Research
Effectiveness of the Picture Exchange
Communication System (PECS) on
Communication and Speech for Children With
Autism Spectrum Disorders: A Meta-Analysis
Michelle Flippin
Stephanie Reszka
Linda R. Watson
University of North Carolina at Chapel Hill
Purpose: The Picture Exchange Communication
System (PECS) is a popular communication-
training program for young children with autism
spectrum disorders (ASD). This meta-analysis
reviews the current empirical evidence for PECS
in affecting communication and speech out-
comes for children with ASD.
Method: A systematic review of the literature on
PECS written between 1994 and June 2009 was
conducted. Quality of scientific rigor was assessed
and used as an inclusion criterion in computation of
effect sizes. Effect sizes were aggregated sepa-
rately for single-subject and group studies for
communication and speech outcomes.
Results: Eight single-subject experiments
(18 participants) and 3 group studies (95 PECS
participants, 65 in other intervention/control) were
included. Results indicated that PECS is a prom-
ising but not yet established evidence-based
D
elayed development of language is an early and per-
sistent marker of autism (Lord, Risi, & Pickles, 2004).
Although estimates vary, approximately 25% of chil-
dren with autism do not develop functional speech (Volkmar,
Lord, Bailey, Schultz, & Klin, 2004). Thus, the need for early
and effective communication training for children with autism
is clear. However, given the myriad communication-training
strategies available, it is difficult for clinicians to choose the
most effective intervention for an individual child with autism
spectrum disorders (ASD). Variability in language outcomes
for children with ASD makes it difficult to predict which
children will go on to develop speech and which children will
require augmentative and alternative communication. In ad-
dition, differential response to intervention for individual
children with ASD makes it difficult for clinicians to identify
the best method of communication training for any one partic-
ular child. Given the heterogeneous nature of ASD, variability
178 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010 • A American Speech-Language-Hearing Association
intervention for facilitating communication in
children with ASD ages 1–11 years. Small to
moderate gains in communication were demon-
strated following training. Gains in speech were
small to negative.
Conclusions: This meta-analysis synthesizes
gains in communication and relative lack of gains
made in speech across the PECS literature for
children with ASD. Concerns about maintenance
and generalization are identified. Emerging
evidence of potential preintervention child char-
acteristics is discussed. Phase IV was identified
as a possibly influential program characteristic
for speech outcomes.
Key Words: autism, Picture Exchange
Communication System, communication
intervention, speech
in treatment outcomes is likely to be a function of individual,
pretreatment characteristics (Lord et al., 2005). To date, there
are no clear guidelines for clinicians in determining which
communication strategy is likely to be effective for an indi-
vidual child with ASD. The purpose of this meta-analysis is
to review the current empirical evidence for one communi-
cation strategy, the Picture Exchange Communication System
(PECS). PECS is a manualized program for teaching children
to use an exchange-based communication system that has
been a common intervention choice for nonverbal children
with ASD in clinical and school settings. In this meta-analysis,
the quality of the current research evidence for the PECS
method is assessed. Additionally, pretreatment characteris-
tics of children who responded to PECS training are identified
across studies to generate a profile of a young child with
ASD for whom PECS may be an appropriate and effective
communication intervention, and program characteristics
that may support the development of speech in children
through the PECS program are discussed.
Brief Overview of PECS
PECS is a behaviorally based pictorial communication
system designed for children with social-communicative def-
icits. Using PECS, expressive communication skills are tar-
geted through the training of requests and, later, comments.
As Bondy and Frost (1994, p. 3) describe, “Children using
PECS are taught to approach and give a picture of a desired
item to a communicative partner in exchange for that item. By
doing so, the child initiates a communicative act for a con-
crete item within a social context.” It is important to note that
the term PECS does not refer generally to all exchange-based
pictorial communication interventions (i.e., exchanging a
photograph or line drawing for a corresponding real item);
rather, PECS is a specific, manualized intervention protocol.
In the PECS program, a child’s expressive communication
abilities are shaped via the use of reinforcement, delay, and
generalization across trainers and settings. PECS training
consists of six phases (see Table 1). In Phase I: The Physical
Exchange, two trainers physically prompt the child to exchange
a single picture for a preferred item, without distractor pic-
tures. In Phase II: Expanding Spontaneity, a communication
book is introduced, and increased distance is placed between
the child and communicative partner. The child is required
to get a picture symbol from his or her communication book
and travel to the communicative partner to request an item.
Placement of picture symbols is varied in the book, and gen-
eralization is targeted across a variety of trainers and contexts.
In Phase III: Picture Discrimination, the child discriminates
between two picture symbols (first between a highly desired
and a nondesired item and then between two desired items). In
Phase IV: Sentence Structure, the child makes a request by
building and exchanging a two-picture-sequence sentence
strip with an “I want” symbol plus the picture symbol for the
preferred item. In Phase IV, after the child has requested by
giving the sentence strip, the communication partner provides
the verbal model “I wantI” and uses a time delay before
labeling the requested item and handing the sentence strip and
requested item back to the child. In Phase V: Responding to
“What Do You Want?” the communicative partner introduces
the verbal prompt “What do you want?” As Phase V interven-
tion continues, a time delay is inserted between the verbal
prompt and an additional gestural prompt toward the “I want”
picture symbol. Eventually, the child begins answering the
question before his or her communicative partner uses the
gestural prompt. Finally, in Phase VI: Responsive and Spon-
taneous Commenting, comments are trained via the exchange
of a sentence strip in response to the communicative partner’s
questions (i.e., “What do you see?” and “What do you have?”
contrasted with the request cue “What do you want?”).
Ease of implementation for both children and interven-
tionists is one of the features that helped PECS to become a
widely popular social-communication-training system for chil-
dren with ASD. For example, children do not need to master
prerequisite skills (e.g., eye contact, gestures, and verbal imi-
tation) prior to beginning PECS training. Rather, children with
relatively limited skills begin exchanging picture symbols to
TABLE 1. Six phases of Picture Exchange Communication
System (PECS) training.
Phase Description
I Training begins on a single picture of highly desired item.
Student picks up picture of desired item and releases into
communicative partner’s hand in exchange for desired
item. Communicative partner gives the item to the child
while naming the item (e.g., “car ”). Two adults (i.e., the
communicative partner and a physical prompter) are used
during this phase.
II A communication book is introduced, and increased distance
is placed between the child and communicative partner.
Child is required to get picture from her communication
book and travel to communicative partner to request item.
To increase spontaneity and persistence, placement of
picture symbol is varied in the book. Also, generalization
across a variety of trainers, contexts, and reinforcers is
introduced at this phase.
III Child is required to discriminate between two picture
symbols (highly desired vs. nondesired item to gradually
multiple desired items). Correspondence checks are
done to ensure that child is truly requesting preferred
item.
IV Child uses a sentence starter (“I want”) to make a request by
building and exchanging a 2-picture-sequence sentence
strip with “I want” symbol plus picture symbol for preferred
item. Communicative partner provides verbal model “I
wantI” and pauses before labeling the requested item
and handing sentence strip and requested item back to
child. Communicative partner differentially reinforces
any vocal attempt.
V Communicative partner introduces the verbal prompt “What
do you want?” Over time, a delay is inserted between
the verbal prompt and an additional gesture prompt
toward the “I want” picture symbol. The child begins
answering the question before her communicative
partner uses the gestural prompt.
VI Comments are trained as child exchanges sentence strips
to respond to partner’s communicative questions (i.e.,
“What do you see?” “What do you want?” “What do
you have?”).
Note. From PECS Training Manual (Frost & Bondy, 2002). Adapted
with permission.
request preferred items immediately upon starting the first
phase of PECS. Also, because PECS is a behavioral approach
that shapes communication via the use of reinforcers, it is
motivating for children. Finally, there is little initial training
required for trainers to implement PECS (i.e., usually a 2-day
workshop).
Limitations of PECS include the restricted range of com-
municative functions targeted in the approach. The communi-
cative repertoire trained in PECS consists primarily of requests
(Phases I–V). A response form that the PECS developers
label “comments” is trained in the final phase (Phase VI).
However, comments as defined in the program are not true,
self-initiated comments. Rather, the comments are responses
to adult prompts, learned via shaping and rewards. PECS
does not include steps in the program to specifically guide the
child to initiate with picture communication symbols to share
interests with others (i.e., the type of communicative acts
generally considered as “commenting”). In addition, other
communicative functions that develop early among typically
developing children, such as protests and refusals, are not
Flippin et al.: Effectiveness of PECS 179
directly targeted in PECS. For example, although PECS trains
discrimination between preferred and nonpreferred items, the
standard PECS protocol does not provide a built-in method for
directly indicating that an item is not wanted. Finally, as PECS is
an aided communication technique, preparation of picture
symbols can be labor intensive for clinicians, and the need to
carry a communication book with limited vocabulary choices
can be restrictive for children using the PECS approach.
In the 14 years since its inception, PECS has been widely
adopted in special education settings for children with ASD.
Descriptive reports have suggested that the PECS method
leads to increased functional communication in a relatively
short time period and, sometimes, speech development in
children with ASD. For example, in a retrospective report on
longitudinal data for children with autism who were 5 years of
age and younger, Bondy and Frost (1994) documented that
more than half of the 66 participating children were able to
use speech without pictures to communicate within a year of
starting PECS. Similar gains in the use of PECS symbols to
communicate and in the development of spontaneous speech
have been documented across other case studies and quasi-
experimental reports (e.g., Magiati & Howlin, 2003; Schwartz,
Garfinkle, & Bauer, 1998; Webb, 2000). Further, these in-
creases in communication and speech were documented to
occur over a relatively short time period, within 6 to 14 months
of starting PECS (Schwartz et al., 1998; Webb, 2000). Al-
though these reports offer anecdotal support for the effec-
tiveness of PECS, the quality of evidence is limited due
to lack of experimental control. Empirical studies on the
acquisition and impact of PECS strengthen the quality of
evidence related to the effectiveness of PECS and have
added to the evidence base for this approach.
Previous Reviews of PECS
Several recent reviews have employed varying scopes and
methodologies to examine the efficacy of PECS for commu-
nication and/or speech outcomes for children and adults with
various disabilities. For instance, Lancioni and colleagues
(2007) reviewed the literature on the effectiveness of pictorial
exchange communication interventions (including PECS)
and voice output communication aids in promoting requesting
among children with developmental disabilities. In that review,
the authors concluded that 170 out of 173 children who par-
ticipated in studies of PECS or other pictorial exchange com-
munication interventions showed improvement in their ability
to make requests. The independent variables in that review,
however, were not limited to PECS, and participant inclusion
criteria were not specific to autism.
In a more narrowly focused synthesis of 13 studies of PECS,
Tien (2008) reached similar conclusions that PECS appears to
be an effective intervention for improving functional commu-
nication skills for participants with ASD. In a broad review of
all of the empirical articles published on the PECS approach,
Sulzer-Azaroff, Hoffman, Horton, Bondy, and Frost (2009)
synthesized data from 34 peer-reviewed studies to conclude
that PECS is an effective means of training functional com-
munication for individuals with impaired or no speech. That
review was not limited to specific participant ages, diagnoses,
or outcome variables. While these reviews provide important
180 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010
syntheses of the evidence for PECS, they do not provide as-
sessments of the quality of the studies included, or quantita-
tive analyses of results.
In contrast, Schlosser and Wendt (2008) employed both
quality assessment and quantitative analyses in their system-
atic review of the effects of augmentative and alternative
communication intervention on communication and speech
production for children with autism. Although the independent
variables examined in that review were not limited to PECS,
articles that met criteria for review included seven studies (six
single-subject experiments and one group design) in which
PECS was the independent variable. The authors proposed that
PECS was highly effective for teaching requesting to children
with autism. In contrast, the authors reported mixed results
for speech outcomes, with two studies yielding percentage of
nonoverlapping data (PND) considered highly effective for
promoting speech, one study ineffective, and one study mixed
(highly effective for one participant and ineffective for another);
however, effect sizes (ESs) were not aggregated. Further-
more, since the publication of that review, several additional
group and single-subject experiments have been published
that add to the evidence base for the PECS approach. Most
recently, Preston and Carter (2009), in their examination of
the efficacy of PECS in 10 single-subject and three group de-
signs, reached similar conclusions to Schlosser and Wendt
(2008) that PECS is effective in providing a means of commu-
nication for individuals with little or no speech but that the
data are not as clear for speech outcomes following PECS
training. Assessment of quality and calculation of ESs were
completed for individual studies in that review; however, par-
ticipant criteria were not limited to children with a diagnosis
of autism, and independent variables were not limited to
standard PECS protocol. Rather, the review included studies
with participants ranging in age from early childhood to adult-
hood, studies of participants with comorbid diagnoses (e.g.,
autism and attention deficit/hyperactivity disorder [ADHD],
blindness, and deafness), and studies that involved modifi-
cations of the PECS approach. Thus, despite the contributions
of these systematic reviews of literature, to date no meta-
analysis has examined the effectiveness of the standard PECS
protocol on communication and speech outcome variables
for children with ASD.
Research Questions and Method
The evidence base for PECS includes both single-subject
designs and group research. To thoroughly evaluate the evi-
dence for this intervention, both types of studies must be
considered in the meta-analysis. Calculation and aggregation
of ESs for meta-analysis is well established for group designs
and is becoming increasingly accepted practice in single-
subject experiments (Schlosser & Sigafoos, 2008). Although
there is not a standard metric, the calculation of ESs in single-
subject designs allows for the comparison of treatment out-
comes within and between individuals as well as comparison
of the relative strength of treatments (Beeson & Robey, 2006).
In the autism literature, specifically, meta-analysis of single-
subject studies has contributed to the evidence base for several
popular interventions, including social skills training (Bellini,
Peters, Benner, & Hopf, 2007; Schneider, Goldstein, & 2. What are the effects of PECS on speech outcomes for
Parker, 2008), video modeling (Bellini & Akullian, 2007), children with ASD?
and self-management (Suk-Hyang, Simpson, & Shogren,
2007). Although there is not a way to aggregate ESs across
single-subject and group designs, including single-subject Search Strategy
research in a meta-analysis allows for a more comprehensive
Studies were identified for inclusion in this meta-analysis
understanding of the effect of an intervention (Kavale, Mathur,
through a three-step process. First, searches were conducted
Forness, Quinn, & Rutherford, 2000). In fact, several studies
to identify conceptual and empirical articles related to PECS
have employed meta-analytic techniques for both single-
published between 1994 and June 2009 that included at least
subject and group designs to determine the effectiveness of
one child participant (18 years or younger) with ASD, in
interventions for children with externalizing behaviors and
the following databases: PsycInfo, ERIC, Academic Search
disruptive behavior disorders (Maughan, Christiansen, Jenson,
Premier, and Cumulative Index to Nursing and Allied Health
Olympia, & Clark, 2005), ADHD (Fabiano et al., 2009), and
Literature (CINAHL). Table 2 describes the search terms and
autism (Schlosser & Wendt, 2008). Given the volume of
yields. Search terms used were Picture Exchange Communi-
single-subject publications, the current meta-analysis includes
both single-subject and group studies of the PECS approach. cation System, autism, PECS, and Bondy and Frost. Reverse
searches were then conducted to identify articles that cited the
This meta-analysis provides an evaluation of the quality of
seminal article on PECS (Bondy & Frost, 1994). Second, re-
empirical evidence, using appropriate quality indicators for
single-subject or group designs. In addition, ESs are aggre- sults were cross-referenced with articles listed on the research
page of the official PECS Web site (www.pecs.com/research.
gated within each type of design to examine the effectiveness
htm). Finally, reference lists were examined from three rele-
of PECS for both speech and communicative outcomes spe-
vant literature reviews (Preston & Carter, 2009; Schlosser &
cifically for young children with ASD. This study addressed
Wendt, 2008; Sulzer-Azaroff et al., 2009) to identify additional
two research questions:
studies that were not captured through previous searches. The
1. What are the effects of PECS on communication outcomes systematic search returned 54 articles. Of the 54 articles iden-
for children with ASD? tified, only empirical studies (single-subject experiments or

TABLE 2. Search strategies across general-purpose databases.

Database Search strategy Yield (references) Revised search

PsycInfo (DE “Picture Exchange Communication System”) 48

(DE “Picture Exchange Communication System” AND DE “autism”) 45 added AND “autism”
(DE “Picture Exchange Communication System” OR DE “PECS”) 154 added OR “PECS”
(DE “Picture Exchange Communication System” OR DE “PECS” 51 added AND “autism”
AND DE “autism”)
(DE “PECS”) 150
(DE “PECS” AND DE “autism”) 45 added AND “autism”
(Reverse search for articles citing Bondy & Frost, 1994) 98
Academic Search (DE “Picture Exchange Communication System”) 36
Premier (DE “Picture Exchange Communication System” AND DE “autism”) 24
(DE “Picture Exchange Communication System” OR DE “PECS”) 3,295 added OR “PECS”
(DE “Picture Exchange Communication System” OR DE “PECS” 71 added AND “autism”
AND DE “autism”)
(DE “PECS”) 3,141 added AND “autism”
(DE “PECS” AND DE “autism”) 28 added AND “autism”
(Reverse search for articles citing Bondy & Frost, 1994) 32
ERIC (DE “Picture Exchange Communication System”) 33
(DE “Picture Exchange Communication System” AND DE “autism”) 24 added AND “autism”
(DE “Picture Exchange Communication System” OR DE “PECS”) 82 added OR “PECS”
(DE “Picture Exchange Communication System” OR DE “PECS” 81 added AND “autism”
AND DE “autism”)
(DE “PECS”) 76
(DE “PECS” AND DE “autism”) 23 added AND “autism”
CINAHL (DE “Picture Exchange Communication System”) 52
(DE “Picture Exchange Communication System” AND DE “autism”) 48 added AND “autism”
(DE “Picture Exchange Communication System” OR DE “PECS”) 192 added OR “PECS”
(DE “Picture Exchange Communication System” OR DE “PECS” 56 added AND “autism”
AND DE “autism”)
(DE “PECS”) 188
(DE “PECS” AND DE “autism”) 49 added AND “autism”
(Reverse search for articles citing Bondy & Frost, 1994) 13

Note. DE = descriptor; ERIC= Education Resources Information Center; CINAHL= Cumulative Index to Nursing and Allied Health Literature.

Flippin et al.: Effectiveness of PECS 181

group design) published in English in a peer-reviewed journal
were considered for inclusion in this synthesis. The remaining
30 studies were reviewed for inclusion criteria by at least two
of the authors. Interrater reliability for inclusion of studies
was 93.3%. In the rare instances of disagreement, the decision to
include or exclude an article was reached by consensus. Studies
included in this meta-analysis met the following criteria:
Participants. This meta-analysis included children younger
than 18 with a diagnosis of autism, ASD, or pervasive devel-
opmental disorder-not otherwise specified (PDD-NOS).
Five studies on the use of PECS with adults (Chambers &
Rehfeldt, 2003; Rehfeldt & Root, 2005; Rosales & Rehfeldt,
2007; Stoner et al., 2006; Ziomek & Rehfeldt, 2008) were
not included. In addition, five studies of participants diag-
nosed with neurological or developmental disorders other
than autism (Bock, Stoner, Beck, Hanley, & Prochnow, 2005;
Kern, Gallagher, Staosta, Hickman, & George, 2006) or with
both autism and a comorbid physical or neurological diag-
nosis such as ADHD (Adkins & Axelrod, 2002), blindness
(Lund & Troha, 2008), and deafness (Malandraki & Okalidou,
2007) were not included.
PECS implementation. The independent variable in this
meta-analysis was one or more of the six manualized PECS
phases. Five studies with independent variables that were
components or modifications of the manualized PECS meth-
odology (Cummings & Williams, 2000; Dooley, Wilczenski,
& Torem, 2001; Ganz, Cook, Corbin-Newsome, Bourgeois,
& Flores, 2005; Ganz, Sigafoos, Simpson, & Cook, 2008;
Yokoyama, Naoi, & Yamamoto, 2006) were not included.
For the alternating treatment single-subject study conducted
by Angermeier and colleagues (Angermeier, Schlosser, Luiselli,
Harrington, & Carter, 2008), which compared the effec-
tiveness of PECS in two conditions (PECS with Picture Com-
munication Symbols and PECS using Blissymbols), only data
from PECS trials using Picture Communication Symbols
(as recommended in the PECS manual) were included. For
the study by Tincani, Crozier, and Alazetta (2006), data were
included for Study I, which used the standard PECS protocol.
Outcome variables. The dependent variables for the meta-
analysis were (a) communicative behaviors (e.g., requests
and initiations) and (b) speech or vocalization. Two studies
with outcomes that were nonlanguage behaviors—that is,
aggressive behavior (Frea, Arnold, & Vittimberga, 2001) and
problem solving (Marckel, Neef, & Ferreri, 2006)—were not
included in this meta-analysis. Finally, one study of PECS
in which symbols were modified with braille for use with a
visually impaired therapist was excluded because the graphed
data of communication outcomes in that study were provided
for the therapist and not the child participants (Charlop,
Malmberg, & Berquist, 2008).
Articles selected for review. A total of 11 studies (eight
single-subject experiments and three group designs) met
criteria for inclusion. For the purpose of this meta-analysis,
findings from articles that analyzed data from the same par-
ticipants (i.e., Carr & Felce, 2007a, 2007b; Yoder & Stone,
2006a, 2006b) were collapsed into a single study.
Data extraction and decisions. Data extracted from pub-
lished studies of PECS included participant diagnoses and
ages, experimental design, outcome variables, phases of
PECS trained, and reported results. For group studies, ESs
182 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010
were extracted if reported; if not, reported statistics from which
ESs could be calculated were extracted. For single-subject
studies, data points on communication and speech outcome
variables were extracted from plotted graphs to calculate ESs.
In the study by Angermeier and colleagues (2008), in which
baseline data were reported separately for each of the
trained PECS phases, ESs calculated for communicative
outcomes were averaged across the trained phases of PECS
for each participant. For the study by Charlop-Christy,
Carpenter, Le, LeBlanc, and Kellet (2002), which employed
a multiple-baseline-across-settings design, ES was averaged
across the two contexts (academic and play sessions) in
which speech outcomes were measured. Finally, to satisfy
the independence assumption of meta-analysis, for four
studies in which multiple outcome variables were reported
for speech (Charlop-Christy et al., 2002; Ganz, Simpson, &
Corbin-Newsome, 2008; Yoder & Stone, 2006a, 2006b)
and communication (Howlin, Gordon, Pasco, Wade, &
Charman, 2007), variables were averaged so that only one
ES per construct (i.e., speech or communication) was included
for each study in calculation of the composite ES (Hedges
& Olkin, 1985). Included outcome variables and summaries
of the data for group and single-subject designs included are
presented in Tables 3–6.
Quality of Evidence
The quality of evidence for the PECS approach was evalu-
ated via the use of rating scales adapted from guidelines by
Horner et al. (2005) and Wolf (1978) for single-subject de-
signs (see Appendix A) and by Gersten et al. (2005) for group
designs (see Appendix B). Quality indicator items were as-
signed a rating of adequate, partially adequate, or inadequate/
unknown and a score of 2, 1, or 0 points, respectively. Each
article was independently coded for quality assessment by
the first two authors. Interrater reliability was calculated via
point-to-point agreement on the 11 included articles and
ranged from 84.2% to 100%. Composite scores were tallied
as a percentage of points assigned out of total possible points
for each article. Scores at 90% and above were considered
to be strong quality of evidence. Scores ranging from 75% to
90% were considered to be adequate quality of evidence, and
scores of 74% and below were considered to be inadequate
quality of evidence.
Overall, the quality of evidence for PECS was considered
to be adequate (see Tables 3–6). Quality assessment ratings
of group studies ranged from strong to inadequate levels of
evidence (one study of strong quality and two of inadequate
quality) for the effectiveness of PECS on communicative and
speech abilities of children with autism. For group designs,
the quality of evidence for PECS would be strengthened by
improved measurement and reporting of treatment fidelity.
For example, in two of the three group studies in this meta-
analysis, treatment fidelity was not reported. Without measures
of treatment fidelity, it is difficult to know whether PECS was
delivered in the appropriate manner and dosage; thus, it is
difficult to demonstrate a functional relationship between the
intervention and the communication and speech outcomes.
Quality assessment ratings of the single-subject experi-
ments ranged from strong to adequate (three studies of strong
 TABLE 3. Summary of communication outcomes and quality ratings for single-subject designs.

Ages PECS Treatment Quality rating

Reference ( years;months) Design phases fidelity (Y/N) Dependent variables Results reported (% scores) PND (%) ES G/M

Angermeier et al. 9;0, 7;0, 6;0, 8;0 Alternating treatments I–III Y % independent PECS Gains in PECS exchanges S (90) 93.7 1.04 M
(2008) and multiple baselines exchanges for all 4 participants
across participants
Beck et al. (2008) NR Alternating treatments I–III Y % accuracy PECS Gains in PECS exchanges A (78) — — G
(3 preschoolers) exchanges for all 3 participants
with autism
Ganz & Simpson 5;8, 7;2, 3;9 Changing criterion I–IV N % independent PECS Gains in PECS exchanges A (83) — — NR
(2004) exchanges for all 3 participants
Ganz, Simpson, & 4;5, 3;1, 4;1 Multiple baselines across I–IV N % independent PECS Mastery for 2/3 participants A (82) 64.4 0.71 NR
Corbin-Newsome participants exchanges in independent PECS
(2008) exchanges
Kravitz et al. (2002) 6;0 Multiple baselines across I–III N Spontaneous language Increases in spontaneous A (76) 64.8 0.16 NR
settings (home, (icons and language (icons and
centers, journal) verbalizations) some verbal)
Tincani (2004) 5;10, 6;8 Alternating treatments I–III Y % independent mands Gains in mands for both S (93) 100 0.30 G
participants; greater
gains with signs for
1 participant
Tincani et al. 10;2, 11;9 Multiple baselines across I–IV Y % independent mands Gains in mands for both S (93) 98.4 0.34 G
(2006; Study I) participants participants

Note. PND = percentage of nonoverlapping data points; ES = effect size; G/M = generalization or maintenance measures included; S = strong quality of evidence; NR = not reported;
A = adequate quality of evidence. Dash indicates incalculable due to absence of baseline phase.

TABLE 4. Summary of communication outcomes and quality ratings for group designs.

Ages PECS Treatment Dependent Quality rating

Reference Participants ( years;months) Design phases fidelity (Y/N) variables Results reported (% scores) ES G/M

Carr & Felce 24 PECS, 3;0–7;0 Group I–III N Initiations Initiations increased for children in PECS I (50) 0.95 NR
(2007a, 2007b) 17 control (nonrandom; group but not for control
nonmatched)
Howlin et al. (2007) 26 immediate, 3;9–8;9 RCT NR N Initiations; Significant increase in frequency of I (45) 0.65 M
28 delayed, 5;2–9;5 PECS usage initiations and PECS usage; gains not
29 control 5;1–10;0 maintained on follow-up
Yoder & Stone 17 PECS, 3;0–7;0 RCT I–VI Y Requesting No main effects for PECS on requesting; S (100) — —
(2006a, 2006b) 19 RPMT PECS more effective than RPMT on
requesting for children with low JA

Note. I = inadequate quality of evidence; RCT = randomized controlled trial; RPMT = Responsive Education and Prelinguistic Milieu Teaching; JA = joint attention. Dash indicates incalculable

Flippin et al.: Effectiveness of PECS

from data presented.

183
 TABLE 5. Summary of speech outcomes and quality ratings for single-subject designs.

Ages PECS Treatment Quality rating

Reference (years;months) Design phases fidelity (Y/N) Dependent variables Results reported (% scores) PND (%) ES G/M

Beck et al. (2008) NR Alternating treatments I–III Y Total utterances; % intelligible Gains in speech outcomes A (78) — — NR
(3 preschoolers) utterances; % spontaneous for 1/3 participants with
intelligible utterances; autism
different words
Charlop-Christy 3;8, 5;9, 12;0 Multiple baselines I–III N Spontaneous speech; MLU Gains in spontaneous A (83) 59.4 –0.05 M
et al. (2002) across participants; speech, MLU for all
multiple baselines 3 participants
across settings
(home, centers,
journal)
Ganz & Simpson 5;8, 7;2, 3;9 Changing criterion I–IV N Average spoken words Gains in average spoken A (82) — — NR
(2004) per trial words for all
3 participants
Ganz, Simpson, & 4;5, 3;1, 4;1 Multiple baselines I–IV N Word approximations and No gains in word A (80) 6.5 0.01 NR
Corbin-Newsome across participants intelligible words approximations or
(2008) intelligible words
Tincani (2004) 5;10, 6;8 Alternating treatments I–III Y Word vocalizations Gains in words for both S (93) 100 0.26 NR
participants, although

184 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010

greater gains with
sign for 1 participant
Tincani et al. 10;2 Multiple baselines I–IV Y Vocal approximations Gains in vocal S (93) 12 –1.45 NR
(2006; Study I) across participants approximations for
1 participant during
Phase IV

Note. Dash indicates incalculable due to absence of baseline phase. MLU = mean length of utterance.
 TABLE 6. Summary of speech outcomes and quality ratings for group designs.

Ages PECS Treatment Dependent Quality rating

Reference Participants (years;months) Design phases fidelity (Y/N) variables Results reported (% scores) ES G/M

Howlin et al. (2007) 26 immediate, 3;9–8;9 RCT NR N Frequency No significant change in I (45) 0.05 M
28 delayed, 5;2–9;5 of speech frequency of words
29 control 5;1–10;0
Yoder & Stone 17 PECS, 3;0–7;0 RCT I–VI Y Nonimitative Overall, PECS more S (100) 0.57 M
(2006a, 2006b) 19 RPMT words; effective than RPMT
nonimitative in facilitating words
spoken acts and spoken acts;
PECS especially
effective for children
with low JA and high
object exploration;
advantages for PECS
group at Time 1 not
maintained at Time 2

Flippin et al.: Effectiveness of PECS

185
quality and five of adequate quality). Quality of the single-
subject experiments would be strengthened by inclusion of
measures of maintenance, generalization, and social validity.
Follow-up measures to assess maintenance and generaliza-
tion were reported in only 50% of the single-subject studies,
and social validity was measured in only two of the eight
single-subject designs. Failure to measure maintenance, gen-
eralization, and social validity in the PECS single-subject
literature is consistent with other single-subject investigations
in the autism literature. For example, Odom and colleagues
(2003) reported that only 35% of single-subject intervention
experiments with individuals with ASD measured mainte-
nance and only 41% reported generalization measures. Know-
ing whether speech and communication gains made during the
PECS program are maintained after stopping PECS interven-
tion is important for clinicians in deciding on a communication-
training approach for children with autism.
Analysis Procedures
For group designs, ESs for posttest group differences were
reported as given or calculated from published data. For one
study that reported results using the nonparametric Mann–
Whitney U statistic (Carr & Felce, 2007a, 2007b), an equiv-
alent of Cohen’s d was calculated as outlined by Rosnow
and Rosenthal (2008). The dequivalent metric represents the
“value of d analogous to the result for an exactly normally
distributed outcome with N/2 units in each group” (Rosnow
& Rosenthal, 2008, p. 382). For another study (Howlin et al.,
2007), Cohen’s d was calculated from the published odds
ratios as outlined by Chinn (2000). Standard interpretation
of Cohen’s d (Cohen, 1988) was used to consider the strength
of evidence for group design studies (i.e., <0.2 = trivial;
0.2–0.5 = small; 0.5–0.8 = moderate; >0.8 = strong).
For single-subject experiments, two methods of calculating
ES were used, as there is not currently an established metric
for ES in single-subject experiments (Beretvas & Chung, 2008).
In the first analysis, data from published graphs were entered
and analyzed using the software program ITSACORR (Crosbie,
1993). ITSACORR conducts an analysis of the single-subject
data by fitting least-squares trend lines to baseline and treat-
ment phases while controlling for autocorrelation and short
data sets (Maughan et al., 2005). ITSACORR was chosen
over other methods of ES calculation (e.g., standardized dif-
ference approach) because of the validity of this approach
for graphs with zero slope in the baseline phase (Huitema,
2004) and undefined standard deviations (i.e., less than two
data points in baseline or all baseline data points equal to zero;
Beeson & Robey, 2006; Kratochwill, Stoiber, & Gutkin,
2000). ITSACORR provides an F statistic as well as tests of
change in intercept and change in slope. The y-intercept
t statistic given by ITSACORR and the number of data points
per phase were used to calculate ESs as Glass’s delta, as
outlined by Maughan et al. (2005).
In addition to the ITSACORR method of data analysis for
single-subject designs, the studies were also analyzed using
the PND method, in which the highest data point in baseline
phase was identified and the percentage of data points during
intervention exceeding this level was calculated (Scruggs,
Mastropieri, & Castro, 1987). PND could not be calculated
186 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010
for three studies that used alternating treatment (Angermeier
et al., 2008; Beck, Stoner, Bock, & Parton, 2008) or changing
criterion designs (Ganz & Simpson, 2004) without a base-
line phase. Interpretation of PND scores as outlined by Scruggs
and colleagues (Scruggs, Mastropieri, Cook, & Escobar, 1986)
is as follows: <50% = unreliable treatment; 50%–70% =
questionable effectiveness; 70%–90% = fairly effective;
>90% = highly effective.
After individual ESs were calculated, composite ESs for
the speech and communication outcome variables were com-
puted independently for single-subject and group designs.
For single-subject multiple-baseline designs across partici-
pants, ESs are reported as the mean ES for all participants. As
study quality is a focus of this meta-analysis, a threshold of
at least adequate quality was set for inclusion of a study in
the computation of aggregate ESs (Pettiti, 2000). All eight of
the single-subject experiments met criteria of at least adequate
quality. For group designs, however, only one of the three
group experiments met quality criteria. Thus, for the group
studies, individual ESs are described here, and aggregate ESs
were not calculated.
Synthesized Results
Findings were synthesized to evaluate the effectiveness of
the PECS approach on communication and speech outcomes
for children with autism. Results are reported separately for
single-subject studies and group designs, as ESs from single-
subject experiments tend to be inflated when compared with
those of group designs (Swanson & Sachse-Lee, 2000), and
there is no method to combine ESs from different experimental
designs (Kavale et al., 2000).
Communication Outcomes
Communication outcomes examined in the PECS litera-
ture include the frequency of PECS exchanges, requests
(Angermeier et al., 2008; Beck et al., 2008; Ganz & Simpson,
2004; Ganz, Simpson, & Corbin-Newsome, 2008; Howlin
et al., 2007; Kravits, Kamps, Kemmerer, & Potucek, 2002;
Tincani, 2004; Tincani et al., 2006), and initiations (Carr &
Felce, 2007a, 2007b; Howlin et al., 2007). Increases in com-
munication outcomes following PECS training were demon-
strated across both single-subject and group studies. Overall,
for the single-subject experiments, the mean weighted ES
was 0.51. The confidence interval did not include zero, 95% CI
[0.04, 0.67]; therefore, the assumption can be made that
PECS treatment had a significant impact on communication
outcomes. The mean PND of 84.3%, 95% CI [68.4%, 100.1%],
indicates that PECS is a “fairly effective” treatment for im-
proving communication for young children with autism. How-
ever, evidence of the maintenance and generalization of
communication gains made through PECS intervention is
limited in the single-subject literature. In fact, maintenance
of communication gains was measured in only one of the
seven single-subject studies that examined communication
outcomes. In that study, Angermeier and colleagues (2008)
reported that all three participants maintained mastery level
of communicative exchanges at the Phase II level of PECS
immediately after completing Phase II training. Furthermore,
generalization of communication gains achieved through
PECS was measured in only three single-subject studies.
Beck et al. (2008) measured generalization across settings
for two of the four participants in their study comparing the
effectiveness of PECS and VOCA. Probes conducted in the
children’s homes demonstrated limited generalization of
communication gains made through PECS 1 week after
school-based training. One participant used PECS to request
only once during the sessions, while the other participant
demonstrated only three requests using PECS (vs. 17 re-
quests when using a voice output device).
In contrast, Tincani (2004) measured generalization across
trainers in an alternating treatment design. In that study, PECS
was more effective than sign language in promoting com-
munication for one child; this child demonstrated picture
exchanges at levels similar to those achieved in training (93%
on average) during generalization sessions conducted with
a new communication partner. Similar results were reported
by Tincani and colleagues (2006), in that both participants
produced levels of independent mands during four generaliza-
tion probes with a new communication partner (i.e., the child’s
teacher) that were similar to those achieved during Phase IV
training. All generalization probes were higher than levels of
communication achieved during baseline phase.
For the group designs, the mean weighted ES could not
be aggregated, as ES was not calculable for communication
outcomes for the PECS intervention in one of the three group
studies (Yoder & Stone, 2006a, 2006b) examining commu-
nication outcomes, and the two group studies reporting cal-
culable ES data did not meet quality inclusion criteria. With
regard to maintenance of communicative gains, concerns were
raised by one group study. Howlin and colleagues (2007)
reported that the increases in rate of initiations and PECS us-
age that made up immediate treatment effects were not main-
tained over time, and upon follow-up, ESs were negligible,
0.04, 95% CI [–0.61, 0.1], and 0.24, 95% CI [–0.42, 0.92],
respectively. Maintenance of communication gains for the
PECS intervention group was not reported in the study by
Carr and Felce (2007a, 2007b) and not calculable from pre-
sented data for Yoder and Stone (2006a, 2006b). In addition,
generalization of communicative gains was not reported for
any of the three group studies of PECS. Thus, overall, small to
moderate effects were demonstrated for the short-term efficacy
of PECS in improving communicative outcomes for young
children with autism across the single-subject experiments
and group studies of PECS. Evidence for maintenance and
generalization of communicative gains achieved through
PECS training, however, is limited and mixed.
Speech Outcomes
Although the developers of the program describe PECS as
an augmentative communication system and are careful not
to claim that PECS improves speech for children with ASD,
speech is a frequently measured outcome variable in the
PECS literature. Clinicians and parents alike desire informa-
tion regarding the effectiveness of PECS in influencing speech
outcomes for young children with autism. Speech outcomes
were measured broadly across the PECS studies and included
the general measures of spontaneous speech (Charlop-Christy
et al., 2002; Howlin et al., 2007) as well as more specific
measures of the frequency of nonimitative spoken acts and
words (Yoder & Stone, 2006a, 2006b), word vocalizations
(Tincani, 2004), word approximations (Ganz, Simpson, &
Corbin-Newsome, 2008), vocal approximations (Tincani
et al., 2006), and average number of words spoken per trial
(Ganz & Simpson, 2004). In the five single-subject experi-
ments examining speech, outcomes varied widely across
the 12 participating children (ES ranged from –1.45 to 1.37).
It is interesting to note that several single-subject studies
reported overall gains in speech based on visual inspection
and interpretation of the data. However, as a group, the mean
weighted ES for speech outcome variables across single-
subject studies was negligible (0.17), and the CI included
zero, 95% CI [–0.01, 0.36]. The mean PND was 44.7%, [1.8%,
87.6%], indicating questionable effectiveness of the PECS
approach for increasing speech for young children with autism
across the single-subject literature.
Furthermore, maintenance of speech gains was measured
in only one of the five single-subject studies examining speech
outcomes. Charlop-Christy and colleagues (2002) reported
1-year follow-up data for one participant who demonstrated
maintenance of speech gains made through PECS at levels
similar to those achieved during PECS training.
Finally, generalization of speech gains made through PECS
was also measured in only one of the five single-subject studies
examining speech outcomes. Tincani and colleagues (2006)
reported that for one participant who made gains in speech
through PECS, four generalization probes implemented by the
child’s teacher demonstrated levels of vocalization similar to
those achieved in training. However, only two of the four
generalization probes were above the child’s baseline levels
of vocalization prior to starting PECS training.
Results of speech outcomes following PECS training were
also variable across the group experiments. In a follow-up
analysis of their study, Carr and Felce (2007b) noted that five
of 17 children in PECS group showed increases in speech;
however, ESs for speech outcomes in this study were not
calculable from the published data. Children in the Howlin
et al. (2007) study achieved a negligible ES for speech (0.05).
In contrast, moderate effects for speech outcome variables
(i.e., frequency of nonimitative spoken acts, ES = 0.63, and
number of different nonimitative words, ES = 0.50) were
reported by Yoder and Stone (2006a, 2006b) at posttest in
their randomized controlled trial comparing PECS with
Responsive Education and Prelinguistic Milieu Teaching
(RPMT). In that study, PECS was found overall to be the
more effective treatment for increasing number of non-
imitative spoken communication acts, t(34) = 2.30, p = .03,
and the number of different nonimitative words used, t(34) =
2.10, p = .04. However, posttest advantages in speech real-
ized by the PECS group were not maintained at follow-up
6 months after intervention. In fact, ES for all speech out-
come measures at 6 months after intervention was negligible
(ES = 0). Thus, the variable effects in speech outcomes follow-
ing PECS illustrate that the program is not equally effective
in improving speech outcomes for all children with autism.
Variability in response to PECS may be due to preinterven-
tion characteristics of individual children. Available evidence
related to this possibility is examined in the following section.
Flippin et al.: Effectiveness of PECS 187
Child Characteristics: Moderating Variables
and Preintervention Characteristics
Given the heterogeneous nature of the population of chil-
dren with ASD, it is important for both clinical intervention
and research to determine which characteristics make indi-
vidual children more likely to benefit from PECS, as well as
to identify which components of the PECS program are most
effective. Therefore, in addition to determining the overall
effectiveness of the PECS communication approach, further
analysis was conducted across group studies and single-subject
experiments to identify modifying variables and preinter-
vention characteristics of children who responded to PECS
training. For group studies, examination of variables that
moderate the effectiveness of PECS provides a strong statis-
tical tool which allows us to identify particular child char-
acteristics that have a measurable and direct influence on
speech and communication outcomes. For single-subject
experiments, examination of preintervention participant char-
acteristics allows us to describe which children gained the
most from PECS, at the level of individual participant, al-
though a direct relationship between preintervention charac-
teristics and speech and language outcomes is not identifiable.
Three child characteristics emerged as potential pretreatment
identifiers of a child with autism who is likely to respond to
PECS intervention: (a) limited joint attention, (b) relatively
stronger object exploration, and (c) limited motor imitation.
Joint Attention
Joint attention refers to three-point, systematic sharing
of attention between (a) an individual, (b) an object or event,
and (c) another individual (Tomasello, 1995). Evidence from
one group design study suggests that PECS may be a more
effective communication intervention than RPMT for chil-
dren with initially low rates of joint attention. In Yoder and
Stone’s study (2006a, 2006b), exploratory analysis of pre-
treatment variables revealed that initial rates of joint atten-
tion were a strong predictor of whether a child made greater
communication (i.e., requesting) gains from either PECS or
RPMT. Initiating joint attention was operationally defined
as an “intentional communication act about an object that
attempts to get the adults to comment, laugh, smile, show at-
tention, or give a label” (Yoder & Stone, 2006b, p. 430). For
children who began an intervention with initially lower fre-
quencies of joint attention (i.e., one instance or less of initiat-
ing joint attention across two assessment procedures), PECS
was the more successful approach in targeting communica-
tion outcomes. Joint attention also emerged as a potentially
influential preintervention characteristic in a single-subject
experiment by Charlop-Christy and colleagues (2002), which
documented that the largest overall gains in both speech
and communication were made by the youngest participant,
who began the study with no spontaneous speech, and rela-
tively weaker social communicative behaviors (i.e., joint at-
tention, eye contact, and toy play). Thus, joint attention may
be one child characteristic to be explored as a moderating
variable of main effects in group designs and as a preinterven-
tion characteristic to describe for participants in single-subject
experiments.
188 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010
Object Exploration
A second potential preintervention variable that may mod-
erate the effects of PECS on speech outcomes is object ex-
ploration. Differential response to treatment based on a child’s
initial levels of object exploration was documented by Yoder
and Stone (2006a, 2006b). In their study, Yoder and Stone defined
object exploration as the number of different toys a child
touched during a play assessment. For children with initially
higher levels of object exploration (+1 SD above the group
mean), PECS was shown to be a more effective treatment than
RPMT in increasing the frequency of nonimitative speech at
posttest. Initial levels of object exploration were also shown to
be important in maintaining gains in speech made through PECS.
In fact, only children with high object exploration maintained
speech gains at the 6-month follow-up, relative to the alternate
treatment group. Thus, object exploration may be a variable
that moderates speech outcomes achieved by children with
autism through the use of PECS, but this finding has not yet
been replicated across studies or by independent researchers.
Imitation
Imitation is a third potential preintervention characteristic
that may influence both speech and communication outcomes
for children participating in PECS intervention. Motor imitation
was examined as a preintervention characteristic that influenced
the acquisition and effectiveness of PECS in a single-subject
study comparing the effectiveness of sign language and PECS
on the training of requests. In that study, Tincani (2004) ex-
amined the pretreatment ability of two participants to imitate
27 hand, arm, and finger movements, similar to those required
to communicate via sign language. As was predicted by the
author, sign language was more effective than PECS in facil-
itating independent requests for a participant with relatively
higher motor imitative ability. In contrast, PECS was the more
effective treatment for improving communication for a partic-
ipant with relatively lower motor imitative ability. With re-
gard to speech outcomes, however, sign language was the
more effective intervention for both participants, regardless
of initial levels of motor imitation.
Verbal imitation has also emerged as a potentially influ-
ential preintervention child characteristic. Charlop-Christy
and colleagues (2002) described the three participants in their
study, who each made gains in both communication and
speech through PECS, as having some ability to verbally imi-
tate before beginning PECS training. The authors postulate
that participants’ baseline level of verbal imitation may have
accounted for the ability to produce spontaneous speech dur-
ing and after training. Assessment measures of preinterven-
tion verbal imitation were not described, however. It is important
to emphasize that results from these two single-subject ex-
periments may not generalize to the overall population of
children with ASD. Nevertheless, motor and verbal imitation
may be a variable of interest in future studies of the effec-
tiveness of PECS on communication and speech outcomes
for children with autism. In fact, given that early imitation
skills have been shown to be a strong predictor of later speech
development in children with autism (Charman et al., 2003;
Toth, Munson, Meltzoff, & Dawson, 2006), it is interesting
that imitation has not been more frequently examined as a
pretreatment characteristic across the autism communication
intervention literature.
Thus, the current evidence base for the effects of modera-
tors and preintervention characteristics is limited, but the
measurement and analysis of preintervention variables in future
studies would be invaluable in informing clinical decisions
about the selection of effective communication interventions
for individual children with ASD. For future group designs,
examination of the potential moderating impact of preinter-
vention variables such as joint attention, object exploration,
and motor/verbal imitation on the effects of PECS on commu-
nicative and speech outcomes is warranted. In future single-
subject experiments, although statistical examination of
moderators is not possible given the constraints of the re-
search design, reporting preintervention assessment results
for these and other participant characteristics would allow for
systematic replication of studies and provide pilot data for
larger group studies to help identify the profile of a child with
ASD who is likely to make communication and/or speech
gains through PECS.
Program Characteristics: Phase IV Intervention
and Speech Outcomes
Another interesting and potentially clinically useful find-
ing of this analysis is the impact of training PECS Phase IV
on spontaneous speech for those children who went on to
develop speech through PECS. In their seminal report, Bondy
and Frost (1994) documented that although speech develop-
ment was not a specific aim of their approach, vocalizations
generally developed in the later phases of PECS training
(IV to VI). Phase IV of PECS is unique in that it introduces
both verbal modeling and time delay strategies. In Phase IV,
the trainer models the phrase “I wantI” and briefly pauses
before handing the requested object to the child. Evidence
from several single-subject studies lends empirical support
to Bondy and Frost’s (1994) initial reports of increased speech
during later PECS phases (Charlop-Christy et al., 2002; Ganz
& Simpson, 2004; Tincani, 2004).
Because single-subject experiments document the partic-
ipants’ changes in speech across each phase of PECS, it was
possible to compare the magnitude of gains in speech between
Phases III and IV for those single-subject experiments that
reported speech outcomes through Phase IVof PECS (Ganz &
Simpson, 2004; Ganz, Simpson, & Corbin-Newsome, 2008;
Tincani, 2004). This analysis resulted in a composite ES for
speech outcomes across Phase IVof the single-subject studies
of 0.73. This lends support to evidence that for children who
go on to develop speech, Phase IV is important. In contrast,
for those same children, communication gains between
Phases III and IV were found to be negative (ES = –0.37).
Large ESs for speech development and negative effects for
communication outcomes between Phases III and IV suggest
that as these children become increasingly more verbal, speech
begins to replace the picture-based exchanges of PECS.
Thus, it serves to highlight that Phase IV may be particularly
important for development of speech.
However, questions remain as to whether speech gains
realized in Phase IV were due to the introduction of verbal
models, the use of time delay, or some combination of strat-
egies that may contribute to an increase in speech production
during PECS Phase IV. Alternatively, it may be that those
children who reach the criterion of 80% mastery in Phases I–III
are the same children who are likely to go on to develop
speech. There is some support in the PECS literature for the
impact of time delay on increased speech production (Charlop-
Christy et al., 2002; Tincani, 2004; Tincani et al., 2006). For
example, after the introduction of a 4-s delay of reinforcement,
one child in Tincani’s study (2004) increased percentage of
word vocalizations from a low of 30.1% during PECS Phase III
training to an average of 90%. Tincani and colleagues (2006)
further documented the effectiveness of using a 3–5-s delay
in an alternating treatment design, with one participant who
demonstrated greater use of speech during those phases that
employed a delay versus baseline phases. Thus, there is some
limited evidence that the verbal modeling, time delay, or some
combination introduced during Phase IV of PECS may play
a role in the acquisition of spontaneous speech for those chil-
dren who go on to develop speech through the PECS program,
but few studies have addressed these questions, limiting the
evidence available. Further research to determine whether in-
cluding verbal models and time delay strategies earlier in the
PECS program results in an earlier speech gains would have
important clinical implications.
Summary, Limitations, and Future Directions
This meta-analysis synthesized findings from both group
and single-subject experiments to evaluate the quality of the
research evidence and the effectiveness of the PECS approach
on speech and communicative abilities for children with au-
tism. With one group design of strong quality and seven single-
subject experiments of at least adequate quality documenting
gains in communication following PECS training, the body
of evidence for the PECS approach demonstrates that PECS is
a promising, although not yet established, evidence-based
practice for promoting communication in children with au-
tism. In contrast, the evidence for gains in speech achieved
through PECS is not as strong. Fewer studies have examined
speech outcomes (one group study of strong quality and four
single-subject studies of at least adequate quality), and ESs
have varied widely across studies. Given the nine controlled,
empirical studies of at least adequate quality that were iden-
tified in this meta-analysis, PECS is relatively well-researched
as compared with other popular communication interven-
tions for children with autism. Considering that there are only
nine such studies, however, our results on the effectiveness of
the PECS approach should be viewed with caution.
Overall, the data do provide evidence that PECS has small
to moderate effects in improving communication skills for
children with autism. In addition, PECS may improve speech
ability for some children with autism relative to speech prior
to intervention or gains made as a function of other interven-
tion approaches, but further research is needed related to speech
development as an outcome of PECS intervention. The find-
ing of a negligible aggregated ES for speech outcomes across
the single-subject experiments and small to negative ESs for
group studies is an important outcome of this meta-analysis
and demonstrates the value of using synthesized results to
Flippin et al.: Effectiveness of PECS 189
uncover trends in the composite data that are not readily appar-
ent by visual inspection and narrative review. These results
also provide information on some preintervention child char-
acteristics and program characteristics that may be influenc-
ing speech and communicative outcomes for children with
autism undergoing PECS training, but studies addressing
these questions are currently few in number.
Despite the overall adequate quality of evidence for the
effectiveness of the PECS approach and the potentially clin-
ically useful identification of child and intervention charac-
teristics for examining which children are most likely to have
favorable speech and/or communication outcomes through
PECS, several concerns and questions remain. One impor-
tant concern is the lack of measurement and reporting of
treatment fidelity for two of the three group studies of PECS
and four of the eight single-subject experiments. Without
clear documentation of how PECS was implemented, includ-
ing descriptions of personnel training and measurement of
adherence to the manualized PECS protocol, the functional
relationship between the intervention and communication
and speech outcomes at both posttest and during generaliza-
tion is unclear. In addition, there is insufficient evidence to
determine whether PECS results in generalization and long-
term maintenance of communication and speech gains for
children with ASD. Two group studies raised concerns re-
garding the maintenance of communication and speech gains
made through PECS, and only a few single-subject studies
reported maintenance or generalization measures. Clinically,
this is a concern, as it is important for interventionists to know
whether gains made in PECS can be maintained without con-
tinued support, across varying contexts. Furthermore, given
that there is only one published group design comparing
PECS with a specific alternative treatment, it is still unknown
whether the PECS approach results in better communication
and speech outcomes than other available autism interven-
tions. Thus, several concerns and questions remain about the
overall effectiveness of PECS for communication and speech
outcomes for children with ASD.
Questions also remain regarding the influence of modera-
tors on the effectiveness of PECS and the identification of
pretreatment characteristics of children who are more likely to
respond to PECS. Given the small number of studies providing
the relevant pretreatment data on participants, the evidence
is inconclusive regarding which of the currently identified
factors (i.e., joint attention, motor and verbal imitation, and
object exploration) contribute the most to the relative effec-
tiveness of PECS on speech and communication outcomes.
In addition, the three preintervention characteristics described
in this synthesis likely do not exhaust the possible initial charac-
teristics of children with ASD influencing response to PECS.
Finally, Phase IV of PECS and two strategies introduced
in that phase (i.e., verbal modeling and time delay) were
discussed as possible influences on speech acquisition for
those children who went on to develop speech through PECS
training. It is still unclear, however, as to whether the doc-
umented increases in spontaneous speech in Phase IV are
related to the introduction of verbal modeling, time delay, or
some combination, or whether those children who are able to
achieve success in Phases I–III are simply more likely to go
on to develop speech. Also unclear is whether introducing
190 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010
verbal modeling and time delay components earlier in the
program than Phase IV would result in earlier gains in sponta-
neous speech or whether it is necessary to master Phases I–III
as a foundation to developing speech in those children who
do go on to develop speech.
In summary, the overall effectiveness of the PECS approach
for communication outcomes with children with ASD is prom-
ising although not yet established. Evidence for the effec-
tiveness of the approach on speech outcomes is not as strong.
PECS may be more beneficial for promoting speech in chil-
dren with a specific developmental profile (i.e., low joint
attention, low motor imitation, and high object exploration)
than some alternative approaches, at least as a short-term
effect. Further empirical research is now needed to directly
examine the generalizablity of speech and communication
gains following PECS and to examine and identify child
characteristics that may account for the variance in outcomes.
Based on this meta-analysis, we recommend that researchers
include measures of treatment fidelity, maintenance, and gen-
eralization in future studies of PECS. We also support the
need for additional studies examining the effectiveness of
PECS on speech and communication outcomes for children
with ASD as compared to other interventions. In addition, the
evidence base for PECS will be enhanced if researchers ex-
amine the potential influence of moderators and preinter-
vention characteristics described in this synthesis (i.e., joint
attention, object exploration, and motor and verbal imitation)
and other relevant pretreatment variables. Implementing these
recommendations will strengthen the evidence base of this
approach and aid clinicians in making informed treatment de-
cisions for individual children with ASD.
Acknowledgment
The authors thank Necdet Karasu for his advice on calculating
effect sizes in single-subject research.
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Received March 19, 2009
Revision received June 30, 2009
Accepted January 25, 2010
DOI: 10.1044/1058-0360(2010/09-0022)
Contact author: Michelle Flippin, UNC—Chapel Hill Division
of Speech & Hearing Sciences, Bondurant Hall, CB 7190,
Chapel Hill, NC 27599. E-mail: mflippin@unc.edu.
Appendix A (p. 1 of 2)
Quality Indicators for Single-Subject Research

Flippin et al.: Effectiveness of PECS 193

Appendix A (p. 2 of 2)
Quality Indicators for Single-Subject Research

194 American Journal of Speech-Language Pathology • Vol. 19 • 178–195 • May 2010

Appendix B
Quality Indicators for Group Research

Flippin et al.: Effectiveness of PECS 195

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