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The Ins and Outs of Early Intervention

PECS With Toddlers?

Published December 18, 2015 2:12 PM by jasna cowan

Alternative and Augmentative Communication is no doubt helpful and can aide children to communicate.

But too often these days I work with young children with autism where behavior therapists immediately recommend A Picture Exchange Communication System (PECS) as the primary means of communication.

I have seen hundreds of young children that may be on the Autism Spectrum Disorder, and I push verbal communication relentlessly with the supplementation of pictures. Although I have worked with some wonderful ABA therapists that make it a point to collaborate and get my opinion on how to encourage language, but too often decisions about language and goals on using a primary AAC/PECS  is used. The parent gets mixed messages.

I say, "Let's push for verbal language and use the pictures as an aide." But the parent heard from other team members that the child should pull a picture off of a board and hand it to the adult when they need something. What about eye gaze, a smile, a grunt. These shared and social communication examples are just as important to teach a child with Autism.

This is such a frustrating topic to me as a speech therapist. I think it's important to collaborate with parents and see what they want for their child. If it is to use words to communicate well then I really work hard at that and use a variety of strategies to encourage that as much as possible.

 Of course I use pictures, I also use music, toys. And books that will motivate the child to speak 

But if we immediately go to a purely AAC approach when a child is a toddler then we are not flexing the child's "speech muscles" to see what they are capable of.

Exhausting all measures, evaluating what works, and practice will truly reveal what the best methods will be to get the child to speak or communicate. I say give speech a chance! Knowing when AAC is necessary and when it should be used to assist your client on the journey to the verbal world is our job.

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I'm the mother of a mildly autistic 3 year old who most likely also has Apraxia or CAS. We've just spent 4 months doing ABA style "speech therapy" that was really more behavior therapy, using PECS, some sign language,  and other ABA prompt/reward style training. The therapist was a bit old school, ignored things like my daughter's use of wiggling her feet to exit her Rifton chair, grabbing her feet and VERY firmly stating "NO!!" and forcing her to use the "open" sign instead of what was quite a valid way to communicate her desire to exit the chair.

She also wanted to force my child to sit in a chair on demand, without any respect for trying to ease her into each session. She constantly reiterated how Autistic kids need boundaries, you have to show them who's boss, etc - and felt that forcing my daughter, who throws no tantrums - to do things even when she didn't want to, making her cry - was all necessary in the name of progress towards "school readiness" - which is not my priority, at all.

My daughter did fine with PECS, can use her sentence strips and all of that - and in fact has met the majority of her 6 month goals at just 4 months (only 1 of which dealt with vocalizing or verbal output of any kind.) Yet on the vocalizing goal, she made no progress at all. Not a stitch.  

The autistic behaviors did progress - she is using her pointer finger, far more engaged in joint attention and turn taking each day, and uses a sign to communicate almost every time she wants something (either "more" or "please") - but it's only since I began pressing her for some verbal output when we left the ABA therapist, and I began a Floortime based routine here at home, that I have seen a big uptick in vocalizations, babbling, and attempts to mimic phonemes. For example, I've been trying to get her to make any kind of approximation of a "P P P" sound when doing the "please" sign, and have been having some success.

Clearly she needs to be pushed verbally - and we have just started with an Apraxia specialist, who intends to use the PROMPT system. While I can't say if that will bear fruit yet, I can tell you that 4 more months of PECS would not have put a dent in her verbal progress. Children with Apraxia do NOT have a "lack of motivation" to communicate that can be fixed by training them like Pavlov's dogs. And Apraxia in Autistic kids is hideously underdiagnosed - just Google it and you'll see that recent studies have shown that up to 65% of Autistic kids may have Apraxia as a comorbid condition. So all of this ABA - which still has a miserable failure rate IMHO when you consider that an estimated 25% to 30% of Autistics remain "minimally verbal" despite the widespread availability of early intervention  -  may in fact be part of the problem, despite its stellar reputation as the most "evidenced based" way to get your Autistic child talking.  

And it's a tragedy that most parents take the word of their "experts" when what they really need to do is an exhaustive review of the literature themselves, coupled with a frank analysis of their child, as well as their own goals. ABA has a definite slant towards school readiness that may in fact come at the expense of developing more authentic, motivated communication that comes from truly being more connected to your world, and the people in it. When I mentioned to our ABA therapist that I was worried that my child would end up talking, but still lack any real connection to other people, or a real feeling for the words she had learned. Her response? "But that's Autism".

We can do better than that.

It has to begin with examining our own attitudes and priorities, as well as the need for SLP's to stay abreast of groundbreaking new studies, such as Apraxia among autistics one mentioned above.

Stacey February 18, 2016 6:33 PM

Having worked with kids with autism for more than 4 decades I have to disagree strongly with you.  As a SLP I know that by the time a child is a toddler they have already lost valuable time learning language and communication.  They are already being their peers and closer to being frustrated.  I don't actually like PECS - I prefer more robust AAC systems - but I do implement them ASAP to give the child access to genuine communication in all environments.

Susan, SLP January 14, 2016 6:08 PM
San Diego CA

As someone completing a PhD on the multimodal communication strategies of children with autism I have to fundamentally disagree with you here.  I think positioning AAC and speech in an adversarial position to each other is very misleading because good AAC SUPPORTS speech and all research evidence points to this.  If a child can learn to talk, good AAC scaffolds and sometimes accelerates the process; and definitely does not impede it.  Good AAC involves clear speech modelling ALONGSIDE the AAC modality (handing over card, operating device, performing signing, etc.). This is hugely supportive of speech.  (And as a note for any worried parents, my own daughter's verbal output rocketed when she started using a speech generating device!)

Lauran Doak January 13, 2016 2:45 PM

I'm not an SLP but I had the exact same opinion when my child's school and SLP suggested the use of PECS. "I want her to learn to speak." Biggest mistake of my life, of my child's life. 8 years later, after realizing my mistake, and fighting for AAC, she finally is improving her speech. And more importantly, she is communicating, which is ultimately what the end goal is and should be.

She doesn't have a large verbal vocabulary but she practices the words, listens to and studies the sounds of the words from her AAC output. She does this because SHE wants to speak. I'm just happy that she had a means to communicate that desire to me.

Michelle January 13, 2016 2:22 PM

I would love for all BCBAs to be so on board with PECS.  Most push verbal output without consideration of apraxia/frustration/other issues that impact speech.  Augmentative Communication ENCOURAGES verbal output.  Research is pointing to that.  I'm not saying not to encourage speech but I very much disagree with your thoughts.  

Emily January 11, 2016 8:28 AM

Hi Laura,

It's hard to say not knowing the child. Some things that have worked for me are using signs (always paired with verbal language), focusing on simple vowel-like speech sounds like imitating animal or car sounds, and make sure that the child can see your face and over exaggerating speech sounds. Sometimes it can take sometime to encourage verbal sound imitation but hang in there. Maybe look into PROMPT too. Stay in touch!

Jasna Cowan, , SLP Speech Goals Speech Therapy December 27, 2015 10:27 AM
South San Francisco CA

I have been working with an Early Intervention agency for almost three years now. I have been working with one 2 year old (for 6 months) who has been having a tremendous amount of difficulty repeating beyond sounds in isolation. He has an older sister who has apraxia. What do you recommend? How do I test for this appropriately in case he has apraxia too? I do not have enough experience with this. Like your article, I have not used PECS, but I have taught him "more" in sign language to get him to communicate beyond a tantrum. I have so much more to write about his case, but do not want to bombard this post. I am just reaching out for advice for this toddler who isn't communicating beyond screaming, grunting, pointing, or saying mama or dada.

Laura I December 25, 2015 7:48 PM

Have you been to PECS training?

Sara December 22, 2015 2:50 PM

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