 2007). In a recent meta-
analysis reviewing data on PECS effects on communi-
cation and speech in children with ASD, Flippin
et al. (2010) underlined that one of the main potential
pre-treatment identifiers of a child with autism who
is likely to respond to PECS intervention is limited
joint attention. Accordingly, Yoder and Stone (2006)
suggested the PECS may be a communication interven-
tion more effective in children with initially low rates of
joint attention. The authors performed an exploratory
analysis of pre-treatment variables and found that initial
rates of joint attention were a strong predictor of
whether a child made greater communication (i.e.
requesting) gains. Joint attention also emerged as a
potentially influential pre-treatment characteristic in a
single-subject study by Charlop-Christy et al. (2002)
which documented that the largest amelioration was
observed in the youngest participant, who took part
to the study with no spontaneous speech, weak joint
attention, eye contact and toy play. Although analysis
of pre-treatment characteristics of children undergoing
PECS intervention was outside the aims of the present
study, the findings are in line with data from literature
reviewed above and strengthen the idea that PECS is a
valuable tool for enhancing social–communicative skills
of children with ASD. It is possible to suggest that
the ‘physical exchange’ (i.e. the communicative act to
receive a concrete item) within an interactive context
(to establish a physical contact with a partner prior to
emitting a referential communicative; Bondy and Frost
1994) is a key feature of PECS intervention favouring
children’s communication and social interaction. An
615
important consideration is that the children with autism
are less motivated by social effects of communication,
such as praise, shared attention or dyadic interaction,
than they are to its concrete effects, such as obtaining a
desired item (e.g. Bondy and Frost 1998). Motivation
to initiate social–communicative skills could occur in
response to internal signals of interest or positive affect,
so there is reason to believe that children can learn
new communicative behaviours, such as requesting or
turn taking (Yoder and Stone 2006), and later generalize
them to social–communicative skills such as initiating
joint attention. Starting from the concept of physical
exchange within an interactive context (Bondy and Frost
1994), we speculated that motivation to interact with
a partner could be first triggered in the children by the
activation of the desire to reach for a concrete target by
means of a social interaction and, only subsequently, by
the desire to share an experience related to objects with
a social partner (e.g. to carry out a game).
It remains to be elucidated why in the PECS group
only one social–communicative variable coded in free-
play, i.e. eye contact, did not improve from pre- to
post-treatment. Although at first sight this finding
seems at odds with improvement of the PECS group
in joint attention, it could be explained by taking
into account the distinction between two different
kinds of joint attention. The child’s ability to follow
gaze direction, head turns and/or pointing gesture of
another individual may be referred to as responding joint
attention, whereas the child’s ability in using eye contact
and/or deictic gestures (e.g. pointing or showing) to
initiate spontaneously coordinated attention with a
social partner may be referred to as initiating joint
attention (Mundy 2003). In this respect, the variable we
labelled here as joint attention corresponded to respond-
ing joint attention, whereas eye contact corresponded to
initiating joint attention. These two aspects of joint
attention can dissociate between each other, because
they reflect different processes of social and emotional
functioning (Mundy et al. 2000). Actually, initiat-
ing joint attention reflects the tendency to initiate
spontaneously a social interaction, whereas respond-
ing joint attention is a measure of the tendency to
respond to another person’s signal to shift attention.
It has been demonstrated that initiating joint attention
can be affected by executive and motivation defects more
than responding joint attention (Mundy et al. 2000). In
particular, initiating joint attention seems to involve the
tendency to initiate spontaneously episodes of sharing
affective experience related to objects or events with
a social partner (Mundy et al. 1992); in this sense,
a difficulty with initiating joint attention represents a
core symptom of autism (Mundy 2003). Results from
the present study showing a dissociation between PECS-
related effects on eye contact and joint attention closely
616
fit the distinction between these two types of joint
attention, revealing that PECS intervention can specifi-
cally influence responding joint attention.
One strength of the present study is represented by
our assessing children in both structured and unstruc-
tured settings. This allowed us to verify whether a
best outcome measure is available to detect PECS-
related changes in the child’s behaviour and to verify
the presence of possible relationships between different
measures. We found that while almost all variables
coded in free-play reflected the positive effects of PECS
treatment, among the formalized measures only the
VABS social domain score demonstrated an advantage
for the PECS group. A specific consideration should
be made on the difference between communicative and
social abilities assessed with the VABS, and communica-
tive and social disabilities measured with the ADOS. The
ADOS quantifies social and communicative behaviours
that are relevant to the diagnosis of autism; the
‘algorithm’ for the specific domains of the ADOS
has been commonly used for characterization of the
level of autistic symptomatology (Lord et al. 1999,
Klin et al. 2007). The VABS in contrast represents a
measure of personal and social self-sufficiency obtained
through a semi-structured interview with the person’s
parents or caregivers, and it examines the adaptive
functioning in everyday life. The data underlining a
dissociation between abilities (VABS) and disabilities
(ADOS) in the communication and social domains
are fully consistent with these differences between the
two measures (Klin et al. 2007). Therefore, we did
not find any relationship between higher levels of
adaptive skills and lower levels of symptomatology; thus,
adaptive skills (abilities) and symptomatology (disabil-
ities) might have to be conceived, at least partially,
as independent domains of intervention. As Klin
et al. (2007) suggested, factors mediating the acquisi-
tion of adaptive skills may be different from factors
mediating the expression of autistic symptomatology.
Related to this difference between abilities and disabil-
ities assesses by VABS and ADOS, respectively, is the
tentative explanation of another aspect of the present
findings, namely that the severity of symptomatology
measured by ADOS remained stable after 6 months, in
contrast to the improvement of socio-communicative
abilities after PECS training measured by VABS. One
could suggest that VABS are sensitive to day-by-day
improvement over a short-term period of 6 months,
while the ADOS detects more global changes over a
longer period. This would be consistent with Howlin
et al.’s (2007) results showing that rates of communica-
tive initiations and PECS usage were significantly
increased after PECS training, whereas the authors
did not find significant changes immediately following
treatment on ADOS-G domain scores for communi-
Anna Lerna et al.
cation and reciprocal social interaction. However, a
specific decrease in the severity score for reciprocal social
interaction was reported at the 10-month follow-up.
Therefore, it could be useful in future studies to repeat
these assessment after a longer interval of time within a
longitudinal protocol.
Limitations of the present study include the lack
of randomization of treatments and the relatively
sample size which, however, although encourage future
randomized trials with larger sample sizes, do not
undermine reliability of the results. Moreover, we did
not collect observational data on dyadic interactions
between the children and the adults in their everyday
environment. While this is a post-hoc consideration
prompted by the fact that the results revealed a major
improvement of children’s social–communicative skills
in an ecological context, it would be useful to investigate
further this aspect following data of recent research (Carr
and Felce 2007, Howlin et al. 2007). For instance, Carr
and Felce (2007) demonstrated significant PECS-related
improvements in the dyadic patterns of communication
between children and teachers in the classroom. Finally,
another aspect that merits comment regards the effect
of PECS on language abilities. Although the present
study did not demonstrate any increase in children’s
language abilities, this negative result could be related
to the nature of measures employed here; we mainly
focused interest on social–communicative functioning
rather than on language abilities (for instance, in free-
play no language assessment was performed).
In conclusion, the present results showed a
significant effect of PECS (Phases I–IV) on social–
communicative abilities of children with ASD which
underwent extensive assessment including formalized
tests and observation during free-play. Outcomes
measures demonstrated that the first four phases of
the PECS intervention can represent an effective
tool for promoting improvement of several social–
communicative skills.
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