5 Reasons We Don’t Use PECS® in Our Evidence-Based Practice
What is PECS® and why is it so widely used?
Picture exchange communication system® (PECS®) is often one of the first tools used to teach young autistic children to communicate. The idea behind it is simple:
Find an object/item the child is motivated by and wants
One person withholds that item from the child
A second person sits behind the child and places a picture of the item in the child's hand
That person then manipulates the child's hand to give the picture to the person withholding the item
The person holding the item gives it to the child
Voila - the child has communicated!
You can find plenty of research on the effectiveness of PECS® for helping children develop communication skills and it's true that due to its use of operant conditioning, caregivers and educators often see quick results, at least for requesting (withheld) items.*
So it’s evidence-based, right?
Well, it’s complicated.
From ASHA.org
Most SLPs are aware of the importance of using Evidence-Based Practice (EBP) in evaluation and therapy. However, it's sometimes forgotten that EBP does not equate to using only methods that have been researched in a laboratory (clinic or classroom). The American Speech-Language-Hearing Association (ASHA) states that EBP is the integration of 3 different things: (1) the knowledge, judgment, and critical reasoning gained through our extensive training and professional experiences; (2) evidence, which includes the best available information gathered from the scientific literature (external evidence) and from data and observations collected on individual clients (internal evidence); and (3) client/patient/caregiver perspectives, or in other words the unique set of personal and cultural circumstances, values, priorities, and expectations identified by a client and their caregivers.
We addressed the external evidence for PECS® above, which is complicated, as are many bodies of research. But we also want to address the other two aspects of EBP with regard to PECS®.
To start, let's talk about client perspectives. Not only should we be informed by our own clients and their caregivers, but we need to listen to other groups as well, including people who have received speech therapy, people who have experienced a disability impacting their ability to communicate, and other neurodivergent individuals.
The Therapist Neurodiversity Collective, Inc. is an international neurodiversity-affirming therapy, education, and advocacy organization, is autistic-led, and is "focused on aligning therapy and education practices within a neurodiversity-affirming paradigm" with the goal to "protect the rights and welfare of autistic and other neurodivergent people." Founding CEO Julie Roberts, a late-diagnosed Autistic ASHA certified, licensed Speech-Language Pathologist, wrote a powerful article called, "The Problem with PECS®" in 2020. If you haven't read it, we highly encourage you to check it out now.
In her article, Ms. Roberts concludes that there are “ethical concerns and philosophical differences pertaining to the use of Applied Behavioral Analysis (ABA) on human beings, including ABA-derived therapy models [of which PECS® is one]. We do not force compliance through the earning of snacks, checkmarks, behavior charts, stickers, access to favorite toys, activities or similar. The fundamental goal of ABA is compliance with the will of the person in the position of authority; this is completely counter-intuitive to self-advocacy, self-determination, and upholding human rights and dignity.”
Ms. Roberts is certainly not alone in her view of ABA. The internet is chock-full of autistic people who will fervently express how traumatizing ABA was for them.
With regard to the role of clinical experience and critical reasoning in the practice of speech therapy, the ASHA Code of Ethics states that SLPs must "use independent and evidence-based clinical judgment" to keep paramount the "best interests of those being served." In other words, we must use our critical thinking skills to make decisions about the therapy we provide. Again, EBP is not looking at the research without taking our clients’ views and our own common sense and critical thinking into account.
In light of the discussion above, here are the 5 main reasons we don’t use PECS® (and yes, this decision is evidence-based).
1. PECS® is compliance-based; it’s aim is to teach compliance
The first step in Phase 1 of PECS® is teaching a child to give someone a picture in exchange for a desired object. In our minds, this begs the question: how do people who use PECS® with children choose the motivating object? This is generally not a trial-and-error process, but rather the facilitator chooses an item the child has already communicated, through their behavior (e.g., reaching, vocalizing, eye gaze), that they like. So using PECS® requires a child to complete an additional step to obtain what they want, even though their communication partner already knows what they want based on their behavior. Seen in this way, it is quite clear that PECS® is not teaching communication, but rather that it is teaching compliance.
We are essentially communicating to children, we know what you want, but we won't give it to you until you communicate the way we want you to communicate.
Again, and we repeat this because it is so important, this is not teaching communication; it is teaching compliance.
2. PECS® violates a child's right to bodily autonomy
Phase one of PECS® involves hand-over-hand prompting, during which a child’s body is physically manipulated to comply with giving pictures in exchange for a reward. The adult’s behavior is implicitly teaching the child that the child does not have a right to decide what happens to their own body. A child could easily conclude that adults are free to do as we please to their bodies, and this may leave them vulnerable to physical and/or sexual abuse. A truly horrifying thought.
3. PECS® is an extremely limiting communication system
There are two systematic reasons for this:
PECS® limits functional communication by focusing on requesting
The system is based on requesting. While requesting is important for children, there are many other, just as important reasons to communicate, including to protest, question, comment, and share news, thoughts, ideas, and feelings (to name just a few).
By focusing heavily on requesting, we're setting children up to be denied access to the things they want. Encouraging requesting can lead to an increase in requests, which leads to more opportunities for denials to these requests, which can potentially cause frustration and externalizing behaviors.
PECS® limits vocabulary by focusing on nouns
The majority of PECS® pictures, particularly at the beginning stages, represent nouns. It's true that nouns are some of the first words children typically learn when acquiring language. However, there are other important early words, including but not limited to words for: greetings and farewells, asking for help, protesting and refusing, asking and answering questions, and sharing feelings.
Unfortunately, the focus on nouns in PECS® ignores a wide breadth of vocabulary that could provide children the words to describe their unique experiences.
In her article titled, “SLPs as AAC Gatekeepers,” Jordyn Zimmerman, M.Ed., a nonspeaking autistic person who was denied access to effective augmentative communication until she was 18, speaks from experience about ableism and the use of PECS®.
“One example of where ableism is often displayed in AAC is when the only type of communication support that is provided to students is PECS. But PECS is a requesting system, not a communication system. It assumes that the student has a language disability, rather than a speech disability. There is serious harm in limiting someone’s communication to a few picture cards in that the student is only allowed to communicate the few words that have been preselected by another person. When we limit or control someone’s communication, we are deciding their worth and assigning them value.”
4. PECS® does not best support all learning styles, particularly those of neurodivergent individuals
PECS® cards do not have designated places within a PECS® binder. This means that cards move and shift anywhere throughout the book depending on where the communicator or the communication partner places any given card.
This is particularly problematic due to differences in neurodivergent learning styles.
One example is in the area of motor learning. Motor learning is defined as an improvement of motor skills through practice, and is associated with long-lasting neuronal changes in the brain. Research shows that motor learning during use of an AAC system is impacted by consistent symbol location. In other words, it’s easier for an individual to locate a symbol on a multi-symbol board when the location of the symbol is in the same place each time. On the other hand, a PECS® card that is constantly moving will require a child to allocate more of their resources to finding the card, and this in turn impacts efficiency of communication. Complicating matters even further is that, according to research, up to 87% of autistic individuals already have difficulty with motor coordination.
Another argument against the use of PECS® with regard to learning style is related to visual processing. Studies show that autistic people may be better at some types of visual processing (e.g., non-social information) than neurotypical people. For example, autistic individuals have been found to be excellent at detecting visual patterns, meaning that they would likely benefit even more than neurotypicals from using an AAC system with consistent location of symbols (i.e., not PECS®).
5. PECS® is expensive, cumbersome, and time-consuming
PECS® is overall more expensive than many iPad AAC apps (this includes training for the facilitators as well as the equipment - notebooks, cards, etc.). There are other costs besides money. In order for a child to use PECS® to communicate with another person, they must always have access to their PECS® notebook and all of its cards. What happens when pictures get lost or damaged? PECS® users must constantly introduce new cards and adjust existing cards within the notebook, both throughout the day as well as over longer periods of time as the environment, context, and/or the child’s needs change. This is extremely time-consuming compared to a system like an app, which can be edited quickly and in which the symbols can be kept in the same position all the time.
In conclusion…
Simply put, we do not use PECS® (and we’ve explained why above). But we want to be clear that if a child is already using PECS® as their current method of communication, they need to continue to have access to it. We would never take away an individual’s mode of communication, ever. However, we would want to provide that child with opportunities to use a more robust communication system that would allow for autonomous communication while also keeping PECS® available.
So what do we recommend instead of PECS®?
- Core boards, flip books, and speech-generating devices
- Modeling without expectations
- Aided language stimulation
Stay tuned for a future blog post with details about the above recommendations. In the meantime, are you looking for a core flipbook for young children that is routines-based and geared towards self-advocacy language? Join our free resources membership to check out out free Core 25 flipbook here. An editable version is also available for purchase through this link.
As always, please let us know what you think in the comments section below. With gratitude!
* There is limited research on whether PECS® improves communication for functions other than requesting and little data on the long-term outcomes of PECS® use.
References
American Speech-Language-Hearing-Association. Evidence-Based Practice. https://www.asha.org/research/ebp/
American Speech-Language-Hearing-Association. Code of Ethics.
Costandi, Moheb. (2011). “Visual skills superior in autism, study says.” https://www.spectrumnews.org/news/visual-skills-superior-in-autism-study-says/
Dorney, K. E., & Erickson, K. (2019). Transactions Within a Classroom-Based AAC Intervention Targeting Preschool Students with Autism Spectrum Disorders: A Mixed-Methods Investigation. Exceptionality Education International, 29, 42-58.
Flippin, Michelle, Reszka, Stephanie, & Watson, Linda R. (2010). “Effectiveness of the Picture Exchange Communication System (PECS) on communication and speech for children with autism spectrum disorders: a meta-analysis.”American Journal of Speech Language Pathology, 19(2), 178-95.
Pyramid Educational Consultants. Picture Exchange Communication System® (PECS®). https://pecsusa.com
Roberts, Julie. (2020). “The Problem with PECS®.” https://therapistndc.org/the-problem-with-pecs/
Schenkman, Lauren. (2020). “Motor difficulties in autism, explained.” https://www.spectrumnews.org/news/motor-difficulties-in-autism-explained/
Holmes, Stephanie A., Horn, Madeline M., & Reum, Alyson M. (2018). “Consistent Symbol Location Affects Motor Learning in Preschoolers Without Disabilities: Implications for Designing Augmentative and Alternative Communication Displays.” American Journal of Speech Language Pathology, 27(3), 1010-17.
Zimmerman, Jordyn. (2022). “SLPs as AAC Gatekeepers.” https://communicationfirst.org/slps-as-aac-gatekeepers/
