An alternating treatment design was used to systematically evaluate the communication response forms, picture exchange communication system (PECS) or sign language, selection for a child with pervasive developmental disorder-not otherwise specified, profound hearing loss, and cochlear implants. The child had a limited pool of high preference items and very few functional skills. Key factors for this child included a structured environment that created a verbal community and contingent access to high preference items. No preference in communication response form was observed. The child successfully used four response forms to communicate: gestures, PECS, sign language, and vocalization. The results are discussed in terms of decision making factors in the selection of response forms.