The Picture Exchange Communication System (PECS)

What Do the Data Say?

Beth Sulzer-Azaroff
University of Massachusetts, Amherst

Focus on Autism and Other Developmental Disabilities Volume 24 Number 2 June 2009 89-103 2009 Hammill Institute on Disabilities 10.1177/1088357609332743 http://focus.sagepub.com hosted at http://online.sagepub.com

Anne O. Hoffman Catherine B. Horton Andrew Bondy Lori Frost

Pyramid Educational Consultants, Inc.
Originally designed to enable young children with autism lacking functional communication to initiate requests and to describe what they observed, the Picture Exchange Communication System (PECS) has been the subject of an ever- expanding body of research and development. Thirty-four peer-reviewed published reports on PECS are analyzed in this article with documentation of research questions, methodology, and results. Findings suggest that PECS is providing people around the globe who have no or impaired speech with a functional means of communication.Refinements in methodology and additional questions that might be addressed in future research are discussed. Keywords: Picture Exchange Communication System; PECS; research trends and issues

he difficulties people with autism often encounter in acquiring and using functional communication typically result in a host of problems. Despite teachers and trainers use of scientifically derived behavioral principles to enable many with delayed speech to speak (e.g., discrete trial training; Lovaas, 1961), success has been far from complete. Consequently, investigators began to explore alternative methods based on behavioral principles for teaching verbal behavior (defined by Skinner, 1957, as any behavior reinforced through the mediation of other persons). Included as verbal behavior was manual signing or exchanging pictures (e.g., Barrera, LobatoBarrera, & Sulzer-Azaroff, 1980; Barrera & SulzerAzaroff, 1983; Frost & Bondy, 1994, 2002). In addition to exploring alternative modalities for communication, researchers have addressed the issue of dependency. When instructors take the lead in occasioning communication, students often are required to wait passively until they are asked what they want. Incidental teaching emerged as one strategy for overcoming that particular barrier (Hart & Risley, 1980), a technique that capitalized on childrens inclination to communicate in some form

(e.g., crying, pointing, reaching) when they saw something appealing but just out of reach. Incidental teaching encourages learners to initiate by seeking the assistance of another person and make requests for what they specifically want or need or to describe things in the environment. In 1994, Bondy and Frost reported their development of the Picture Exchange Communication System (PECS), a picture-based procedural package to teach children lacking spoken language skills to initiate requests and to describe what they observe. The system is an applied behavior analytic program designed for early communication training and is intended for use during typical activities within the natural settings of the classroom and the home. Bondy and Frost (1994) reported using PECS with a 36-month-old boy, who progressed from displaying no functional communication skills to using over 100 pictures to obtain reinforcers and comment about his environment using simple sentences and who gradually shifted his
Authors Note: Address correspondence to Beth Sulzer-Azaroff, Pyramid Educational Consultants, Inc., 13 Garfield Way, Newark, DE 19713 (e-mail: bazaroff@comcast.net).

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ommunicative modality over to speech in less than a year. c Seven other children learned to communicate in less than 22 months, mostly in the form of spoken language. Over the next 5 years, the developers of PECS followed 85 children with autism who were taught according to the PECS protocol, including 66 who used PECS for more than 1 year. Of this latter group, 59% acquired speech independent of visual supports, while another 30% spoke while using PECS (see Bondy, 2001; Bondy & Frost, 2001; and Bondy, Tincani, & Frost, 2004, for further details). Since the original demonstration in 1994, the application of PECS has been accelerating across the autism and other developmental disabilities communities, with personnel trained to apply the approach in dozens of countries. Yet popularity is not the same as functional effectiveness, in either a scientific or a public policy sense. For instance, the U.S. Department of Educational Research and Improvement requires that decisions about instruction be based on professional wisdom plus the best available empirical evidence (Whitehurst, 2004). The research community has been responsive to this call for scientific evidence in the application of augmentative communication training methods in general. (See also Lancioni et al., 2007; Millar, Light, & Schlosser, 2006; and Tien, 2008, for reviews of research on augmentative and alternative communication methods, including PECS.) By synthesizing key features of the published, peer-reviewed, data-based research reports of PECS applications, the present article addresses the question How solid is the scientific evidence supporting PECS effectiveness? In the process, a summary of both general and specific research methods and findings along with future directions and methodological considerations will be provided.

Google Scholar, using the following terms: picture exchange communication system, PECS, Frost, and Bondy. The reference sections of articles returned in the search also were examined to locate additional publications.

Sorting Articles
Over 50 published articles were located and reviewed. The 34 articles that included data and protocol containing the key features of PECS (as delineated by Frost & Bondy, 2002) were retained in the pool. Excluded from the current analysis were three articles written in languages that could not be read by the authors and any that used the term PECS to describe different pictorial intervention methods (e.g., Dooley, Wilczenski, & Torem, 2001). While this pool of publications may be incomplete, it represents a fair, unbiased array of the current data-based publications in the field. In an attempt to heighten the objective summarization of the reports, the authors discussed, designed, tested, compared, and revised a list of key features that should be included in reports of research on PECS. These included the purpose, participants (gender, ages, diagnoses), experimental design, measures, reliability, and when feasible, how closely the investigators followed the PECS protocol and/or any specific variations. Additional features included the amount of training provided, PECS levels achieved, and other direct and generalized results. Also noted were reports of collateral benefits, such as emerging speech, reduced rates of contextually inappropriate behaviors (CIBS; Bondy & Sulzer-Azaroff, 2002), and increases in social approaching. At least two of the authors read and analyzed each of the articles for the specified key elements. In the rare instances of disagreement, the conclusions were discussed to reach consensus.

Method
Personnel
The authors served as the research personnel for this study. They included a specialist in the field of applied behavior analysis and consultant to Pyramid Educational Consultants (the organization for PECS training and consultation); a special educator and a speech and language pathologist, both of whom serve as PECS trainers and consultants; and the developers of PECS.

Results
The publication trends over time, variables investigated, personnel and participants involved, data recorded, methodological features, and general results are summarized under separate subheadings.

Number and Trends of Published Articles

As shown in Figure 1, the number of PECS research publications has increased dramatically. Yoder and Stone (2006a, 2006b) reported different aspects of the same study in two articles; their data are counted and reported as a single study. The number of publications ranges from 1 to 7 per year, totaling 34 at the time of this writing.

Locating Articles
An exhaustive search was conducted of abstracting sources, including Science Direct, ERIC, PsycINFO, and

Sulzer-Azaroff et al. / Picture Exchange Communication System 91

Figure 1 Cumulative Number of Picture Exchange Communication System Articles

Note: Shading change indicates change in year.

Variables Examined
The variables examined across the studies included purpose, number and characteristics of participants, settings in which the studies were conducted, instructional and research personnel involved, materials required to implement the studies, measures for assessing participants and participant change, whether reliability was documented, types of research designs used, variations from recommended PECS procedures, whether the investigators documented procedural fidelity, duration and level of PECS training, and general outcomes. Table 1 summarizes the results of the analysis. Purpose. In about half of the studies, the purpose was simply to discover whether PECS would enable nonspeaking participants to initiate functional communication. Investigators also were interested in assessing collateral benefit such as participants acquisition and use of spoken communication skills (Carr & Felce, 2007a, 2007b; Charlop-Christy, Carpenter, Le, LeBlanc, & Kelley, 2002; Ganz & Simpson, 2004; Ganz, Simpson, &

Corbin-Newsome, 2008; Kravits, Kamps, & Kemmerer, 2002; Stahmer & Ingersoll, 2004; Yokoyama, Naoi, & Yamamoto, 2006) and language-skill generalization to untrained settings and language functions (Schwartz, Garfinkle, & Bauer, 1998; Webb, 2000). In addition, some researchers monitored play versus repetitive TV watching (Anderson, Moore, & Bourne, 2007), social approaching (Kravits et al., 2002), and turn taking (Yoder & Stone, 2006a, 2006b). Several also examined related changes in rates of aggressive, disruptive, or dangerous behaviors (CIBS; e.g., Frea, Arnold, & Vittimberga, 2001; Heneker & MacLaren-Page, 2003; Tincani, Crozier, & Alazetta, 2006; Webb, 2000). Frost and Bondy (2002, pp. 114, 136) encouraged testing adaptations of PECS, and this became the purpose in several investigations. Because their participants ability to ambulate was limited by athetoid quadriplegia, Almeida, Piza and Lamnica (2005) altered the standard format of promoting student initiation from walking to signaling a request with an auditory stimulus (a rattle, in this case). Ganz, Cook, Corbin-Newsome, Bourgeois, and Flores

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n 1 7 years PDD-NOS Alternating treatment AB Yes Not reported Phase V No Not reported Not reported Ages Diagnosis Design Measures Reliability Reported Training Results PECS took less time to teach Taught all 6 phases PECS Level Achieved 1 9 years 10 months 6 years ASD Case report Yes Cerebral palsy % physical prompts trial by trial; preferred response spontaneous responses throughout day Trials: unsuccessful; physically assisted, verbally assisted, no assistance 1 6 4 years DD Alternating treatment % of intervals containing language, play, & TV watching during 10-min segments of free play Correct unprompted responses Yes From 16 echolalic to 89 functional words; TV watching reduced 2 performed better with PECS; 1 performed better with VOCA 85 3.5 years ASD Case report Time to acquire pictures; no. pictures, no. spoken words No No 30-min training; Phase IV 30-min free play for 21 sessions Not reported 5 to Phase III with PECS; 2 to Phase III with VOCA 5 to 22 months Varied by child 15 hr; 12 weeks Phase III 24/41 37 years ASD Comparison group 29% used speech + pictures; 48% speech alone; 23% pictures alone Significant increase in child to adult initiations and other variables in group using PECS 5/5 5685 months ASD Comparison group Alternating treatment Multiple baseline Child initiations, with and without adult response; adult initiations, child opportunity to respond, response from child; adult initiations; no opportunity for child to respond Word initiations; word + pictures; word response % correct mands in generalization probe (object not in view) Trials and minutes to criteria Yes 45 weeks Phase III 4 Adults Severe/ profound ID Yes 3040 min, 3 times per week Yes 15 min 2 times per week Phase III All in experimental group increased no. words; 1 in control group increased 3 of 4 learned mands with PECS; 2 of 4 with sign Phase V All learned in M = 170 min, M = 146 trials; follow-up = spontaneous speech 68%100% No. PECS responses; aggression Yes Two 1-hr teaching sessions Changing criterion Time to mastery; sessions; no. trials Yes 25 sessions per week; 15 trials per session Phase III PECS increased from 0 to 5.5/session; aggression reduced from 3.9 to .02 Phase IV In less than 2 months, word utterances and complexity of grammar increased 3 12 years; 3 years ASD 8 months; 5 years 9 months 4 years ASD Multiple baseline 1 3 5 years 8 ASD months; 7 years 2 months; 3 years 9 months

Table 1 Summary of 34 Studies of the Picture Exchange Communication System

Author(s) (Year)

Purpose

Adkins & Axelrod (2002) Almeida, Piza, & Lamnica (2005)

Sign vs. PECS

Demonstration; adapted PECS symbols

Demonstration; behavior change in home VOCA vs. PECS

Anderson, Moore, & Bourne (2007) Bock, Stoner, Beck, Hanley, & Prochnow (2005) Bondy & Frost (1994)

Demonstration

Carr & Felce (2007a)

Demonstration

Carr & Felce (2007b)

Control group follow-up

Chambers & Rehfeldt (2003)

Manual sign vs. PECS

Charlop-Christy, Carpenter, Le, LeBlanc, & Kelley (2002)

Demonstration

Frea, Arnold, & Vittimberga (2001)

Demonstration

Ganz & Simpson (2004)

Demonstration

(continued)

Table 1 (continued)
n 1 5 years 1 month ASD Changing criterion Independent exchanges Yes Phase IIIa Ages Diagnosis Design Measures Reliability Reported Training PECS Level Achieved Results Mastered Phase IIIa in 97 sessions

Author(s) (Year)

Purpose

Ganz, Cook, Test supplemental Corbin-Newsome, step (items in Bourgeois, & clear box) Flores (2005) Ganz, Simpson, Effects of PECS & Corbinon intelligible Newsome words (2008) 3 Not reported 4 years 5 ASD, DD months; 3 years 1 month; 5 years 1 month Not reported ASD Case report No. communicative acts; function of communication; method of communication; level support needed Rates of communication use of PECS & speech; speech in classroom No Not reported No Not reported Not reported Multiple baseline % independent exchanges; word approximations Yes Phase IV

33 sessions in Phase I; 17 in II; 3 in IIIa 41110 sessions

Increased functional communication; no increase in spoken language Increase in attempts to communicate

Heneker & MacLaren-Page (2003)

Howlin, Gordon, Pasco, Wade, & Charman (2007)

Effectiveness of using PECS training within program environment Control group comparison 26 6.1, 7.1, and 7.2 years ASD

Not reported

Kern, Gallagher, Staosta, Hickman, & George (2006)

Demonstration of durability of change in aggression over 3 years

Age at start = 10 years

ADHD, Down syndrome, ODD

Randomized group: immediate; delayed; no treatment Case report Aggression in 10-sec intervals; engagement across 10-sec intervals; Longitudinal Evaluation Frequency per 30 min Yes

Not reported

Not reported

Kravits, Kamps, & Demonstration; Kemmerer (2002) trained mother 2 16 and 12 years PDD-NOS, autism AB

6 years

ASD

Multiple baseline

Frequency of spontaneous, unprompted language; social interactions; icons or speech Correspondence assessment

Yes

Not reported

Phase III

Increase in child to adult initiations and PECS use; not maintained on follow-up for 1 group; no increase in speech Used PECS to request break, attention, and participation; aggression decreased though some increase at follow-up due to implementation lapses and illness Increased icon use and verbalizations with adults and peers Yes 6 sessions for Not relevant 1 participant following PECS training Both learned correspondence

Lancioni et al. (2007)

Assessing correspondence

Liddle (2001)

Demonstration

6, then Not reported 15

ASD, LD

Case report

Phases completed, time to complete; increased vocalization/word use

No

Across 2 years

Not reported

Lund & Troha (2007)

Teach PECS with tactile symbols

17, 13, and 12 years

ASD & blind Multiple baseline

Independent, incorrect, no response

Yes

2134 sessions

20 of 21 learned to request, 11 to Phase IV (8 with 4 symbols on strips, 1 with 2 symbols on strips, & 2 with one symbol on sentence strips) Phases III, II, 1 completed to Phase III; 2 & I, respectively required physical prompts

(continued)

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Table 1 (continued)
n 34 512 years; M = 7.8 years ASD Case report PECS level; frequency of spontaneous PECS use; PECS symbols used; use of signs/spoken words/phrases Behavioral descriptions, questionnaires Yes No Not reported Average phase achieved = 4.6 Ages Diagnosis Design Measures Reliability Reported Training Results PECS Level Achieved

Author(s) (Year)

Purpose

Magiati & Howlin (2003)

Demonstration

Malandraki & Okalidou (2007)

Demonstration

10 years

ASD & Case report profound hearing loss

Marckel, Neef, & Ferreri (2006) 3 20, 34, and 27 years Severe ID Multiple probe

Demonstration

5 and 4 years

ASD

Changing criterion

No. descriptors on sentence strip

Yes

No. signs used increased to M = 1.62, words increased to M = 3.21, and phrases to M = 1.53 with spontaneous communication M = 7.38 Phases I, II, & III: Phase VI with Increased use of pictures, 63 training modifications written words, signs, and sessions (2 all (pictures faded started to verbalize day); Phases IIIV: to written 3045-min words) sessions per week; Phases IV and V: more intensive, less structured PECS & incidental training 810 hr per day 35+ and 45+ Achieved Phase Mand-tact combinations sessions VI prior to study under multiple control Yes Up to 180 training Phase III sessions Matched words to pictures and pictures to words with at least 89% accuracy Yes Not reported Phase III Both participated acquired derived requesting Yes 328 months Phase VI

Rehfeldt & Root (2005)

Test improvisation

Derived requesting skills 31 Case report

Multiple probe

Derived mands, stimulus relations

Derived requesting skills 1 Statistical comparison

Rosales & Rehfeldt (2007) Schwartz, Garfinkle, & Bauer (1998) Simon, Whitehair, & Toll (1996)

31 and 58 years Down syndrome, PDD-NOS 36 years ASD, Down synd rome, DD 7 years ADHD, ID

Correct, incorrect responses

Yes

Not reported

Not reported

Stahmer & Ingersoll (2004) M = 28 months

Pictures vs. Facilitated Communication (follow-up assessment) Analyze outcomes in inclusive program 20 ASD Inferential statistics

Scores on specific standardized and norm-referenced tests

No

Not reported

Not reported

After M = 14 months, participants communicating with peers Correctly identified known object inside bag with pictures 100% but 0% with Facilitated Communication After 7 months, mean differences on Bayley and Vineland scales were significant (p < .01); mean differences on the AQ were significant (p < .05)

(continued)

Table 1 (continued)
n 5 30, 22, 22, 31, and 30 years 5 years 10 MR, PDDmonths; 6 years NOS 8 months Study 1: multiple baseline; Study 2: ABAB % response opportunities; prompted, unprompted manding; word vocalization, word approximations Yes Alternating treatment Prompted or unprompted motor mands Yes ID ABAB Correct/incorrect Yes Ages Diagnosis Design Measures Reliability Reported Training PECS Level Achieved Results 3 of 5 acquired functional communication

Author(s) (Year)

Purpose

Stoner et al. (2006) 2

Demonstration

Tincani (2004)

PECS vs. sign

15 min or at least Phase IV with 10 exchange max 12 icons opportunities for 3 of 5 22 response Phase III opportunities per day Up to 30 response Phase IV opportunities

Tincani, Crozier, & Alazetta (2006)

Effect of PECS on acquisition of manding and speech

2, then 1 10 years 2 ASD months; 11 years 9 months; then 9 years 2 months

1 participant used sign more effectively, while the other used PECS more effectively Study 1: Both learned to mand in training setting (80%) and in generalization setting (75%); no speech; Study 2: Increased vocalizations with reinforcement delay No Yes

Webb (2000) 36 1866 months Randomized group

Demonstration

4.75.10 years

Case report

No. pictures; no. spoken words Frequency of nonimitative spoken communication acts and no. different nonimitative words during free play % correct trials; frequency of vocalizations (vowel only; consonant-vowel combo) and label approximation

Yoder & Stone (2006a, 2006b)

RPMT vs. PECS

5 ASD, 1 unknown ASD

At least 30 Phase VI exchanges daily Three 20-min Not reported sessions per week for 6 months Yes 2030 min, 1 time per week Phase III

Yokoyama, Naoi, & Yamamoto (2006)

Demonstration

5 years; 5 years ASD 11 months; 7 years 11 months

Changing criterion

All 6 completed all phases and began to speak PECS increased the occurrence and no. spoken words (outcomes not sustained on follow-up) All increased use of spoken words and exhibited more vocalizations and word approximations

Note: ADHD = attention-deficit/hyperactivity disorder; AQ = Achievement Quotient; ASD = autism spectrum disorders; DD = developmental delays; ID = intellectual disabilities; LD = learning disabilities; MR = mental retardation; ODD = oppositional defiant disorder; PDD-NOS = pervasive developmental disordernot otherwise specified; PECS = Picture Exchange Communication System; RPMT = Responsive Educational and Prelinguistic Milieu Technology; VOCA = voice-output communication aid.

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(2005) added a 3-D icon to the standard PECS protocol for a child who after numerous trials had been unable to choose and exchange a picture icon. Lund and Troha (2007) investigated the efficacy and utility of substituting tactile for pictorial symbols with young people who are blind. A further purpose of investigation involved comparison studies, designed to assess the communication skills acquired from PECS training to those obtained via other alternative augmentative communicative systems. Bock, Stoner, Beck, Hanley, and Prochnow (2005) compared the results of PECS with those obtained by teaching clients to use voice-output communication aides (VOCA). Other comparisons to PECS included sign language (Adkins & Axelrod, 2002; Chambers & Rehfeldt, 2003; Tincani, 2004), play routines (Heneker & MacLaren-Page, 2003), and Responsive Education and Prelinguistic Milieu Teaching (Yoder & Stone, 2006a, 2006b). Simon, Whitehair, and Toll (1996) compared a boys communicative abilities as a function of expressing himself via Facilitated Communication versus demonstrating the verbal labels he previously had acquired through PECS. Marckel, Neef, and Ferreri (2006) tested the effectiveness and generality of teaching students at more advanced stages of PECS instruction to generate and apply requesting skills by combining icons representing colors, sizes, and shapes. Rehfeldt and Root (2005) investigated whether learners might become capable of building on their PECS foundation by shifting from picture icons to the items dictated names, then from the dictated names to their corresponding text (i.e., reading). Number and characteristics of participants. Given that Bondy and Frost (1994) originally designed the system for use with nonspeaking students in the Delaware Autistic Program, the majority of the 386 study participants have been children on the autism spectrum, especially preschoolers involved in early intervention programs. A few case investigations involved only single individuals. Most studies included two or three participants; the largest reported group of participants was 85 (Bondy & Frost, 1994). Diagnoses for the child and adult participants include pervasive developmental disordernot otherwise specified, attention-deficit/hyperactivity disorder, cerebral palsy, severe or profound mental retardation, developmental delays, severe learning difficulties, severe disabilities, blindness, deafness, severe or profound hearing loss, or otherwise nonspeaking. When gender was indicated, the ratio of male to female participants was about 4:1. Settings. Most of the studies have been conducted in special and regular schools (e.g., Carr & Felce, 2007a, 2007b; Charlop-Christy et al., 2002; Liddle, 2001; Magiati & Howlin, 2003; Yokoyama et al., 2006) and

preschools (Frea et al., 2001; Heneker & MacLarenPage, 2003; Schwartz et al., 1998; Tincani, 2004; Webb, 2000; Yoder & Stone, 2006a, 2006b). A small proportion of the studies were conducted within or across locations, including integrated preschools, day care centers, homes, vocational training sites, and the community (e.g., Stahmer & Ingersoll, 2004; Stoner et al., 2006). Instructional and research personnel. Typically, external or internal consultants and/or parents coached personnel (e.g., Carr & Felce, 2007a, 2007b; Magiati & Howlin, 2003; Tincani, 2004; Webb, 2000) and/or parents (Heneker & MacLaren-Page, 2003) in the use of PECS. When reported, it generally was an experimental team and/or teachers or parents who collected the data and/or implemented the system. In addition, undergraduates, university faculty (e.g., Stoner et al., 2006), direct care staff (Chambers & Rehfeldt, 2003), researchers (Carr & Felce, 2007a), or staff with prior data collection experience (Kern, Gallagher, Staosta, Hickman, & George, 2006) served in those capacities. Materials. The majority of investigators reported using either color or black-and-white line drawings or photographic cardboard icons, often laminated, 2'' 2'' in size. Occasionally, icon size varied (e.g., 3'' 4''; Webb, 2000). Some reported using symbolic drawings representing colors, shapes, or sizes to assess and teach their students communicative improvisation skills (Chambers & Rehfeldt, 2003; Ganz et al., 2005; Marckel et al., 2006). As suggested by Frost and Bondy (2002), when individuals failed over many trials to learn to use the pictorial icon properly for exchange purposes, three- dimensional symbols (Lund & Troha, 2007) were substituted for two- dimensional drawing. In one situation, the reinforcer itself was encased within acrylic material (Ganz et al., 2005). Generally, students were furnished with their own individual portable communication binders. Investigators often selected rewarding consequences, including tangible items, food, toys, or sensory items (e.g., Tincani, 2004), or activities (e.g., Bock et al., 2005) on the basis of frequent formal or informal preference assessments (e.g., Lancioni et al., 2007; Schwartz et al., 1998; Webb, 2000). Investigators rarely used formal functional assessments (as recommended by ONeill, Horner, Albin, Storey, & Sprague, 1990) as a method of choosing reinforcers. Measures. Measures related to the types of research questions asked. Most looked at rates of acquisition of correct responses during training, although others counted frequency of spontaneous requesting via PECS as well as

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speech. Magiati and Howlin (2003) recorded use of PECS, spontaneous communication, and adaptive behavior. Because they were comparing two different augmentative methods, Adkins and Axelrod (2002) assessed for generalization of sign and PECS, while Bock et al. (2005) recorded rates of acquisition of requesting skills between PECS and VOCA. Carr and Felce (2007a, 2007b) documented communicative initiations and interactions between students and their teachers. Heneker and MacLaren-Page (2003) recorded the number, function, and method of communication, along with the level of adult support required under each of four contexts: free play, snack, swimming, and structured teaching. Tincani et al. (2006), Ganz and Simpson (2004), and Webb (2000) assessed number of words spoken. Webb (2000) and Ganz and Simpson (2004) recorded size, complexity, and/or length of phrases and numbers of nonword vocalizations as well. Kravits et al. (2002) noted their participants verbalizations and socialization skills, while Frea et al. (2001) counted communicative and aggressive episodes over a 10-min period. Charlop-Christy et al. (2002) recorded direct measures of acquisition of PECS skills, along with instances of social-communicative and problem behaviors. Webb (2000) and Yokoyama et al. (2006) assessed disruptive, aggressive, and cooperative behavior, as did Frea et al. (2001), who specifically measured their participants rates of aggression. To assess for retention and generalization to new language functions, Schwartz et al. (1998) collected language samples a year following the training of their preschool population. Carr and Felce (2007a, 2007b), Ganz and Simpson (2004), and Liddle (2001) identified the PECS phases their students achieved, the latter also indicating the time it took for the phase to be completed. Other investigators recorded number of spontaneous requests, comments or expansions emitted within standard 10-min periods, type and number of icons used, intelligible verbalizations, initiations and/or durations of social interactions, unprompted correct trials at each level, correct or incorrect trials and independent exchanges, and correct trials to criterion (for moving on to the next phase or level). Where investigators compared PECS with other interventions (Adkins & Axelrod, 2002; Tincani, 2004), the rates of progress under the various conditions also were noted. In his comparison of sign language versus PECS, Tincani (2004) measured motor imitation, mands, and word vocalizations. Reliability. The authors of 23 of the 34 studies reported assessing reliability, providing varying details as to schedules for those assessments and whether they

occurred within and/or across phases. Authors in 18 studies supplied indices of agreement (IOA) data, 8 reported collecting IOA but did not report results, and 7 did not report collecting such data. Research designs. Many of the researchers provided descriptive, data-based reports of applications of PECS. To demonstrate functional relations, single-case designs included multiple baselines, changing criterion, alternating treatment, and multiple probe. Randomized group comparison designs also were used. Variations in procedures. The majority of the authors indicated adhering to the procedures in one of the Frost and Bondy training manuals (e.g., Frost & Bondy, 2002). In a few studies, some of the critical elements of the PECS procedure (e.g., involving a second trainer to guide the student to approach his communicative partner, using the carefully designed system of training conditional discriminations, etc.) were omitted (e.g., Lund & Troha, 2007; Yokoyama et al., 2006). In the Ganz et al. (2005) study, when the student failed to grasp a picture, the researchers purposely added a step of the type Frost and Bondy (2002) suggested, by enclosing the actual reinforcing item (i.e., a piece of candy) in a clear box. In addition, training methods were purposely varied in cases in which the investigators wanted to compare methods or augment results (e.g., Malandraki & Okalidou, 2007; Rehfeldt & Root, 2005; Simon et al., 1996). To further document procedures, authors of many of the articles also indicated number of trials conducted per session and frequency of formal training sessions. Procedural fidelity. Authors in only a few articles reported numerical treatment fidelity scores (e.g., Kern et al., 2006; Stoner et al., 2006; Tincani, 2004; Tincani et al., 2006; Yoder & Stone, 2006a, 2006b). Among those that did, specific schedules and methods varied across those studies. For example, Stoner et al. (2006) reported conducting fidelity assessments daily. Duration and level of PECS training and use. Several of the authors provided information about the time spans covered in their studies (e.g., Anderson et al., 2007). These ranged from 1 to 36 months. Many investigators, though not all, reported the PECS level at which they terminated training, with the majority reporting teaching only through Phase IIIa or IIIb. Phase IIIa teaches simple discrimination, generally between a preferred and a nonpreferred (or noncontextual) object or event, while IIIb teaches conditional discrimination between at least two equally reinforcing items or events.

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Though critical to teaching broad-based communication skills, information on number of generalization trials held, by whom, and when was rarely provided in the reviewed articles. Exceptions were Tincani et al. (2006) and Bock et al. (2005), who reported assessing for generalization by taking their participants out into the community and recording their use of PECS to order food.

Discussion
The data examined in this review demonstrate that PECS has become an increasingly popular low-technology means for teaching an alternative form of communication to individuals around the world who lack functional speech. Analysis of the studies strongly supports the conclusion that by adhering to the PECS protocol, professionals and parents can teach individuals to successfully initiate exchanges of pictures for tangible and nontangible reinforcers. Beyond the entering skill repertoires of the trainers and students, other factors probably influence the extent to which those communicative skills develop and generalize. Results of several of the studies (e.g., Bondy & Frost, 1994; Howlin et al., 2007; Liddle, 2001) appear to indicate that intensive PECS training and maintenance across the time and settings for up to 2 years can enable many participants to attain a functional communicative repertoire.

Outcomes
Researchers reported improvement in communication among the vast majority of their participants, including that between adult and child (Carr & Felce, 2007a, 2007b; Charlop-Christy et al., 2002; Tincani, 2004; Webb, 2000; Yoder & Stone, 2006a, 2006b) or adult and adult (Chambers & Rehfeldt, 2003; Rehfeldt & Root, 2005; Rosales & Rehfeldt, 2007; Schwartz et al., 1998; Stoner et al., 2006; Tincani, 2004; Tincani et al., 2006; Yokoyama et al., 2006). Participants used their communication skills with their teachers and caregivers (e.g., Carr & Felce, 2007a, 2007b; Ganz & Simpson, 2004), as well as with their parents (Webb, 2000) and members of the community (Stoner et al., 2006). Most participants learned to make requests, some learned to describe (Webb, 2000), and a few used the pictorial icons to improvise (Marckel et al., 2006) or to derive textual responses (Rehfeldt & Root, 2005). When different communicative training methods were compared, the participants taught to request via PECS performed equivalently or better than those receiving the alternative teaching methods. Adkins and Axelrod (2002, p. 259) reported their participants performance with PECS was more effective in all areas, including rate of acquisition and generalization of words. When offered a choice between two modes, two of three participants in the Bock et al. (2005) study chose PECS. However, Tincani (2004) reported that one of the two children in his study made more rapid progress in the sign-language modality. Several investigators provided evidence that learning to use PECS was associated with some of their participants increasing their speaking and social approaching (e.g., Kravits et al., 2002). In addition, a number of investigators cited decreases in disruptive or dangerous behaviors. PECS also was found to broaden participants communicative repertoires (Marckel et al., 2006), and when directly instructed, the participants learned to use text rather than pictures (Rehfeldt & Root, 2005). Over a period of a year, Schwartz et al. (1998) examined generalization of skills, reporting that many of their participants language skills generalized to untrained settings and language functions.

Treatment Integrity
A major challenge to providers is to assure that the program is properly instituted and maintained. Although PECS consists of a clearly articulated set of complex steps, implementation probably varies as a function of numerous factors including the characteristics of the individuals being taught, preparation of the trainers, supervision, fidelity of intervention, and scheduling. As with any labor-intensive intervention, continuing to provide training for the people implementing PECS requires strong organizational support. In fact, Howlin et al. (2007) suggested that student progress may begin to level off if staff no longer receive ongoing training and/ or consultation. Reporting methodological information is especially important because the broader the training and application circumstances and the greater the number of communicative partners involved (e.g., professionals, program staff, relatives, friends), the stronger the probability that communicative skills learned will be applied more generally (e.g., Doss, Locke, & Johnston, 1991). Personnel function and scheduling details are critical to interpreting the outcomes of individual studies (Ganz et al., 2005; Schwartz et al., 1998; Simon et al., 1996; Stoner et al., 2006; Tincani et al., 2006). Including data on the procedural fidelity (degree to which investigators adhered to the full research protocol) and/or the treatment integrity (degree to which investigators adhered to the treatment elements) with which the PECS method was implemented is especially important in PECS research; the precision with which the methods are applied

Sulzer-Azaroff et al. / Picture Exchange Communication System 99

can directly influence the results. Each facet of the program was crafted to capitalize on contemporary knowledge of the principles of learning and behavior. For instance, the methods used in Phase IIIb to teach students to distinguish one picture from another relate directly to extensive work on promoting fine discriminations between stimuli (e.g., conditional discriminations; Sidman & Tailby, 1982). Additional components of PECS implementation need to be assessed repeatedly to ensure optimal participant involvement. For example, prompting must be held to a bare minimum and rapidly eliminated. Trainers need to exchange their functions (i.e., prompter vs. communication partner) to minimize students dependence on particular individuals. Critically, scientifically established stimulus control methodology must be used to heighten discrimination learning. As a final example, particular strategies need to be incorporated to promote fluency and generalization of responding.

Validity and Dependability of the Data

In PECS research, a key question is whether investigators identify the number of different icons the participant regularly uses in context. This especially important measure reflects the size of the learners growing verbal repertoire and certainly should be reported. The same is true of PECS level because specifying the degrees of skill, complexity, and independence is essential for readers to assess the effectiveness of any given instructional arrangement (e.g., Chambers & Rehfeldt, 2003; Frea et al., 2001; Webb, 2000). In terms of the other categories of data to be collected during formal training trials, researchers and users should record, at a minimum, the dates, times, settings, personnel involved and in what roles and with what training, reinforcing and other materials being used, and correct and incorrect student responses. The PECS Training Manual (Frost & Bondy, 2002) provides a number of sample recording forms. Also integral to the effectiveness of PECS are opportunities to promote generalization of newly developing skills outside the formal training sessions. Therefore, investigators should collect data on responses to formally designed incidental teaching opportunities (Hart & Risley, 1980; McGee, Morrier, & Daly, 1999; Stahmer & Ingersoll, 2004) as well as fully spontaneous instances of generalization across settings, materials, and communicative partners. Given the range of measures reported, researchers may be wondering if they have been remiss in not collecting every measure mentioned above on a daily basis. However, taking data for its own sake can be costly and time

onsuming. Instead, data collection should match the c purpose of the investigation. For instance, to study patterns of daily student progress, especially during the initial phases, data should be collected on correct or incorrect trials. Lack of any evidence of progress after a few weeks of intensive effort might trigger a search for supplementary steps (e.g., Ganz et al., 2005). Otherwise, progress data might be sampled weekly or every other week. By noting the specific reinforcers employed, investigators can analyze such features as how those stimuli influence the students accuracy of responding and progress rates as well as whether those selected are retaining their potency or if there is a need to assess for and shift to new ones. As implied, recording and graphing over time the number and names of icons and phases mastered permit rate and breadth of student progress to be displayed and analyzed. As a basis for judging learner progress, trainers concentrating on teaching attributes or icons depicting parts of speech other than object-noun combinations may wish to categorize pictures according to their functional characteristics. While the clearly specified purpose of PECS is to enable people to communicate functionally, not to speak, a number of investigators reported that a proportion of participants did begin to talk, especially those whose training began at an early age (Bondy & Frost, 1994) and continued to Phase IV and beyond. It is in those latter phases where vocalizations tend to emerge (e.g., Bondy & Frost, 1994; Ganz & Simpson, 2004; Tincani et al., 2006; Yoder & Stone, 2006a). Because professionals, family members, and other educators generally are eager to find ways to promote speech, it stands to reason that any evidence of spoken language and the conditions under which it occurs should be recorded and reported routinely. Programs also are encouraged to use a system for itemizing distinctive functional spoken words (see Frost & Bondy, 2002, for suggestions). Reliability also needs to be assessed regularly throughout PECS instruction and research to avoid the risk of observer drift. A reasonable rule of thumb would be to involve dual independent data recorders charged with observing simultaneously (approximately weekly) during formal training and while assessing for various forms of generalization (i.e., across icons, communicative partners, materials, and settings) and to report those reliability measures in any submissions for publication. Most investigators reported the PECS phases they taught and the level at which they terminated training. A striking fact is that many of the researchers reported teaching only through Phase III. It is unclear why this occurred, but one possibility is investigators eagerness to publish

100 Focus on Autism and Other Developmental Disabilities

their results, because by Phase III, participants were using PECS as a medium of functional communication. It is entirely possible that PECS instruction continued beyond the time when researchers prepared their earlier findings for publication (see Carr & Felce, 2007a, 2007b, for such examples). If instruction actually was discontinued at Phase III, it might have been because the students were no longer resorting to using other, less preferred communicative methods such as screaming, injuring themselves, or becoming aggressive or destructive. While this is sheer conjecture, perhaps experiencing a reduction in maladaptive behaviors could diminish the incentive to continue teaching to the more advanced levels. Investigators are urged to record and report data on the methods used to promote and assess generalization (e.g., incidental teaching trials and other opportunities for participants to transfer their newly acquired skills across materials, personnel, and locations). In a spirit of collegiality, investigators might offer to share recording systems and forms to interested consumers of their work. Investigations of PECSs effectiveness continues to demonstrate its impact on speech production and, more broadly, functional communication. To illustrate, very recently, Schreibman (2008) presented the preliminary results of a 5-year project comparing a package using Pivotal Response Training (PRT; Koegelet al., 1989) with PECS for 39 young children with autism. All children met the following criteria upon entrance: 3 years or younger (mean age = 29 months) and used 10 or fewer spoken words. Parental reports for word use 6months after training were used, and no differences were found between the two groups inspeech production for both those who had some speech upon entry and those who had none. The same proportion of children in each groupfailedto show speech gains. However, children in the PECS group acquiredfunctional communication via their use of icons. Thus, for children whohaveno speech at program entry, using PRT to focus on training speech for 6months may fail to promote functional communication. However, the participants who were taught to use PECS, while no more likely to acquirespeech, were likely to acquire some functional communication skills via their picture use.

and others? Can the program be streamlined without sacrificing efficacy? How closely does the extent to which formal and informal PECS training and generalization opportunities across time of day, materials, activities, and so forth, relate to the rate of acquisition of communicative skills? What are the specific influences of the kinds of modifications the designers and trainers of PECS suggest in overcoming learning obstacles (e.g., Ganz et al., 2005)? How useful might PECS prove to be as an adjunct to teaching communicative skills through other means (e.g., speech, sign, or other augmentative methods)? Can PECS be readily adapted to more advanced, technological, and affordable instruments of the kind recently explored by Miller, Leroy, Huang, Chuang, and Charlop-Christy (2006)? How do variations in the protocol, such as gradually expanding the time delay (i.e., progressive time delay) between the I want and the desired article in Phase IV, relate to emergence of speech? How might the standard PECS protocol be adapted for other categories of individuals with distinct challenges such as victims of strokes or other traumatic brain injuries and those with hearing impairments? Is there an interaction among the number of icons that students master, their frequency of and fluency in using those, and other dependent variables such as rates of generalization, emergence and use of speech, impact on behaviors not appropriate in the particular context, generality of communicative skills, social approach and other interpersonal skills, and independence, as a function of strictly adhering to the PECS protocol versus nonrecommended modifications (e.g., staff maintaining control over posting the pictures)? What other aspects of PECS and PECS applications should be investigatedfor example, acquisition, efficiency, and generality of academic (e.g., reading, writing) skills, social skills, and consumer satisfaction?

Future Research
Given the complexity of PECS, numerous additional questions remain to be asked about its operation. Future researchers might investigate the following questions:
How crucial is each behavior-analytic-based element to the success of PECS and/or to augmentative communication programs such as sign, voice- operated systems,

Each of these questions looks at PECS as an alternative modality to speech. However, speech pathologists emphasize that Alternative/Augmentative Communication is a subset specialty beyond speech alternatives. In other words, it would be interesting to know if using PECS can serve to augment or facilitate the use of another modality. Similarly, researchers could investigate the effect of PECS on the vocal production of individuals who have some speech. Here, too, the effects may be narrow or broad; one child could speak only when given access to PECS, whereas another may speak in more elaborate or complex ways while using PECS. In addition, researchers could explore whether PECS can assist speakers of different languages to acquire speech or facilitate their learning a local language. If so, would it be possible for speech to fully replace the use of PECS for these individuals?

Sulzer-Azaroff et al. / Picture Exchange Communication System 101

Conclusions
The growing body of research reported above supports the conclusion that PECS is an especially promising system for enabling nonspeaking individuals to communicate functionally across a wide audience of listeners (including those who speak a language other than English). The controlled single-case studies and group experimental reports reviewed in this article suggest that PECS has enabled hundreds of individuals effectively to express their wants, needs, and observations. Though not directly designed to teach speech or to reduce aggression, a number of individuals who use PECS have begun to speak and/or to diminish maladaptive behaviors. Optimal methods for attaining these and other auspicious outcomes need further exploration. Analysis of the available research leads to the conclusion that the majority of participants who lacked functional communication skills did acquire extensive functional vocabularies. Of course, everyone would like to see a nonspeaking individual acquire speech, but autism and other related disabilities are communication, not speech, disorders as those familiar with children with echolalia recognize. Consequently, if a child previously lacking any functional communicative skills acquired an extensive vocabulary with multiple communicative functions but did not acquire any speech, most would still consider the program a success. That PECS is being applied globally is apparent. Anecdotal evidence in the form of invited workshops, conference proceedings, newsletter articles, and other informal papers substantiates the conclusion. For instance, Weiss (2007, p. 14) stated,
Many children are currently communicating efficiently and independently with PECS, and should continue to build communicative ability within that system. As clinicians, it is imperative that we be as individualized and data-based as possible in decisions about issues such as communication modality.

It is indisputable that the growing popularity of PECS is supported by an ever-expanding body of scientific evidence. Researchers are encouraged to continue exploring ways to optimize and refine the scope, utility, and efficacy of the system.

References
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Sulzer-Azaroff et al. / Picture Exchange Communication System 103 *Tincani, M., Crozier, S., & Alazetta, L. (2006). The Picture Exchange Communication System: Effects on manding and speech development for school-aged children. Education and Training in Developmental Disabilities, 41, 177184. *Webb, T. (2000). The Picture Exchange Communication System The talking goes on. Special Children, 130, 3034. Weiss, M. J. (2007). [Review of the book The verbal behavior approach: How to teach children with autism and related disorders, by Mary Lynch Barbera with Tracy Rasmussen]. Autism & Related Developmental Disabilities (Special Interest Group Newsletter), 23, 1415. Whitehurst, G. (2004). Individuals with Disabilities Education Act of 2004. Pub. L. No. 5300.35; section 9101(37) of the Elementary and Secondary Education Act. Washington, DC: U.S. Department of Education. *Yoder, P., & Stone, W. (2006a). Randomized comparison of the effect of two prelinguistic communication interventions on the acquisition of spoken communication in preschoolers with ASD. Journal of Speech, Language, and Hearing Research, 49, 698711. *Yoder, P., & Stone, W. (2006b). Randomized comparison of two communication interventions for preschoolers with autism spectrum disorders. Journal of Consulting and Clinical Psychology, 74, 426435. *Yokoyama, K., Naoi, N., & Yamamoto, J. (2006). Teaching verbal behavior using the Picture Exchange Communication System (PECS) with children with autistic spectrum disorder. Japanese Journal of Special Education, 43, 485503.

Beth Sulzer-Azaroff, PhD, BCBA, is professor emeritus at the University of Massachusetts, Amherst and a private consultant. She has authored numerous texts and research papers in the area of applied behavior analysis. Her main interests are in promoting and supporting excellence in educational and organizational performance. Anne O. Hoffman, MEd, is a consultant for Pyramid Educational Consultants, Inc. Her current interests include staff training in the general area of Applied Behavior Analysis, using the Pyramid Approach to Education framework. Catherine B. Horton, MS, CCC-SLP, is a consultant for Pyramid Educational Consultants, Inc. Her current interests include teaching functional communication skills via PECS. Andrew Bondy, PhD, is cofounder of Pyramid Educational Consultants, Inc. His current interests include autism, education, and verbal behavior. Lori Frost, MS, CCC-SLP, is cofounder of Pyramid Educational Consultants, Inc. Her current interests include autism and communication training.

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