The Use of Augmentative and Alternative Communication Methods with Infants and Toddlers with Disabilities: A Research Review

Parental expectations and perceptions of augmentative and alternative communication: A Sri Lankan perspective

From a critical disability rights lens, everyone has a right to communicate using any means available, which includes augmentative and alternative communication. The uptake of augmentative and alternative communication beyond the therapy room may be influenced by awareness, perceptions and acceptance of augmentative and alternative communication by caregivers, family members and the wider society. This study aimed to uncover parental perceptions of augmentative and alternative communication in a Global South context. Ten mothers and six fathers (16 participants) of children with complex communication needs were invited to be part of the study. A focus-group discussion and semi-structured interviews were undertaken using an interview guide. The participant data were analysed using Framework Analysis and through the lens of gender and critical disability theory. The key theme expressed was fear of augmentative and alternative communication deterring speech development. In addition, there was also concern that siblings might adopt the alternative communication method and stop talking. The participants questioned whether the visibility of a communication device could highlight their child's disability, thereby fearing societal stigma and negativity. Overall, parents' attitudes towards perspectives of and openness to use augmentative and alternative communication impact its uptake. The results suggest the need to consider the preparedness of parents prior to introducing augmentative and alternative communication and the need to offer on-going parental training.Lay abstractEverybody has a right to communicate in any way they can, which includes augmentative and alternative communication. The uptake of augmentative and alternative communication in everyday life may be influenced by awareness, perceptions and acceptance of augmentative and alternative communication by caregivers, family members and the wider society. This study aimed to uncover what parents thought about augmentative and alternative communication in a Global South context. Eleven mothers and five fathers (16 participants) of children with complex communication needs were included. Data were collected using an interview guide from a focus-group discussion and semi-structured interviews. The data were analysed using Framework Analysis and from a gender and critical disability theory viewpoint. The key theme found was fear of augmentative and alternative communication stopping the child from learning to speak. The parents wondered if siblings might also use the alternative communication method and stop talking. They worried whether the communication device will negatively highlight their child in society. As parents' views on augmentative and alternative communication influence whether they use it with their child, informing and preparing parents before introducing augmentative and alternative communication to a child and on-going parent training should be considered.

Introducing a self-managed early communication resource for parents - A mixed methods feasibility study of the Swedish "ComAlong online"

BACKGROUND

Web-based programmes offer parents of children with communication difficulties promising access to parent-mediated, early interventions. However, empirical evaluations of such programmes are limited. This study focused on parents and used mixed methods to examine the feasibility of ComAlong online.

METHODS

ComAlong online is a Swedish, self-managed web-resource teaching parents supportive strategies to promote child communication. Data of different types were collected from a total of 71 parents: ten individual parent interviews, 21 pre-questionnaires and 10 post-questionnaires, and finally 50 anonymous digital evaluation surveys. Descriptive statistics and deductive qualitative content analysis were used.

RESULTS

Findings indicate that parents perceived improved child communication and own competence after using the ComAlong online. The most valued parts included podcasts with experts and videos of parent-child interaction. Parents reported that the resource was easy to use, but they wanted to have gained access to the resource when the child was younger. Suggestions for changes included adding a chat function with experts, a parent net forum, and the possibility of creating personalised playlists of videos and podcasts. Evaluation of the research process revealed difficulties in recruiting parents from local child healthcare services and parents of children not yet with a diagnosis.

CONCLUSIONS

This study supports the potential for self-managed, web-based resources to disseminate evidence-based parent training for supporting early communication development. Importantly, parents lack individual guidance from experts and contact with other parents. Also, measures need to be made to disseminate the resources within local child healthcare services.

Process evaluation of a complex intervention in augmentative and alternative communication care in Germany: a mixed methods study

BACKGROUND

In Germany, clear care pathways for people without natural speech who require augmentative and alternative communication (AAC) are currently lacking. Therefore, AAC is often not sustainably implemented in everyday life. For this reason, a complex intervention was developed that supplements existing AAC consultation with additional AAC training, AAC therapy, and case management. This article presents the results of the process evaluation of the complex intervention. It examines (1) how caregivers and AAC consultants rate the intervention (2), which contextual factors influence its implementation, and (3) the acceptance, use competence, and use of the new AAC system.

METHODS

The process evaluation used a mixed methods design. Quantitative data were collected with a longitudinal survey of caregivers of AAC users in the intervention and comparison groups at three time points (T0: after AAC consultation; T1: 4 weeks after AAC system receipt; T2: 4 months after AAC system receipt). Semi-structured focus group interviews were conducted with caregivers of AAC users and with AAC consultants. The quantitative data were analysed descriptively and with nonparametric mean value comparisons. The qualitative results were analysed using structured qualitative content analysis.

RESULTS

The evaluation and presentation of results were based on the Medical Research Council process evaluation guidance by Moore et al. The intervention elements were rated positively. AAC training and therapy enabled the participants to use the AAC system effectively in different contexts. Case management provided support, particularly in the event of problems in the care process. However, the results also show the heterogeneity of the intervention, as it depended on various contextual factors. Overall, acceptance, use competence, and use of the AAC system were rated higher in the intervention group than in the comparison group.

CONCLUSIONS

The process evaluation illustrates various contextual factors that can influence the implementation of the AAC intervention. The results highlight the potential of the intervention to improve AAC care and establish a sustainable use of AAC systems in everyday life. In addition, the process evaluation provides indications of how AAC interventions can be adapted for successful implementation.

TRIAL REGISTRATION

Grant number 01NVF17019.

Measuring communicative style in parents of infants with suspected neurodevelopmental disorders: Reliability test and adaptation of the RAACS instrument

INTRODUCTION

The Responsive Augmentative and Alternative Communication Style Scale, version 3 (RAACS 3) has been used when assessing communicative style in parents of children with communicative disabilities between 12 and 60 months of age and it has demonstrated validity and reliability. The aim of this study was to investigate the reliability of RAACS when applied to video-recorded communication between parents and their infants (aged four to 12 months) with suspected neurodevelopmental disorders, and, if needed, adapt, and retest the instrument.

METHOD

Four speech language pathologists performed a three-phase reliability procedure using twenty-six audio-video recordings of interactions between parents and infants. Inter- and intrarater agreement was calculated. In phase I the original instrument RAACS 3 was used, on twenty recordings. In phase II the instrument was adapted to better suit the target group (parents of infants aged four to 12 months) and was called RAACS 4. In phase III RAACS 4 was pilot tested on six new audio-video recordings. This phase also included two joint ratings and a consensus discussion between the raters preceding the rating procedure.

RESULTS

The testing during phase I showed low reliability rates of RAACS 3 independent of statistical test method. The pilot testing that was done during phase III showed that the adapted version, RAACS 4, had higher reliability rates.

CONCLUSIONS

RAACS 3 was not reliable for assessment of communicative style in parents of infants. RAACS 4 showed promising results when assessing communicative style of parents of infants with neurodevelopmental delays. Further reliability and validity investigation is needed.

The role of the body in SGD-mediated interactions

Most research about augmentative and alternative communication (AAC) has focused on improving use of and access to speech generating devices (SGDs). However, many adults with significant physical and developmental disabilities express a preference for unaided, embodied forms of communication. This study used conversation analysis (CA) techniques to analyze the forms and functions of embodied communication that occurred during interactions between a young man who used unaided, embodied communication and an SGD to communicate with a familiar communication partner. Close analysis revealed that embodied resources were required for both unaided and aided forms of communication. Furthermore, both participants used their bodies to establish interactional spaces with different focal points during interaction, which placed different demands on the aided speaker. Unfortunately, when the SGD was the focal point, problematic demands were placed on the aided speaker, which in turn resulted in increased embodied effort on his part. The forms and functions of the body, differences in the participants' interactions when communication did and did not involve the SGD, and implications for research and practice are all reported and discussed.

"My child is completely underestimated": Canadian parents' perspectives on implementing an accessible language comprehension assessment for non-speaking children with cerebral palsy

PURPOSE

Reliable assessment of language comprehension is difficult for children with significant speech and motor limitations. The Computer-Based instrument for Low motor Language Testing (C-BiLLT) was designed for children with cerebral palsy (CP) and speech and motor limitations. A Canadian English version (C-BiLLT-CAN) has been validated. However, early investigation identified feasibility challenges necessitating further exploration. This study aimed to understand parents' perceived barriers and facilitators to implementing the C-BiLLT-CAN in the Canadian clinical context.

MATERIALS AND METHODS

Seven focus groups were conducted synchronously online with 16 parents from five Canadian provinces/territories. Transcripts were analyzed using semi-deductive thematic analysis, framing results within the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Parents unanimously expressed interest in making the C-BiLLT-CAN clinically available. Facilitators and barriers were discussed under five themes. Key facilitators included the unique design, standardized nature, and potential flexibility of the C-BiLLT-CAN. Barriers involved the inability to accommodate all children, the potential for unintended assessment impacts, and clinics' readiness and willingness to prioritize implementation.

CONCLUSIONS

This study contributes new knowledge surrounding the assessment needs of parents of children with CP and speech and motor limitations. Alongside findings from a parallel clinician study, results will inform adaptations to the C-BiLLT-CAN to facilitate implementation.

Frequency and correlates of augmentative and alternative communication use in an autistic inpatient sample

Although augmentative and alternative communication (AAC) strategies are often used by autistic youth, little is known about the use of AAC in inpatient psychiatric settings. This study evaluated how demographic and clinical factors (e.g., language level, IQ) related to AAC use in a well-characterized sample of 527 autistic youth (78.7% male, mean age 12.94) who participated in the Autism Inpatient Collection. AAC use was common, with 42.5% of caregivers reporting at least one form of AAC. White children were more likely to use AAC than non-white children at the bivariate level. In regression analyses, young children were more likely to use AAC than older children. These results suggest the importance of provider training and improved equitable access to AAC.

Augmentative and alternative communication with children with severe/profound intellectual and multiple disabilities: speech language pathologists' clinical practices and reasoning

PURPOSE

Augmentative and alternative communication (AAC) is recommended to be included in communication interventions directed at children/youth with severe/profound intellectual and multiple disabilities (S/PIMD). Even so, the evidence base for AAC practices with children with S/PIMD is limited. Also, little is known about how frequently AAC is implemented with this target group, which AAC tools and methods are applied, and the related clinical reasoning of speech-language pathologists (SLPs). This study aimed to explore SLPs' beliefs, clinical reasoning and practices in relation to AAC implementation with children/youth with S/PIMD.

MATERIALS AND METHODS

In this sequential, mixed-methods study, 90 SLPs working with children with disabilities within habilitation services in Sweden participated in an online survey. The survey answers were statistically analysed. Subsequently, focus group data were collected from seven SLPs and analysed using thematic analysis.

RESULTS AND CONCLUSIONS

Despite AAC being highly prioritized, SLPs found it challenging and complex to implement with this target group. A wide variety of AAC methods and tools were considered and implemented. Clinical decision-making was a balancing act between competing considerations and was mainly guided by the SLPs' individual, clinical experiences. The resources, engagement and wishes of the social network surrounding the child were considered crucial for clinical decision-making on AAC. Implications for research and practice are discussed.Implications for rehabilitationSpeech-language pathologists (SLPs) seemingly find a wide variety of Augmentative and Alternative Communication (AAC), ranging from unaided methods to assistive technology of various complexity, to be potentially suitable for children/youth with severe/profound intellectual and multiple disabilities (S/PIMD).The motivation and preferences of the social network surrounding the child with S/PIMD seem to influence SLPs' clinical decision-making on AAC to a high degree. Sometimes this may be considered an even more important factor than the abilities of the child.SLPs' clinical decision-making on AAC for children/youth is guided by their individual, clinical experience to a high degree.An increase in family oriented AAC intervention research targeting individuals with S/PIMD could potentially strengthen the association between research and the current, experience-based clinical practice.

Speech-language pathologists' perceptions of augmentative and alternative communication in Thailand

Augmentative and alternative communication (AAC) systems are not well-known and broadly used in Thailand. To begin introducing AAC systems and interventions to children with complex communication needs in Thailand, understanding speech-language pathologists' (SLPs) perceptions toward various AAC systems is an important first step. This study assessed SLPs' perceptions of three AAC modalities: gestural communication, communication boards, and iPad1-based speech-output technologies. A total of 78 SLPs watched three video vignettes of a child using each mode and rated their impressions of intelligibility, ease of learnability and use, effectiveness, and preference. Then they were asked to rate factors on visual analog scales that provided additional insights into their rationales and their preferences for AAC modalities for nonverbal clients and for themselves if they were nonverbal. The results indicated that most of the SLPs rated iPad-based speech-output technologies as being the more intelligible, effective, and preferred mode of communication. Gestural communication was rated as the easiest mode to learn and use for a child with complex communication needs. Despite infrequent use of iPad-based speech-output technologies in Thailand, SLPs' ratings indicated high social acceptance of this modality for promoting communication abilities of children with complex communication needs. Results also revealed some biases and lack of knowledge about AAC systems in Thailand.

"They aren't waiting for an SLP, they think 'what can I as a parent do now?'" course leaders' perceptions of AAC interventions targeting parents

Parental interventions can help parents use strategies to support their child's language and communication development. The ComAlong courses are parental interventions that focus on responsive communication, enhanced milieu teaching, and augmentative and alternative communication. This interview study aimed to investigate the course leaders' perceptions of the three ComAlong courses, ComAlong Habilitation, ComAlong Developmental Language Disorder, and ComAlong Toddler, and to evaluate their experiences of the implementation of the courses. Qualitative content analysis was used to analyze the interview data. Thereafter, three categories resulted from the findings: Impact on the Family, A Great Course Concept, and Accessibility of the Courses. The results indicate that participants perceived that the courses had positive effects on both parents and themself. Furthermore, it was described that parents gained knowledge about communication and strategies in how to develop their child's communication; however, the courses were not accessible to all parents. The collaboration between the parents and course leaders improved, and course leaders viewed the courses as an important part of their work. The following factors had an impact on the implementation: several course leaders in the same workplace, support from colleagues and management, and recruitment of parents to the courses.

The use of augmentative and alternative communication by children with developmental disability in the classroom: a case study

PURPOSE

Augmentative and alternative communication (AAC) systems are often introduced to children with disabilities who demonstrate complex communication needs. As attending school is an essential part of these children's lives, it is important that they use their AAC system to communicate in the classroom. This study aimed to describe the nature of the use of AAC by students with developmental disabilities in the classroom.

MATERIALS AND METHOD

This study was conducted in Malaysia. Six students were observed twice each in their classroom and their classroom interactions were video recorded. The video recordings were transcribed and coded for the presence of a communication event, the student's mode of communication and communication function, the communication partner involved, and access to the AAC system.

RESULTS

Contrary to past studies, most students in this study spontaneously initiated interaction almost as many times as they responded. They primarily communicated with gestures and verbalizations/vocalizations despite having been introduced to an AAC system. When students communicated using their AAC system, they mainly interacted with the teachers, and for the function of either behavioral regulation or joint attention. It was found that for 39% of communicative events, the student's aided AAC system was not within arm's reach.

CONCLUSION

The findings highlight the need for efforts to encourage students with complex communication needs to use AAC more frequently in their classroom to be able to communicate more effectively and for a wider range of communicative functions. Speech-language pathologists can work closely with teachers to provide the necessary support to these students.

CDK13-related disorder: a deep characterization of speech and language abilities and addition of 33 novel cases

Speech and language impairments are central features of CDK13-related disorder. While pathogenic CDK13 variants have been associated with childhood apraxia of speech (CAS), a systematic characterisation of communication has not been conducted. Here we examined speech, language, non-verbal communication skills, social behaviour and health and development in 41 individuals with CDK13-related disorder from 10 countries (male = 22, median-age 7 years 1 month, range 1-25 years; 33 novel). Most participants used augmentative and alternative communication (AAC) in early childhood (24/41). CAS was common (14/22). Performance varied widely across intellectual ability, social behaviour and expressive language skills, with participants ranging from within average through to the severely impaired range. Receptive language was significantly stronger than expressive language ability. Social motivation was a relative strength. In terms of a broader health phenotype, a quarter had one or more of: renal, urogenital, musculoskeletal, and cardiac malformations, vision impairment, ear infections and/or sleep disturbance. All had gross and fine motor impairments (41/41). Other conditions included mild-moderate intellectual disability (16/22) and autism (7/41). No genotype-phenotype correlations were found. Recognition of CAS, a rare speech disorder, is required to ensure appropriately targeted therapy. The high prevalence of speech and language impairment underscores the importance of tailored speech therapy, particularly early access to AAC supports.

Parents' perception on the use of augmentative and alternative communication by children with complex communication needs in Malaysia

PURPOSE

Children with developmental disabilities who have complex communication needs (CCN) frequently need to use augmentative and alternative communication (AAC) to communicate effectively and efficiently. Speech-language pathologists (SLPs) often work closely with parents and other professionals when deciding on the best AAC system to introduce to these children. This study aimed to describe the use of AAC by children with CCN in Malaysia as reported by their parents.

MATERIALS AND METHOD

An online survey distributed for this study was completed by 235 parents.

RESULTS

Most of the parents of children with CCN who participated in this study reported that their children used low-tech AAC systems. A majority of respondents were satisfied with their child's AAC system. Parental satisfaction was positively associated with the frequency of use and whether the use of AAC helped parents understand the child better. Challenges reported by parents when using AAC and the reason some families abandoned the use of AAC were similar. Examples of challenges include parents having limited time and the child lacking the motivation to use the AAC system.

CONCLUSION

The findings of this study suggest the importance of SLPs actively involving parents in the selection of their children's AAC system so they are agreeable with the system introduced and continuously supporting children and their families to encourage and sustain the use of AAC. Implications for rehabilitationSpeech-language pathologists (SLPs) can create communication opportunities for the child to use augmentative and alternative communication (AAC) and experience success, teach parents how to incorporate AAC into the family's daily routine and activities, and reduce the demands on parents by preparing the AAC materials and programming the AAC system where possible.SLPs can provide ongoing support to school teachers to equip them with the necessary knowledge and skills to support the use of AAC in the classroom.

A Systematic Review of Augmentative and Alternative Communication Interventions for Children Aged From 0 to 6 Years

PURPOSE

This systematic review evaluates the latest available evidence regarding augmentative and alternative communication (AAC) interventions in children from 0 to 6 years old diagnosed with various disabilities.

METHOD

A systematic search was conducted in MEDLINE (OVID), PsycINFO (EBSCO), ERIC (ProQuest), SCIELO (WOS), Teacher Reference Center (EBSCO), and Education Database (ProQuest), and studies on AAC interventions in children from 0 to 6 years old diagnosed with various disabilities were selected independently by two reviewers (A.L.-R. and N.I.M.) according to the purpose of the review.

RESULTS

Twenty-nine of 1,709 studies met the inclusion criteria for this review. The methodological quality of the included studies was assessed, and the characteristics and results of the studies were extracted by a descriptive analysis (O.L.S. and M.O.-V.).

CONCLUSION

This analysis revealed that children with different diagnoses show improvements in expressive and receptive communication, functional communication behaviors, communication participation skills, interaction strategies, and symbol and multisymbol production and comprehension by using various AAC systems.

Speech-language pathologists’ practices in augmentative and alternative communication during early intervention

This survey study examined augmentative and alternative communication (AAC) practices reported by early intervention speech-language pathologists (SLPs) across the United States (N = 376). The study examined (a) types of AAC that SLPs reported using (i.e., sign language, photographs, pictures, symbols, talking switches, and iPad apps or dedicated speech-generating devices); (b) SLPs' perspectives on the influence of child spoken language ability on AAC recommendations; (c) factors that influenced AAC decision-making within early intervention; and (d) perceived barriers associated with AAC implementation. SLPs reported that they were significantly more likely to introduce all types of AAC to children without spoken language abilities compared to children in later stages of language development. On average, they were most likely to report using or recommending sign language and photographs, and least likely to report using or recommending talking switches or speech-generating devices. Of the options provided, child expressive and receptive language abilities were rated as the most important factors to consider when determining AAC use, followed by cognitive ability, diagnosis, and chronological age. SLPs identified caregiver buy-in and carryover across providers as the most significant barriers to AAC implementation. Recommendations for future research and current AAC practices within early intervention are discussed.

Efficacy of a novel augmentative and alternative communication system in promoting requesting skills in young children with Autism Spectrum Disorder in India: A pilot study

Background & aims: The study assessed the efficacy of a novel, child-friendly, socio-culturally sensitive, icon-based Augmentative and Alternative Communication (AAC) system called Jellow Communicator, in teaching requesting skills to young children with Autism Spectrum Disorder (ASD) in a special school in Mumbai, India. Jellow is a comprehensive AAC system with a lexicon and pictorial library designed using a participatory, user-centric design process. The content of Jellow has been developed bearing in mind the socio-cultural and linguistic diversity of India. Jellow is available in low-tech (flashcards, booklet) and high-tech (Android and iOS app and desktop application) versions. Methods: The quasi-experimental longitudinal study involved seventeen 3.5-12-year-old children with ASD with communication challenges. Children were taught to use the Jellow AAC system to request for preferred items, as part of their regular speech therapy sessions. Each child received one-on-one training sessions with a licensed speech therapist twice a week over a 3-month duration, with each session lasting around 20-30 min. A systematic training protocol adapted from the original Picture Exchange Communication System (PECS) was developed to train children to use the Jellow system, progressing from flashcards to the app version of Jellow. Behavioral training strategies such as modeling, least-to-most prompting, differential reinforcement, and behavior chain interruption were used to facilitate requesting behaviors. The speech therapist assessed children's developmental level across multiple domains at pretest and posttest. We coded 3 videos per child, i.e., one early, one mid, and one late training session each, to assess changes in children's stage of communication, spontaneous requesting abilities, level of attention during training trials, and average time to completion for requesting trials. In addition, caregivers filled out questionnaires to assess training-related changes in children's adaptive functioning levels as well as the psychosocial impact of the Jellow AAC system on children's quality of life. Results: Children significantly improved their stage of communication, and a majority of children transitioned from flashcards to using the Jellow app to request for preferred items. Children also increased the proportion of spontaneous requests over the course of training. Caregivers reported a positive perceived psychosocial impact of the Jellow AAC system on their child's self-esteem, adaptability, and competence. Conclusions: The findings from our pilot study support the use of the novel, socio-culturally adapted, Jellow Communicator AAC system for teaching requesting skills to young children with ASD who use multiple communication modalities. Future studies should replicate our findings with a larger group of participants using a randomized controlled trial design. Implications: This is the first experimental study to systematically assess the effects of an indigenously-developed comprehensive AAC system adapted to the sociocultural and linguistic landscape of India. Our study results provide support for the use of the cost-effective Jellow Communicator AAC system in facilitating requesting skills in children with ASD who use multiple communication modalities. Clinicians can use low-tech and high-tech versions of Jellow to promote communication skills in children with ASD.

Cognitive Assessment in GNAO1 Neurodevelopmental Disorder Using an Eye Tracking System

GNAO1 gene mutations are associated with a neurodevelopmental disorder characterized by developmental delay, epilepsy, and movement disorder. Eye tracking and eye movement analysis are an intriguing method to assess cognitive and language function and, to the best of our knowledge, it has never been tested in a standardized way in GNAO1. GNAO1 children are usually wheelchair-bound and with numerous motor constrains, including dystonic movements and postures, heterotropia, and hypotonia, making the cognitive assessment arduous. These contribute to the burden and disability, with a high level of frustration of caregivers and patients. We have herein demonstrated that, through an eye tracking system, six GNAO1 patients evaluated showed variable degrees of communicative intent through intentionally directed gaze. Moreover, three of these were able to complete a cognitive evaluation, and showed normal fluid intelligence and lexical comprehension. In conclusion, in GNAO1-related disorders, the degree of cognitive development is underestimated; eye tracking technologies may help in overcome these boundaries.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews

IMPORTANCE

Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years.

OBJECTIVE

To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

EVIDENCE REVIEW

The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument.

FINDINGS

Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5).

CONCLUSIONS AND RELEVANCE

When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Spoken Vocabulary Outcomes of Toddlers With Developmental Delay After Parent-Implemented Augmented Language Intervention

Purpose Early intervention using augmentative and alternative communication (AAC) supports both receptive and expressive language skills. However, many parents and clinicians still worry that augmented language intervention might delay or impair speech development. This study aimed to (a) characterize and analyze the speech sound development of toddlers with developmental delay who participated in a parent-implemented language intervention; (b) examine the accuracy of speech sounds among toddlers who participated in an augmented language intervention using speech-generating devices and toddlers who participated in a traditional, spoken language intervention; and (c) examine the relationship between baseline factors (i.e., receptive and expressive language skills, vocal imitation, and number of unintelligible utterances) and the number of spoken target vocabulary words after intervention. Method This study used extant data from two randomized control trials of parent-implemented language interventions using AAC or spoken language. Out of 109 children who completed the intervention, 45 children produced spoken target vocabulary words at the end of the intervention. We identified and phonetically transcribed spoken target vocabulary words for each child and then classified them based on Shriberg and Kwiatkowski's (1982) developmental sound classes. Results Children's speech sound accuracy was not significantly different across intervention groups. Overall, children who produced more words had more speech sound errors and higher baseline language scores. Intervention group and baseline receptive and expressive language skills significantly predicted the number of spoken target vocabulary words produced at the end of intervention. Conclusions Participation in AAC intervention resulted in significantly more spoken target vocabulary words and no statistically significant differences in speech sound errors when compared to children who received spoken language intervention without AAC. Results support using AAC interventions for very young children without the fear that it will delay speech or spoken language development. Supplemental Material https://doi.org/10.23641/asha.14265365.

A Systematic Review of Research on Augmentative and Alternative Communication Interventions for Children Aged 6-10 in the Last Decade

Purpose The purpose of this systematic review was to identify, appraise, and critically synthesize the latest available evidence on the effects of augmentative and alternative communication (AAC)-based interventions on communication skills in children aged between 6 and 10 years with mixed diagnoses. Method MEDLINE (OVID), PsycINFO (EBSCO), ERIC (ProQuest), SCIELO (WOS), Teacher Reference Center (EBSCO), and Education Database (ProQuest) were searched. The studies were independently selected by two reviewers for the purposes of the review. The methodological quality of the included studies was assessed, and characteristics and results of the studies were extracted. Results This review included 14 studies from a total of 1,204 found through an electronic search. The AAC interventions studied were effective at improving various outcomes in children with mixed diagnoses. Interventions that focused on narrative skills were the most common type. When considering the quality of the studies, the independence of assessors, data analysis, replication, and generalization of interventions were the weaker areas. Conclusions Interventions analyzed in this review improve communication skills, including phonological awareness, vocabulary, requesting, and developing narrative skills in children aged between 6 and 10 years with mixed diagnoses. The results of one study also indicate that the acquisition of skills using an AAC method is superior when the child prefers the method. Supplemental Material https://doi.org/10.23641/asha.14462256.

Augmentative and Alternative Communication for Children with Intellectual and Developmental Disability: A Mega-Review of the Literature

Establishing evidence- and research-based practices relies upon research synthesis of individual studies in reviews and meta analyses. Further summarizing scientific evidence about a specific topic by synthesizing reviews is an area of need to determine practices that have a strong evidence base and to identify areas of methodological weakness and gaps in the literature. A mega-review of literature reviews, systematic reviews, and meta-analyses on interventions using aided augmentative and alternative communication (AAC) interventions for children with intellectual and developmental disabilities from 2000 to mid-2020 was conducted. Participant and interventionist demographics, interventions, settings, outcomes, and recommendations of each review were reported and summarized. A MeaSurement Tool to Assess systematic Reviews Revised (AMSTAR 2; Shea et al., 2017) was used to examine the methodological rigor of 84 included reviews. Over the past 20 years, published reviews have increased slightly in methodological rigor but demonstrate a number of methodological weaknesses that detract from the strength of evidence for AAC interventions with this population. Suggestions for improving the methodological rigor of literature reviews and areas for future research specific to AAC interventions are discussed.

Using AAC to unlock communicative potential in late-talking toddlers

PURPOSE

The purpose of this study was to report on modifications we made to a standardized input-based word learning treatment for two late-talking toddlers. The modifications were the addition of an augmentative alternative communication (AAC) device and the requirement that the children use this device, or speech, to communicate.

METHOD

We used a single-subject design to track late-talking toddlers' progress through an input-based word learning treatment, which was part of a larger study. Because the input-based treatment protocol was not effective for each toddler based on absent or clinically insignificant treatment effect sizes, we modified the protocol. The modifications were meant to address each child's potential over-reliance on nonverbal communication and the potential impact of speech sound delay. We then measured their linguistic output.

RESULTS

Both toddlers showed no evidence of learning during the input-based treatment. Each child's linguistic output increased by over 600 % once we made the protocol modification and introduced the AAC device. They used both AAC and vocal speech to communicate. Both toddlers produced novel words, and one began to produce multiple word combinations.

DISCUSSION

While input-based therapy has an evidence base and has been successful for some toddlers, it may require modifications for children who have not learned the pragmatic convention of using spoken language, and for children with difficulty with speech sound production.

An AAC Mobile-Based Application for People with Intellectual Disability: A Case Study in Brazil

Augmentative and Alternative Communication (AAC) techniques are employed to mediate communication with people who have communication disorders, as in cases of intellectual disability. Although there are various digital solutions that promote alternative communication options for individuals with communication disorders, only a few of them have been specifically designed or targeted to people with intellectual disability (ID). This work is motivated by the lack of AAC solutions contributing to the rehabilitation processes of individuals with intellectual disability in Brazil. The study presents a mobile-based AAC solution conceived as a tool to assist the rehabilitation process of people with ID. The design was based on user-centered design principles and accessibility standards. The System Usability Scale (SUS) questionnaire was used to evaluate the solution. Four specialists and twenty-five students participated in this study. The proposed solution shows the potential educational value for professionals who assist individuals with intellectual disability in Brazil.

Teaching Preschoolers With Down Syndrome Using Augmentative and Alternative Communication Modeling During Small Group Dialogic Reading

Purpose This study evaluated the effect of aided augmentative and alternative communication modeling (AAC-MOD) on the communication skills of children with Down syndrome (DS) during small group dialogic reading. Method Four children with DS between 3;1 and 5;3 (years;months; M = 4;5) and 5 typically developing peers between 3;5 and 5;9 (M = 4;3) participated. Effects were examined using a multiple probe across behaviors design with 4 children with DS. To simulate typical dialogic reading routines in inclusive classrooms, a strategy called Read, Ask, Answer, Prompt (Binger, Kent-Walsh, Ewing, & Taylor, 2010) was applied during the baseline and intervention sessions. Results A functional relation was demonstrated between (a) AAC-MOD and percentage of correctly identified symbols for 3 participants, (b) AAC-MOD and rate of symbolic communication for 2 participants, and (c) AAC-MOD and number of different words for 2 participants. Increases in number of multiple word combinations occurred for 2 participants. All 4 children maintained their percentage of correctly identified symbols. Increases in rate of symbolic communication did not generalize to thematic play contexts, a distal measure of response generalization. Conclusion AAC-MOD is an effective strategy for teaching target vocabulary and increasing rate of symbolic communication in young children with DS. Supplemental Material https://doi.org/10.23641/asha.10093538.

Examining perceptions of a communication course for parents of children with profound intellectual and multiple disabilities

The overall aim was to examine participants' perceptions of a communication course as held for parents of children with profound intellectual and multiple disabilities. The course curriculum included responsive strategies and augmentative and alternative communication. The research questions addressed the favourability, changes in parents' or children's communication and appreciated or unappreciated course features. Twenty-two written course evaluations were analysed. The mean scores for ratings were compared with ratings in a previous study, including those of parents of children with generally milder disabilities. Comments and answers to open-ended questions were analysed using thematic analysis. Participants were slightly more satisfied with the course as compared with parents who had children with milder disabilities. The thematic analysis suggested increased parental responsiveness after the course. Perceptions of augmentative and alternative communication varied. It was unclear whether the course altered the children's communication or not. The supportive social milieu offered by the course was highly appreciated. Although generalisation beyond this course and setting is to be determined, the results suggest that parents of children with profound intellectual and multiple disabilities can appreciate a communication course and find it useful. An individual approach within the group setting and practical learning opportunities seem important.

Key word signing: Parents' experiences of an unaided form of augmentative and alternative communication (Lámh)

Parents' experiences of using Lámh, a key word signing approach used in Ireland, were captured through in-depth face-to-face interviews with parents of children with a range of intellectual disabilities. It emerged that Lámh provides child users with one of the rudiments of inclusion, that is, a means of engaging with others. A number of factors can potentially influence the engagement achieved, namely ongoing family commitment to the sustainment of Lámh, available communication partners, accessibility, appropriate Lámh training, speech and language therapy support and the existence of a Lámh signing environment external to the home. The child's family, education and community need to commit to Lámh in order to support a child user become an active member of their community.

Complex intervention in augmentative and alternative communication (AAC) care in Germany: a study protocol of an evaluation study with a controlled mixed-methods design

INTRODUCTION

The current practice of service delivery in Germany for people with complex communication needs (CCN) who are in need of augmentative and alternative communication (AAC) is characterised by diverse problems, including a lack of clarity in the responsibilities of the service providers involved. To address these issues a new service delivery model has been put in place, implemented in three AAC counselling centres for patients with a particular health insurance across Germany. The implementation of a new service delivery model aims to improve individualised service delivery. The model goes beyond standard care by adding case management, counselling, AAC training and, if needed, AAC therapy. This study aims to evaluate the effectiveness of this complex intervention.

METHODS AND ANALYSIS

In consideration of the complexity of the new service delivery model, formative and summative evaluation will be conducted. The formative evaluation will provide data based on qualitative and quantitative assessments of the competences and perspectives of all involved stakeholders, including a proxy measurement of persons with CCN. The summative evaluation will include a controlled study design as the new service delivery model will be compared against the service delivery in an existing contract and against data gathered from caregivers of AAC users provided with standard care. With the exception of the individual interviews the data will be collected from proxies-that is, informal and formal caregivers.

ETHICS AND DISSEMINATION

Data collection, storage and evaluation meet the currently valid data protection regulations. Consultation by the responsible data protection officer of the Oldenburg Medical School and a positive vote from its Ethics Committee were obtained prior to the start of the study. Dissemination strategies include the presentation of the obtained data and results in the form of publications and at conferences.

TRIAL REGISTRATION NUMBER

DRKS00013628.

The Effects of Systematic Instruction in Teaching Multistep Social-Communication Skills to Children with Autism Spectrum Disorder Using an iPad

Objective: Tablets have successfully been used with individuals with autism spectrum disorder (ASD) and other developmental disabilities to request preferred items, label objects, share information, and engage in social interactions. However, there are limited data on the efficacy of utilizing such devices to teach multistep social-communication skills. Method: We used nonconcurrent multiple baseline design across behaviors to examine the effectiveness of systematic instruction on teaching multistep social-communication skills using an iPad^® loaded with Proloquo2Go™. Three children between the ages of 7 and 10 years diagnosed with ASD and other developmental disabilities participated in the study. Results: To varying degrees, the participants were successful in using the iPad^® to perform a multistep sequence in requesting, saying "thank you," and answering personal questions. Procedural modifications were made during the intervention phase for two participants so that they were able to acquire social-communication skills using AAC. Conclusions: The findings indicate that systematic instruction is effective in developing advanced social-communication skills.

The study design of ComAlong Toddler: a randomised controlled trial of an early communication intervention

Aims: This study design article aims to describe a research study focused on evaluating the use of the Infant-Toddler Checklist to identify children at 18 months with early communication difficulties, and to study the ComAlong Toddler intervention for parents to support their child's communication development. Background: Communication disorders are a common public health problem affecting up to 20% of children. Evidence points to the importance of early detection and intervention to improve young children's communicative abilities and decrease developmental delay. Early identification of communication difficulties is possible with instruments such as Infant-Toddler Checklist. The ComAlong Toddler intervention is tailored to the needs of parents of young children with communication delay before definitive diagnosis. The parents are provided with guidance in communication enhancing strategies during home visit and five group sessions. Methods: The study uses a prospective cohort design. Children were consecutively recruited during 2015-2017, and data will be collected 2015-2023. The screening was performed at the child health centre through use of the Infant-Toddler Checklist. An assessment and first consultation were then performed by a speech and language therapist for children with suspected communication delay according to the screen as well as for children referred for other reasons before the age of 2.5 years. Children with confirmed communication delay were randomised between two interventions: the ComAlong Toddler parental course or a telephone follow-up. Outcome measures include child communication and language skills and use of augmentative and alternative communication. To gain insight into the participants' perspectives, surveys have been collected from parents. Conclusion: The study will provide information regarding identification and intervention for 18-month old children with communication delay. Trial registration: ISRCTN13330627.

Toward greater involvement of youth with complex communication needs in the selection of augmentative and alternative communication devices

Purpose: The study aim was to examine the measurement properties of the Youth Evaluation of Products Scale for Augmentative and Alternative Communication (YEP-AAC) as a means to understand the product attitudes of youth toward their AAC devices.Methods: In study 1, four males and two females between the ages of 8 and 17 years (median age = 14 years) participated in face-to-face interviews. A researcher administered the YEP-AAC and then asked youths to explain the rationale for their item ratings. Two researchers analyzed masked transcripts of the interviews to predict the valence of item ratings assigned by youths. In study 2, 18 families participated in a mailed survey to examine the reliability and validity of the scale domains. Seventeen mothers/one father and their children (9 male/9 female) between the ages of 10 and 20 years participated (median age = 16 years).Results: The level of chance-corrected agreement between valences converted from youth ratings on the YEP-AAC and those assigned by researchers was fair (weighted kappa = 0.38). Internal consistencies of the scale domains were acceptable. Youths who rated their AAC devices more favourably had higher functional communication as hypothesized.Conclusion: The two studies provide support for the face validity, internal consistency and convergent validity of the YEP-AAC as a measure of the product attitudes of youth with complex communication needs.Implications for rehabilitationDeveloping reliable ways to understand the product needs, preferences and values of youth with complex communication needs will help to support the selection, acquisition and use of augmentative and alternative communication (AAC) devices.Consumer socialization helps to explain how youth may acquire the skills, knowledge and experience relevant to their role as AAC consumers.Reliable youth-report questionnaires that are grounded in consumer socialization provide an expedient way to understand the product attitudes of young consumers with complex communication needs.

Effects of a Least-to-Most Prompting Procedure on Multisymbol Message Production in Children With Autism Spectrum Disorder Who Use Augmentative and Alternative Communication

PURPOSE

In this study, we investigated the efficacy of a least-to-most (LTM) prompting procedure (Ault & Griffen, 2013; MacDuff, Krantz, & McClannahan, 2001; Neitzel & Wolery, 2009) for increasing use of multisymbol messages in school-age children with autism spectrum disorder (ASD) who use augmentative and alternative communication (AAC) during a storybook reading activity.

METHOD

In the study, we used a single-subject, multiple-probe research design across participants (Kazdin, 1982) with 6 children (ages 8-12) with ASD and who used AAC systems for communication. There were 4 phases in this investigation: (a) baseline, (b) intervention, (c) generalization, and (d) maintenance.

RESULTS

All participants exhibited a positive increase in multisymbol message production almost immediately upon introduction of the LTM prompting procedure.

CONCLUSIONS

The results of the investigation contribute important information on the efficacy of the LTM prompting procedure for teaching use of multisymbol messages to school-age children with ASD who use AAC.

Comparing Single Case Design Overlap-Based Effect Size Metrics From Studies Examining Speech Generating Device Interventions

Meaningfully synthesizing single case experimental data from intervention studies comprised of individuals with low incidence conditions and generating effect size estimates remains challenging. Seven effect size metrics were compared for single case design (SCD) data focused on teaching speech generating device use to individuals with intellectual and developmental disabilities (IDD) with moderate to profound levels of impairment. The effect size metrics included percent of data points exceeding the median (PEM), percent of nonoverlapping data (PND), improvement rate difference (IRD), percent of all nonoverlapping data (PAND), Phi, nonoverlap of all pairs (NAP), and Tau(novlap). Results showed that among the seven effect size metrics, PAND, Phi, IRD, and PND were more effective in quantifying intervention effects for the data sample (N = 285 phase or condition contrasts). Results are discussed with respect to issues concerning extracting and calculating effect sizes, visual analysis, and SCD intervention research in IDD.

Communicative participation changes in pre-school children receiving augmentative and alternative communication intervention

PURPOSE

This paper reports changes in communicative participation skills-systematically measured and described-in an empirical observational case series of eight children receiving augmentative and alternative communication (AAC) interventions.

METHOD

The eight children (seven boys, one girl), ranging from 1 year 4 months to 4 years 11 months (mean = 2.8 years; SD = 1.32 years) received varied AAC interventions (i.e. sign language, assistive technology, PECS), averaging 15 hours of treatment over a 12-month period. Parents completed an outcome measure (FOCUS) three times: at the start, mid-point (6 months) and end of the intervention period (after 12 months). They also completed the ASQ-SE at the start and end of intervention.

RESULT

FOCUS scores increased over the treatment interval, indicating improvement in real-world communication skills as observed by their parents. The ASQ-SE items that pertained to communication also improved, while the items that did not correspond to communication did not. This divergence suggests that the communicative participation improvements resulted from treatment rather than general developmental gains. The largest improvements were noted in receptive language/listening, pragmatics and social/play skills. Improvements in intelligibility were also measured for several children.

CONCLUSION

These results suggest that AAC intervention facilitated improvements in communicative participation skills in pre-school children.

What We Write about When We Write About AAC: The Past 30 Years of Research and Future Directions

For the past 30 years, the Augmentative and Alternative Communication (AAC) journal has both documented and instigated change in the field of AAC. We reviewed the papers published in the AAC journal from 1985-2014 in order to identify trends in research and publication activities. Intervention research made up the largest proportion of the four types of research (i.e., intervention, descriptive, experimental, and instrument and measurement development) reported in the journal. Intervention research has most commonly focused on the individual with complex communication needs, and most frequently on younger individuals (aged 17 and younger) with developmental disabilities. While much has been learned in the past 30 years, there continues to be a need for high quality research in a large number of areas. There is a special need for reports of interventions with older individuals with complex communication needs as a result of acquired disabilities, and for information on effective interventions for the communication partners of persons with complex communication needs.