sembles a more naturalistic approach to teaching in thatcommunication is child initiated rather than controlledby adult verbal cues. The PECS was developed to(1) provide an effective AAC for nonverbal children,while simultaneously minimizing the prompt depen-dency by teaching children to spontaneously initiatetheir wants/needs through an exchange of a picture forthe corresponding item/activity, and (2) to provide ver-bal models of language with use of the picture exchangeto encourage oral language. In addition, PECS combinespreviously researched procedures into the teaching pro-tocol to encourage child initiation/motivation including(a) child choice and preference (e.g., Dyer, 1989;Koegel, O’Dell, & Koegel, 1987), (b) time delay (e.g.,Charlop, Schreibman, & Thibodeau, 1985; Halle, 1982),(c) environmental arrangement (e.g., Carta, Sainato, &Greenwood, 1988), and (d) differential reinforcement(e.g., Koegel et al., 1987; Reichle & Sigafoos, 1991).

In descriptive reports, Bondy and Frost (1994)noted improved communication for children withautism using the PECS as well as increases in sponta-neous language acquisition; however, few empiricaldemonstrations have been reported. In a second de-scriptive study with 31 preschoolers with disabilities,the use of PECS showed increased spontaneous use of

INTRODUCTION

Augmentative communication systems (AACs)have been shown to be a successful language inter-vention for many nonverbal children (e.g., Reichle &Sigafoos, 1991; Shafer, 1993; Zangari, Lloyd, &Vicker, 1994). Unfortunately, instructional strategiesusing AAC systems may rely on the overuse of verbaland/or physical prompts such as “What do you want?”or “Point to what you want.” As a result, some childrenbecome prompt dependent and lack spontaneity in theircommunication (Mirenda & Dattilo, 1987).

A promising instructional intervention with AACis the Picture Exchange Communication System (PECS)developed by Bondy and Frost (1994), which addressesthese concerns. PECS is structured in a way that re-

Brief Report: Increasing Communication Skills for anElementary-Aged Student with Autism Using the PictureExchange Communication System

Tamara R. Kravits,1 Debra M. Kamps,1,4 Katie Kemmerer,2 and Jessica Potucek3

The purpose of this study was to examine the effects of the Picture Exchange CommunicationSystem (PECS) on the spontaneous communication skills of a 6-year-old girl with autismacross her home and school environments. The effects of the PECS were also examined forsocial interaction. Results indicated increases in spontaneous language (i.e., requests and com-ments) including use of the icons and verbalizations across those settings in which PECS wasimplemented. Intelligible verbalizations increased in two of three settings, and changes in peersocial interaction were noted in one of the two school settings.

KEY WORDS: Picture Exchange Communication System; augmentative communication; peer training.

Journal of Autism and Developmental Disorders, Vol. 32, No. 3, June 2002 (© 2002)

2250162-3257/02/0600-0225/0 © 2002 Plenum Publishing Corporation

1 University of Kansas, Juniper Gardens Children’s Project, KansasCity, Kansas 66101.

2 Autism Training Center, University of Louisville, Louisville, Ken-tucky.

3 Project S.A.I.L., 10401 Holmes Road, Suite 440, Kansas City, Mis-souri 64131.

4 Correspondence should be addressed to Debra M. Kamps, JuniperGardens Children’s Project, 650 Minnesota Ave., 2nd Floor, KansasCity, Kansas 66101; e-mail: dkamps@ukans.edu

Brief Reports

icons and generalization to novel school settings(Schwartz, Garfinkle, & Bauer, 1998). Verbalizationsincreased for talkers but not for nonverbal childrenin the study. The purpose of the current study was to(a) evaluate the effectiveness of teaching PECS on thespontaneous communication of an elementary-agedchild with autism, (b) determine feasibility of use bythe mother, classroom teachers, and peers across homeand school environments, and (c) note effects in con-junction with social skills training for social interactionbehaviors.

METHOD

Participant, Settings, Materials

Molly was a 6-year-old girl with a diagnosis ofautism. She was integrated, with the assistance of a para-professional, in a half-day kindergarten program in thepublic school. In addition, she received 30–60 minutesof special education services per day from the learningcenter teacher and language therapist. Molly’s score onthe Vineland indicated a 2 years 8 months performancelevel. Scores on the Wechsler Preschool and PrimaryScale of Intelligence (WPPSI-R) were within the 27thpercentile for verbal behavior and the 1st percentile foradaptive behavior. Her developmental age was 2–2.5years on the Psychoeducational Profile-Revised (PEP-R). When prompted, Molly communicated using 1- to2-word utterances (e.g., “Want cookie”), but her speechwas difficult to understand, and her frequency of initi-ations was very low. She also used gestures and eye con-tact to communicate, but she initiated and used moreverbalizations at home with her mother than with teach-ers or peers at school. Thus, the PECS was chosen toprovide Molly with an effective communication systemacross settings and to increase her spontaneous initia-tions and interactions with others in her environment.

Settings for the study included leisure and snacktime in Molly’s home and play periods with peers dur-ing journal (writing/coloring in notebooks followed byplay) and center activities (free play) at school. All set-tings were similar to free time with play with others asa primary activity and the inclusion of peers at school.Materials consisted of food (e.g., popcorn, candy, soda,cookies), toys (e.g., Casio piano, Koosh Balls, Slinkys,markers, Silly Putty), and games (e.g., Don’t Break theIce). Graphic symbols/icons (line drawings) of itemswere taken from the Mayer-Johnson Picture Commu-nication Symbols (1990) or were hand drawn (2 3 2-inch black and white).

226 Kravits, Kamps, Kemmerer, and Potucek

Measurement

The frequency of spontaneous languageincludingrequests (i.e., words or approximations asking for itemsor help), comments (i.e., labeling or describing items,situations), or expansions (adding new elements to pre-vious utterances) was selected as the target behavior(dependent variable) to be treated with the PECS.Requests and comments were counted only if theyoccurred without prompting (i.e., no instruction, ques-tion within 5 seconds prior).

Data were collected by the experimenters for lan-guage behaviors that occurred within 10-minute sam-ple periods. When the student communicated, theobserver recorded what the student communicated, themode(e.g., verbal, symbol, sign), the function (e.g.,request, comment), and to whom(i.e., adult or peer) thestudent was communicating. Repeated verbalizationswere recorded as one communicative episode, endingafter a 5-second pause.

Social interactiondata were collected in 5-minuteintervals using a laptop computer programmed with theMulti Option Observation System for ExperimentalStudies (MOOSES) developed by Tapp, Wehby, andEllis (1992). This system was used to code the dura-tion of interaction between Molly and her peers or theadults in her environment. Once an interaction (i.e., ini-tiation followed by a response within 5 seconds) wasobserved, it was keyed in and continuously recordeduntil the observer keyed the end of the interaction; seeprior reports for program description (Kamps, Potucek,Gonzalez-Lopez, Kravits, & Kemmerer, 1997).

Language samples and social interaction data werecollected at least once every session across all settings(i.e., two times a week in journal time and centers, twoor three times a week at home).

Interobserver agreementwas collected for eachlanguage variable for 11% of the observation sessions.The mean percentage of agreement for content of theverbalizations was 93% in baseline and 91% in inter-vention; 97% in baseline for mode (icon versus sign ver-sus verbal) and 96% in intervention; and 89% inbaseline for function (i.e., spontaneous request versuscomment) and 86% in intervention. Reliability wascomputed on an item-by-item basis, with the numberof agreements divided by the number of agreementsplus disagreements. Reliability for social interactiondata for 14% of the MOOSES files was computed me-chanically using software that matched the files of theprimary and second observers with the mean agreementat 86%.

Design and Procedures

A multiple baseline design across settings(Baer,Wolf, & Risley, 1968) was used to document treatmenteffectiveness. The experimental conditions includedtwo baseline conditions and two treatment phases thatoccurred during play activities at home and school.

Baseline (A1)

Molly was observed while in play situations acrossall settings before teaching using the PECS. Reinforcerassessment was also conducted once before beginningbaseline. Then in baseline, sessions included a varietyof available materials, including those noted as pre-ferred items from the reinforcer assessment. These wereavailable without contingent requests during the playtime. Data were collected on the frequency of Molly’sspontaneous language and social interaction across4 weeks in all settings (i.e., home, centers, and journaltime). Verbalizations to Molly were typical to the set-tings (i.e., directions for the activity, some questionsregarding her needs, general commenting). The schoolactivities were more independent play with occasionaladult interactions, whereas the mother engaged in morechatting during the leisure activities with general com-menting and some contingent questioning (e.g., “Whatdo you want?”).

Baseline (A2)

During the second baseline condition, the com-munication board with symbols was introduced acrossall environments, but Molly was not prompted to useit. Data were collected under the same conditions asthose described in the A1 condition across 1 week athome, 12 weeks during centers, and 17 weeks duringjournal time.

Treatment (B)

The PECS was implemented during play activitiesacross all settings following procedures as outlined inthe manual (Frost & Bondy, 1994). The PECS is anAAC system that uses a variety of behavioral tech-niques to teach children to communicate. These tech-niques are incorporated into six teaching phases thattarget different components of communication (i.e.,spontaneous requesting, discriminating, building sen-tence structure, responding to questions). Phases I–IIIas outlined in the training protocol were conducted inthis study, including reinforcer assessment at the be-ginning of each training session (Frost & Bondy, 1994).

PECS 227

Phase I, Physically-Assisted Exchange,consisted ofteaching Molly to initiate a communicative exchangeby giving her a picture of a desired item/activity to thetrainer. Training consisted of placing the item slightlyout of her reach. When she reached for the item, aprompter (seated behind Molly) assisted her using“hand over hand” to pick up the picture and hand it tothe trainer. If she did not reach within 3–4 seconds, thetrainer prompted from behind. The receiving trainerheld out her hand serving as a cue. Once the picturetouched the hand of the receiving trainer, the trainerstated “Oh, you want _____,” and the requested itemwas given to the student. Delays were increased to pro-mote spontaneity and discrimination. The criterion forPhase I consisted of Molly exchanging the pictures in-dependently without the prompter’s assistance andwithout the open hand cue from the trainer for 80% ofthe teaching period trials (typically 5–10 each session,with 17 trials in the initial session to teach picking upthe icon and the exchange). Phase II, Expanding Spon-taneity,consisted of three steps: the introduction of thecommunication board (pictures attached with Velcro),an increase in the distance of the receiving trainer andMolly, and an increase in the distance of the board fromMolly. Again, 80% correct, independent requesting wasthe criterion. Phase III, Discrimination of Pictures,consisted of discrimination between multiple pictureson the communication board, correspondence checks(use of icons to force correct discriminations basedupon preferences), and picture size reduction (initialsize 5 2 3 2 inches, then 1 3 1 inches). Phases I–IIIwere taught to criterion in the home setting, and thentreatment was implemented in classroom settings.

All sessions consisted of both teaching periods andplay periods. The procedures of the PECS were taughtduring the teaching periods (5–10 trials, approximately5 minutes) immediately followed by the free play pe-riods (15–20 minutes), during which a choice of itemsand activities was available for play contingent on re-questing using the PECS (the same materials as avail-able in baseline, with new items assessed periodically).Peers at school also received brief training in use of thePECS with Molly. Data were collected under the sameconditions as those described in the A1 and A2 condi-tions, during the play periods after training. Note thatinitially during PECS training in the home, reinforcerassessment was conducted before training and thosematerials were used in training. When free play began,however, the mother chose an activity that typicallywas not an activity from those determined as reinforcersbased on assessment. Although preferred items from

the assessment were still available, the mother directedMolly to use the item she selected, rather than allow-ing Molly to choose her activity. Thus, beginning withthe 13th session of the home intervention phase, Mollywas allowed to choose (with the icon initiation) whichitems to use during free play. A total of 71 trials overfive training periods was required to reach criterion forPhases I–III at home, 41 trials over eight sessions wererequired in centers, and 15 trials over five sessions wererequired in journal time. Once criteria for the phaseswere reached, reinforcer assessment and a minimum offive training trials continued at the beginning of ses-sions; however, the time for training became muchshorter over time as Molly mastered initiations withPECS.

Social Intervention with the PECS (C)

During this condition, the PECS was used in com-bination with social skills training to increase the du-ration of Molly’s interaction with her peers. Molly’speers were instructed on how to keep her engaged dur-ing game playing situations (games were used in placeof free choice activities). Peer training was conductedfor four sessions, followed by peer practice (i.e., a fewminutes of models and reminders) conducted beforeeach play/leisure period. Social skills included sharingmaterials, taking turns, asking and answering questions,and extending the play interactions. Training includeddefining the skill, modeling, and practice trials with thepeers and Molly. Data were collected under the sameconditions as described.

RESULTS AND DISCUSSION

As displayed inFigure 1, the total frequency ofspontaneous languageusing icons or icons plus ver-bals per 10-minute session increased during settingswhen the PECS treatment conditions were imple-mented. Effects were consistent across home and schooland when PECS was used by the mother, teachers, andpeers. No use of icons was demonstrated during base-line (although icons were present), and with the PECSinstructional protocol, Molly demonstrated successfuluse of the augmentative system. An increase in initia-tions at home was noted when materials from the rein-forcer assessment and training were also availableduring free play, indicating choice as a critical aspectto increasing spontaneity within PECS.

Table I. presents mean data by condition for useof icons, as well as spontaneous verbalizations and du-ration of social interaction. Reliable use of icons oc-

228 Kravits, Kamps, Kemmerer, and Potucek

curred in all settings, with 38 learned icons and4–8 icons used during 10-minute intervention sessions.Intelligible verbalizations also showed increases in twoof three settings, home and journal time, with a rangeof 15–16 at home and 5–8 at school. Thus, spontaneouslanguage, which often included icon use but also in-cluded some verbal language without the icons, in-creased with the intervention. At home, Molly averaged8–9 initiations during play in baseline (all verbal) and18 during PECS (icons and verbals). During school cen-ters, Molly averaged 3–5 initiations in baseline, withincreases to 11 during the intervention. During journaltime, similar effects were noted with a mean of 4–7initiations in baseline and 14 during intervention. Thesefindings indicate that increased spontaneous languageincluded both increased verbalizations and icon use intwo settings. The t tests indicated significantly more

Fig. 1. Total frequency of spontaneous icon-based language andicon-plus verbals (i.e., requests, comments, and expansions) acrosssettings.

initiations (df 5 1, F 5 114.9, p , .01) and verbal-izations (df 5 1, F 5 30.1, p , .01) during interven-tion sessions over baseline sessions. Observations alsoindicated, however, that Molly did not significantly in-crease the range of spoken vocabulary during inter-vention. For younger children, it has been reported thatif verbal language begins, it generally occurs after ap-proximately a year in the PECS program (Bondy, Hoff-man, & Glassberg, 1999). Thus, this case was not areliable one for study of the PECS in regards to verballanguage acquisition due to (a) prior verbal languageby Molly as exhibited in baseline and (b) length of theintervention.

The duration of social interaction with peers(seeTable I) was also monitored to note treatment effects.Minimal changes were noted at home for interactiontime with use of the PECS, but this is likely an effectof opportunity as Molly’s brother was the only “peer”available at home, with an occasional friend fromschool. At school, however, increases were only notedwith PECS intervention in one of two settings ( journaltime), with increases in the duration to 146 secondsover baseline levels of 26–60. Differential effects mayhave been due to peer proximity in the two settings withchildren seated on the floor 1–2 feet apart in journaltime play and at tables (3–4 feet apart) during centerplay. A few follow-up sessions were conducted usingPECS and social skills training with peers in centersand journal time (C), with probes indicating additionalincreases in both settings (means 5 173, 183, respec-

PECS 229

tively). These increases reflect increased contact witha small number of peers rather than increases in thenumber of peers contacted.

SUMMARY

This study provided an empirical demonstration ofthe effectiveness of PECS in increasing spontaneouscommunication skills for a young child with autism.These findings are consistent with descriptive reports(e.g., Bondy & Frost, 1994; Schwartz et al.,1998) andexperimental reports documenting specific strategiessuch as the use of child preference/choice and timedelay tactics in language intervention (e.g., Dyer, 1989;Halle, 1982; Koegel et al.,1987). Findings expand priorstudies by including an older child (kindergarten age)and by including the home as an intervention setting.Experimenters also noted that Molly’s use of the sys-tem helped her become a much more spontaneous per-son using the icons in home and school activities. Theduration of Molly’s peer interactions increased in jour-nal time, and the frequency increased in both, from 0to 2 in baseline to 7 in centers and 13 in journal timeusing the PECS, clear documentation for the social va-lidity of the system in school. Before the PECS, ob-served communication was nonverbal, more passive(e.g., gestures, smiles), and primarily directed towardthe adults. It is unclear, however, what social effectswere from PECS alone versus PECS plus the socialskills booster sessions. Limitations thus include theconfound of the social skills enhancement, a confoundto PECS alone as an intervention, and no generaliza-tion or follow-up probes. Future research with PECSshould include (a) implementation with multiple par-ticipants and those with varying levels of functioning,(b) long-term study of PECS with completion of thetraining protocol (advancement through all six trainingphases) and use of PECS across longer periods of theschool day, and (c) alternative social interventions incombination with the PECS.

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Table I. Means of Behaviors by Session

A1 A2 B C

Mean frequency of icon useHome 0 0 5.2 4Centers 0 0 4.4 6.5Journal time 0 0.8 7.8 7.6

Mean frequency of intelligible verbalizationsHome 9.6 5.8 15.5 16Centers 2.5 5.3 7.2 5.8Journal time 6.0 3.8 6.5 8.3

Mean frequency of initiations = icon verbalizations or icons 1 verbalizations or verbalizations alone

Home 9.9 8.0 17.4 19.0Centers 2.5 5.2 11.2 11.0Journal time 7.7 4.3 14.2 14.3

Mean duration of social interaction with peers (300 seconds total time)

Home 38 0 16 54Centers 71 31 54 173Journal time 60 26 146 183

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