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PECS: The Picture Exchange Communication System training manual

Article in Seminars in Speech and Language · February 1998

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 SEMINARS IN SPEECH AND LANGUAGE-VOLUME 19, NUMBER 4 1998

THE PICTURE EXCHANGE

COMMUNICATION SYSTEM
Andrew S. Bondy, Ph.D., and Lori A. Frost, M.S., CCC/SLP

ABSTRACT-The Picture Exchange Communication System (PECS) was de-

veloped as a means to teach children with autism and related developmental
disabilities a rapidly acquired, self-initiating, functional communication system.
Its theoretical roots combine principles from applied behavior analysis and
guidelines established within the field of alternative and augmentative commu-
nication. This approach has several potential advantages relative to imitation-
based strategies (both vocal and gestural) and symbol selection strategies.
The system begins with the exchange of simple icons but rapidly builds "sen-
tence" structure. The system also emphasizes developing the request function
prior to developing responding to simple questions and commenting. The de-
velopment of requesting with a sentence structure also permits the rapid devel-
opment of attributes more traditionally taught within a receptive mode. The re-
lationship between the introduction of PECS and various other behavioral
issues (i.e., social approach and behavior management) as well as its relation-
ship to the codevelopment of speech are reviewed.

KEY WORDS: autism, functional communication, initiation

A hallmark characteristic of children cation system, PECS teaches children to ini-

with autism is their difficulty in acquiring
spoken functional communication skills.
Traditional communication training method-
ologies for children with autism include
speech imitation, sign language, and pic-
ture point systems. After discussing some of
the limitations associated with these strate-
gies in a child's development of spontaneous,
functional communication skills, we describe
the Picture Exchange Communication Sys-
tem (PECS), which was developed as a
means of circumventing these limitations. A
unique augmentative/alternative communi-
tiate functional communication within a s e
cia1 context. PECS follows a combined behav-
ioral and functional developmental approach
which relies on principles of behavior analysis
that focus on the acquisition of functional be-
havior sequences (Gewirtz & Pelaiz-Norueras,
1996) and with developmental perspectives
and guidelines having a pragmatic or func-
tional language emphasis (Warren & Rogers
Warren, 1985). The training sequence for
PECS initially teaches spontaneous requesting
within a social context, but rapidly pro-
gresses to teach sentence structure, vocabu-

Pyramid Educational Consultants, Inc., Cherry Hill, New Jersey

Reprint requests: Dr. Bondy, Pyramid Educational Consultants, Inc.,
1930 Street, Highway 70, Suite D-20, Cherry Hill, NJ 08003.

Copyright 0 1998 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001.
Tel. +1 (212) 760-0888. All rights reserved. 373

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 SEMINARS IN SPEECH AND LANGUAGE-VOLUME 19, NUMBER 4 1998

lary concepts, and commenting. Following sponding appropriately to and maintaining

a review of the sequence of training associ- social approaches made by adults or peers.
ated with the PECS, we summarize the re- Assessment of a child's social interaction
search on its use and impact on the codevel- and skills is clearly related to the specific
opment of speech, then suggest areas for communication skills (and modality) used
further research. by a child.
There are several behaviors that simul-
taneously involve communication and so-
LANGUAGE AND BEHAVIORAL cial interaction. For example, establishing
CHARACTERISTICS OF joint attention involves a communicative act
CHILDREN WITH AUTISM associated with a specific event. A child with
typical development may observe something
Children with autism are most often di- novel or unusual and immediately turn to
agnosed between the ages of 2 and 4 years. an adult and engage in behaviors that cul-
A typical profile would be a boy (80% of all minate in the adult responding to the same
cases; Schreibman, 1988) who displays little, event or change. The reinforcing conse-
if any, functional speech; has fleeting eye quence for the child's behavior in this sce-
contact; rarely imitates speech, actions, ob- nario is associated with the social response
ject selection, or object manipulation; rarely of the adult (rather than the receipt of a
approaches adults or peers; rarely responds material reward). This type of social interac-
appropriately to or maintains the social ap- tion usually is observed in typically develop-
proach of others; and rarely shows off or calls ing children prior to their demonstration of
attention to interesting events or changes in formal speech. Furthermore, this type of in-
the environment. teraction has been noted as absent in very
Various studies have estimated that 25% young children with autism (Stone et al.
to 61% of children with autism remain essen- 1994). Another social behavior which ap-
tially mute (Weitz et al. 1997). As many as pears to be significantly delayed or absent in
80% of these preschool-age children who en- very young children with autism is imita-
ter public school demonstrate virtually no tion, including motor, manipulative, and vo-
functional communication; they either use cal imitation behaviors (Stone et al., 1994).
no speech or other formal language, or pro- It is important to note that these types of so-
duce nonfunctional vocalizations (Bondy & cial routines are well established in children
Peterson, 1990). When speech develops in with typical development prior to the devel-
young children with autism, it is usually char- opment of speech, and these same behav-
acterized by a host of atypical features, in- iors are typically absent from the repertoires
cluding echolalia, problems with prosody of very young children with autism (who are
(ranging from flat affect to rhythmic patterns also likely not to have begun to speak).
that accompany all statements, regardless of Although the absence of speech is pro-
function), perseveration of words, phrases, nounced in this population, it is appropri-
or topics, and pronominal reversal (Mirenda ate to consider whether autism involvesjust
& Schuler, 1994; Schreibman, 1988). a speech disability or a more pervasive com-
A second major characteristic of this munication disability. The latter view recog-
population is difficulty with social interac- nizes that functional communication is not
tion, whether associated with language, play, defined by modality. Indeed, those in the
or other aspects of social routines (Arneri- fields of speech-language pathology and lin-
can Psychiatric Association, 1994).This char- guistics have long recognized the indepen-
acteristic typically remains present even dence between modality and function, the
for those individuals who acquire reason- same distinction that Skinner (1957) made
ably complex (or perhaps age-appropriate) in his definition of "verbal behavior."
speech and includes difficulty approaching The consequences associated with early
374 adults and peers, as well as difficulty in re- language development appear to derive from

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THE PICTURE EXCHANGE COMMUNICATION SYSTEM-BONDY, FROST

two distinct sources. Some communication production (Lovaas, 1966; Lovaas, 198I ) ,
acts are reinforced by consequences speci- even though most of these preschoolers do
fied by the act itself (requests, demands, not initially have good imitative skills. There-
commands, or "mands"). Other codevelop- fore, many such programs work on teaching
ing communication acts are associated with imitation before working on speech pro-
consequences that are purely social in na- duction (Taylor & McDonough, 1996). For
ture (comments that elicit agreement or modeling to be effective, however, children
acknowledgment, imitations that result in should look at the teacher, and most of
playful reactions, etc.). This latter set also is these preschool-age children do not have
associated with comments, answering sim- good eye contact, so these skills must be
ple questions about the environment, show- taught before imitation lessons can be effec-
ing off one's own actions ("look [at me]") tive. In some cases, children are taught to sit
or events in the environment ("look [at quietly and to stop engaging in a host of po-
that] ") . Both kinds of communicative acts tentially problematic behaviors in order to
appear to be equally motivated, implying develop "learning readiness" before eye con-
that social consequences are as motivating tact or social interaction training begins
as the receipt of concrete outcomes for typi- (Anderson et a]., 1996). Although the initial
cally developing children. goal may be speech, it is often viewed as es-
When working with children with sential for these children to develop eye
autism, their relative insensitivity to social contact and imitation prior to working di-
consequences dramatically affects the learn- rectly on speech acquisition.
ing typically associated with these types of Another emphasis of many behaviorally
reinforcers. For example, imitation is typi- oriented programs is establishing "instruc-
cally learned for its social consequences, but tional control" over the child's behavior,
for children with autism, more concrete re- which is often justified as another method
wards are often needed to help develop this of getting the child "ready to learn." For ex-
skill. In similar fashion, lessons associated ample, the child is taught to follow simple
with commenting, labeling, and answering instructions involving motor acts (e.g., "Clap
simple questions (e.g., regarding informa- hands"), object selection (e.g., 'Touch cup"),
tion about the environment) are difficult to object manipulation (e.g., "Put in"), object
arrange for these children, because the con- or symbol matching-to-sample (e.g., "Match"
sequences provided by a trainer are often or "Put with same"), or imitation (e.g., "Do
contrived and, therefore, not the social re- this"). A specific cue or discriminative stim-
wards that should be associated with these ulus provided by the teacher starts each of
communication skills. these types of lessons. A common concern
about this general approach, however, is the
lack of attention to the child's development
TRADITIONALAPPROACHES TO of spontaneous speech and social approach.
LANGUAGE TRAINING Even if children learn to respond to the
specific cues or prompts used in these
SPEECH IMITATION AND lessons, they may not learn to use these
LEARNING READINESS skills in a spontaneous or self-generated
manner.
Because the majority of preschoolers When these training strategies are suc-
with autism entering school programs lack cessful (Lovaas, 1987), outcomes are re-
speech, (and any other modality of func- ported to be dramatic for a significant por-
tional communication), the focus for many tion of children in terms of changes in their
intervention programs has been on the rapid intelligence scores, personality measures, and
development of speech (Silverman, 1995). placement outcomes. However, some chil-
Many behaviorally based programs have dren who acquire good vocal imitative skills,
sought to use modeling to enhance speech during a sometimes long period of training, 375

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 SEMINARS IN SPEECH AND LANGUAGE-VOLUME 19, NUMBER 4 1998

may have acquired no functional communi- tive behavior, which is a potential advan-
cation skills, a concern often raised in the tage, because there is no need to develop
literature about this overall strategy. Thus, imitative skills prior to introducing symbols.
some children learn to imitate and answer Also, these symbols can remain in the child's
direct questions (e.g., "What do you want? visual field for a long time, which may im-
What is this?" etc.), but they do not use the prove their salience relative to the more
same words to initiate requests or com- transitory auditory cues of speech.
ments. Many of them have been described Several potential problems are associ-
as "prompt dependent." Because lessons in- ated with picture-point systems. In both
volving imitation and answering simple pragmatic and behavioral programs, it is as-
questions are led by the teacher, it is more sumed that a child's ability to match a pic-
appropriate to recognize that such prompt ture to an object is a prerequisite to using a
dependency is likely a function of teaching picture communication system. Many devel-
strategies rather than the learning capabili- opmentally oriented clinicians have stressed
ties of the child. For children who need to that prior to symbol-object matching, chil-
learn to initiate interactions, other types of dren need to have established object-to-
prompting strategies are necessary. object matching. Thus, many programs start
with this type of training, matching cups to
cups, balls to balls, and so forth, prior to
matching a picture of a cup to a real cup
and beginning the formal communication
Another general approach to language phase of training. This type of matching to
training with this population has involved sample format is minimally motivating for
the introduction of sign language (Binkoff many children, involves rewards selected by
et al, 1978; Carr, 1982). Among the poten- the teacher, and is an activity that is not re-
tial advantages of this approach is that visual lated to a "real-life" functional skill. Then,
cues may not be as transitory as vocal cues. children are taught to point to pictures with
On the other hand, many sign-language the teacher interpreting this action as com-
training protocols rely on modeling and im- municative. This method relies on a teacher
itative skills on the part of the child, which being present and noticing that a child is
often necessitates teaching general imitative pointing to a picture. Thus, it is the teacher
skills prior to beginning formal sign train- rather than the child who initiates commu-
ing. Furthermore, if modeling is used, along nication.
with other prompting strategies associated Some children using picture-point sys-
with asking direct questions, then the issues tems are inaccurate pointers or have diffi-
just noted about the difficulty of acquiring culty isolating a finger with which to point.
spontaneous language use also apply. Finally, These children may touch the picture dis-
the usefulness of sign language in commu- play with their whole hand, making contact
nity settings where only a limited number of with several pictures, which requires the
communication partners understand this teacher to interpret which picture the child
language, except for those children who have meant to touch. Finally, in most picture-
autism and are deaf, is another concern. point communication strategies, it is the
teacher who leads the interaction and who
displays objects before saying, "What's this?"
or 'What do you want?" or even "Find the
same." Thus, children may use their picture
A third broad approach to language system if the teacher produces one of these
training has involved the use of a variety of types of direct prompts; however, in the ab-
symbol selection systems, using photographs, sence of a prompt, the child has not learned
line drawings, or similar symbols. Most rely how to initiate communication within a so-
376 on pointing to a symbol as the communica- cial context.

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T H E PICTURE EXCHANGE COMMUNICATION SYSTEM-BONDY, FROST

THE PICTURE EXCHANGE than by social interaction. Thus, the first

COMMUNICATION SYSTEM PECS lesson focuses on requesting tangible
items and obtaining them, rather than on
We believe that an effective communi- labeling items and receiving only social feed-
cation training system should (1) use cur- back. For example, if a child were observed
rently effective reinforcers, not less effective to reach persistently for and to take cookies,
social reinforcers, and should teach requests the first lesson would involve teaching this
rather than labels; (2) begin with sponta- child to request cookies. To do this, the
neous communication in which the child teacher places a picture of a cookie in front
initiates an approach to an adult; (3) avoid of the child while showing the child a cookie.
the development of prompt dependency; Typically, the child's initial reaction is to
and (4) not require extensive prerequisite reach for the cooke. The child's act of
training. This initial emphasis on requests is reaching is physically guided to pick up the
supported by the recent work of Stone et al., picture and give it to the teacher until the
(1997), who reported that 2- and 3-year-old child does it without assistance. Because the
children with autism had high rates of non- goal is to teach the child to be spontaneous,
verbal requests but very low rates of com- it is important for the teacher to avoid
menting. They suggested that early inter- any direct prompts, such as questions (e.g.,
vention programs should place an initial "What do you want?"), direct commands
emphasis on teaching these children to re- (e.g., "Give me the picture!"), or direct ges-
quest, a suggestion that was incorporated tures (e.g., pointing to the picture). There-
into PECS (Frost & Bondy, 1994). fore, the potential teaching dilemma is how
To assure that children are motivated the child can be prompted to pick up the
to engage in functional communication, picture without the teacher providing the
potential reinforcers must be identified. direct prompt.
Therefore, before PECS is begun, the teacher The strategy used with PECS is similar
performs a reinforcer assessment. There to a verbal prompt-free strategy (Mirenda &
are several formal assessment strategies Dattilo, 1987) and peripheral physical
(Fisher et al., 1992; Reichle et al., 1991) that prompting (Macduff et al., 1993). A second
may help teachers to identify effective rein- teacher, who is behind the child, provides
forcers for a child, although informal strate- the physical guidance needed for the child
gies may be sufficient for many children. to pick up the picture, extend it to the
For example, a child may be given a choice teacher, then release it into her hand, which
between two items, so that the teacher can is based on a backward-chain prompt strat-
observe which one the child persistently egy (Sulzer-Azaroff & Meyer, 1991). It is crit-
takes. Teachers need to develop a hierarchi- ical for the second teacher to wait for the
cal list of reinforcers, ranging from highly child to initiate reaching for the reinforcer
potent to mildly motivating rewards, that before providing physical assistance, which
also include items the child actively avoids. is then faded as quickly as possible. At the
end of this first phase of training, when pre-
sented with a potential reward and a corre-
INTRODUCINGPECS sponding picture, the child will indepen-
dently pick up the picture and give it to the
The first lesson in PECS is to teach the teacher in exchange for the item.
child the fundamental aspect of communi-
cation: to approach the communicative part-
ner and deliver a message in exchange for
something that is reinforcing. This initial
lesson must use a potent reinforcer for the Training next focuses on enhancing
child, because children with autism tend to the child's spontaneity, which involves as-
be much more motivated by tangible items sessing both generalization and prompting 377

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 SEMINARS IN SPEECH AND LANGUAGE-VOLUME
issues. Generalization across trainers initially
involves having the two trainers switch roles,
which often can be accomplished during the
first training session. Generalization across
environments occurs immediately also, be-
cause training is conducted all day in what-
ever environments the child's teaching oc-
curs. Generalization across materials or
reinforcers is achieved quickly, because each
lesson involves teaching the child to request
whatever item is being used as a reinforcer.
Spontaneity is strengthened by paying
careful attention throughout training to par-
ticular cues or prompts that are inadver-
tently introduced into the lesson. For exam-
ple, if the child is seated, it is necessary to
teach him or her to communicate while
standing and away from a table. If the trainer
typically is in close proximity to the child,
the trainer systematically moves farther and
farther away so that the child learns to "go
find" the communicative partner. In addi-
tion to moving farther away, the trainer also
needs to systematically fade any facial cues,
such as an "expectant look," which she might
be providing. The child eventually learns to
approach the communicative partner when
the trainer's back is turned or is in another
room.
Eliminating picture-proximity prompts
further refines spontaneity. Thus, the train-
ers teach the child to go get the picture of a
reinforcer by systematically moving the pic-
ture farther and farther away from the child.
Eventually all of the child's pictures are
placed in a small communication binder,
and the child learns to get the binder when
he or she needs or wants to communicate
with someone. During these lessons, train-
ing is focused on teaching the nature of
communication rather than on discriminat-
ing between symbols; therefore, the trainer
places one picture at a time on the front of
the book, depending on the current activity
and what is likely to be currently reinforcing
for the child. Two trainers continue to be
necessary, with one acting as the child's po-
tential communicative partner and the other
being available to physically prompt the stu-
dent to go to or find the communicative
378 partner or the communication book.
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19. NUMBER 4 1998
Another dimension for generalization
training involves the child's potential audi-
ence. In traditional settings, children with
severe communication disabilities are taught
initially to communicate with adults, which
is true with PECS in large part because
adults (parents and teachers) control the
important reinforcers. So how can these chil-
dren be taught to communicate with their
peers? In one study (Garfinkle & Schwartz,
1996), children who had been taught PECS
with adults were placed in a group of chil-
dren without disabilities or with other types
of disabilities, and PECS was taught during
snack time. The teacher initially taught the
children without disabilities how to "share,"
then allowed them to control the snack items.
The children with autism readily learned to
use PECS with their peers during snack time,
and generalization to an untrained play sit-
uation also was observed. Furthermore, an
increase in general social approach by the
children with autism to their peers was noted
even when PECS was not available. Evans
and Belknap (1996) reported similar results
with adolescents who were learning to use
PECS with their peers.
Finally, the acquisition of requesting
within PECS also appears to have an impact
on eye contact. As noted earlier, traditional
approaches focus on teaching a child to
look at an adult when prompted by a spo-
ken instruction. Children with typical devel-
opment, however, display another type of
eye contact. When a toddler wants his
mother's attention but she is otherwise oc-
cupied (e.g., when talking on the telephone),
the child typically engages in a series of ac-
tions (e.g., repeating her name, pulling on
her clothes, finally taking her face in his
hands), which appear to indicate that the
child knows he or she cannot deliver the
message before obtaining the mother's at-
tention. Once a child has learned to use
PECS he or she can be taught the impor-
tance of gaining eye contact. To accomplish
this task, it is necessary for one communica-
tive partner to actively look away from the
child, and even to exaggerate this action by
lowering her head toward her lap. Because
this lesson, like PECS phase I, is focused on
THE PICTURE EXCHANGE COMMUNICATION SYSTEM-BONDY,FROST
initiation, it is taught most effectively with
two trainers. As the child approaches the
communicative partner, the second trainer
physically assists the child in gently touch-
ing the shoulder or cheek of the partner.
Upon being touched, the partner looks up
immediately, in an expectant fashion, and
the child proceeds to deliver the message
using PECS (Frost & Bondy, 1994).
Once a child has become a persistent,
spontaneous communicator and reliably ap-
proaches different adults to request a vari-
ety of objects, he or she is ready to be taught
to discriminate between symbols. This train-
ing is begun by adding a second picture that
differs significantly in reinforcement value
from the other item picture on the front of
the communication book. For example, if
the child wants bubbles, discrimination train-
ing begins by using a picture of bubbles
along with a picture of a sock (i.e., something
not desired). If the child selects and gives
the teacher a picture of bubbles, he or she is
given the bubbles, together with animated
social praise. If the child gives the teacher a
picture of a sock, he or she is given the sock.
If the child reacts negatively when given the
sock (e.g., fusses, throws it back, etc.), then
he or she is likely to pay attention to the
stimuli that results in being given the sock
(i.e., the sock picture). On the other hand,
if the child does not react negatively and
simply starts to play with the sock, this strat-
egy is not likely to be effective, because the
child is unlikely to pay more attention to
prior stimuli than to consequences. If the
child reacts negatively, however, the teacher
uses a gestural prompt to identify the cor-
rect picture before arranging and starting
the next trial, and if the child identifies the
correct picture, the teacher gives him or her
the bubbles. When this type of discrimina-
tion training strategy is effective, the child
gradually learns to discriminate between
pictures of equally reinforcing items.
Sometimes a child may enjoy receiving
either of the two available items, seem
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equally happy with either of them, and may
not be motivated to select specific pictures.
A potential dilemma at this point in train-
ing, then, is assessing the child's accuracy.
How can we find out which item the child
"really" wants? In such cases the child's per-
formance is assessed by conducting a "corre-
spondence check" to determine if what the
child takes corresponds with what was re-
quested. For example, if the child asks for a
cookie while cookie and pretzel pictures are
on the board, the trainer holds out both
cookies and pretzels and says, "Go ahead
and take it. " If the child reaches for the
cookies after having asked for them, then
he or she is allowed to take them; however,
if the child reaches for the pretzels after
having asked for cookies, he or she is not al-
lowed to take either item. In the latter case,
the trainer prompts the correct response
(using an error-correction sequence) and
repeats the opportunity to choose.
Discrimination training continues by
increasing the number of pictures available
and by monitoring the child's accuracy with
frequent correspondence checks. The trainer
systematically displays only pictures of cur-
rent reinforcers, and when the child is able
to discriminate among five pictures at a time,
he or she is taught to open the communica-
tion book and to select any picture from the
front or from inside the book.
Given PECS' emphasis on using pic-
tures to develop functional communication,
it is reasonable to question whether match-
ing-to-sample is a prerequisite for PECS
phase I. It has been our experience that some
children begin to discriminate pictures us-
ing this request format prior to being suc-
cessful in a matching-to-sample format.
Whether one type of training is necessary
before the other has not been determined
empirically. There is some evidence, how-
ever, that PECS training outcomes are con-
sistent with other research on the stimulus
equivalence (Krendel-Ames et al., 1996) of 379
 SEMINARS IN SPEECH AND LANGUAGE-VOLUME
the picture, the object, and the spoken word
associated with the object. If training order
is not a necessary condition (i.e., matching-
to-sample does not have to precede picture
selection in a request format), then it may
be possible to demonstrate that improve-
ments in discrimination using PECS are re-
lated to improvements in matching-to-sam-
ple formats, and vice versa.
Initially, PECS focuses on the issue of
"act on" another person as the cornerstone
of communication in contrast to refining
the message that is being delivered. Dis-
criminating between symbols is independent
of learning to socially approach others. When
discrimination training is begun, the most
effective level of representation may not be
selected at first, and in some cases, increas-
ing the discriminability of the pictorial rep-
resentations may be necessary. Frost and Sc-
holefield (1996), using a single case design,
demonstrated that the use of three-dimen-
sional symbols led to improved discrimina-
tion by a child with multiple handicaps. Over
time, each three-dimensional representa-
tion was gradually covered with a line draw-
ing,
- and the child's discrimination of these
drawing was acquired. Further research as-
sessing the efficacy of different pictorial
representations while using the PECS for-
mat is certainly warranted.
A related question pertains to the rela-
tionship between the acquisition of vocal
imitation and matching-to-sample or related
visual discriminations. In a preliminary
study by Cummings and Williams (1997),
findings from five children (ages 3 years 6
months to 5 years) indicated that vocal imi-
tation was acquired only after completing
the discrimination phase of PECS. Further
research on this question is extremely im-
portant to those concerned about when to
introduce PECS. Some discrete-trial propo-
nents suggest that if vocal imitation has not
occurred after 3 or 4 months of training,
then a visual system, such as PECS, should
be attempted. We are not aware of any em-
pirical findings showing that introducing
PECS at the beginning of intervention would
have an adverse impact on acquisition of vo-
380 cal imitation or any other important skill.
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19, NUMBER 4 1998
So far, the steps in PECS have involved
teaching a child to request desired items.
The other broad category of communica-
tive functions is commenting. When typically
developing children learn to communicate,
their single word utterances are just as likely
to be requests as comments. The child's in-
tonation that accompanies the single word
often helps listeners determine whether the
word is a comment or a request. In a pic-
ture-based communicative exchange, how-
ever, additional cues must be present in
order for the communicative partner to un-
derstand whether the picture represents a
request or a comment. In PECS, these added
cues involve the use of simple icon phrases.
For example, the child is taught to request
using the icon-phrase "I want
and to comment using the picture phrase "I
see " or "It's a ." Rather
than teaching a new communicative func-
tion and the use of an icon-phrase, the child
is first taught to request using a phrase. This
lesson is taught by attaching a long card
(called the sentence strip) to the bottom of
the communication book, and teaching the
child to form the phrase by attaching two
icons to the strip. One icon represents "I
want" and the other is a picture of the de-
sired item. After the child has constructed
the phrase "I want . . . X, " he removes the
strip, approaches the adult, and hands the
adult the entire strip. The adult, in turn,
"reads" the strip aloud to the child, then
gives the child the requested item. The use
of this sort of backward-chaining sequence
has been Supported empirically by the rapid
acquisition of appropriate sentence strip
use in a study of four children (ages 8 to 13
years) with severe developmental disabili-
ties (Weatherup et al., 1996).
Children with autism learning to use
PECS at this stage typically remain relatively
insensitive to social consequences, such as
those associated with commenting; there-
fore, teaching spontaneous commenting is
often difficult (Bondy et al., 1991). Rather
than moving from spontaneous requests to
spontaneous comments, Bondy et al. (1991)
THE PICTURE EXCHANGE COMMUNICATION SYSTEM-BONDY,FROST
found it was more effective to teach com-
menting initially as responses to simple ques-
tions (e.g., "What d o you see?"). In order to
build support for the introduction of this
cue for comments, responses are intro-
duced within the previously acquired re-
quest function. Thus, the next step in PECS
teaches the child to respond to a question
that has effective concrete consequences
(e.g., "What do you want?").
This lesson is taught using a delayed
prompt procedure (Halle et al., 1979) in
which the question is paired with a gestural
prompt to the "I want" picture. Initially the
question and prompt are presented simulta-
neously, but gradually a delay is inserted be-
tween asking the question and presenting
the gestural prompt. Over successive trials,
the child learns to "beat" the trainer by an-
swering the question before the gestural
prompt is used. Because the consequences
for answering the question continue to be
effective reinforces and because the form
used in answering the question is familiar,
this step in PECS typically is acquired rapidly.
The final phase of PECS involves teach-
ing the child to comment first by answering
a direct question using the delayed prompt-
ing procedure. A crucial step in this phase
of training is teaching the child to answer
both 'What do you see?" and "What do you
want?" and to provide appropriate conse-
quences for each (social vs. concrete). Once
the child reliably answers both question
forms (and is maintaining high rates of spon-
taneous requests), prompts are faded to en-
courage spontaneous comments. For exam-
ple, during an activity that involves teaching
a child to comment on items drawn from a
"surprise box," the trainer begins the activ-
ity by taking the first item from the box, ex-
claiming, "Oh!" in a dramatic, drawn-out
style, and asking, "What do you see?" Over
time, the trainer continues to draw items
from the box and gradually fades the ele-
ments of this sequence, progressing from
the exclamation and the entire question to
the exclamation plus "What?", to just the ex-
clamation, and, finally, to simply pulling the
item from the box. When the child re-
sponds appropriately to just this cue, spon-
This document was prepared for the exclusive use of Andrew Bondy. Unauthorized distribution is strictly prohibit
taneously commenting is occurring. Of
course, this skill needs to be generalized to
a variety of settings and should not be lim-
ited to the training environment.
The development of spontaneous com-
menting seems to be critically important in
the overall development of communicative
skills in children with autism. Children who
only comment in response to an adult ques-
tion (e.g., "What do you see?"; "What is it?";
"Tell me about it," etc.) do not appear to be
using language in the generative, sponta-
neous fashion associated with competent
communicators. Although the strategies in-
volving the use of the sentence strip and
specific questions appear to help many chil-
dren learn to comment (Bondy et al.,
1991), not all children with autism acquire
spontaneous commenting. It appears that
the rate of acquiring comments is more
closely correlated with these children's long-
term communicative development than is
the acquisition rate of requests (Finnegan &
Bondy, 1989). Thus, children who acquire
commenting and those who acquire only re-
questing display similar rates of acquisition
for requests during PECS training. Whether
this outcome is related to the need for more
refined teaching strategies or is associated
with complex factors regarding a child's re-
sponsivity to social reinforcers (e.g., the
maintaining factor for spontaneous com-
ments) is not known.
RESEARCH QUESTIONS PERTAINING
TO THE ACQUISITION OF PECS
One important question associated with
the first phase of PECS concerns which chil-
dren should start PECS training. One study
compared how children responded to dif-
ferent communication modalities (Overcash
et al., 1996). A set of potential reinforcers
was identified for seven preschool-age chil-
dren entering a public school program who
did not display functional communication.
The reinforcers were randomly assigned to
training for (1)vocal imitation, (2) sign imi-
tation, or (3) acquiring the first phase of
PECS. Training sessions were provided daily 381
 SEMINARS IN SPEECH AND LANGUAGE-VOLUME
in a counterbalanced design. In addition to
measuring acquisition rates, data on a vari-
ety of problem behavior management targets
(e.g., crying, leaving the area, tantrums, etc.)
were also recorded each session. A clear pat-
tern emerged over the 20 consecutive train-
ing sessions for six of the seven children;
they demonstrated no appropriate imita-
tion of sounds or signs, but exhibited rapid
acquisition of the picture exchange. During
vocal imitation and sign imitation training,
frequent problem behaviors were exhibited,
although few such behaviors were observed
during PECS trials. The seventh child ac-
quired responses in all three modalities
equally rapidly.
The strategy of assessing a child's abil-
ity to imitate vocal behavior and to acquire
exchange responses while simultaneously
monitoring problematic behaviors associ-
ated with each training modality is one way
to select an initial communication training
modality. Of course, selecting PECS as an
initial communication modality does not
imply that working on imitations of actions
or vocal behavior needs to be avoided. Diffi-
culties associated with imitation training
may only indicate that PECS may be rapidly
acquired while control of the vocal system is
developing.
As children acquire skills during initial
phases of training, it is obvious that they
must actively approach an adult in order to
request successfully. Research is currently
underway on the generalized social approach
of these young children as a function of
their introduction to PECS. Casual observers
(including parents) have commented that
requests constitute the first calm social ap-
proach to an adult by many of the children
who have learned to use PECS. In one case
study of an adult who was taught to request
social contact with staff using PECS, it was
reported that picture symbols were being
used to control the length of social interac-
tions (Castrogiovanni et al., 1997). This adult
would give a picture corresponding to "talk
to me" to a trainer, then take the picture
back when he wanted to end the interaction.
Another question involves children's
382 preferences for particular communication
This document was prepared for the exclusive use of Andrew Bondy. Unauthorized distribution is strictly prohibited
19, NUMBER 4 1998
systems. Simon et al. (1996), using a case
study format, compared a child's use of PECS
with his use of facilitated communication.
As has been found in numerous other stud-
ies, there is no satisfactory
. way. to assess the
accuracy of a child's communicative behav-
ior in a facilitated communication format.
More relevant to the question here was the
observation that, when given a choice be-
tween using facilitated communication and
using his PECS book, the child always chose
to use PECS. After children have learned to
communicate with PECS and it is made un-
available to them periodically, many of them,
including those who can say a few words,
show various signs of distress until they are
able to retrieve their communication book
(Frost et al., 1997).Another study looked at
three children (ages 10 to 12 years) and
compared their rate of acquisition of tradi-
tional picture-point systems to that of PECS,
which found that each child acquired use of
PECS more rapidly (Forgeron et al., 1996).
THEIMPACTOF PECS ON
OTHERSKILLSAND LESSONS
The rapid acquisition of requesting with
PECS provides opportunities to change the
way other communicative functions are
taught. For example, the traditional behav-
ioral approach to teaching attributes, often
referred to as "cognitive skills" (e.g., color,
size, shape, position, number, body parts,
etc.), usually involves a receptive task. Ob-
jects are selected by the teacher and placed
before the child and the teacher instructs,
"Touch blue . . . touch your nose . . . show
me big . . . point to 3 . . . ," etc., as the
teacher tries to make certain features salient
to the child. Once a child has learned to re-
quest using PECS, however, another format
is available. For example, assume that a child
consistently picks out the red candy when
given a handful of fruit-flavored candies.
Because the child can already request "I
want candy," it is relatively simple to teach
him or her to request "I want RED candy" by
placing the new icon, RED, on the sentence
strip. This lesson has been taught to chil-
THE PICTURE EXCHANGE COMMUNICATION SYSTEM-BONDY,FROST
dren who have not gone through formal
matching-to-sample training but who clearly
can discriminate a particular feature (Frost
& Bondy, 1994). In similar fashion, a child
can be taught to request a "big" pretzel if he
or she reliably selects the big pretzel from a
choice of a big and a small pretzel. To teach
a child the conditional discrimination of fea-
tures involving polar characteristics (i.e.,
size), the teacher must create a situation in
which both features are important to the
child. The advantage to teaching attributes
and other vocabulary in this manner is the
use of a more natural reinforcing contin-
gency--one selected by the child rather than
the teacher.
After a child has learned to request
with PECS, there are increased opportuni-
ties to design additional lessons within a mul-
titude of environments. Essentially, when-
ever the child is in a situation in which he or
she wants something, a lesson is immedi-
ately available. It is not necessary to create a
quiet, isolated area in order to proceed with
all lessons. Natural settings have many moti-
vating features for many new lessons. For
example, children are not given everything
they request. All of us have to wait occasion-
ally for a reward. If a child has learned to re-
quest using PECS, the child aso can be
taught to wait immediately after a request
for a short period of time. Such learning is
often aided by giving the child who just re-
quested something a card that says, 'WAIT,"
then pausing for a few seconds, taking the
wait card back, and saying, "Nice waiting!"
while simultaneously giving the child the re-
quested item. Over time, the wait interval is
gradually increased. Research is currently
underway that compares the ease of acquir-
ing this type of skill when training either
precedes or follows the acquisition of PECS.
PECS AND BEHAVIOR MANAGEMENT
During the past decade, a great deal of
research has focused on understanding the
potential communicative functions of vari-
ous problem behaviors (Carr & Durand,
1985). Given the role that PECS can serve in
This document was prepared for the exclusive use of Andrew Bondy. Unauthorized distribution is strictly prohibite
providing students control over receiving
significant reinforcers and avoiding signifi-
cant punishers, it is not surprising that PECS
has been reported to have positive effects in
reducing behavior management problems.
Finnegan et al. (1987) reported that train-
ing adolescents with autism to use PECS had
a rapid and positive impact in reducing the
rate of aggression and similar problem be-
havior targets, including their occurrence
in community settings. Belknap et al. (1996)
reported similar reductions in problem be-
haviors in several adolescents with multiple
disabilities who were trained to use PECS.
Displays of frustration are common among
children who cannot calmly request impor-
tant items. For those children who need to
take a break from an activity, the use of
PECS to ask for a break can replace the use
of more dramatic and dangerous ways of
not doing or completing a task. Although
PECS training alone is not always sufficient
to improve communication-related behav-
ior management problems, it is often an es-
sential component in an intervention pack-
age (Bondy & Battaglini, 1992).
THE CODEVELOPMENT OF
SPEECH AND PECS
PECS is introduced to children and
adults to help them acquire functional com-
munication skills. Many of those who
learned to use PECS had been mute or had
used speech in nonfunctional ways. Al-
though it is natural for parents and teachers
to want silent children to acquire speech, a
goal that is readily understandable, this is
not the goal of PECS. It should be noted,
however, that after PECS has been intro-
duced to children, especially preschool-aged
children, a significant portion of these chil-
dren develop speech.
For children with autism who develop
speech (Figure I ) , often there is a period of
time when they are acquiring a repertoire
of picture requests with PECS but are not
displaying any speech, including vocal imi-
tation. After a few months of acquiring pic-
tures and other visual symbols, a child may 383
 SEMINARS IN SPEECH AND LANGUAGE-VOLUME 19, NUMBER 4 I998

Age at Start = 2 years 8 months

First
Spoken

Figure 1. The number of pictures used within PECS training and the number of spoken words used by F during
the months following the introduction of P E G .

produce single words (or even a short ever, as can be seen in Figure 1, this child
phrase). First words are often produced dur- continued to expand his picture repertoire
ing exchanges involving delayed prompt- after he began to speak. In the months fol-
ing, when the teacher is reading the sen- lowing the utterance of his first spoken word,
tence strip aloud. Other children may begin this young boy increased his PECS reper-
to speak as they hand the sentence strip to toire by 50%, expanding his vocabulary for
the teacher. Once a preschooler begins to individual items, adding syntax and new lin-
speak, however, there is usually a gradual in- guistic structures. Although there has been
crease in the number of spoken words over no systematic study of the effects of elimi-
the next several months. For example, the nating a child's access to PECS immediately
child whose progress is depicted in Figure 1 after he or she starts speaking, our experi-
rapidly acquired many pictures but did not ence suggests that such a removal does not
say his first word until 11 months after be- foster faster communicative or speech de-
ginning PECS training. At that time, he was velopmen t.
using over 50 pictures. For approximately For children who are in this "mixed
the next six months, he continued to ex- stage," speaking while still using their PECS
pand his PECS use as he expanded his pro- system, there is evidence that their speech is
duction of both words and phrases. About significantly reduced if they are denied ac-
18 months after his introduction to PECS, cess to their PECS system (Frost et al., 1997).
he no longer used pictures but relied solely Using a multiple-baseline design across chil-
on speech as his mode of communication. dren, each of four children produced signif-
It is tempting for professionals and staff icantly fewer spoken words, shorter phrases,
to conclude that a when child is talking, the and fewer social approaches when their
PECS materials should be put away. How- PECS books were not available compared
384

This document was prepared for the exclusive use of Andrew Bondy. Unauthorized distribution is strictly prohibit
THE PICTURE EXCHANGE COMMUNICATION
with when they had free access to their sys-
tems. Two children who spoke only in single
words when their systems were not available
used five- and six-word sentences when ex-
changing sentence strips with the teacher.
Thus, the removal of PECS may have ac-
counted, in part, for the less sophisticated
use of speech to communicate in these chil-
dren.
In a review of one group of preschool-
ers who developed speech after learning
PECS, it was found that the number of
months that passed from a child starting
PECS to using first spoken word averaged
8.5 months, with a range of 3 to 18 months
(Bondy, 1993). At the time when a child's
spoken vocabulary became as large as the
picture vocabulary, the mean number of pic-
tures was 85. Further study and analysis of
the codevelopment of speech in relation to
these children's use of PECS is clearly needed.
Bondy and Frost (1994a) described the
communicative modality outcomes of a group
of preschoolers who were taught PECS. Of
the 19 preschool-age children with autism
who used PECS for less than 1 year, two ac-
quired independent speech and five devel-
oped speech while using PECS. The remain-
ing 12 children used PECS as their sole
communication modality. Among 66 chil-
dren who had used PECS for more than l
year, 39 developed independent speech
(59%) and 20 other children used speech
while using PECS (30%). Seven children
within this group were not observed to use
speech at all. Thus, a large proportion of
preschool-age children who are trained to
use PECS because they do not display ap-
propriate functional communication skills
develop independent speech, although not
necessarily age appropriate, generally from
6 to 18 months after starting PECS training.
At this time, there has not been a controlled
study of the codevelopment of speech dur-
ing PECS training. Therefore, no causal re-
lationship can be inferred between using
PECS and acquiring speech.
A related question is how age at the be-
ginning of training relates to the subse-
quent development of speech. Bondy (1993)
This document was prepared for the exclusive use of Andrew Bondy. Unauthorized distribution is strictly prohibit
reviewed the communication modality out-
comes of 57 children with autism who had
been introduced to PECS between the ages
of 2 and 5 years. Of the 37 children who be-
gan at 2 and 3 years of age, 65% developed
speech and 41% spoke independently. Of
the 20 children who began at ages 4 and 5
years, 65% also developed speech and 35%
spoke independently, At the time of this
study, some of these children spoke only
while using their PECS system. It appears,
therefore, that children who are introduced
to PECS at ages 4 and 5 years are as likely to
develop speech as are children from 2 to 3
years of age. There were too few cases of
children older than 5 years when they are
introduced to PECS to draw any conclu-
sions about the impact of introducing PECS
on the subsequent development of speech
among somewhat older children.
Among the questions that arise from
observing the development of speech among
some of the children being trained on PECS
is what characteristics are predictive of their
long-term communicative modality out-
comes. For example, is there a relationship
between the severity of their autism and
their development of speech after using
PECS? A review of the scores from the
Autism Behavior Checklist (ABC) (Krug et
al., 1980) of 41 children with autism who
learned to use PECS, found no substantial
differences in the intake scores of children
who developed independent speech, devel-
oped speech only in concert with using
PECS, or used only PECS to communicate
(Bondy & Peterson, 1990). At the time of
this review (1 to 3 years after the children
were introduced to PECS) , the children who
relied on PECS to communicate displayed a
relatively small reduction in their ABC scores,
the children who were in the "mixed" out-
come group showed modest changes in
their scores, and the children who had ac-
quired independent speech demonstrated
substantial reductions in their ABC scores.
Thus, children's initial ABC scores were not
correlated with their long-term commun-
icative modality outcomes, although their
long-term ABC scores were correlated with
 SEMINARS IN SPEECH AND LANGUAGE-VOLUME
long-term communicative modality. Other,
related questions pertain to the relationship
between these children's initial cognitive
skills and their eventual communicative
modality after using PECS.
Does the use of PECS influence the
type of educational outcome and placement
for a child? Bondy and Frost (1994b) re-
ported that 20 of 27 preschoolers entering a
public school program had used PECS. When
the group's identification and placement
were reviewed at first and second grade lev-
els, 10 children had been reclassified, typi-
cally as learning disabled, or were no longer
receiving any special educational services.
Of these 10 children, seven had been trained
successfully on PECS. Thus, 43% of the chil-
dren who had displayed speech upon enter-
ing the program achieved excellent outcomes
in terms of their educational placements,
and 35% of the children started on PECS
achieved similar outcomes. It should be
pointed out that the group included three
children who functioned in the severe/pro-
found range of mental retardation, all of
whom learned to use basic levels of PECS
but did not develop speech. Thus, the out-
comes for children with autism who were
not severely/profoundly retarded and had
started on PECS and who entered this pub-
lic school program appear to be compara-
ble with the outcomes of children with autism
who displayed some functional speech upon
entry. Obviously, educational placement can
be influenced by factors other than the child's
progress. However, guidelines for the place-
ment of children within this public school
program was predicated upon independent
placement with minimal support (i.e., speech
services) rather than placement governed
by a full-time "shadow" or paraprofessional.
Additional information is needed on how
PECS use relates to measures of long-term
educational success for children with autism
and related developmental disabilities.
Currently, there is no substantial data
base regarding the codevelopment of speech
on children older than 6 years who are in-
troduced to PECS. In general, it would ap-
pear that the likelihood of developing speech
386
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19, NUMBER 4 1998
after age 6 is low, but not impossible. We
have heard testimonial accounts of adoles-
cents, and some adults, who display some
speech after successful use of PECS. Of
course, these testimonials have to be inter-
preted conservatively, and only systematic
observations will provide adequate answers
to this issue.
SUMMARY
The Picture Exchange Communication
System is a functional communication sys-
tem for children with autism, related devel-
opmental disabilities, and related commu-
nication disorders. Its use has a number of
distinct advantages. The sequence of train-
ing steps begins with rapidly teaching a
learner to approach an adult spontaneously
and exchange a picture for 3 desired item.
This fist step aims to teach communicative
skills within a social context that are initi-
ated by the learner. Although it is important
to teach children to imitate and follow sim-
ple directions, these skills are not prerequi-
sites for functional communication. The
phases of training in PECS begin to build
vocabulary and sentence structure, and feed-
back from teachers provides potential asso-
ciations between spoken words, items or
events, and their corresponding pictures.
Feedback also is arranged to enhance the
likelihood that children will imitate or fill in
abbreviated phrases spoken by the teacher.
The use of PECS by preschool children with
autism also has been found to correlate pos-
itively with the development of speech in a
substantial proportion of children.
At this time, preliminary research has be-
gun to provide systematic information about
the acquisition of PECS, its impact on such
other important issues as social approach and
behavior management, and the relationship
between PECS use and speech development.
We hope this review will spark continued in-
terest in this strategy and generate more for-
mal studies of PECS and the communicative
development of children with autism and re-
lated communicative disabilities.
THE PICTURE EXCHANGE COMMUNICATION SYSTEM-BONDY, FROST
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THE PICTURE EXCHANGE COMMUNICATION SYSTEM-BONDY,FROST
ARTICLE THREE
SELF-ASSESSMENT QUESTIONS
1. All of the following are reasons for ini-
tially focusing on the "request" function
in communication intervention with
young children with autism and related
developmental disorders, except:
(a) These children are typically sensi-
tive to the social consequences asso-
ciated with lessons that teach com-
menting.
(b) Effective communication training
should begin with spontaneous
child initiations.
(c) Training requests decreases the
opportunity for "prompt depen-
dency" to develop.
(d) Children with autism are more mo-
tivated by tangible items that can
be used as effective reinforcers.
2. The first lesson in PECS is:
(a) to establish rates of requests and
comments.
(b) to teach the child how to initiate
an interaction with a communica-
tive partner.
(c) to establish that the child can per-
form symbol-to-object matching
tasks.
(d) to teach the child to respond to
questions such as "What do you
want?"
3. A "correspondence check" is performed
when:
(a) both items presented to the stu-
dent are reinforcing.
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(b) the student reacts negatively to be-
ing given one of the reinforcers.
(c) the child takes the item which cor-
responds to the item selected from
an array of items.
(d) the child selects the cbrrect picture
when presented with two alterna-
tive pictures.
4. During the final phase of PECS, prompt
fading strategies are used:
(a) once the child begins to maintain
high rates of spontaneous requests.
(b) to encourage the child to com-
ment spontaneously.
(c) to increase the child's ability to re-
spond to environmental cues.
(d) all of the above.
5. Which one of the following comments
is not true about PECS?
(a) PECS is a system designed to help
individuals acquire functional com-
munication skills.
(b) Children introduced to PECS be-
tween the ages of 4 and 5 are as
likely to develop speech as chil-
dren between the ages of 2 and 3.
(c) There exists a causal relationship
between using PECS and acquiring
speech.
(d) PECS assists in building vocabulary
and sentence structure.