Augmentative and Alternative Communication (AAC) A Research Review Claire Hess Caldwell College

Overview Search Description Search Description Relevant Issues in AAC Research Relevant Issues in AAC Research Research Summary Research Summary Discussion of Studies Discussion of Studies Comparison with Criteria for Evidence- Based Practice (EBP) Comparison with Criteria for Evidence- Based Practice (EBP) Future Research Future Research References References

Search Description PsychINFO PsychINFO –Search for literature reviews  “AAC,” “review,” “autis*”(12) –Search for peer-reviewed, empirical studies  “AAC”(684)  “AAC,” “autis*”(47)  “AAC,” “VOCA” (12)  “AAC,” “VOCA,” “autis*”(12)  “AAC,” “sign”(32)  “AAC,” “sign,” “autis*”(8)  “AAC,” “picture”(40)  “AAC,” “picture,” “autis*”(7)  “AAC,” “PECS” (3)  “AAC,” “autis*,” “aided”(7)  “AAC,” “autis*,” “unaided”(4) –Search for peer-reviewed, empirical comparison studies  “AAC,” “autis*,” “compar*”(5) Search PsycINFO and Google Scholar for specific studies Search PsycINFO and Google Scholar for specific studies

Relevant Issues in AAC Research One third to one half of all persons with autism are functionally non-vocal (National Research Council, 2001) One third to one half of all persons with autism are functionally non-vocal (National Research Council, 2001) Role of motor and vocal imitation as a predictive measure (Yoder & Layton, 1988) Role of motor and vocal imitation as a predictive measure (Yoder & Layton, 1988) Functions served by AAC Functions served by AAC Relation of AAC to the development of speech Relation of AAC to the development of speech Role of unfamiliar listeners in supporting AAC users Role of unfamiliar listeners in supporting AAC users Maladaptive behavior Maladaptive behavior Comparisons of various modes of AAC (picture exchange, sign, voice output communication aids – VOCAs) Comparisons of various modes of AAC (picture exchange, sign, voice output communication aids – VOCAs) Pros and Cons of each form of AAC Pros and Cons of each form of AAC Mirenda (2003); Millar, Light, & Schlosser (2006); Wilkinson, & Hennig (2007)

Research Summary: Picture Exchange Facilitating communication with picture exchange can decrease disruptive behavior (Frea, Arnold, & Vittimberga, 2001) Facilitating communication with picture exchange can decrease disruptive behavior (Frea, Arnold, & Vittimberga, 2001) Picture communication symbols (PCS), as a form of AAC, can increase rates of social interaction ( Garrison-Harrell, Kamps, & Kravits, 1997) Picture communication symbols (PCS), as a form of AAC, can increase rates of social interaction ( Garrison-Harrell, Kamps, & Kravits, 1997) PECS training, as compared to sign training, can result in fewer instructional trials to criterion, improved generalization, more spontaneous communication, and more vocalizations (Adkins & Axelrod, 2001) PECS training, as compared to sign training, can result in fewer instructional trials to criterion, improved generalization, more spontaneous communication, and more vocalizations (Adkins & Axelrod, 2001) PCS, as compared to sign, can facilitate improved communication with unfamiliar listeners (Rotholz, Berkowitz, & Burberry, 1989) PCS, as compared to sign, can facilitate improved communication with unfamiliar listeners (Rotholz, Berkowitz, & Burberry, 1989) PECS can facilitate vocal speech production (Charlop- Christy, Carpenter, Le, LeBlanc, & Kellet, 2002) PECS can facilitate vocal speech production (Charlop- Christy, Carpenter, Le, LeBlanc, & Kellet, 2002)

Research Summary: Sign Manual sign or total communication training can result in faster and more complete acquisition of receptive and/or expressive vocabulary and more spontaneous communication (Barrera, Lobatos-Barrera & Sulzer-Azaroff, 1980; Barrera & Sulzer- Azaroff, 1983; Layton, 1988) Manual sign or total communication training can result in faster and more complete acquisition of receptive and/or expressive vocabulary and more spontaneous communication (Barrera, Lobatos-Barrera & Sulzer-Azaroff, 1980; Barrera & Sulzer- Azaroff, 1983; Layton, 1988) Sign training can decrease aggressive behavior by decreasing the response effort of communication (Richman, Wacker, & Winborn, 2001) Sign training can decrease aggressive behavior by decreasing the response effort of communication (Richman, Wacker, & Winborn, 2001) Sign training can facilitate vocal speech production (Conaghan, Singh, Moe, Landrum, & Ellis, 1992; Layton & Watson, 1995; Goldstein, 2002) Sign training can facilitate vocal speech production (Conaghan, Singh, Moe, Landrum, & Ellis, 1992; Layton & Watson, 1995; Goldstein, 2002) Sign training can increase vocalizations and word combinations in already vocal learners (Linton & Singh, 1984; Barrett & Sisson, 1987) Sign training can increase vocalizations and word combinations in already vocal learners (Linton & Singh, 1984; Barrett & Sisson, 1987) Sign training can facilitate cross-operant responding (Braam & Sundberg, 1991) Sign training can facilitate cross-operant responding (Braam & Sundberg, 1991)

Research Summary: VOCAs The use of VOCAs can increase spontaneous social interactions (Schepis, Reid, Behrmann, & Sutton, 1998) The use of VOCAs can increase spontaneous social interactions (Schepis, Reid, Behrmann, & Sutton, 1998) High-quality VOCAs, as compared to PCS, can improve communication with unfamiliar listeners (Doss, Locke, Johnston, Reichle, Sigafoos, Carpenter, et al., 1991) High-quality VOCAs, as compared to PCS, can improve communication with unfamiliar listeners (Doss, Locke, Johnston, Reichle, Sigafoos, Carpenter, et al., 1991)

Research Summary: Combination AAC A combination of AAC training can increase requesting and decrease aggressive behaviors (Sigafoos & Drasgow, 2001) A combination of AAC training can increase requesting and decrease aggressive behaviors (Sigafoos & Drasgow, 2001)

Research Summary Mirenda (2003)

Response Efficacy During Functional Communication Training: Effects of Effort on Response Allocation (Richman, Wacker, & Winborn, 2001) Participants Participants –Non-vocal 3-year-old boy –Diagnosed with pervasive developmental disorder –Severe disruptive and aggressive behaviors Setting Setting –Inpatient unit for assessment and treatment of aggression Procedure Procedure –6-second partial-interval recording during functional analysis –Count within partial-interval recording for independent mands and aggressions –Phase 1 (3 conditions): use of communication card vs. aggression –Phase 2 (3 conditions): use of communication card vs. sign IOA data were collected during 26% of sessions; 89% (84 – 100%) IOA data were collected during 26% of sessions; 89% (84 – 100%) Neither treatment integrity, nor generalization, nor maintenance data were collected Neither treatment integrity, nor generalization, nor maintenance data were collected

Results (Richman, et al., 2001)

Topography- Versus Selection-Based Responding Comparison of Mand Acquisitions in Each Modality (Adkins & Axelrod, 2001) Participants Participants –7-year-old boy –Infrequent, nonfunctional vocalizations –Diagnosed with pervasive developmental disorder and ADHD –3-5 sign words and PECS words Setting Setting –Self-contained classroom for children with autism and developmental disabilities Procedure Procedure –4 types of experimental sessions: PECS training, sign training, PECS generalization, and sign generalization –Frequency data were collected on all spontaneous vocal responses throughout the school day –Alternating treatments design Neither IOA, nor treatment integrity, nor generalization, nor maintenance data were collected Neither IOA, nor treatment integrity, nor generalization, nor maintenance data were collected

Results (Adkins & Axelrod, 2001)

Results (Adkins & Axelrod, 2001), cont.

Conditional Use of Aided and Unaided AAC: A Review and Clinical Case Demonstration (Sigafoos & Drasgow, 2001) Participants Participants –14-year-old boy –Diagnosed with moderate to severe intellectual disability and communication deficit with characteristically autistic behaviors –Severe disruptive and aggressive behaviors –Very rarely emitted single words Setting Setting –University-affiliated clinic for individuals with developmental disabilities Procedure Procedure –ABCD design –Baseline, acquisition training, conditional use IOA data were collected during 100% of sessions; 91% (85 – 100%) IOA data were collected during 100% of sessions; 91% (85 – 100%) Neither treatment integrity, nor generalization, nor maintenance data were collected Neither treatment integrity, nor generalization, nor maintenance data were collected

Results (Sigafoos & Drasgow, 2001)

Comparison with Criteria for EBP EBP (Gina Green’s “Gold Standard”) EBP (Gina Green’s “Gold Standard”) –At least three studies, conducted by three different experimenters, that demonstrate experimental control when comparing baseline to intervention phases –Each phase of baseline, intervention, and replication comprised of at least six data points demonstrating stability –Continuous measurement of the dependent variable (DV) –Inter-observer agreement (IOA) and treatment integrity both assessed for at least 25% of sessions

Comparison with Criteria for EBP (cont.) Overall efficacy of AAC for individuals with autism and other developmental disabilities (YES) Overall efficacy of AAC for individuals with autism and other developmental disabilities (YES) Facilitation of vocal speech production (NO) Facilitation of vocal speech production (NO) Overall superiority of one mode of AAC (NO) Overall superiority of one mode of AAC (NO) Associated increases in spontaneous communication with AAC (NO) Associated increases in spontaneous communication with AAC (NO) Reductions in disruptive or aggressive behaviors with AAC (NO) Reductions in disruptive or aggressive behaviors with AAC (NO) Identification of predictive participant variables (NO) Identification of predictive participant variables (NO)

Future Research Role of prerequisite motor and vocal imitation skills Role of prerequisite motor and vocal imitation skills Common diagnoses and participant characteristics Common diagnoses and participant characteristics Replicated goals of intervention Replicated goals of intervention Methodological Precision Methodological Precision Treatment integrity, maintenance, and generalization measures Treatment integrity, maintenance, and generalization measures Comparison studies Comparison studies

References Adkins, T., & Axelrod, S. (2001). Topography-based versus selection-based responding: Comparison of mand acquisition in each modality. The Behavior Analyst Today, 2, Adkins, T., & Axelrod, S. (2001). Topography-based versus selection-based responding: Comparison of mand acquisition in each modality. The Behavior Analyst Today, 2, Barrera, R., & Sulzer-Azaroff, B. (1983). An alternating treatment comparison of oral and total communication training programs with echolalic autistic children. Journal of Applied Behavior Analysis, 16, Barrera, R., & Sulzer-Azaroff, B. (1983). An alternating treatment comparison of oral and total communication training programs with echolalic autistic children. Journal of Applied Behavior Analysis, 16, Barrera, R., Lobatos-Barrera, D., & Sulzer-Azaroff, B. (1980). A simultaneous treatment comparison of three expressive language training programs with a mute autistic child. Journal of Autism and Developmental Disorders, 10, Barrera, R., Lobatos-Barrera, D., & Sulzer-Azaroff, B. (1980). A simultaneous treatment comparison of three expressive language training programs with a mute autistic child. Journal of Autism and Developmental Disorders, 10, Barret, R. P., & Sisson, L. A. (1987). Use of the alternating treatments design as a strategy for empirically determining language training approaches with mentally retarded children. Research in Developmental Disabilities, 8, Barret, R. P., & Sisson, L. A. (1987). Use of the alternating treatments design as a strategy for empirically determining language training approaches with mentally retarded children. Research in Developmental Disabilities, 8, Braam, S. J., & Sundberg, M. L. (1991). The effects of specific versus nonspecific reinforcement on verbal behavior. Analysis of Verbal Behavior, 9, Braam, S. J., & Sundberg, M. L. (1991). The effects of specific versus nonspecific reinforcement on verbal behavior. Analysis of Verbal Behavior, 9, Charlop-Christy, M., Carpenter, M., Le, L, LeBlanc, L., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS) with children with autism: Assessment of PES acquisition, speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35, Charlop-Christy, M., Carpenter, M., Le, L, LeBlanc, L., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS) with children with autism: Assessment of PES acquisition, speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35, Conaghan, B. P., Singh, N. N., Moe, T. L., Landrum, T., & Ellis, C. R. (1992). Acquisition and generalization of manual signs by hearing-impaired adults with mental retardation. Journal of Behavioral Education, 2, Conaghan, B. P., Singh, N. N., Moe, T. L., Landrum, T., & Ellis, C. R. (1992). Acquisition and generalization of manual signs by hearing-impaired adults with mental retardation. Journal of Behavioral Education, 2, Doss, S., Locke, P., Johnston, S., Reichle, J., Sigafoos, J., Carpenter, P., et al. (1991). Initial comparison of the efficiency of a variety of AAC systems for ordering meals in fast food restaurants. Augmentative and Alternative Communication, 7, Doss, S., Locke, P., Johnston, S., Reichle, J., Sigafoos, J., Carpenter, P., et al. (1991). Initial comparison of the efficiency of a variety of AAC systems for ordering meals in fast food restaurants. Augmentative and Alternative Communication, 7, Frea, W., Arnold, C., & Vittimberga, G. (2001). A demonstration of the effects of augmentative communication on the extreme aggressive behavior of a child with autism within an integrated preschool setting. Journal of Positive Behavior Interventions, 4, Frea, W., Arnold, C., & Vittimberga, G. (2001). A demonstration of the effects of augmentative communication on the extreme aggressive behavior of a child with autism within an integrated preschool setting. Journal of Positive Behavior Interventions, 4, Goldstein, H. (2002). Communication intervention for children with autism: A review of treatment efficacy. Journal of Autism and Developmental Disorders, 32, Goldstein, H. (2002). Communication intervention for children with autism: A review of treatment efficacy. Journal of Autism and Developmental Disorders, 32, Layton, T. (1988). Language training with autistic children using four different modes of presentation. Journal of Communication Disorders, 21, Layton, T. (1988). Language training with autistic children using four different modes of presentation. Journal of Communication Disorders, 21,

References (cont.) Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. Journal of Speech, Language, and Hearing Research, 49, Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. Journal of Speech, Language, and Hearing Research, 49, Mirenda, P. (2003). Toward a functional augmentative and alternative communication for students with autism: Manual signs, graphic symbols, and voice output communication aids. Language, Speech, and Hearing Services in Schools, 34(3), Mirenda, P. (2003). Toward a functional augmentative and alternative communication for students with autism: Manual signs, graphic symbols, and voice output communication aids. Language, Speech, and Hearing Services in Schools, 34(3), National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press. National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press. Richman, D., Wacker, D., & Winborn, L. (2001). Response efficiency during functional communication training: Effects of effort on response allocation. Journal of Applied Behavior Analysis, 34, Richman, D., Wacker, D., & Winborn, L. (2001). Response efficiency during functional communication training: Effects of effort on response allocation. Journal of Applied Behavior Analysis, 34, Rotholz, D., Berkowitz, S., & Burberry, J. (1989). Functionality of two modes of communication in the community by students with developmental disabilities: A comparison of signing and communication books. Journal of the Association for Persons with Severe Handicaps, 14, Rotholz, D., Berkowitz, S., & Burberry, J. (1989). Functionality of two modes of communication in the community by students with developmental disabilities: A comparison of signing and communication books. Journal of the Association for Persons with Severe Handicaps, 14, Schepis, M., Reid, D., Behrmann, M., & Sutton, K. (1998). Increasing communicative interactions of young children with autism using a voice output communication aid and naturalistic teaching. Journal of Applied Behavior Analysis, 31, Schepis, M., Reid, D., Behrmann, M., & Sutton, K. (1998). Increasing communicative interactions of young children with autism using a voice output communication aid and naturalistic teaching. Journal of Applied Behavior Analysis, 31, Schlosser, R. W., & Blischak, D. M. (2001). Is there a role for speech output in interventions for persons with autism. Focus on Autism and Other Developmental Disabilities, 16(3), Schlosser, R. W., & Blischak, D. M. (2001). Is there a role for speech output in interventions for persons with autism. Focus on Autism and Other Developmental Disabilities, 16(3), Sigafoos, J., & Drasgow, E. (2001). Conditional use of aided and unaided AAC: A review and clinical case demonstration. Focus on Autism and Other Developmental Disabilities, 16, Sigafoos, J., & Drasgow, E. (2001). Conditional use of aided and unaided AAC: A review and clinical case demonstration. Focus on Autism and Other Developmental Disabilities, 16, Sigafoos, J., & Drasgow, E.(2001). Conditional use of aided and unaided AAC: A review and clinical case demonstration. Focus on Autism and Other Developmental Disorders, 16(3), Sigafoos, J., & Drasgow, E.(2001). Conditional use of aided and unaided AAC: A review and clinical case demonstration. Focus on Autism and Other Developmental Disorders, 16(3), Sigafoos, J., O’Reilly, M., Seely-York, S., & Edrisinha, C. (2004). Teaching students with developmental disabilities to locate their AAC device. Research in Developmental Disabiliites, 25(4), Sigafoos, J., O’Reilly, M., Seely-York, S., & Edrisinha, C. (2004). Teaching students with developmental disabilities to locate their AAC device. Research in Developmental Disabiliites, 25(4), Wilkinson, K. M., & Hennig, S. (2007). The state of research and practice in augmentative and alternative communication for children with developmental/intellectual disabilities. Mental Retardation and Developmental Disabilities, 13, Wilkinson, K. M., & Hennig, S. (2007). The state of research and practice in augmentative and alternative communication for children with developmental/intellectual disabilities. Mental Retardation and Developmental Disabilities, 13,

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