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

Augmentative and Augmentative and Alternative Alternative

Communication (AAC)Communication (AAC)

A Research ReviewA Research Review

Claire HessClaire HessCaldwell CollegeCaldwell College

OverviewOverview

Search DescriptionSearch Description Relevant Issues in AAC ResearchRelevant Issues in AAC Research Research SummaryResearch Summary Discussion of StudiesDiscussion of Studies Comparison with Criteria for Comparison with Criteria for

Evidence-Based Practice (EBP)Evidence-Based Practice (EBP) Future ResearchFuture Research ReferencesReferences

Search DescriptionSearch Description PsychINFOPsychINFO

– Search for literature reviewsSearch for literature reviews ““AAC,” “review,” “autis*”AAC,” “review,” “autis*” (12)(12)

– Search for peer-reviewed, empirical studiesSearch for peer-reviewed, empirical studies ““AAC”AAC” (684)(684) ““AAC,” “autis*”AAC,” “autis*” (47)(47) ““AAC,” “VOCA” AAC,” “VOCA” (12)(12) ““AAC,” “VOCA,” “autis*”AAC,” “VOCA,” “autis*” (12)(12) ““AAC,” “sign”AAC,” “sign” (32)(32) ““AAC,” “sign,” “autis*”AAC,” “sign,” “autis*” (8)(8) ““AAC,” “picture”AAC,” “picture” (40)(40) ““AAC,” “picture,” “autis*”AAC,” “picture,” “autis*” (7)(7) ““AAC,” “PECS” AAC,” “PECS” (3)(3) ““AAC,” “autis*,” “aided”AAC,” “autis*,” “aided” (7)(7) ““AAC,” “autis*,” “unaided”AAC,” “autis*,” “unaided” (4)(4)

– Search for peer-reviewed, empirical comparison studiesSearch for peer-reviewed, empirical comparison studies ““AAC,” “autis*,” “compar*”AAC,” “autis*,” “compar*” (5)(5)

Search PsycINFO and Google Scholar for specific studiesSearch PsycINFO and Google Scholar for specific studies

Relevant Issues in AAC Relevant Issues in AAC ResearchResearch

One third to one half of all persons with autism One third to one half of all persons with autism are functionally non-vocal (National Research are functionally non-vocal (National Research Council, 2001)Council, 2001)

Role of motor and vocal imitation as a predictive Role of motor and vocal imitation as a predictive measure (Yoder & Layton, 1988)measure (Yoder & Layton, 1988)

Functions served by AACFunctions served by AAC Relation of AAC to the development of speechRelation of AAC to the development of speech Role of unfamiliar listeners in supporting AAC Role of unfamiliar listeners in supporting AAC

usersusers Maladaptive behaviorMaladaptive behavior Comparisons of various modes of AAC (picture Comparisons of various modes of AAC (picture

exchange, sign, voice output communication aids exchange, sign, voice output communication aids – VOCAs)– VOCAs)

Pros and Cons of each form of AACPros and Cons of each form of AAC

Mirenda (2003); Millar, Light, & Schlosser (2006); Wilkinson, & Hennig (2007)Mirenda (2003); Millar, Light, & Schlosser (2006); Wilkinson, & Hennig (2007)

Research Summary: Picture Research Summary: Picture ExchangeExchange

Facilitating communication with picture Facilitating communication with picture exchange can decrease disruptive behavior exchange can decrease disruptive behavior (Frea, Arnold, & Vittimberga, 2001) (Frea, Arnold, & Vittimberga, 2001)

Picture communication symbols (PCS), as a form Picture communication symbols (PCS), as a form of AAC, can increase rates of social interaction of AAC, can increase rates of social interaction ((Garrison-HarrellGarrison-Harrell, Kamps, & Kravits, 1997), Kamps, & Kravits, 1997)

PECS training, as compared to sign training, can PECS training, as compared to sign training, can result in fewer instructional trials to criterion, result in fewer instructional trials to criterion, improved generalization, more spontaneous improved generalization, more spontaneous communication, and more vocalizations (Adkins communication, and more vocalizations (Adkins & Axelrod, 2001)& Axelrod, 2001)

PCS, as compared to sign, can facilitate PCS, as compared to sign, can facilitate improved communication with unfamiliar improved communication with unfamiliar listeners (Rotholz, Berkowitz, & Burberry, 1989) listeners (Rotholz, Berkowitz, & Burberry, 1989)

PECS can facilitate vocal speech production PECS can facilitate vocal speech production (Charlop-Christy, Carpenter, Le, LeBlanc, & (Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002)Kellet, 2002)

Research Summary: SignResearch Summary: Sign

Manual sign or total communication training can Manual sign or total communication training can result in faster and more complete acquisition of result in faster and more complete acquisition of receptive and/or expressive vocabulary and more receptive and/or expressive vocabulary and more spontaneous communication (Barrera, Lobatos-spontaneous communication (Barrera, Lobatos-Barrera & Sulzer-Azaroff, 1980; Barrera & Sulzer-Barrera & Sulzer-Azaroff, 1980; Barrera & Sulzer-Azaroff, 1983; Layton, 1988)Azaroff, 1983; Layton, 1988)

Sign training can decrease aggressive behavior by Sign training can decrease aggressive behavior by decreasing the response effort of communication decreasing the response effort of communication (Richman, Wacker, & Winborn, 2001)(Richman, Wacker, & Winborn, 2001)

Sign training can facilitate vocal speech production Sign training can facilitate vocal speech production (Conaghan, Singh, Moe, Landrum, & Ellis, 1992; (Conaghan, Singh, Moe, Landrum, & Ellis, 1992; Layton & Watson, 1995; Goldstein, 2002)Layton & Watson, 1995; Goldstein, 2002)

Sign training can increase vocalizations and word Sign training can increase vocalizations and word combinations in already vocal learners (Linton & combinations in already vocal learners (Linton & Singh, 1984; Barrett & Sisson, 1987)Singh, 1984; Barrett & Sisson, 1987)

Sign training can facilitate cross-operant Sign training can facilitate cross-operant responding (Braam & Sundberg, 1991)responding (Braam & Sundberg, 1991)

Research Summary: VOCAsResearch Summary: VOCAs

The use of VOCAs can increase The use of VOCAs can increase spontaneous social interactions spontaneous social interactions (Schepis, Reid, Behrmann, & Sutton, (Schepis, Reid, Behrmann, & Sutton, 1998)1998)

High-quality VOCAs, as compared to High-quality VOCAs, as compared to PCS, can improve communication with PCS, can improve communication with unfamiliar listeners (Doss, Locke, unfamiliar listeners (Doss, Locke, Johnston, Reichle, Sigafoos, Johnston, Reichle, Sigafoos, Carpenter, et al., 1991)Carpenter, et al., 1991)

Research Summary: Research Summary: Combination AACCombination AAC

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

Research Summary Research Summary Mirenda (2003)Mirenda (2003)

Response Efficacy During Functional Communication Response Efficacy During Functional Communication Training: Effects of Effort on Response Allocation Training: Effects of Effort on Response Allocation

(Richman, Wacker, & Winborn, 2001)(Richman, Wacker, & Winborn, 2001)

ParticipantsParticipants– Non-vocal 3-year-old boyNon-vocal 3-year-old boy– Diagnosed with pervasive developmental disorderDiagnosed with pervasive developmental disorder– Severe disruptive and aggressive behaviorsSevere disruptive and aggressive behaviors

SettingSetting– Inpatient unit for assessment and treatment of Inpatient unit for assessment and treatment of

aggressionaggression ProcedureProcedure

– 6-second partial-interval recording during functional 6-second partial-interval recording during functional analysisanalysis

– Count within partial-interval recording for independent Count within partial-interval recording for independent mands and aggressionsmands and aggressions

– Phase 1 (3 conditions): use of communication card vs. Phase 1 (3 conditions): use of communication card vs. aggressionaggression

– Phase 2 (3 conditions): use of communication card vs. Phase 2 (3 conditions): use of communication card vs. signsign

IOA data were collected during 26% of sessions; IOA data were collected during 26% of sessions; 89% (84 – 100%)89% (84 – 100%)

Neither treatment integrity, nor generalization, Neither treatment integrity, nor generalization, nor maintenance data were collectednor maintenance data were collected

Results (Richman, et al., 2001)Results (Richman, et al., 2001)

Topography- Versus Selection-Based Responding Topography- Versus Selection-Based Responding Comparison of Mand Acquisitions in Each Modality Comparison of Mand Acquisitions in Each Modality

(Adkins & Axelrod, 2001)(Adkins & Axelrod, 2001)

ParticipantsParticipants– 7-year-old boy7-year-old boy– Infrequent, nonfunctional vocalizationsInfrequent, nonfunctional vocalizations– Diagnosed with pervasive developmental disorder Diagnosed with pervasive developmental disorder

and ADHDand ADHD– 3-5 sign words and 10-15 PECS words3-5 sign words and 10-15 PECS words

SettingSetting– Self-contained classroom for children with autism Self-contained classroom for children with autism

and developmental disabilitiesand developmental disabilities ProcedureProcedure

– 4 types of experimental sessions: PECS training, 4 types of experimental sessions: PECS training, sign training, PECS generalization, and sign sign training, PECS generalization, and sign generalizationgeneralization

– Frequency data were collected on all spontaneous Frequency data were collected on all spontaneous vocal responses throughout the school dayvocal responses throughout the school day

– Alternating treatments designAlternating treatments design Neither IOA, nor treatment integrity, nor Neither IOA, nor treatment integrity, nor

generalization, nor maintenance data were generalization, nor maintenance data were collectedcollected

Results (Adkins & Axelrod, 2001)Results (Adkins & Axelrod, 2001)

Results (Adkins & Axelrod, 2001), Results (Adkins & Axelrod, 2001), cont.cont.

Results (Adkins & Axelrod, 2001), Results (Adkins & Axelrod, 2001), cont.cont.

Conditional Use of Aided and Unaided AAC: A Review Conditional Use of Aided and Unaided AAC: A Review and Clinical Case Demonstration (Sigafoos & Drasgow, and Clinical Case Demonstration (Sigafoos & Drasgow,

2001)2001)

ParticipantsParticipants– 14-year-old boy14-year-old boy– Diagnosed with moderate to severe intellectual Diagnosed with moderate to severe intellectual

disability and communication deficit with disability and communication deficit with characteristically autistic behaviorscharacteristically autistic behaviors

– Severe disruptive and aggressive behaviorsSevere disruptive and aggressive behaviors– Very rarely emitted single wordsVery rarely emitted single words

SettingSetting– University-affiliated clinic for individuals with University-affiliated clinic for individuals with

developmental disabilitiesdevelopmental disabilities ProcedureProcedure

– ABCD designABCD design– Baseline, acquisition training, conditional useBaseline, acquisition training, conditional use

IOA data were collected during 100% of IOA data were collected during 100% of sessions; 91% (85 – 100%)sessions; 91% (85 – 100%)

Neither treatment integrity, nor generalization, Neither treatment integrity, nor generalization, nor maintenance data were collectednor maintenance data were collected

Results (Sigafoos & Drasgow, Results (Sigafoos & Drasgow, 2001)2001)

Comparison with Criteria for Comparison with Criteria for EBPEBP

EBP (Gina Green’s “Gold Standard”)EBP (Gina Green’s “Gold Standard”)– At least three studies, conducted by three At least three studies, conducted by three

different experimenters, that demonstrate different experimenters, that demonstrate experimental control when comparing experimental control when comparing baseline to intervention phasesbaseline to intervention phases

– Each phase of baseline, intervention, and Each phase of baseline, intervention, and replication comprised of at least six data replication comprised of at least six data points demonstrating stabilitypoints demonstrating stability

– Continuous measurement of the Continuous measurement of the dependent variable (DV)dependent variable (DV)

– Inter-observer agreement (IOA) and Inter-observer agreement (IOA) and treatment integrity both assessed for at treatment integrity both assessed for at least 25% of sessionsleast 25% of sessions

Comparison with Criteria for Comparison with Criteria for EBP (cont.)EBP (cont.)

Overall efficacy of AAC for individuals Overall efficacy of AAC for individuals with autism and other developmental with autism and other developmental disabilities (YES)disabilities (YES)

Facilitation of vocal speech production Facilitation of vocal speech production (NO)(NO)

Overall superiority of one mode of AAC Overall superiority of one mode of AAC (NO)(NO)

Associated increases in spontaneous Associated increases in spontaneous communication with AAC (NO)communication with AAC (NO)

Reductions in disruptive or aggressive Reductions in disruptive or aggressive behaviors with AAC (NO)behaviors with AAC (NO)

Identification of predictive participant Identification of predictive participant variables (NO)variables (NO)

Future ResearchFuture Research

Role of prerequisite motor and vocal Role of prerequisite motor and vocal imitation skillsimitation skills

Common diagnoses and participant Common diagnoses and participant characteristicscharacteristics

Replicated goals of interventionReplicated goals of intervention Methodological PrecisionMethodological Precision Treatment integrity, maintenance, and Treatment integrity, maintenance, and

generalization measuresgeneralization measures Comparison studiesComparison studies

ReferencesReferences Adkins, T., & Axelrod, S. (2001). Topography-based versus selection-based Adkins, T., & Axelrod, S. (2001). Topography-based versus selection-based

responding: Comparison of mand acquisition in each modality. responding: Comparison of mand acquisition in each modality. The Behavior The Behavior Analyst Today, 2,Analyst Today, 2, 259-266. 259-266.

Barrera, R., & Sulzer-Azaroff, B. (1983). Barrera, R., & Sulzer-Azaroff, B. (1983). An alternating treatment comparison of An alternating treatment comparison of oral and total communication training programs with echolalic autistic children. oral and total communication training programs with echolalic autistic children. Journal of Applied Behavior Analysis, 16,Journal of Applied Behavior Analysis, 16, 379-394. 379-394.

Barrera, R., Lobatos-Barrera, D., & Sulzer-Azaroff, B. (1980). Barrera, R., Lobatos-Barrera, D., & Sulzer-Azaroff, B. (1980). A simultaneous A simultaneous treatment comparison of three expressive language training programs with a mute treatment comparison of three expressive language training programs with a mute autistic child. autistic child. Journal of Autism and Developmental Disorders, 10,Journal of Autism and Developmental Disorders, 10, 21-37. 21-37.

Barret, R. P., & Sisson, L. A. (1987). Use of the alternating treatments design as a Barret, R. P., & Sisson, L. A. (1987). Use of the alternating treatments design as a strategy for empirically determining language training approaches with mentally strategy for empirically determining language training approaches with mentally retarded children. retarded children. Research in Developmental Disabilities, 8,Research in Developmental Disabilities, 8, 401-412. 401-412.

Braam, S. J., & Sundberg, M. L. (1991). The effects of specific versus nonspecific Braam, S. J., & Sundberg, M. L. (1991). The effects of specific versus nonspecific reinforcement on verbal behavior. reinforcement on verbal behavior. Analysis of Verbal Behavior, 9,Analysis of Verbal Behavior, 9, 19-28. 19-28.

Charlop-Christy, M., Carpenter, M., Le, L, LeBlanc, L., & Kellet, K. (2002). Using Charlop-Christy, M., Carpenter, M., Le, L, LeBlanc, L., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS) with children with autism: the Picture Exchange Communication System (PECS) with children with autism: Assessment of PES acquisition, speech, social-communicative behavior, and Assessment of PES acquisition, speech, social-communicative behavior, and problem behavior. problem behavior. Journal of Applied Behavior Analysis, 35,Journal of Applied Behavior Analysis, 35, 213-231. 213-231.

Conaghan, B. P., Singh, N. N., Moe, T. L., Landrum, T., & Ellis, C. R. (1992). 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 Acquisition and generalization of manual signs by hearing-impaired adults with mental retardation. mental retardation. Journal of Behavioral Education, 2,Journal of Behavioral Education, 2, 175-203. 175-203.

Doss, S., Locke, P., Johnston, S., Reichle, J., Sigafoos, J., Carpenter, P., et al. (1991). 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 Initial comparison of the efficiency of a variety of AAC systems for ordering meals in fast food restaurants. in fast food restaurants. Augmentative and Alternative Communication, 7,Augmentative and Alternative Communication, 7, 256-265. 256-265.

Frea, W., Arnold, C., & Vittimberga, G. (2001). A demonstration of the effects of Frea, W., Arnold, C., & Vittimberga, G. (2001). A demonstration of the effects of augmentative communication on the extreme aggressive behavior of a child with augmentative communication on the extreme aggressive behavior of a child with autism within an integrated preschool setting. autism within an integrated preschool setting. Journal of Positive Behavior Journal of Positive Behavior Interventions, 4,Interventions, 4, 194-198. 194-198.

Goldstein, H. (2002). Communication intervention for children with autism: A Goldstein, H. (2002). Communication intervention for children with autism: A review of treatment efficacy. review of treatment efficacy. Journal of Autism and Developmental Disorders, 32,Journal of Autism and Developmental Disorders, 32, 373-396.373-396.

Layton, T. (1988). Language training with autistic children using four different Layton, T. (1988). Language training with autistic children using four different modes of presentation. modes of presentation. Journal of Communication Disorders, 21,Journal of Communication Disorders, 21, 333-350. 333-350.

References (cont.)References (cont.) Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The impact of augmentative and 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 alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. developmental disabilities: A research review. Journal of Speech, Language, and Hearing Journal of Speech, Language, and Hearing Research, 49,Research, 49, 248-264. 248-264.

Mirenda, P. (2003). Toward a functional augmentative and alternative communication for Mirenda, P. (2003). Toward a functional augmentative and alternative communication for students with autism: Manual signs, graphic symbols, and voice output communication students with autism: Manual signs, graphic symbols, and voice output communication aids. aids. Language, Speech, and Hearing Services in Schools, 34(3),Language, Speech, and Hearing Services in Schools, 34(3), 203-216. 203-216.

National Research Council. (2001). National Research Council. (2001). Educating children with autism.Educating children with autism. Washington, DC: Washington, DC: National Academy Press.National Academy Press.

Richman, D., Wacker, D., & Winborn, L. (2001). Response efficiency during functional Richman, D., Wacker, D., & Winborn, L. (2001). Response efficiency during functional communication training: Effects of effort on response allocation. communication training: Effects of effort on response allocation. Journal of Applied Journal of Applied Behavior Analysis, 34,Behavior Analysis, 34, 73-76. 73-76.

Rotholz, D., Berkowitz, S., & Burberry, J. (1989). Functionality of two modes of Rotholz, D., Berkowitz, S., & Burberry, J. (1989). Functionality of two modes of communication in the community by students with developmental disabilities: A communication in the community by students with developmental disabilities: A comparison of signing and communication books. comparison of signing and communication books. Journal of the Association for Persons Journal of the Association for Persons with Severe Handicaps, 14,with Severe Handicaps, 14, 227-233. 227-233.

Schepis, M., Reid, D., Behrmann, M., & Sutton, K. (1998). Increasing communicative Schepis, M., Reid, D., Behrmann, M., & Sutton, K. (1998). Increasing communicative interactions of young children with autism using a voice output communication aid and interactions of young children with autism using a voice output communication aid and naturalistic teaching. naturalistic teaching. Journal of Applied Behavior Analysis, 31,Journal of Applied Behavior Analysis, 31, 561-578. 561-578.

Schlosser, R. W., & Blischak, D. M. (2001). Is there a role for speech output in Schlosser, R. W., & Blischak, D. M. (2001). Is there a role for speech output in interventions for persons with autism. interventions for persons with autism. Focus on Autism and Other Developmental Focus on Autism and Other Developmental Disabilities, 16(3),Disabilities, 16(3), 170-178. 170-178.

Sigafoos, J., & Drasgow, E. (2001). Conditional use of aided and unaided AAC: A review Sigafoos, J., & Drasgow, E. (2001). Conditional use of aided and unaided AAC: A review and clinical case demonstration. and clinical case demonstration. Focus on Autism and Other Developmental Disabilities, Focus on Autism and Other Developmental Disabilities, 16,16, 152-161. 152-161.

Sigafoos, J., & Drasgow, E.(2001). Conditional use of aided and unaided AAC: A review Sigafoos, J., & Drasgow, E.(2001). Conditional use of aided and unaided AAC: A review and clinical case demonstration. and clinical case demonstration. Focus on Autism and Other Developmental Disorders, Focus on Autism and Other Developmental Disorders, 16(3),16(3), 152-161. 152-161.

Sigafoos, J., O’Reilly, M., Seely-York, S., & Edrisinha, C. (2004). Teaching students with Sigafoos, J., O’Reilly, M., Seely-York, S., & Edrisinha, C. (2004). Teaching students with developmental disabilities to locate their AAC device. developmental disabilities to locate their AAC device. Research in Developmental Research in Developmental Disabiliites, 25(4),Disabiliites, 25(4), 371-383. 371-383.

Wilkinson, K. M., & Hennig, S. (2007). The state of research and practice in augmentative Wilkinson, K. M., & Hennig, S. (2007). The state of research and practice in augmentative and alternative communication for children with developmental/intellectual disabilities. and alternative communication for children with developmental/intellectual disabilities. Mental Retardation and Developmental Disabilities, 13,Mental Retardation and Developmental Disabilities, 13, 58-69. 58-69.

QUESTIONS?QUESTIONS?