Remedial and Special Education

32(6) 458470
2011 Hammill Institute on Disabilities
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DOI: 10.1177/0741932510362494
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Quantitative Synthesis and

Component Analysis of
Single-Participant Studies on
the Picture Exchange
Communication System

Matt Tincani1 and Kathryn Devis2

Abstract
The Picture Exchange Communication System (PECS) has emerged as the augmentative communication intervention of choice
for individuals with autism spectrum disorder (ASD), with a supporting body of single-participant studies. This report
describes a meta-analysis of 16 single-participant studies on PECS with percentage of nonoverlapping data (PND) as the
metric of effect size. Results suggest that PECS was moderately effective in establishing mands (PND = 80.1) for 41 participants up to Phase IV of the system. Higher levels of manding were found when PECS was taught to individuals without
ASD diagnoses versus those with ASD diagnoses and in single settings versus multiple settings; however, these differences
were not statistically significant. For a smaller subset of participants for whom vocalizations were recorded, PECS appeared
to facilitate speech, though considerable variability in speech acquisition was evident. While these results support PECS
as an evidenced-based communication intervention, they indicate that more research is needed on speech with PECS, to
establish the efficacy of PECS when implemented across settings and communicative partners, and to confirm efficacy of
Phases IV, V, and VI.
Keywords
autism, behavior analysis, meta-analysis research methodology, single-participant research methodology

Communication deficits are a core feature of autism (American Psychiatric Association, 2000). Of individuals with
autism, 30% or fewer develop functional speech (MirandaLinn & Melin, 1997), and up to 50% may remain mute as
adults (Wetherby & Prizant, 2005). A variety of interventions
has evolved to address communication deficits that accompany autism (Mirenda, 2003; Simpson et al., 2005). These
include unaided communication systems, such as gestures and
sign language, and aided communication systems, such as
voice output communication aides and picture-based systems.
One picture-based system, the Picture Exchange Communication System (PECS; Frost & Bondy, 2002), is among the
most popular interventions for children with autism and related
disabilities. For example, Stahmer, Collings, and Palinkas
(2005) found that 95% of children with autism served in
California community early intervention programs received
PECS, more than any other intervention methodology.
The PECS protocol comprises six phases (Frost &
Bondy, 2002). The individual is taught to initiate interactions

and to communicate in real-world situations in Phases I and

II, whereas Phases III and IV seek to increase vocabulary
and to introduce sentence structure. Phase V teaches
responding to anothers request (i.e., What do you want?),
and Phase VI establishes commenting in response to a question (e.g., What do you see?). Although the intent of
PECS is to teach functional communication by establishing
an increasingly complex repertoire of picture exchange
(Bondy, Tincani, & Frost, 2004), development of speech has
been reported for some users (e.g., Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002; Tincani, Crozier, &
Alazetta, 2006; Yoder & Stone, 2006).
1

Temple University, Philadelphia, PA

University of Nevada, Las Vegas, Las Vegas, NV

Corresponding Author:
Matt Tincani, 1301 Cecil B. Moore Ave., Room 367, Philadelphia,
PA 19122
Email: tincani@temple.edu

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Tincani and Devis

Research demonstrating PECSs efficacy, although promising, is emerging. A few recent studies have used group
comparison methodologies to examine the effects of PECS
on communicative skills of children with an autism spectrum
disorder (ASD), finding favorable, if mixed, outcomes (Carr
& Felce, 2007a, 2007b; Howlin, Gordon, Pasco, Wade, &
Charman, 2007; Yoder & Stone, 2006). For example, Yoder
and Stone (2006) conducted a randomized controlled trial
(RCT) study comparing PECS and Responsive Education
and Prelinguistic Milieu Teaching with 36 preschool children with ASD. Both interventions increased childrens
generalized spoken communication at posttreatment and
follow-up; however, PECS resulted in a differentially higher
frequency of spoken communication for children who demonstrated high object exploration before treatment. This finding makes sense in light of an initial emphasis within PECS
on using childrens preexisting interests in reinforcing items
to promote communication (Frost & Bondy, 2002). Similar,
Carr and Felce (2007a) reported an increase in child-to-adult
initiations of 24 children who received PECS up to Phase III
in comparison to 17 children who did not receive PECS. In
contrast, Howlin et al. (2007) conducted a RCT study evaluating the impact of classroom-level training and consultation
in PECS on communication skills of elementary-age children with ASD. Although increases in communicative initiations and picture exchanges occurred in conjunction with
PECS training and consultation, these improvements diminished on cessation of classroom consultation visits. Moreover, they did not observe increases in childrens vocal
communication skills with PECS, as measured by classroom
observations and standardized assessments.
Although group comparison studies have yielded fruitful
and promising results, significant questions remain about
the efficacy of PECS as an augmentative communication
system. For instance, PECS was initially developed for children with ASD and has been empirically validated for preschool- and elementary-age students. However, more recent
studies suggest that PECS can be successfully used with
adolescents and adults, including individuals who lack diagnoses of autism or pervasive developmental disorder, not
otherwise specified (PDD-NOS; Chambers & Rehfeldt,
2003; Ziomek & Rehfeldt, 2008). It remains unclear if factors such as age and diagnosis affect acquisition of PECS
and if the system is useful for individuals who are older or
who lack ASD diagnoses.
Furthermore, although the PECS phases are cumulative,
with advancement contingent on mastery of previous
phases (see Frost & Bondy, 2002), rates of mastery may
vary considerably among individuals (Bondy & Frost,
1994), and it is unclear if learners tend to advance through
most or all of the system. For instance, although the beneficial effects on basic communication skills of Phases I
through III are apparent (e.g., Carr & Felce, 2007a), less is

known about a users acquisition of the more advanced

communication skills taught in Phases IV through VI.
Finally, as speech has been reported as a desirable side
effect for some users, more information is needed to confirm the utility of PECS in promoting speech. This is particularly important given inconsistent findings yielded by
group comparison studies relative to speech (Carr & Felce,
2007a; Howlin et al., 2007).
In addition, PECS is a complex implementation system
involving an array of teaching techniques derived from the
field of applied behavior analysis (Bondy & Frost, 1994).
The systems relative complexity sets the occasion for procedural variations, both intended and unintended. For
example, Howlin et al. (2007) speculated that less reliable
or less frequent implementation of PECS (p. 479) may
have diminished students communication skills following
the end of classroom consultation in their study. Therefore,
it is critical for investigators who are validating PECS to
demonstrate fidelity with the teaching procedures outlined
within Phases I through VI; however, the extent to which
such fidelity measures are in place within published studies
has yet to be fully quantified.
To date, the majority of published studies supporting
PECS have utilized single-participant designs (e.g., CharlopChristy et al., 2002). These studies provide a potentially
rich source of data to augment findings of group studies
and to answer specific questions regarding the viability of
PECS. Importantly, because PECS is among the most popular interventions for persons with autism and related disabilities, there is a need to synthesize single-participant
studies to verify the systems efficacy in promoting functional communication and speech and to address specific
questions regarding characteristics of individuals who may
benefit from the system, mastery of phases, and production
of speech. Although several investigators have recently
conducted summaries of PECS research including singleparticipant studies, these have lacked quantitative measures
of effect size or have not included a component analyses to
evaluate the interaction of critical variablessuch as participants diagnosis, setting, and ageon acquisition of
picture exchanges and speech (cf. Ostryn, Wolfe, & Rusch,
2008; Sulzer-Azaroff, Hoffman, Horton, Bondy, & Frost,
2009; Tien, 2008).
Meta-analysis is a procedure for quantitatively synthesizing the effects of an intervention across several studies, thus
providing one measure of the efficacy of a particular treatment
(Scruggs & Mastropieri, 1998). Several comparable methods exist for quantitatively synthesizing single-participant
studies (Olive & Smith, 2005); however, calculating the percentage of nonoverlapping data (PND) between baseline and
intervention phases is a commonly used metric. Specifically,
PND is the percentage of data points in the treatment phase
over the highest data point occurring in the baseline phase

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Remedial and Special Education 32(6)

(Scruggs, Mastropieri, & Casto, 1987). Thus, the higher the

PND, the more effective an intervention. Specifically, a PND
of 90% or higher demonstrates highly effective, 90% to 70%
indicates moderately effective, 70% to 50% represents
mildly or questionably effective, and 50% or below demonstrates ineffective treatment (Ma, 2006; Scruggs & Mastropieri, 1998).
The purpose of the present study was to examine the
efficacy of PECS in establishing functional communication
and speech in individuals with autism and other disabilities.
A meta-analysis of 16 peer-reviewed single-participant
studies comprising 44 participants was conducted with
PECS as the independent variable and picture exchange and
vocalization as dependent variables. Of the 44 participants
in the studies, data on picture exchange were graphically
depicted for 41 participants, whereas data on vocalizations
were graphically depicted for 12 participants. Nonparametric component analysesthe MannWhitney U and Kruskal
Wallis one-way ANOVAwere conducted to assess for
interactions among participant characteristics (gender, age,
disability, highest phase of PECS mastered), setting characteristics (single setting vs. multiple settings, type of setting),
and picture exchange acquisition. Conclusions about the
efficacy of PECS and relevance for persons with autism and
other disabilities are drawn based on these results.

Method
Procedure
Peer-reviewed articles were identified by the first and second authors through searches of the PsycINFO, ERIC, and
ISI Web of Knowledge databases conducted by the first
author. Picture exchange communication system, PECS,
and autism were the keywords used to search the databases.
In addition, manual searches of the following journals were
conducted to locate studies meeting the authors inclusion
criteria: Education and Training in Developmental Disabilities, Research in Autism Spectrum Disorders, Journal of
Applied Behavior Analysis, Journal of Autism and Developmental Disorders, Remedial and Special Education, and
Focus on Autism and Other Developmental Disabilities.
From the articles identified through database searches,
articles for analysis were selected based on the following
five criteria: (a) the researchers used a single-participant
research design (i.e., alternating treatment with baseline,
multiple baseline, multiple probe, or ABAB reversal); (b) the
PECS intervention as described in Frost and Bondy (2002)
was implemented in the study; (c) the participants were
reported to have autism diagnoses, PDD-NOS diagnoses, dual diagnoses, or other diagnoses of disability; (d) the
effect of the intervention on picture exchange and/or
vocalizations was empirically measured and graphically

illustrated with clearly identifiable baseline and intervention phases; and (e) the article was published in a peerreviewed journal.
The first and second authors identified 16 studies published between 2002 and 2009 in nine journals: Behaviour
Change, Focus on Autism and Other Developmental Disabilities, Education and Training in Developmental Disabilities, Japanese Journal of Special Education, Journal
of Applied Behavior Analysis, Journal of Autism and Developmental Disorders, Remedial and Special Education,
Research in Autism Spectrum Disorders, and Research in
Developmental Disabilities. The second author manually
reviewed each of the 16 articles to confirm that they met
the five inclusion criteria.
These 16 articles used single-participant designs, reporting quantitative data for picture exchange and/or vocalizations. Importantly, each of the studies employed a baseline
from which the effectiveness of PECS could be evaluated
and made explicit reference to Frost and Bondys (2002)
PECS training manual in its current or previous edition
within a description of the procedures. Additional refereed
journal articles on the PECS found in database searches
were excluded from the analysis because they were (a) descriptive or anecdotal in nature (e.g., Bondy & Frost, 1994);
(b) did not meet all of the authors inclusion criteria, including presence of a baseline (Ganz & Simpson, 2004) and
implementation of the PECS protocol (Buckley & Newchok,
2005); and/or (c) did not use a single-participant research
design (Magiati & Howlin, 2003; Schwartz, Garfinkle, &
Bauer, 1998). For instance, Ganz and Simpson (2004)
employed a single-participant design to evaluate PECS, but
their study lacked baseline measures of participants communication skills prior to intervention. Related, Schwartz
et al.s (1998) quasi-experimental group study on PECS
employed neither baseline measures nor a comparison group.
In addition, one single-participant study (Angermeier,
Schlosser, Luiselli, Harrington, & Carter, 2008) was excluded
from the analysis because baseline measures strongly suggested that the participant had a history of PECS training
prior to the study.
Of the 44 participants included, 34 were male and 10
were female. The participants diagnoses included autism,
PDD-NOS, nonspecific developmental delays, mental
retardation, seizure disorder, Down syndrome, blindness,
cerebral palsy, and expressive and receptive language disorder. For analysis purposes, the participants were divided
into three age groups: (a) preschool age (2 to 5 years old),
(b) school age (6 to 17 years old), and (c) adults (18 years
and older). All 44 participants were treated with the PECS
intervention; however picture exchanges (mands) were
reported for only 41 participants. Vocalizations were
reported for a total of 12 participants, including 3 participants for whom picture exchange data were not reported.

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Tincani and Devis

For the 41 participants for whom picture exchange was
measured as a dependent variable, information was coded
relative to the following: (a) diagnosis, (b) gender, (c) age,
(d) highest PECS phase mastered, and (e) setting. Autism
or PDD-NOS constituted 51% (n = 21) of the sample, and
other diagnoses constituted 49% (n = 20). Males comprised
76% (n = 31) of the participants, females 24% (n = 10).
Preschool-age participants constituted 41% (n = 17) of the
sample, 32% (n = 13) were school age, and 27% (n = 11)
were adults. Only 7% (n = 3) of the sample mastered only
up to Phase I, 15% (n = 6) mastered up to Phase II, 49%
(n = 20) mastered up to Phase III, 20% (n = 8) mastered up
to Phase IV, and 9% (n = 4) did not report mastered phases.
Intervention was performed in single settings (e.g., home,
school, training center) for 83% (n = 34) of the sample and
in multiple settings for 17% (n = 7) of the sample.
For the 12 participants for whom vocalizations were
recorded as a dependent variable, the following characteristics were recorded. Individuals with autism or PDD-NOS
constituted 100% (n = 12) of the sample. Males comprised
92% (n = 11) and females 8% (n = 1). Preschool-age participants constituted 50% (n = 6) of the sample, and 50%
(n = 6) were school age. None mastered up to Phase I, none
up to Phase II, 33% (n = 4) up to Phase III, 42% (n = 5) up
to Phase IV, and 25% (n = 3) up to Phase VI. Intervention
was performed at school for 50% (n = 3), and for 50% (n = 3)
it was performed in multiple settings.
In addition to the aforementioned variables, it was coded
whether or not each study included quantified procedural
fidelity data. A study was coded Y if the authors reported
that an observer monitored the PECS intervention and
reported the percentage of steps correctly implemented. A
study was coded N if the authors did not report that an
observer monitored the PECS intervention and did not
report the percentage of steps correctly implemented.
Table 1 presents a brief description of the 16 peerreviewed studies, including participant characteristics,
research design, phases of PECS intervention received,
results, whether procedural fidelity measures were taken,
and average PND for picture exchange and/or vocalizations
across participants.

Analyses
The PND between baseline and treatment phases was calculated for the first to last phases of PECS received per participant. PND was calculated by dividing the number of
picture exchange or vocalization data points exceeding the
highest baseline data point by the total number of data
points in the treatment phase and multiplying the sum by
100 (Scruggs et al., 1987).
For each article reviewed, PND scores for picture
exchange (mands) were calculated between baseline and

intervention phases for each participant. The PNDs for each

participant were then averaged to provide an aggregate
PND score for each study (see Table 1). In the case of the
ABAB reversal design, PND was calculated for each AB of
the ABAB design, considering Kazdins (1982) observation
that it is quite possible that behavior will not revert toward
baseline levels once the intervention is withdrawn or
altered (p. 121). The individual PNDs for each AB of the
reversal design were averaged to provide one estimate of
the acquired phases for each participant. The first author
and a graduate student simultaneously coded and calculated
PNDs for 5 of the 16 studies (31%). Interobserver agreement was 100%.
Researchers employed varying operational definitions
and measurement procedures for the 12 participants for whom
vocalization data were reported. For instance, CharlopChristy et al. (2002) measured spontaneous and imitative
speech in play and academic demand settings, whereas Tincani (2004) and Tincani et al. (2006) measured words and
word approximations during PECS training. Furthermore,
some participants demonstrated no improvements in speech
on implementation of PECS; hence, speech data were not
graphically depicted for these participants. Vocalization
data thus could not be aggregated in the same manner as for
picture exchange. Instead, for Charlop-Christy et al. (2002),
PND speech scores were averaged for spontaneous and imitative speech across their three participants. For Anderson,
Moore, and Bourne (2007), Ganz, Simpson, and CorbinNewsome (2008), Jurgens, Anderson, and Moore (2009),
Tincani (2004), and Tincani et al. (2006), PND speech scores
were reported individually by participant, and the type of
vocal response was indicated. For additional participants in
these studies for whom vocalization data were not reported,
a PND of zero denoted failure to acquire any speech. In the
study by Yokoyama, Naoi, and Yamamoto (2006), vocalization data were graphically depicted; however, the method
of graphing used by these authors did not permit calculation
of PND. Therefore, it was simply indicated that increases in
vocalization were reported for the participants in this study
(see Table 1).
Nonparametric tests were used to analyze the relationship, if any, between participant characteristics and participants acquisition of picture exchange (Scruggs et al.,
1987). To investigate whether the dichotomous variables of
diagnosis (autism or PDD-NOS vs. other diagnosis), gender, and setting (single vs. multiple) affected PECS acquisition, separate MannWhitney U tests were conducted using
individual participants picture exchange PND scores
grouped accordingly as dependent variables. The effects of
age (preschool, school age, or adult) and highest PECS
phase (I, II, III, IV, V, or VI) mastered were examined with
separate KruskalWallis one-way ANOVAs, with individual participants picture exchange PND scores also serving

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Multiple
baseline
design across
participants

Alternating
treatment
design w/
baseline

Multiple
baseline
design across
settings and
participants

Multiple
baseline
design across
participants

Carr, Le Grice,
Blampied, and
Walker (2009)

Chambers and
Rehfeldt
(2003)

Charlop-Christy,
Carpenter, Le,
LeBlanc, and
Kellet (2002)

Ganz, Simpson,
and CorbinNewsome
(2008)

Alternating
treatment
design w/
baseline

Bock, Stoner,
Beck, Hanley,
and Prochnow
(2005)

IIII; all children demonstrated stable, low baselines before

intervention was initiated; all children advanced to Phase II;
5 children met criterion and moved to Phase II; 2 children
met criterion for completion of Phase III.

IVI; phases were acquired but results for picture exchange

were not reported; all participants displayed an increase
of spontaneous speech or imitation (vocalizations) from
pretraining to posttraining; during 1-year follow-up sessions,
spontaneous speech gains were maintained.

IIII; all adults were not able to mand (picture exchange)

for any items during baseline; 3 participants performed
with 100% accuracy using PECS; 1 participant showed
improvement from baseline but did not continue training
because of acquired infectious disease.

3 preschool-age: 1 male w/ IIV; participants demonstrated no picture exchanges during

autism, aphasia, global
baseline; 2 participants acquired Phase IV; 1 participant
developmental delay,
acquired no PECS phases and demonstrated low levels of
and ADHD (P1); 1 male
responding throughout intervention; participants did not
w/ autism (P2); 1 female
significantly increase word approximations or intelligible
w/ global developmental
words with PECS training.
delay and seizure
disorder (P3)

2 preschool-age and 1
school-age males w/
autism

4 adults (2 males, 2
females): 1 w/ MR
and expressive and
receptive language
disorder; 1 w/ severe
MR, cerebral palsy, and
seizure disorder; 1 w/
Down syndrome, MR,
and seizure disorder; 1
w/ MR

Fidelity?
(Y/N)

IIV. Zero levels of picture exchange and very low levels of

vocalization observed during baseline. Increases in picture
exchange, vocal initiations, and new words spoken following
PECS training. Increases in play also observed.

PECS: Phases Received and Results of Training

3 children (2 males, 1
IIII; participants demonstrated zero levels of picture exchange
female) between 5 and
at baseline; all participants acquired at least Phase II during
6 years old; 2 w/ autism,
training. Participants demonstrated moderate and varying levels
1 w/ Down syndrome
of generalization of picture exchange in nontraining settings;
and autistic features
higher rates of picture exchange were observed in classroom
generalization settings than home generalization settings.

6 preschool-age males w/
developmental delaysa

A-B-C-D design 1 school-age male w/

autism

Participant
Characteristics

Anderson,
Moore, and
Bourne (2007)

Authors

Research
Design

Table 1. Peer-Reviewed Single-Participant Studies on the Picture Exchange Communication System (PECS)

Not reported

Not reported

Not reported

Initiations: 82.4

Vocalization PND

64.1

(continued)

P1: 9.6 (vocal

approximations)
7.7 (intelligible
words); P2:
4.6 (vocal
approximations),
2.8 (intelligible
words); P3: Not
reported (0)

Not
Spontaneous: 62.8,
reported
imitative: 75.2

100.0

50.4

93.0

70.6

Picture
Exchange
PND

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Multiple
baseline
design across
participants

Multiple
baseline
design across
descriptors
Multiple probe
design across
participants

Lund and Troha

(2008)

Marckel, Neef,
and Ferreri
(2006)

ABAB, reversal
design

Multiple
baseline
design across
settings

Kravits, Kamps,
Kemmerer,
and Potucek
(2002)

Sigafoos, Ganz,
OReilly,
Lancioni, and
Schlosser
(2007)
Stoner et al.
(2006)

A-B-C-D-E
design

Jurgens,
Anderson, and
Moore (2009)

Authors

Research
Design

Table 1. (continued)

5 adults (4 males, 1
female): 2 w/ Down
syndrome, 1 w/
developmental delays,a
1 w/ cerebral palsy, and
seizure disorder, 1 w/
seizure disorder

2 school-age males: 1 w/
PDD-NOS and MR, 1
w/ autism

2 preschool-age males w/
autism

3 school-age (2 males,
1 female) w/ autism,
blindness, and cognitive
impairment

1 school-age female w/
autism

1 preschool-age male w/
autism

Participant
Characteristics

IIV; 3 of 5 participants successfully completed PECS through

Phase IV, other 2 participants did not progress past
Phase III; successful participants: 2 demonstrated stable
baselines, other participant engaged in low level of picture
exchange; 1 participant maintained ability to use PECS
even after second baseline, other participants showed
a decrease in performance; unsuccessful participants: 1
engaged in low level of picture exchange during initial
baseline, other participant demonstrated stable baseline;
both demonstrated difficulties progressing through phases,
1 discontinued PECS training, other participant showed
reduction in accuracy after seizure, was reinstated at Phase
1, and then discontinued training shortly after.

Not specified; participants maintained zero level baselines;

a rapid increase in mands picture exchanges were
demonstrated when training was implemented.

IIII with tactile modifications; no participants demonstrated

picture exchanges during baseline; 1 participant
demonstrated mastery of Phase III and 2 participants
demonstrated mastery of Phase I with tactile modifications
of PECS.
Not specified; during baseline, picture exchanges rarely
occurred, if at all; mands steadily increased and were
maintained at high levels as PECS was implemented.

IIII; picture exchanges rarely occurred during baseline;

picture exchange increased when PECS implemented;
effects were consistent across settings; vocalizations
reportedly increased, however, results for vocalizations
were not separately graphed.

IIV; picture exchanges were measured in generalization

settings only. Participant demonstrated zero levels of
picture exchange during baseline; picture exchanges
remained at low levels during PECS intervention; however,
vocal initiations and vocal mands increased in generalization
settings.

PECS: Phases Received and Results of Training

Fidelity?
(Y/N)

78.1

100.0

98.0

55.0

89.8

20.0

Picture
Exchange
PND

(continued)

Not reported

Not reported

Not reported

Not reported

Not reported

Vocal initiations:
60.0, vocal
mands: 35.0

Vocalization PND

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Alternating
treatments
design w/
baseline

Ziomek and
Rehfeldt
(2008)
3 adults (1 male, 2
females) w/ MR and
multiple disabilities

2 preschool-age and 1
school-age w/ autism

2 school-age males w/
autism

1 preschool-age male
w/ autism and MR; 1
school-age female w/
PDD-NOS

Participant
Characteristics
IIII; participants picture exchanges increased overall;
1 participant demonstrated more success with other
treatment; therefore, PECS was not chosen for final besttreatment phase; the other participant demonstrated 3
times more mands in PECS than other treatment; therefore,
PECS was chosen for final best-treatment phase; both
participants vocalizations increased overall.
IIV; during baseline, picture exchanges rarely occurred, if
at all; for both participants, exchanges increased during
Phases IIV and were maintained during generalization;
vocalizations reported for only 1 participant, who
displayed a substantial increase in speech while PECS was
implemented.
IIII; 2 participants demonstrated low levels of independent
picture exchanges during baseline, 1 participant
demonstrated a high level of independent picture
exchanges, thus lowering overall PND. All participants
acquired PECS skills up to Phase III. Collateral increases in
speech were also reported.
IIII; participants demonstrated zero levels of picture
exchange during baseline. 2 participants acquired Phase
III; the other participant acquired only Phase I. For the
participants who acquired Phase III, picture exchanges
generalized across people, settings, and functions.

PECS: Phases Received and Results of Training

Fidelity?
(Y/N)

97.6

64.2

97.5

86.4

Picture
Exchange
PND

Not reported

P1: 62.5 (word

approximations),
P2: not
reported (0),
P3: 100 (word
approximations)
Increases
reported for all
participants

P1: Not reported

(0), P2:
100 (word
vocalizations)

Vocalization PND

Note: PND = percentage of nonoverlapping data; MR = mental retardation; ADHD = attention-deficit/hyperactivity disorder; P1 = Participant 1; P2 = Participant 2; P3 = Participant 3; PDD-NOS =
pervasive developmental disorder, not otherwise specified.
a. Diagnostic criteria not available.

Multiplebaseline with
changing
criterion

Alternating
treatment
design w/
baseline and
final besttreatment
phase
Delayed
multiplebaseline
design across
participants

Yokoyama, Naoi,
and Yamamoto
(2006)

Tincani, Crozier,
and Alazetta
(2006)

Tincani (2004)

Authors

Research
Design

Table 1. (continued)

465

Tincani and Devis

as the dependent variable. Nonparametric tests were not
conducted for vocalizations because of the small number of
participants, 12, for whom vocalization data were reported
and variations in operational definitions and measurement
of speech evident in these studies.

Table 2. PND Score Means and Standard Deviations for

Picture Exchange Communication System (PECS) by Participant
Characteristics

Results

Diagnosis
Autism or PDD-NOS
21
75.4
28.8
Other
20 85.0 24.1
Gender
Male
31 80.8 25.8
Female
10 77.6 30.8
Age
17 80.5 23.8
Preschool
13
71.3
34.8
School age
11 89.7 17.3
Adult
Highest PECS phase mastered
3 45.5 32.2
I
6 81.1 19.9
II
20 82.5 26.8
III
8 76.7 28.6
IV
4
99.0
2.1
Not reported
Setting
34 81.8 26.4
Single
7 71.5 28.7
Multiple

The meta-analysis resulted in 41 unique PND scores for picture exchange. The overall mean PND for picture exchange
across participants was 80.1 (n = 41, SD = 26.7). According
to Scruggs and Mastropieris (1998) criteria, a PND value of
80.1 represents a moderately effective treatment.
PND scores for picture exchange by participant characteristics are presented in Table 2. Acquisition of PECS was
substantially similar across both male (PND = 80.8) and
female (PND = 77.6) participants; however, variability in
acquisition of PECS was apparent for individuals with differing diagnoses and ages, those with differing phases of
PECS mastered, and those taught PECS in single versus
multiple settings. Specifically, higher levels of manding
were found when PECS was taught to individuals without
autism or PDD-NOS diagnoses (PND = 85.0) versus those
with autism or PDD-NOS diagnoses (PND = 75.4). PECS
also produced differing levels of acquisition for preschool
(PND = 80.5), school-age (PND = 71.3), and adult (PND =
89.7) participants. In addition, PECS produced substantially lower levels of acquisition for the three participants
who mastered only Phase I (PND = 45.5) compared to those
who mastered Phase II (PND = 81.1), Phase III (PND =
82.5), and Phase IV (PND = 76.7). Finally, individuals who
were taught PECS in single settings demonstrated higher
levels of acquisition (PND = 81.8) compared to those
taught PECS in multiple settings (PND = 71.5).
MannWhitney U tests were conducted to assess for significant differences among groups, with individual participants picture exchange PND scores grouped according to
diagnosis, gender, and setting. KruskalWallis one-way
ANOVA tests were also conducted, with participants picture exchange PND scores grouped according to age and
highest phase of PECS mastered. No statistically significant differences were found when PND scores were
grouped according to diagnosis (MannWhitney U = 165.50,
p = .15), gender (MannWhitney U = 153.00, p = .96), age
(2 = 2.74, p = .25), highest phase of PECS mastered ( 2
= 8.18, p = .08), and setting (MannWhitney U = 84.50, p
= .222), indicating that PND scores did not significantly
differ on the basis of diagnosis, gender, age, highest phase
of PECS mastered, and setting.
Vocalization PND scores were not aggregated across studies. As shown in Table 1, there was considerable variability
between participants in the degree of speech acquired with
PECS, with some studies indicating moderate to substantial

PND
Participant Characteristic

n M SD

Note: PND = percentage nonoverlapping data; PDD-NOS = pervasive

developmental disorder, not otherwise specified.

improvement and others indicating little or no improvement.

For instance, the participant in the Anderson et al. (2007)
study had a PND score of 82.4 for vocal initiations, and participants in the Charlop et al. (2002) study had, on average,
PND scores of 62.8 for spontaneous speech and 75.2 for imitative speech, suggesting that PECS was mildly to moderately
effective for increasing speech in these investigations. In contrast, in the Tincani (2004) study, Participant 1 demonstrated
no speech with implementation of PECS, whereas Participant
2 demonstrated a substantial increase in word vocalizations
(PND = 100). In Tincani et al. (2006), Participant 1 demonstrated a mild increase in word approximations with PECS
(PND = 62.5), Participant 2 demonstrated no speech, and Participant 3 demonstrated a substantial increase in word approximations (PND = 100) with PECS.
Finally, procedural fidelity data were reported for 7 of
the 16 studies analyzed. Researchers used differing procedures to calculate procedural fidelity, reflecting varying
levels of specificity, and most did not report quantitative
fidelity data (e.g., as a percentage of implementation steps
accurately completed). For example, Bock, Stoner, Beck,
Hanley, and Prochnow (2005) reported that procedural
fidelity was documented on a form that was created for
each phase of...PECS (p. 269) without additional detail,
whereas Marckel, Neef, and Ferreri (2006) reported that
procedural fidelity was scored with a 13-step checklist.

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In contrast, Tincani (2004) explicitly stated that the procedural fidelity checklist used in this study followed the procedures outlined in the phases of PECS, providing an
example of the Phase I checklist within the report and
reporting procedural fidelity as an average percentage of
steps accurately completed (97.1).

Discussion
The findings of this meta-analysis support the PECS as an
effective intervention to promote functional communication
for individuals with ASD and other disabilities. Regardless
of participants diagnosis, gender, age, highest phase of
PECS mastered, and setting, PECS training, on average,
produced moderate improvements in communication, as
measured by increased picture exchange during intervention
in comparison to baseline (PND = 80.1). This result is consistent with previous quantitative reviews of augmentative
communication systems, which demonstrated enhanced
communication for individuals with autism, mental retardation, and other disabilities (Millar, Light, & Schlosser, 2006;
Schlosser & Wendt, 2008).
The findings of this meta-analysis support group comparison studies for which the results demonstrated that
Phases I through III of the PECS enhanced childrens
communicative initiations with others (Carr & Felce,
2007a, 2007b; Yoder & Stone, 2006). For the most part,
the reviewed studies did not assess or report acquisition
data on PECS Phases IV through VI. More data are needed
to evaluate (a) whether users readily acquire the skills
taught in these latter phases and (b) what, if any, enhancements to individuals communicative skills the phases
provide. Therefore, although these single-participant data
are supportive of PECS as a basic augmentative communication system to establish mands, the utility of PECS in
promoting more advanced communication skills, including tacts (i.e., expressive labels) and intraverbals (i.e.,
conversation), has not been established.
Although PECS was initially designed to promote communication in young children with autism, it is noteworthy
that 20 of the 41 participants for whom picture exchange
was a dependent variable were not reported to have a diagnosis of autism or PDD-NOS. This finding tentatively suggests that PECS is effective for individuals with diagnoses
beyond the autism spectrum; however, it should be noted
that specific diagnostic information was not reported for
seven individuals, who were described as having nonspecific developmental delays (Bock et al., 2005; Stoner et al.,
2006). Thus, it is possible that individuals described as having developmental delays met the criteria for an ASD
diagnosis though this was not specifically reported.
Participants demonstrated higher levels of picture exchange
when PECS was taught in single setting (PND =

81.8) versus multiple (PND = 71.5) settings. Although

these differences were not statistically significant, this finding is not surprising given difficulties with stimulus overselectivity and stimulus generalization intrinsic to persons
with ASD (Chiang & Carter, 2008). As PECS is purported
to be a functional communication system with utility across
environments, this finding underscores Frost and Bondys
(2002) emphasis within the PECS protocol on the importance of teaching across multiple trainers, environments,
and reinforcers to promote generalized communication. As
few studies in this review examined users generalized
acquisition of picture exchange and vocalizations across
settings and communicative partners, more research is
needed to establish the efficacy of PECS in promoting generalized communication skills.
There was considerable variability among participants
in the PECS phases mastered. Only one study reported that
participants acquired all six phases (Charlop-Christy et al.,
2002). In contrast, the majority of participants for whom
picture exchange was graphically measured, 29 or 41, mastered only up to Phases I, II, or III. Three factors could
account for participants limited acquisition of PECS. First,
variability in participants acquisition rates could preclude
experimenters from progressing through all the systems
phases by the conclusion of the experiment. For example,
participants in the Charlop-Christy et al. (2002) study were
described as mastering all six PECS phases within an average of just 246 total trials. By comparison, one of the participants in the study by Tincani et al. (2006) required an
average of 358 trials to master only Phases I and II. Second,
Stoner et al. (2006), who taught PECS to Phase IV with
four of their participants, reported that Phases V and VI
could not be completed because of limits in implementers
training schedules. Thus, experimental time limitations
could have prevented participants in some studies from
progressing through the latter phases of PECS. Third,
although participants diagnoses of autism or PDD-NOS
versus another disability did not appear to influence acquisition of picture exchange, participants cognitive abilities
could have influenced acquisition rates. Unfortunately,
because most studies lacked quantitative and complete
descriptions of participants cognitive functioning levels, it
was not possible to assess for the influence of IQ score, for
example, as an independent variable on acquisition of
PECS. Nonetheless, empirical support for Phases V and VI
of the system is lacking.
PECS training produced varying levels of speech among
the limited number of participants for whom speech was
documented. Six participants evidenced little or no improvements in speech, whereas another ten evidenced mild, moderate, or substantial improvements in speech. This finding is
consistent with Schlosser and Wendt (2008), who found
varying, yet generally modest, improvements in speech with

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Tincani and Devis

augmentative communication systems, including PECS.
Group studies have yielded similar varying findings with
respect to speech (Carr & Felce, 2007a, 2007b; Howlin et al.,
2007). One possible source of variability in speech acquisition
could be differing exposure to PECS among participants in
terms of duration and intensity of intervention. Importantly,
because the primary focus of PECS is to teach functional
communication and not speech per se, the absence of speech
development for some users should not be viewed as a deficit of the system. Moreover, there is no evidence within the
reviewed studies to suggest that PECS inhibited speech; to
the contrary, if any effect was observed, it was facilitative
rather than inhibitory.

Limitations
There are several potential limitations to the investigation
that should be considered in relation to the results. The first
limitation is the relatively small number of participants,
44, for whom picture exchange and/or speech data were
reported. Given the sample size, caution should be exercised in generalizing results to the general population of
individuals with ASD and other disabilities. Particular caution should be used in generalizing the speech data given
the small number of participants, 12, for whom speech data
were documented.
Second, the PECS protocol is a complex system requiring myriad teaching procedures, including most-to-least
prompting, least-to-most prompting, shaping, chaining, and
error correction (see Frost & Bondy, 2002). Indeed, Howlin
et al. (2007) found that teachers had difficulty maintaining
communicative gains achieved with PECS when classroom
consultation visits ended, perhaps in part because expert
consultation did not fully establish complex teaching repertoires necessary to implement PECS without external support. Although 7 of 16 studies in this review reported
procedural fidelity suggesting conformity with the PECS
procedures described by Frost and Bondy (2002), it is not
unreasonable to assume some degree of procedural variation from the PECS protocol in these studies given the systems complexity. Several studies, including those by Lund
and Troha (2008), Marckel et al. (2006), Sigafoos, Ganz,
OReilly, Lancioni, and Schlosser (2007), and Tincani
(2004), involved procedural variations not explicitly delineated within the PECS protocol. Therefore, caution should
be exercised in generalizing results from these studies to
field-based implementations of PECS. For practitioners
and parents, this finding indicates that, in some cases, the
PECS system may need to be modified from Frost and
Bondys (2002) protocol to accommodate the needs of individual learners, for example, those with visual impairments, fine and gross motor difficulties, and problems with
discriminating between picture symbols.

A third limitation involves the vocalization data collected

for 12 participants. Although some researchers reported
increases in vocalizations with implementation of PECS,
there was considerable variation in how vocalizations were
measured across participants. For example, CharlopChristy et al. (2002) measured spontaneous speech and imitative speech in play and academic demand settings,
whereas Tincani (2004) and Tincani et al. (2006) measured
words and word approximations emitted during PECS
training. Furthermore, in one study (Kravits, Kamps, Kemmerer, & Potucek, 2002), vocalizations were measured and
were reported to have increased, but vocalization data were
not graphed separately from picture exchange data. Differing measurement and data displays across studies limits
conclusions that can be drawn about the efficacy of PECS
in promoting speech.
Fourth, use of PND as a metric to evaluate effect size
across studies has potential limitations that should be considered. Specifically, this metric evaluates the degree of
nonoverlap between baseline and intervention phases but
does not consider other relevant indicators of effect size,
including latency and magnitude of behavior change across
phases. Although in most cases the reviewed studies yielded
PNDs of 70 to 100 for picture exchange, participants performance levels were typically at low or zero levels prior to
intervention. Therefore, marginal and clinically insignificant performance improvement could have produced high
PND scores. However, it is important to consider that PECS
requires a criterion of at least 80% independence for progression to the next phase. Therefore, participants who
exhibited marginal levels of improvement with PECS
would not progress beyond Phase I of the system. Because
a majority of participants in the review acquired at least
Phases I, II, and III, this suggests a higher and clinically
significant magnitude of behavior change, though PND
does not necessarily reflect this magnitude of change.
Finally, although the current review considered effect size
for PECS intervention in conjunction with phases acquired, it
did not systematically evaluate for quality indicators of
single-participant research (Horner et al., 2005) beyond
inclusion of procedural fidelity measures. Quality indicators
include complete descriptions of participants and settings, at
least three demonstrations of experimental control, and social
validation of dependent variables. Given the importance of
quality indicators to establishing the efficacy of a particular
intervention, future reviews should carefully and systematically consider these factors.

Future Research
These results yield several directions for future research.
First, given that the majority of participants taught PECS
mastered only up to Phase III, additional research is needed

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Remedial and Special Education 32(6)

to establish efficacy of the latter phases, particularly Phases

V and VI, for which no data were graphically reported.
Second, additional research is needed to confirm the effectiveness of PECS in promoting speech. Given the observed
variability among studies in the manner in which speech
was defined and measured, future researchers should consider replicating the operational definitions and settings
used in the current studies (Charlop-Christy et al., 2002;
Tincani, 2004; Tincani et al., 2006) in systematic replications. Third, additional research on PECS as taught across
settings is needed. Research addressing this particular issue
is especially critical given that PECS is purported to be a
functional communication system with utility across settings. Furthermore, in several studies it was apparent that
researchers, rather than peers, parents, or teachers, were
both the trainers and recipients of communication. Therefore, future studies should investigate the effects of PECS as
taught in the context of natural behavior change agents to
determine the feasibility of the system for secondary consumers. In addition, researchers should carefully document
critical outcome variables related to PECS that were not
described in most of the reviewed studies, specifically,
the number of trials or sessions required to acquire each
of the six phases and the total number of pictures or
words acquired. Documentation of these important variables would contribute to an understanding of the utility of
PECS as a functional augmentative communication system.
Finally, future studies should employ procedural fidelity
measures that demonstrate direct correspondence with the
procedures outlined by Frost and Bondy (2002) to validate
the PECS protocol.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.

Financial Disclosure/Funding
The authors received no financial support for the research and/or
authorship of this article.

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About the Authors

Matt Tincani, PhD, is an associate professor of special education and
applied behavior analysis at Temple University in Philadelphia, PA.
Kathryn Devis, BA, is a graduate student in marriage and family
therapy at the University of Nevada, Las Vegas in Las Vegas, NV.

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