Picture Exchange Communication System

PECS is a protocol rather than a type of picture

A child pointing to a snack photo on a wall board is using picture-based AAC. A school posting pictures for “arrival, reading, lunch” is using a visual schedule. A person exchanging a detachable symbol through the ordered PECS teaching phases is participating in PECS.

The ASHA AAC Practice Portal describes PECS as a low-tech intervention program with six progressive instructional phases and specific implementation parameters. It sits within the wider field of augmentative and alternative communication, which also includes gesture, sign, communication boards, writing, and speech-generating devices.

This distinction matters for records and family conversations. Write “picture board,” “visual schedule,” or “photo choice” when that is what occurred. Use PECS when the team is implementing the named protocol with fidelity and appropriate training.

The six phases build different skills

The developers' public PECS overview describes the sequence:

1. How to communicate: exchange one picture for a desired item or activity.
2. Distance and persistence: approach partners and communicate across people, places, and distance.
3. Picture discrimination: choose from two or more pictures.
4. Sentence structure: build a simple sentence strip, followed by attributes and language expansion.
5. Responsive requesting: answer a question such as “What do you want?”
6. Commenting: respond to questions about what the person sees, hears, feels, or encounters.

A phase number is useful only when the associated skills, teaching conditions, errors, prompts, partners, and data are defined. Reaching a phase in one room with one partner does not establish fluent use elsewhere.

Fit depends on the person and the communication goal

PECS may be one AAC option for a person who can learn to select, remove, carry, and exchange symbols. Assessment should examine vision, motor access, symbol understanding, scanning, discrimination, distance, communication purposes, vocabulary needs, portability, repair, and partner availability. The person may also need direct access, partner-assisted scanning, larger or tactile symbols, sign, writing, or a speech-generating system.

Start with the messages the person wants and needs to communicate. Early requesting can create a usable entry point, while a broad system also needs language for refusal, pain, help, people, places, comments, questions, relationships, privacy, and unexpected events. Keep reliable gestures, speech, signs, writing, and other AAC available during teaching.

PECS is not a prerequisite for a speech-generating device. A team can compare options through feature matching, trials, the person's experience, data across settings, and consultation with an SLP who has relevant AAC expertise. A chosen system may include PECS alongside other modes or may use another route entirely.

Implementation requires access and ethical safeguards

Use the current protocol rather than an improvised imitation. Define who is trained, which phase is active, what counts as an opportunity and independent exchange, how errors are corrected, how skills generalize, and when the plan will be reviewed.

Protect the person's communication system throughout the day. Food, water, bathroom access, pain care, mobility, rest, relationships, and emergency help remain available regardless of an exchange. Partners should honor a clear refusal, pause on withdrawal or distress during nonemergency teaching, and avoid making eye contact or speech a hidden requirement.

Pictures should be recognizable and current. The book or board needs a consistent location, portable access, vocabulary maintenance, a backup, and partners who respond. Data should identify whether a missed exchange reflects symbol access, partner availability, motivation, teaching, motor demands, vocabulary, or another condition.

Research supports measured, individualized expectations

A 2009 review by Preston and Carter identified 27 PECS studies, including randomized, group, and single-case designs. The authors called the evidence preliminary, found that many participants learned PECS as a communication method, and described limited evidence for broader social-communication or behavior effects. Effects on speech remained unclear.

A 2011 secondary analysis by Gordon and colleagues examined 84 children from 15 schools in a randomized classroom PECS trial. Observed spontaneous picture, speech, and combined communication increased following training. Object requesting increased, while social-purpose requesting did not show a statistically significant increase. That study does not predict one person's response, every communication purpose, maintenance, or fit against another AAC option.

Families can ask what outcome the team expects, which evidence applies to this person, and what result would prompt adaptation or a different system. Speech emergence can be recorded if it occurs. The central decision is whether communication becomes more accessible, self-directed, broad, and useful to the person.

A fictional example separates fidelity and outcome

Lena is a fictional eight-year-old using PECS Phase II with a trained team. Across ten planned routines, the book, current symbols, preferred activities, and trained partner are ready at the first check in 8 of 10 routines, or 80%. The two missed routines stay recorded as system failures.

Within the eight ready routines, Lena encounters 16 defined opportunities to request, refuse, or seek help. She initiates and completes an exchange before a gestural content prompt in 11 of 16 opportunities, or 68.8%. Partners honor the message or explain the next step within a fictional 10-second window for 10 of 11 exchanges, or 90.9%.

Lena uses exchanges for requests in seven opportunities, refusal in three, and help in one. The counts show access, exchange, partner response, and message variety. They have no baseline or comparison system, so they establish neither treatment effect nor superiority over another AAC approach.

Families can review more than phase completion

Ask:

• Which assessment supported PECS, and which AAC options were compared?
• Which phase, skill, prompt, error procedure, and mastery rule are in use?
• Can the person communicate refusal, pain, help, comments, questions, and novel messages?
• Is the system available across home, school, clinic, community, and medical settings?
• How are assent, dissent, authorship, privacy, cultural and language needs, and partner behavior protected?
• What do the person and family report about effort, usefulness, and fit?
• Which data trigger broader vocabulary, another access method, or a different system?

Useful measures include access-ready routines; exchanges by purpose; independent exchanges divided by eligible opportunities; partner responses divided by exchanges; distance and partner variation; errors and prompts; repairs; vocabulary availability; and the person's rating. Define every numerator, denominator, response window, phase, setting, and exclusion before interpreting a percentage.