A meta-analysis in 2010 found that PECS resulted in small to moderate effects for improving communication skills, suggesting that PECS has promising effectiveness in improving communication outcomes in children with autism spectrum disorder. Findings also suggested PECS may be beneficial, at least in short-term effects, in promoting speech in children with a specific developmental profile (i.e., low joint attention, low motor imitation, high object exploration).

While the research is still unclear on whether PECS specifically will lead to better speech output (talking) for children with autism, Schlosser, R. W., & Wendt, O. looked at all of the research on augmentative and alternative communication (AAC) in general in 2008 and made this statement:

This review found no evidence that AAC intervention hinders speech production in children with autism or PDD-NOS and suggests that AAC may result in increased speech production. The authors note that the “observed gains in speech production may vary across individuals and, if they do occur, are typically small in magnitude”

The PECS program teaches a child to exchange a picture for something he/she wants.  In this regard, it is very helpful for teaching a child to request.  Often, this is a great first step for children who don’t seem interested in interacting with others because it shows them an easy way to get started.

However, once a child moves beyond basic requests, speech therapy may need to incorporate other types of communication strategies to help them continue to expand their communication skills.

A meta-analysis in 2008 indicated that a multimodal approach may be most appropriate. For example, PECS may be appropriate for manding and tacting but other approaches may be necessary for asking questions and developing social closeness. Additionally, considerations should be made for transitioning PECS users to more appropriate long-term communication interventions (that can accommodate larger vocabularies and more mature mediums for communication).

In order to participate in the Picture Exchange Communication System (PECS), the adult who is working with the child must be trained in how to use PECS.  The program involves very specific steps that must be taught in the correct order and in the correct manner.

This article will give you an overview of the PECS process, but if you are interested in doing this with a child, you should find a training near you:

Click Here to Find a PECS Training Near You!

Speech therapy using the PECS program will follow the phases outlined below.  In general, the child will be taught to exchange a picture for something he wants through the use of a back prompter (who will help move the child to complete the exchange).

The PECS System is broken down into six phases that are strictly controlled in terms of how they are implemented.  Here is a basic overview of what those phases involve.

Phase 1. How to Communicate

In the first phase of PECS, the child will learn that if they hand an adult a picture, they will get what they want in return.  For this phase, there is one adult in front of the child who is holding what the child wants, and another adult behind the child guiding the child’s hand and arm to help him pick up the picture and give it to the first adult.  Like I said before, this is a very specific program with very specific instructions.

Each adult in this situation has an important role and has instructions on what to do.  For the first phase, the child only has one picture in front of him.  He’s not choosing the picture he wants from a selection, he’s just practicing the idea of handing a picture and getting what he wants.

Phase 2. Distance and Persistence

In this phase of PECS, the child is taught to be more persistent with his communication attempts.  Some of the time, the picture will be moved farther away from the child and he’ll have to go get it.  In other attempts, the picture will be right next to the child but the person who is holding what he wants will start walking away.  The child learns that he needs to be persistent to communicate and can’t give up.

Phase 3. Picture Discrimination

At this point in the program, the child will be given two pictures to choose from.  The child must find the picture that he wants and give that to the adult.  Typically, the second picture is something that the child does not want so that he understands that he really does need to look at the pictures.  Just like the other stages, this stage describes different roles for each of the two adults and shows you exactly what to do to help the child learn how to choose the correct picture.

Phase 4. Sentence Structure

At this point, the program teaches the child how to form a simple sentence.  The picture choices are placed on the front of a notebook with Velcro along with a picture that says “I want”.  There is also a separate strip of Velcro that detaches from the book.  The child is required to place the “I want” picture on the strip along with the picture of what they want.  When the child takes that strip and hands it to the adult, the child is helped to point at each picture as the adult says the words out loud.  At this point, I have seen some children with autism begin to speak the message along with the adult.  That’s not the case for all children, but I definitely have seen some success with this for some children.

Attributes and Language Expansion:

Though not necessarily a true phase, there is also training on how to help a child use adjectives and other words to expand his sentences at this point.

Phase 5. Answering Questions

This phase teaches the child how to answer the question “what do you want” using the PECS notebook and pictures.  For the children that I have used with PECS, I have not often had one get this far.  Typically, the child either starts talking or we have tried a different AAC system, such as a speech output device, and had success with that.  That’s not to say that you can’t continue with this program, that’s just what I’ve done in the past.

Phase 6. Commenting

This phase teaches the child to comment in response to a question.  For example, you may ask “what do you see?” and the child replies with “I see ___”.

What Are the Benefits of Using PECS?

Personally, I have used PECS with many children.  I find it to be especially helpful to those who are not really interested in interacting with anyone.  This program teaches kiddos to initiate an interaction by handing them a picture.  By using PECS, you can often take a child with no interest in other people and get them to the point where they spontaneously initiate an interaction.  This can be a huge first step for children with autism or other developmental delays who were previously uninterested in communicating.  Often, once they see the power of this communication, they are more open to trying other forms of communication, including speech.

What Are the Downsides of Using PECS?

PECS requires special training and two adults to complete the therapy.  You cannot and should not use the materials if you haven’t been trained and it can often be difficult to find two adults to work on this at the same time.  This can be especially hard if you are an SLP working in a school without a lot of other support or if you are a parent at home without another adult around most of the time.  I’ve also had families tell me that it is difficult to keep the notebook and pictures around without losing or forgetting them.

Can I Use Pictures Without Doing the PECS Training?

Of course!  Just because you haven’t been trained on using PECS, it doesn’t mean you can’t use pictures to support a child’s language development.  Showing a child pictures of words that you are saying can increase comprehension and letting a child choose what he wants from a few pictures can be extremely helpful for a non-verbal child.  Just know that if you do that without the PECS training, you are using pictures to support language development but not doing PECS.

In the following video, speech-language pathologist Carrie Clark will explain the best way to use PECS with a toddler and what to do even if you’re not actually trained in PECS.

Identify Top Priority Words First:

• What are the child’s favorite foods/objects/activities?
• What does the parent wish the child could communicate?
• What does he need to be able to use in his daycare/preschool?
• Make pictures for these things and put the book together.

Follow Him Around with the Notebook at the Ready:

• Wait for the child to express an interest in something.
• Find that picture and put it on the outside of his book.
• Place the book in front of him while he’s playing.
• Ask for a turn with the object and take it to play with it (or wait till he runs out if it’s consumable).
• Have your back-prompter ready to prompt him to use PECS to ask for it back (or for more).

If the Child is at a Higher Level:

• Have all of the pictures inside his book and either put a few choices on the front depending on the activity or allow the child to “go shopping” and pick the picture he wants from the inside pages of the book.
• Have the book with him at all times so he can use it whenever he wants to.

If you’re Not Actually Doing PECS:

If you’re just having the child point to pictures to communicate or even hand them to you but you’re not doing the structured PECS program, you can do things like…

• Have pictures velcroed in different locations around the house or classroom.  For example, you can have a few pictures of your child’s favorite drinks velcroed to the fridge door and a few of his favorite snacks velcroed to the pantry door.
• Have a shelf with toys up high (out of the child’s reach) and Velcro a picture that represents that toy down lower where he can reach it.
• Velcro a picture to an actual toy, like a picture of bubbles on the bubble jar or a picture of a train car on the box of train tracks.
• Use place mats and boards to offer common picture choices during certain activities (snack mat with common foods and things like “more”, “eat”, “drink”, “all done”, and “yummy”).