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RESEARCH ARTICLE
Abstract
Augmentative and alternative communication (AAC) provides a means of effective communication to individuals with autism
spectrum disorder (ASD), many of whom are unable to use conventional speech effectively. The purposes of this article are (a) to
summarize and synthesize the last few decades of research on the use of AAC with people with ASD; (b) to indicate implications
of this research for stakeholders such as people with ASD, their family members, and educators with whom they work; and (c) to
outline priorities for future research to improve communication and other outcomes for individuals with ASD and their loved ones.
People with ASD stand to greatly benefit from AAC, particularly with current AAC technologies, as described in this article.
Keywords: Augmentative and alternative communication (AAC); Aided AAC; Assistive technology; Autism spectrum disorder;
Communication
Introduction
*This paper is part of the Special 30th Anniversary of Augmentative and Alternative Communication Series
Correspondence: Jennifer B. Ganz, Department of Educational Psychology, 4225 TAMU, Texas A&M University, College Station, TX 77843, USA. E-mail: jeniganz@
tamu.edu
(Received 1 September 2014; revised 14 March 2015; accepted 19 April 2015)
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treatments. Although other topics could have been covered, due to space constraints, these were selected for
review due to their prominence in the recent literature,
or their importance to families and individuals with
ASD and complex communication needs.
Effective AAC Modes for People with ASD
Research has produced more support for aided AAC
than manual sign language for people with ASD,
although a few studies have been conclusively deemed to
demonstrate the effectiveness of manual sign language
(Schlosser & Wendt, 2008a). Literature has addressed
the use of sign language with people with ASD since the
1970s (Ganz & Gilliland, 2014). At best, this literature
can be described as demonstrating weak or questionable
effects, in some cases resulting in learned use of a small
number of signs with a small number of participants
(Bonvillian & Nelson, 1976; Carr, 1979; Hinerman,
Jenson, Walker, & Petersen 1982; Remington & Clarke,
1983). In many reports, participants with ASD learned
only a limited number of sign vocabulary words, and
teaching of these few signs often required much time
and effort (Carr, Binkoff, Kologinsky, & Eddy, 1978;
Carr, Kologinsky, & Leff-Simon, 1987; Falcomata,
Wacker, Ringdahl, Vinquist, & Dutt, 2013; Hinerman
et al., 1982; Kee, Casey, Cea, Bicard, & Bicard, 2012;
Remington & Clarke, 1983; Valentino & Shillingsburg,
2011). Finally, much of the literature in support of using
manual sign language includes anecdotal reports, case
studies (Bonvillian & Nelson, 1976; Kee et al., 2012;
Konstantareas, Hunter, & Sloman, 1982), and underpowered group designs (Watters et al., 1981).
Given this body of literature, it seems apparent that
unaided AAC is not the most effective and efficient
means of providing functional and spontaneous communication for most people with ASD. This is not to say
that sign language is never effective for individuals with
ASD; however, sign language has not been highly effective for many or most individuals with ASD (Ganz &
Gilliland, 2014). In studies that have evaluated preference, sign language is infrequently selected by children
with ASD (e.g. van der Meer, Sutherland, OReilly,
Lancioni, & Sigafoos, 2012).
Both low-tech and high-tech aided AAC systems
have been demonstrated to be effective with people with
ASD. Both picture-exchange-based AAC and speechgenerating devices (SGDs) have been demonstrated,
via meta-analyses and systematic reviews, to have at
least moderate effects overall on outcomes for people
with ASD (Flippin, Reszka, & Watson, 2010; Ganz,
Earles-Vollrath, et al., 2012; Ostryn, Wolfe, & Rusch,
2008; Preston & Carter 2009). Although recent papers
have investigated the use of current technologies (e.g.,
handheld-device and tablet-based AAC applications
or apps) with people with ASD (Flores et al., 2012;
Ganz, Boles, Goodwyn, & Flores, 2014), this is an
emerging area, and the efficacy of these technologies is
unclear. Furthermore, and perhaps more importantly,
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settings and contexts and with all possible communicative partners (Light, 1997; Ogletree, Davis, Hambrecht,
& Phillips, 2012). Whether or not AAC skills are initially
taught in didactic, highly structured contexts, they must
quickly and repeatedly be addressed in other contexts.
Service providers may use aspects of incidental teaching
(Hart & Risley, 1978), or milieu teaching, to provide
naturalistic instruction in AAC use to people with ASD,
as well as providing instruction that may be mediated
by their natural communicative partners (Trottier et al.,
2011). Incidental AAC interventions require initiating
communication opportunities or temptations, inserting
communication within preferred activities or routines,
using wait time to encourage communicative behaviors
from the person with ASD and complex communication needs, and using cues and prompts to teach use of
an AAC system (Ogletree et al., 2012).
Avoidance of Unproven Treatments in AAC
Although it is a common occurrence in the fields of
medicine, allied health, and special education for practitioners and family members to adopt unsubstantiated
treatments, it is not clear how to best educate and persuade practitioners and families to avoid unproven treatments such as FC. The rise of the Internet, although
providing a means of gathering information, provides
an apparently equal voice to unproven and to evidencebased practices, making it difficult for stakeholders to
judge the accuracy and reliability of information. Service providers are frequently faced with the problem of
how to discuss such issues with family members who
may be swayed by sensational reports in popular and
social media and online.
Practitioners can try to persuade family members
to use efficacious interventions by gently refusing to
participate in implementation of unproven treatments
and by providing family members with resources that
direct them to rely on evidence-based practices. These
include the National Standards Project of the National
Autism Center (www.nationalautismcenter.org), the
National Professional Development Center on Autism
Spectrum Disorders (autismpdc.fpg.unc.edu), and the
U.S. Department of Health and Human Services Interagency Autism Coordinating Committee (iacc.hhs.gov).
A number of authors have discussed this issue at length
in relation to unsubstantiated fad treatments for individuals with ASD, such as facilitated communication
(Simpson et al., 2005). They suggest that practitioners
(a) evaluate the originality of the message produced
by facilitated communication (Konstantareas, 1998;
Shane, 1994), (b) request that prompts and other physical supports and cues be faded quickly (Ganz, 2014),
(c) consider the potential for harm resulting from false
messages (e.g., false accusations of abuse, false attribution of skills or knowledge) (Simpson & Myles, 1995),
and (d) consider the potential for wasted time or money
that may be better spent on evidence-based practices
(Simpson & Myles, 1995).
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Future research is needed to address how to best provide instruction that will generalize across natural contexts. In this research, borrowing from AAC research
into other disability categories, such as intellectual and
developmental disabilities, may assist the development
and evaluation of treatment protocols, particularly for
naturalistic AAC interventions. One means of increasing AAC use would be to promote multimodal AAC
use. Providing multiple means of communication, as
appropriate for particular contexts, may increase communication across the board (Light & Drager, 2007).
This might include use of a mobile AAC app in the
cafeteria and community, and use of an exchange-based
system during lessons, with picture cards specifically
related to educational content, and supplemented by
speech approximations.
Finally, there is a need for development and efficacy
research that incorporates or packages communication
interventions into protocols specifically designed to
meet the unique needs of people with ASD and complex communication needs. A suitable protocol might
include functional communication training, behavioral
techniques, and naturalistic AAC instruction.
Understudied Populations and Matching Characteristics to
Interventions
Studies are needed to address gaps in the research about
people with ASD who have complex communication
needs and to better match individual characteristics to
AAC designs and intervention approaches. In particular,
AAC intervention for adolescents and adults with ASD
has been severely understudied and research is urgently
needed to address this gap (Ganz, Earles-Vollrath, et al.,
2012). Furthermore, future research should investigate
the design of high-tech AAC systems, with a view to
better matching the needs and strengths of people
with ASD (Light & McNaughton, 2013). Specifically,
research and app development should consider ease of
use and the level of cognitive demand, type of display
(e.g., visual scene displays that embed language within
familiar contexts), and visual attention to AAC displays
(Light & McNaughton, 2013, 2014; Wilkinson & Light,
2014). Finally, questions regarding what modes of aided
AAC, what design elements of high-tech AAC, and what
instructional protocols may be most appropriate for
particular individuals with ASD should be investigated,
in order to allow for individualization in AAC interventions based on characteristics and functioning level.
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Conclusion
The recommendations offered here are ambitious,
though possible, with sufficient time and resources.
It is clear that the rapidly increasing prevalence of
ASD (CDC, 2014) is taxing, and will continue to tax,
school systems and adult service systems. In particular,
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for design of visual scene displays. Augmentative and Alternative
Communication, 30, 130146. doi:10.3109/07434618.2014.
904434
Wilkinson, K. M., & McIlvane, W. J. (2013). Perceptual factors
influence visual search for meaningful symbols in individuals with
intellectual disabilities and Down syndrome or autism spectrum
disorders. American Journal on Intellectual and Developmental
Disabilities, 118, 353364. doi:10.1352/1944-7558-118.5.353