نوع مقاله : مقاله پژوهشی

نویسندگان

• سعید حسن زاده ¹
• سینا شاویسی ²

¹ استاد گروه روان‌شناسی و آموزش کودکان استثنایی، دانشگاه تهران، تهران، ایران

² دانشگاه تهران

چکیده

پژوهش حاضر مطالعة تأثیر سیستم ارتباط مبادلة تصویر (پکس) بر روی رشد مهارت‍های ارتباطی و اجتماعی کودکان دارای اختلال طیف اوتیسم بود. این پژوهش ازلحاظ هدف کاربردی و ازلحاظ گرد‍آوری داده‍ها کیفی بود. طرح پژوهش از نوع مطالعة مروری نظام‍مند بود. یافته‍های پژوهشی مرتبط با پکس، در افزایش مهارت‍های ارتباطی و اجتماعی کودکان دارای اختلال طیف اوتیسم بررسی شد. در پژوهش حاضر به بررسی تأثیر سیستم ارتباط مبادلة تصویر بر رشد مثبت مهارت‍های ارتباطی و اجتماعی کودکان دارای اختلال طیف اوتیسم پرداخته شد. در این مطالعه 51 پژوهش منتشرشده بین‌المللی از سال 2012 تا 2024 در پایگاه‍های اطلاعاتی گوگل‌اسکولار، پاب‍مید و ساینس دایرکت از میان 77 مقاله انتخاب شد تا تأثیر سیستم ارتباط مبادلة تصویر بر مهارت‍های اجتماعی و ارتباطی موردبررسی و تحلیل قرار گیرد. یافته‍ها حاکی از آن بود که پکس در رشد مهارت‍های ارتباطی و اجتماعی افراد دارای اختلال طیف اوتیسم مفید و مؤثر است. پژوهش نشان داد که پکس می‍تواند در افزایش مهارت‍های ارتباطی و مهارت‍های اجتماعی کودکان دارای اختلال طیف اوتیسم مؤثر باشد و سبب بهبود کیفیت زندگی کودکان دارای اختلال طیف اوتیسم شود و می‍توان از پکس در مراکز آموزشی دارای کودکان اوتیستیک برای افزایش مهارت‍های ارتباطی و اجتماعی استفاده کرد.

کلیدواژه‌ها

• کلیدواژه‌ها: پکس
• مهارت‌های اجتماعی و ارتباطی
• اختلال طیف اوتیسم. 

عنوان مقاله [English]

A Systematic Review on the Effect of the Picture Exchange Communication System (PECS) on the Development of Social and Communication Skills of Children with Autism Spectrum Disorder

نویسندگان [English]

• saeid Hasan zadeh ¹
• sina shavaisy ²

¹ Professor, Department of Psychology and Education of Exceptional Children, University of Tehran, Tehran, Iran

² University of Tehran

چکیده [English]

Abstract
This systematic review evaluates the efficacy of the Picture Exchange Communication System (PECS) in promoting communication and social skill development among children with autism spectrum disorder (ASD). Employing qualitative research methods, the study analyzed 51 peer-reviewed international studies (2012-2024) selected from an initial pool of 77 articles across Google Scholar, PubMed, and Science Direct databases. The investigation specifically addressed whether PECS contributes to measurable improvements in communicative and social functioning for children with ASD. Results demonstrated consistent positive outcomes, including enhanced communication abilities, improved social interaction skills, and increased quality of life indicators. The findings provide robust empirical support for implementing PECS as an evidence-based intervention in special education curricula, underscoring its value for fostering critical developmental skills in ASD populations.
Keywords: Autism Spectrum Disorder (ASD), Picture Exchange Communication System (PECS, social skills, communication skills, Augmentative and Alternative Communication (AAC), systematic review
 
Extended Abstract

Introduction

Autism spectrum disorder (ASD) represents a complex neurodevelopmental condition characterized by: (1) persistent deficits in social communication and interaction across multiple contexts, and (2) restricted, repetitive patterns of behavior, interests, or activities (RRBs). The disorder exhibits remarkable phenotypic heterogeneity, manifesting in wide variations across individuals regarding symptom onset trajectories, severity gradients, clinical profiles, and comorbid psychiatric or medical conditions. While social communication impairments constitute a universal core feature, their specific behavioral manifestations and associated functional impacts demonstrate substantial interindividual variability, ranging from subtle pragmatic language difficulties to complete absence of verbal communication.
The Picture Exchange Communication System (PECS) is an empirically supported augmentative and alternative communication (AAC) intervention that has become one of the most extensively implemented support methodologies for individuals with ASD. Grounded in applied behavior analysis (ABA) principles, this structured protocol employs a graduated six-phase instructional approach to systematically develop functional communication competencies. As a visually based system, PECS specifically addresses core communication challenges in ASD by: (1) circumventing verbal language demands through picture-based exchanges, (2) reinforcing spontaneous communication initiations, and (3) progressively building complex communication repertoires.
The Picture Exchange Communication System (PECS) facilitates the development of both expressive and receptive communication skills. Rooted in behavioral theory, PECS incorporates Skinner's verbal operants (1957) within a pyramidal training framework to systematically teach functional communication. This approach mirrors natural language acquisition patterns, progressing from basic picture exchanges to constructing multi-phrase sentences using sentence strips.
Empirical evidence confirms PECS's effectiveness in supporting communication development. Maj's (2018) study demonstrated that PECS implementation not only reduces speech acquisition difficulties but also enhances overall communication growth. Functioning as a dual-purpose intervention, PECS serves as both:

A supplementary aid for developing verbal skills
An alternative communication system for individuals with complex communication needs

Notably, PECS facilitates functional communication—intentional, socially-directed exchanges that enable users to express needs and desires (Maj, 2018). This capacity for purposeful interaction constitutes a critical developmental milestone for nonverbal individuals or those with limited verbal abilities.
Children with autism spectrum disorder (ASD) exhibit significant impairments in both communication and social skills. While these domains are distinct—with social skills involving appropriate behavioral responses in social contexts, and communication skills encompassing verbal and nonverbal expression of needs and intentions—they remain fundamentally interconnected. Improvements in one domain often lead to gains in the other (Gobro et al., 2021).
Recent empirical studies (Pratama & Paramita, 2023; Tamanaha et al., 2023) have demonstrated the effectiveness of the Picture Exchange Communication System (PECS) in addressing these core deficits among children with ASD. Nevertheless, despite accumulating evidence supporting PECS efficacy, the literature has lacked a comprehensive systematic review synthesizing this research. This gap motivated our current systematic examination of PECS interventions targeting communication and social skill development in ASD populations.
Research Question(s)
In this article, we examine the role of the Picture Exchange Communication System (PECS) in developing communication and social skills among children with autism spectrum disorder (ASD), drawing upon both theoretical foundations and empirical evidence. Subsequently, through a systematic review of studies published between 2012 and 2024, we investigate the following research question: Does the Picture Exchange Communication System (PECS) effectively enhance social and communication skills in children with ASD?

Literature Review

Historically, therapeutic interventions for language and communication development in children with autism spectrum disorder (ASD) focused predominantly on speech production through response training. In contrast to nonverbal training approaches, this method demonstrated limited efficacy in developing functional communication abilities. Modern rehabilitation paradigms for nonverbal children with ASD now prioritize cultivating functional spontaneous communication (Lerna et al., 2012).
Autism interventions commonly target both speech and social skills development, with treatment outcomes typically assessed through multiple behavioral indicators including:
Eye contact frequency and duration
Verbal output measures (e.g., number of spoken words)
Appropriateness of motor movements
Frequency and quality of social interactions
Context-appropriate facial expressions
Relevance and pragmatics of speech content
Matheson and colleagues categorized these interventions into five primary approaches:
(a) Modeling and reinforcement techniques
(b) Mediated intervention strategies
(c) Structured reinforcement programs and activities
(d) Social scripts and narrative-based interventions
(e) Miscellaneous intervention programs (including response-centered training and Picture Exchange Communication System implementation) (Mayharvid et al., 2021).
Applied Behavior Analysis (ABA) is an evidence-based intervention designed to support communication skill development in children with autism spectrum disorder (ASD). This structured approach utilizes reinforcement-based learning principles to help children acquire essential language and communication abilities, including language comprehension, verbal fluency, interpretation of facial expressions and body language, and effective social communication. By systematically breaking down complex skills into manageable components and employing positive reinforcement, ABA facilitates meaningful progress in both verbal and nonverbal communication domains, ultimately promoting more successful social interactions for children with ASD.
Empirical research has consistently demonstrated the efficacy of Applied Behavior Analysis (ABA) in promoting language and communication skill acquisition among children with autism spectrum disorder (ASD). ABA-based interventions systematically employ three core components: (1) structured instructional techniques, (2) positive reinforcement strategies, and (3) continuous progress monitoring. This comprehensive approach not only enhances fundamental communication capabilities but also enables children with ASD to develop the necessary skills for establishing meaningful social connections (Prattama & Pradhanaparamita, 2022).
Within his theoretical framework, Skinner proposed that verbal behavior, like other behavioral domains, is acquired through fundamental principles of behavior modification. He argued that such verbal behavior can be methodically shaped and strengthened through structured intervention, wherein appropriate reinforcement contingencies serve to increase the probability of desired verbal responses.
Skinner conceptualized verbal behavior as a broad behavioral category encompassing all forms of communication, including - but not limited to - spoken language, sign systems, pictorial representations, written expression, and alternative verbal response modalities. He introduced this comprehensive framework alongside his foundational theory of verbal operants in his seminal 1957 work Verbal Behavior, which established a systematic approach for analyzing language as learned behavior.
The Pyramid Approach to Education is a comprehensive instructional framework that specifies the essential components for establishing effective learning environments. This three-dimensional model consists of two primary structural elements: (1) a foundational base addressing core pedagogical considerations ("what to teach" and "why students learn"), and (2) supporting pillars implementing instructional delivery. The base incorporates four critical elements: functional skills development, reinforcement systems, functional relationships, and challenging behavior prevention/management. The model's pillars comprise: (a) generalization - involving systematic, incremental modifications to produce measurable behavioral gains, and (b) effective lesson design - requiring deliberate planning of instructional variables for optimal skill acquisition (Maj, 2018).
The Picture Exchange Communication System (PECS) is one of the most widely used augmentative and alternative communication (AAC) interventions for individuals with autism spectrum disorder. As an evidence-based AAC approach, PECS is specifically designed to enhance communication skills and facilitate participation across multiple domains, including academic settings, social relationships, and community interactions. This structured protocol follows a six-phase training sequence grounded in behavioral and developmental principles to teach functional communication skills. The intervention progresses systematically from teaching basic requesting behaviors (Phases I–V) using preferred items and activities. As learners master each phase, the program introduces increasingly sophisticated communication demands, such as: (1) initiating interactions with partners across varying distances, and (2) constructing simple sentence structures (Jassim Omar & Shiromaru, 2022).
The Picture Exchange Communication System (PECS) is an augmentative and alternative communication (AAC) system that utilizes visual symbols to facilitate functional communication of wants and needs (Kasanen, 2020). Designed to promote rapid, independent, and functional communication skills in children with autism spectrum disorder (ASD), PECS begins with basic symbol exchange and systematically progresses to more complex sentence construction (Al-Dawaidah & Al-Amirah, 2013). While comprehensive meta-analyses have not yet conclusively established PECS efficacy across all ASD populations, multiple empirical studies demonstrate consistent positive outcomes in communication and social skill development. Key findings include:

Pratama & Paramita (2023): Significant improvements in communication skills
Kruger (2022): Enhanced social skills and functional independence
Santos et al. (2021): Progress in social and functional skills among nonverbal children
Mehravar et al. (2020): Particularly strong effects from Phases I–III of the six-phase protocol
Mark (2019): Benefits for both communication and social skills in nonverbal individuals
Mirnovati (2018): Effective communication skill acquisition

This converging evidence from multiple research teams, using varied methodologies across different populations, substantiates PECS as an effective intervention for enhancing communication and social skills in children with ASD.

Methodology

This study was conducted with an applied purpose, adopting a qualitative approach and employing a systematic review as the research method. Data collection involved systematically reviewing articles available on Google Scholar, PubMed, and ScienceDirect using the following keywords: image exchange communication system, autism spectrum disorder, social skills, and communication skills. The inclusion criteria stipulated that article titles must contain at least one of the two key phrases: autism spectrum disorder and/or image exchange communication system. Additionally, the full text of the articles had to include references to image exchange communication system, autism spectrum disorder, social skills, and communication skills.
An initial screening compiled a list of article titles and abstracts published between 2012 and 2024. Out of the 77 initially selected articles, 26 were excluded due to irrelevance to the research question or duplication across databases, leaving 51 articles for final analysis. The study's inclusion criteria were as follows:

Exclusion of purely qualitative research,
Requirement for full keywords (image exchange communication system, communication, and social skills) in the article title,
Inclusion of qualitative studies, single-case studies, and case reports

For analysis, key details including author names, publication year, and study results were examined.

Results

Research on the Picture Exchange Communication System (PECS) and autism spectrum disorder (ASD) demonstrates that this image-based intervention can significantly benefit children with ASD by increasing vocabulary, reducing maladaptive behaviors, and enhancing observational learning and skill generalization. PECS effectively promotes communication initiation—including requesting and expressing needs—while expanding expressive language through improved speech production. Educationally, it strengthens attention span, reduces distractions, and increases task completion, while also improving compliance with rules in both school and home settings. The system further encourages help-seeking behavior, reduces restricted or repetitive behaviors, and enhances language comprehension (including words, sentences, and contextual meaning). Additional observed benefits include decreased self-injury and tantrums, better instruction-following, and reduced screaming episodes. Collectively, these findings underscore PECS as a comprehensive intervention for addressing core ASD challenges.
The reviewed studies collectively highlight the importance of the Picture Exchange Communication System (PECS) for children with autism spectrum disorder (ASD). All examined research consistently reported PECS's effectiveness in improving communication and social skills in this population. From an initial screening of 77 articles using predetermined inclusion/exclusion criteria, 51 studies were selected for final analysis of PECS's impact on ASD children's communication and social skills. These studies' key details - including authors, publication years, and main findings - are systematically organized in the table below.

Discussion

This study investigated both theoretical foundations and empirical evidence to answer a key research question: How effective is the Picture Exchange Communication System (PECS) in fostering communication and social skill development in children with autism spectrum disorder (ASD)? ASD is a lifelong neurodevelopmental condition marked by core symptoms including restricted/repetitive behaviors and profound challenges in communication and social interaction. These deficits significantly impair quality of life and independent functioning. Maladaptive behaviors like aggression and emotional outbursts often result in social exclusion, further restricting peer interactions and environmental engagement. Among various interventions designed to enhance communication skills in children with ASD, PECS has demonstrated particular effectiveness as a systematic approach.
This review study demonstrates that the Picture Exchange Communication System (PECS) offers multifaceted benefits for children with autism spectrum disorder (ASD), including: (1) enhanced communication skills through vocabulary expansion, improved communication initiation, advanced expressive language (including speech production), and increased ability to request and express needs; (2) improved social functioning manifested through greater attention-seeking, help-seeking behaviors, and adherence to rules in both school and home environments; (3) reduction in maladaptive behaviors including diminished self-injury, tantrums, screaming episodes, and restricted/repetitive behaviors; and (4) cognitive and educational improvements such as enhanced observational learning, skill generalization, sustained attention, task completion, visual processing, and comprehension of verbal and written language. These robust findings collectively highlight PECS's substantial impact on improving core communication and social skills in children with ASD, as consistently evidenced across all examined studies.

Conclusion

The findings confirm that the Picture Exchange Communication System (PECS) serves as an effective intervention for developing social and communication skills in children with autism spectrum disorder (ASD). Implementation can be adapted to specific needs, ranging from individual stages to the complete six-stage protocol. While studies indicate that even partial implementation enhances communication abilities and social functioning, the most significant outcomes emerge from full protocol adherence. These evidence-based results advocate for wider adoption of PECS in special education contexts, specifically through: (1) broader implementation across specialized educational institutions and therapy centers, and (2) comprehensive training initiatives for both professionals and parents to ensure treatment fidelity.
To advance research in this field, future studies should: (1) employ larger sample sizes with more comprehensive datasets to strengthen generalizability, and (2) examine broader applications across diverse demographic and clinical populations. Institutional support through education and welfare systems—particularly via professional development programs for practitioners—could substantially improve both the accessibility and implementation fidelity of PECS. While this systematic review offers meaningful insights, its scope was inherently constrained by existing literature, underscoring the necessity for more extensive empirical investigations in future research.
Acknowledgments
We express our profound gratitude to the professors and subject matter experts whose invaluable guidance and thoughtful recommendations greatly contributed to both the implementation and refinement of this study. Their specialized knowledge and insightful feedback were pivotal in shaping the research methodology and strengthening our findings.

کلیدواژه‌ها [English]

• Keywords: Autism Spectrum Disorder (ASD)
• Picture Exchange Communication System (PECS
• social skills
• communication skills
• Augmentative and Alternative Communication (AAC)
• systematic review