In 2009 Golnik et al. (1) conducted a study to explore the perspective of general pediatricians and family physicians on primary care for children with autism in the USA. Results of this research revealed that doctors rated themselves much less competent and less educated in the area of developmental disabilities than in case of other childhood neurodevelopmental conditions. This is a concern taking into account that, according to Dosreis et al. (2), the majority of general pediatric providers have had contact with children with autism. Additionally, studies show that children with autism use health care services more often than typically developing children, presumably due to medical conditions that co-occur with autism as well as behavioral and emotional problems (3). Respondents in Golnik et al.’s study expressed a great desire for autism education, both from the perspective of improving knowledge base and as a likely means of increasing competency in daily practice. Such results are in line with the fact that primary health care providers differ in how much they know about autism, especially about prognosis, course and treatment when compared to professionals working directly with this population (4).Thus, it is of paramount importance to pass information from the clinicians and scientist-practitioners to medical doctors, so that a more comprehensive support for children with complex health care needs is provided.

One area of persistent difficulties for children with autism is communication (5). Not only is the development of language delayed, but approximately 25% of children with autism do not develop functional speech (6). That means that if they are not taught alternative to speech ways of conveying their needs, wants and observations, they are virtually not able to pass various messages to others in a socially acceptable ways. A likely result of this is development of inappropriate behaviors that serve a communicative function (7). Applied behavior analysis (ABA) is a discipline that provided foundation for many effective techniques of teaching numerous skills to children with autism (8). Behavioral strategies have been successfully used to teach language to atypically developing children, both those who can speak and those for whom speaking is very difficult or impossible (9). For the latter group of pupils, one communication strategy that has its roots in ABA is Picture Exchange Communication System (PECS). Because of the popularity of PECS in clinical and school settings and its empirical basis (10), we believe it is important that primary health care providers are aware of this strategy, so they can make recommendations to parents, if needed. In the following paragraphs, we will provide a short “tutorial” on the characteristics and effectiveness of PECS. We also will briefly discuss some of the misconceptions associated with PECS.

Picture Exchange Communication System (PECS) was developed by Dr. Andy Bondy and Lori Frost as a method of teaching induviduals with autism and other developmental dlisabilities how to engage in functional communication. It is usually, although not necessarily, a picture-based system that may serve as an alternative or augmentative communication. PECS is strongly based on basic principles of behavior, especially positive reinforcement and shaping of new responses, and it has its origin in B.F. Skinner’s analysis of verbal behavior (11). The main focus of PECS is to teach spontaneous, functional social-communication skills (12).

According to Skinner (11), verbal behavior is learned behavior mediated through the action of others, which means that the reinforcement is dependent on the what someone else does. For example, if a child is thirsty, he can get a drink on his own (this would not be an instance of verbal behavior since the child’s behavior was reinforced via a straightforward change in the environment) or he/she can get someone else to give him a drink by asking for it (this would be an instance of verbal behavior because reinforcement, i.e., the drink, was facilitated by another person). Frost and Bondy (13) write that “communication involves behavior (defined in form by the community) directed to another person who in turn provides direct or social rewards” (pg. 24). This definition can be treated as analogous to saying that functional communication is the exchange of information between at least two people. The message may be delivered using words, gestures, texts, images or symbols. Therefore, communication can be divided into vocal (words, vocalizations) and non-vocal communication (gestures, facial expressions, pictures, symbols). However, communication is not mere gestures or words. In order to talk about “communication”, certain conditions must be met:

– at least two people participate (“the speaker” and “the listener”),

– one person (“the speaker”) has to address the second person,

– “the listener” responds to the message coming from the “speaker” in ways that have been conditioned precisely so that the behavior of the speaker is reinforced.

In other words, functional communication is a kind of an “exchange” of information between the speaker and the listener. The listener reacts appropriately to the activity of the speaker by providing reinforcement (e.g. giving attention or a desired item). As already mentioned, the communication does not have to be done by means of words. For example, pictures/gestures/ /written words can be used. In PECS, as the name suggests, pictures are used most often. What is most important, though, is that the transmission of information is understood by the people participating in the exchange of information.

PECS is not only the name of a system used by children with autism. It is also a well-designed protocol for teaching communication to pupils who have language delays (13). The PECS teaching protocol is based on B.F. Skinner’s approach to understanding verbal behavior. Verbal behavior – or communication – is subject to basic principles of behavior and can be taught using behavioral techniques – reinforcement, prompting, shaping. A proper implementation of the PECS teaching protocol should ultimately lead to independent communication of the people who previously had difficulty with such an activity. The PECS teaching protocol consists of six phases which should be taught sequentially. Each phase should be mastered before teaching the next one is begun.

Phase I (Physical Exchange) teaches a child how to communicate. The student learns that if he wants something but does not have access to it, he needs to hand a picture to a communicative partner. It is important to remember that communication is about the exchange between two people – “the speaker” gives a picture to “the listener” and the listener, having understood the message, gives the desired item to the child. During this phase one should not ask the student directly about what he wants (e.g., “what do you want”, “do you want it?” etc.). The student himself will show us what he wants at any given time (e.g. by reaching out for something). In the first phase, it is not crucial that there is actually a correct drawing on the piece of paper. As a matter of fact, the drawing is less of an essence than the exchange itself. In this phase, we do not teach discrimination (i.e., choosing) of one of two pictures, either. The students has only one picture available at a time. The first phase is mastered when the student by himself (without any suggestions) picks up a picture of the item, reaches toward the trainer, and releases the picture into the trainer’s hand.

Phase II (Expanding Spontaneity) teaches the “triangle of communication” (i.e., me, my communication book, and my communicative partner). The student still uses individual pictures but at this stage he learns how to generalize the new skill. Generalization is ability to exchange information with a variety of communicative partners (e.g., mom, dad, grandma), in many different settings (e.g., preschool, kitchen, playground) and under diverse conditions (e.g. the listener is standing far away, the listener is turned away from the child). At this stage, we teach persistence in communication! We still do not teach discrimination. Phase II is mastered when the student is able to find his own communication book and the communication partner to whom he must pass the picture.

Phase III (Picture Discrimination) teaches selecting the correct image from many possibilities. The student learns how to make a choice between two or more images to get the item that he really wants to get. Pictures can be found in the communication book (in the form of a binder) and they are attached with a Velcro tape, thus being readily available at the time of communication. First, we teach how to discriminate between highly desired items and the undesired ones, later the desired versus neutral and at the end we proceed to the two desired objects. During the exchange, one should remember about naming the items as we give them to the student after the communication takes place. Furthermore, in this phase we begin to teach the meaning of the words “wait” and “no”. We can move to the next phase only if the student chooses the item that corresponds to his desires at the time. In addition, the student should look into the book to find the picture.

Phase IV (Sentence Structure) teaches the student to “utter” longer requests. The student learns to construct simple sentences by means of a sentence strip, using the picture “I want,” and then an image of the object that he asks for. The student gives his sentence strip to the communication partner who reads the sentence “I want...”, waits maximum 5 seconds for a verbal reaction and then adds the name of the item, such as, for instance, “a car”. In this way, the child is encouraged to speak. One should augment the successful vocal attempts. We can move to the next phase only when the students learns how to make his own sentence strip. When the skill is mastered, the student often moves to phase V and learns how to make elaborate sentences by adding adjectives, verbs and prepositions.