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Augmentative and Alternative Communication
ISSN: 0743-4618 (Print) 1477-3848 (Online) Journal homepage: http://www.tandfonline.com/loi/iaac20
AAC Interventions for Individuals with Autism
Spectrum Disorders: State of the Science and
Future Research Directions
Jennifer B. Ganz
To cite this article: Jennifer B. Ganz (2015) AAC Interventions for Individuals with Autism
Spectrum Disorders: State of the Science and Future Research Directions, Augmentative and
Alternative Communication, 31:3, 203-214, DOI: 10.3109/07434618.2015.1047532
To link to this article: http://dx.doi.org/10.3109/07434618.2015.1047532
Published online: 21 May 2015.
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203
RESEARCH ARTICLE
AAC Interventions for Individuals with Autism Spectrum Disorders:
State of the Science and Future Research Directions
*
JENNIFER B. GANZ
Department of Educational Psychology, Texas A & M University, College Station, TX, USA
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 bene t 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
According to the United States Centers for Disease
Control and Prevention (CDC, 2014), approximately 1
in 68 children has a diagnosis of autism spectrum disor-
der (ASD). This represents a rapid increase in diagno-
ses. Similarly, increasing prevalence has been observed
recently in Israel (Davidovitch, Hemo, Manning-Courtney,
& Fombonne, 2013), Sweden (Nygren et al., 2012), and
Taiwan (Lai, Tseng, Hou, & Guo, 2012), although not
at rates as high as in the US.
ASD is characterized by social-communication
de cits and restricted and repetitive behaviors (Ameri-
can Psychiatric Association [APA], 2013). Individuals
with ASD have social-communication de cits in the
following three areas, all of which may impact their
communication and speech skills and their responsive-
ness to augmentative and alternative communication
(AAC) interventions. First, they experience dif culties
with emotional reciprocity or understanding and infer-
ring others ’ thoughts and feelings (APA, 2013; Kuo,
Orsmond, Cohn, & Coster, 2013). They may be less
likely than typically developing peers to orient toward
other people, resulting in less frequent and poorer
quality interactions (Kuo et al., 2013). They may
infrequently take turns or share information and inter-
ests (Rowley et al., 2012). Second, people with ASD
have dif culty using and comprehending nonverbal
communication (APA, 2013), including dif culty
using and understanding facial expressions, tone of
voice, eye contact, and body language (Kanner, 1971;
Matson, Dempsey, & LoVullo, 2009; Shriberg et al.,
2001). Finally, individuals with ASD have de cits in
forming and maintaining relationships compared to
same-age peers (APA, 2013). These de cits include
showing minimal interest in others, neglecting to main-
tain contact with others, having fewer friendships and
less intimacy with others, and appearing to prefer being
alone (Kuo et al., 2013; Matson et al., 2009; Rowley
et al., 2012; Solomon et al., 2011). These de cits often
become more apparent as children get older and social
and communication expectations increase in quantity
and complexity (Tantam, 2003).
Although language impairment is no longer included
within the core social-communication criteria for ASD,
it is considered an additional potential descriptor within
the ASD diagnosis (APA, 2013). The diagnosis includes
a rating of severity in the social-communication domain,
wherein Level 3 is considered to be the most severe, or
that the person requires major supports (APA, 2013).
People with ASD with this level of severity would likely
be at high risk for complex communication needs and
would likely bene t from AAC. Furthermore, individuals
Augmentative and Alternative Communication, 2015; 31(3): 203–214
© 2015 International Society for Augmentative and Alternative Communication
ISSN 0743-4618 print/ISSN 1477-3848 online
DOI: 10.3109/07434618.2015.1047532
*
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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204 J. B. Ganz
Augmentative and Alternative Communication
with ASD and complex communication needs are more
likely to have associated intellectual disabilities (Hewitt
et al., 2012; Luyster, Kadlec, Carter, & Tager-Flusberg,
2008) and oral-motor dif culties (Gernsbacher, Sauer,
Geye, Schweigert, & Goldsmith, 2008). This further com-
plicates their responsiveness to AAC interventions. It is
particularly critical to address these needs early because a
lack of effective communication skills negatively impacts
outcomes in all domains, including social-communica-
tion, academic, behavioral, and post-secondary outcomes
(Branson & Demchak, 2009; Hamm & Mirenda, 2006).
Overall, individuals with ASD and complex commu-
nication needs are more likely to require intensive ser-
vices and supports throughout their lives, particularly
if communication is not addressed prior to secondary
school completion (Hewitt et al., 2012). Further, severe
de cits in social interest and understanding set people
with ASD apart from other people with disabilities who
have complex communication needs. Many people
with complex communication needs (e.g., people with
cerebral palsy or Down syndrome) are interested in
communicating with others and have a basic intuition
regarding how communication works, although this
may not be the case for individuals with both ASD
and complex communication needs. AAC intervention
for people with ASD is a critical area of research, par-
ticularly because the prevalence of ASD is rising and
because these individuals are at high risk for complex
communication needs.
There are three key purposes of this article: (a) to
summarize and synthesize the state of the science
related to individuals with ASD and AAC; (b) to pro-
vide insights relating to the implications of this research,
particularly the implications for people with ASD, their
family members, and service providers; and (c) to sug-
gest priorities for future research related to individuals
with ASD and AAC, re ecting on the above-mentioned
state of the science and implications for stakeholders.
Synthesis of Research on AAC and Individuals
with ASD
Over the last few decades, a large body of research,
primarily single-case experimental design, has demon-
strated the ef cacy of AAC for people with ASD. Stud-
ies have been published on a variety of AAC modes,
including manual sign language, exchange-based com-
munication, and speech-generating devices. Practitio-
ners and family members often question which modes
of AAC will produce the best results, or the best means
of functional communication. The sections that follow
will cover the research to date on: (a) effective modes
of AAC, (b) designs for AAC systems that reduce learn-
ing demands and maximize performance, (c) choice
and preference in AAC interventions, (d) the impact of
AAC on particular communication skills and functions,
(e) generalization of AAC skills across communicative
partners and contexts, and (f) unsubstantiated fad AAC
treatments. Although other topics could have been cov-
ered, 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 under-
powered group designs (Watters et al., 1981).
Given this body of literature, it seems apparent that
unaided AAC is not the most effective and ef cient
means of providing functional and spontaneous com-
munication 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 effec-
tive for many or most individuals with ASD (Ganz &
Gilliland, 2014). In studies that have evaluated prefer-
ence, sign language is infrequently selected by children
with ASD (e.g. van der Meer, Sutherland, O ’ Reilly,
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 speech-
generating 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 ef cacy of these technologies is
unclear. Furthermore, and perhaps more importantly,
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State of the Science in AAC and ASD 205
© 2015 International Society for Augmentative and Alternative Communication
only one instructional protocol – the Picture Exchange
Communication System (PECS; Frost & Bondy,
2002) – has been succinctly described and thoroughly
investigated, although most of this work has focused
on early phases of the protocol that target requesting
skills (Ganz et al., 2012).
Meta-analytic techniques have been used for pre-
liminary investigations to determine for whom, among
people with ASD, aided AAC is most effective (Ganz,
2014; Ganz, Mason, et al., 2014). In particular, people
who had ASD without other co-occurring diagnoses had
signi cantly better results with aided AAC interventions
than those with ASD plus intellectual disabilities or sen-
sory impairments (Ganz, Earles-Vollrath, et al., 2011).
However, when disaggregated by disability category and
mode of AAC, individuals with ASD and intellectual/
developmental disabilities had statistically signi cantly
better results with both PECS and SGDs than individu-
als with ASD alone. Furthermore, people with ASD
and intellectual/developmental disabilities performed
statistically signi cantly better with SGDs than with
PECS (Ganz, Mason, et al., 2014). Youngsters also had
signi cantly better results than older people when con-
sidering AAC interventions in aggregate (Ganz, Earles-
Vollrath, et al., 2011). In addition, for both SGDs and
PECS, preschoolers signi cantly outperformed all
other age groups evaluated (Ganz, Mason, et al., 2014).
To a degree, however, these studies should be inter-
preted with caution because PECS includes a distinct
instructional protocol while SGDs are a mode of AAC
and thus these approaches are not equivalent or directly
comparable.
Designs that Reduce Learning Demands and Maximize
Performance
Although availability of mobile technology has become
ubiquitous, the focus must remain on individuals
who use ASD, rather than on the technology (Light &
McNaughton, 2013). Accordingly, research has begun
to investigate high-tech AAC designs that best match
strengths and challenges (e.g., visual, cognitive, and
linguistic processing) in people with ASD and other
disabilities (Light & McNaughton, 2014). This research
may positively impact assessments for and design of AAC
interventions (Light & McNaughton, 2013). Eye track-
ing technology has been successfully used to measure
the receptive language understanding (e.g., matching
spoken words with images) in children with ASD, which
may be useful in selection of AAC vocabulary (Brady,
Anderson, Hahn, Obermeier, & Kapa, 2014). Further,
visual scene displays that incorporate photographs,
often with familiar settings and people, have begun to be
investigated for use in AAC, in contrast to typical grid-
based AAC displays (Blackstone, 2005). These visual
scene displays contain hotspots that embed sounds or
speech into the images, with the purpose of promot-
ing language via natural contexts (Wilkinson & Light,
2014). Previous eye-tracking research indicated that
young children with ASD do not look at people at rates
as high as their peers (Anderson, Colombo, & Shaddy,
2006). However, recent research has suggested that
incorporating human gures into visual scene displays
may increase attention to the images in older children
with ASD (Wilkinson & Light, 2014). This literature
base, albeit preliminary, points to the need to ensure
that the technology is a good t for the individual with
ASD and complex communication needs, lest the tech-
nology be abandoned (Light & McNaughton, 2013).
Caution should be taken in interpreting much of the
display research because, to date, much of the work has
been conducted with high-functioning individuals with
ASD rather than those with complex communication
needs, and because the studies have been conducted in
laboratory settings instead of real-world applications
(Gillespie-Smith & Fletcher-Watson, 2014).
Choice and Preference in AAC Inter ventions
Over the last decade or so, researchers have investigated
the preferences of people with ASD for particular modes
of AAC (Ganz, 2014; van der Meer, Sigafoos, O ’ Reilly, &
Lancioni, 2011). This work has often involved conduct-
ing preference assessments. For example, one might put
two or more modes of AAC, including low-tech AAC,
high-tech AAC, and images representing manual sign
language, in front of an individual and ask him or her to
take or point to the preferred system (Cannella-Malone,
DeBar, & Sigafoos, 2009; van der Meer et al., 2011).
Preferences have been assessed both before and after
the interventionists provided instruction in the use of
the systems (Ganz, Hong, & Goodwyn, 2013; van der
Meer et al., 2012), most often after the individual has
demonstrated at least a basic ability to use the systems
(Cannella-Malone et al., 2009). To date, the partici-
pants in these studies have varied greatly in their dem-
onstrated preferences, and it is unclear which factors
are at play (Ganz, 2014). Variables such as familiarity,
preference for technology, and mastery of particular
modes may be involved. As a group, people with ASD
do not demonstrate a strong preference between types
of aided AAC.
AAC Interventions to Target Communication Skills
and Communicative Functions
Although aided AAC systems have been deemed to be
more effective in improving communication skills than
other skills, they are also at least moderately effective
in addressing challenging behaviors and social interac-
tions skills, according to recent meta-analyses (Ganz,
Davis, Lund, Goodwyn, & Simpson, 2012; Ganz,
Earles-Vollrath, et al., 2012). Challenging behaviors
appear to be more greatly impacted by SGDs than by
picture-exchange-based systems, although more stud-
ies are needed before these results can be interpreted
with con dence (Ganz, Rispoli, Mason, & Hong, 2014).
Unfortunately, most of the research involving AAC and
people with ASD has focused on behavior regulation,
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206 J. B. Ganz
Augmentative and Alternative Communication
or use of communication to request or protest, to
the exclusion of most other communicative functions
(Ganz, Earles-Vollrath, et al., 2012). Speci cally, much
work has been done on requesting skills and very little
research has been conducted on how to best teach other
types of communication skills (e.g., socially-motivated
joint attention). Meta-analytic methods have been used
to investigate the relationship between speech at outset
of the intervention and speech outcomes as measured
throughout the study. Ganz, Mason, et al. (2014) found
that children who had some speech at study onset had
signi cantly more improvement in speech than those
who demonstrated no speech prior to intervention. That
is, although not an explicit target of AAC and although
some stakeholders fear that speech will be impeded by
AAC, in fact, in some children with ASD, AAC has
enhanced speech skills. Schlosser and Wendt (2008b)
also suggest, via a systematic review, that AAC has no
negative and at least moderate positive effects on speech
in some children with ASD.
Context in which AAC is Implemented
Meta-analyses and single-case studies have begun to
investigate the implementation of AAC across varied con-
texts, including types of educational settings, with varied
communicative partners, and across didactic and natu-
ralistic settings. Some of this work has pointed to AAC
implementation in general education as more effective
than in other settings (Ganz, Rispoli, et al., 2014); how-
ever, without additional study, it is unclear what other
confounding variables, such as functioning level, may be
at play. A few studies have indicated that implementa-
tion of AAC in natural contexts may be as effective with
people with ASD as implementation in didactic, highly
structured contexts, which is key to increasing generaliza-
tion of communication skills (Ganz & Hong, 2014; Nunes
& Hanline, 2007; Schepis, Reid, Behrmann, & Sutton,
1998). Further, a small number of studies indicated that
AAC interventions implemented by varied communica-
tive partners of people with ASD; including parents, peers,
or classroom staff; may be as effective as implementation
by researchers or specialists (Durand, 1999; McMillian,
2008; Nunes & Hanline, 2007; Park, Alber-Morgan, &
Cannella-Malone, 2011; Sigafoos et al., 2004; Trottier,
Kamp, & Mirenda, 2011). This is critical to promoting
generalization across communicative partners and con-
texts. Single-case studies investigating best practices in
teaching caregivers and practitioners to implement AAC
are needed (Ganz, Goodwyn, et al., 2013; Hong, Ganz,
Gilliland, & Ninci, 2014). Unfortunately, research involv-
ing implementation across contexts and communicative
partners is limited, so that effectiveness must be extrapo-
lated based on existing research related to other develop-
mental disabilities (Ganz & Hong, 2014).
Lack of Evidence to Support Facilitated Communication
Although, as noted above, several AAC interventions
have empirical support, Facilitated Communication
(FC) has long been debunked (Todd, 2012) and use
of FC has been demonstrated to result in harm; yet FC
continues to be promoted by some service providers.
FC involves having a facilitator provide ongoing physi-
cal support to the arm of the client using a keyboard
or letter board (International Society on Augmentative
and Alternative Communication [ISAAC], 2014). The
person with complex communication needs reportedly
selects the message with the emotional support of the
facilitator.
The research literature has clearly and repeatedly
debunked facilitated communication, noting that the
majority of the messages having been produced by the
facilitator, or prompter, rather than the person with
complex communication needs (Ganz, 2014; Mostert,
2001, 2010; Saloviita, Lepp ä nen, & Ojalammi, 2014;
Schlosser et al., 2014). That is, researchers have demon-
strated that when the facilitator and the individual with
complex communication needs are given separate stim-
uli, the message produced most frequently corresponds
with the stimuli given to the facilitators (Bebko, Perry,
& Bryson, 1996; Cabay, 1994; Hirshoren & Gregory,
1995; Kerrin, Murdock, Sharpton, & Jones, 1998).
Further, in a number of cases, facilitated communica-
tion has been associated with false accusations of abuse
of people with developmental disabilities, causing
these individuals to be removed from their families
(Gorman, 1999; Hostler, Allaire, & Christoph, 1993; Siegel,
1995). Notably, a former facilitator who was involved
in a false abuse allegation case has disavowed the use
of facilitated communication (Boynton, 2012). Given
the potential dangers associated with this method, the
lack of evidence of effectiveness, federal requirements
for schools to implement evidence-based practices, and
position statements from professional organizations
(ISAAC, 2014), it is strongly recommended that practi-
tioners and family members avoid use of FC.
Implications of AAC and ASD Research
for Practice
Research is most useful when it can be translated into
a form accessible to practitioners, family members, and
other stakeholders. To that end, the sections that follow
will address the implications of the AAC research on
individuals with ASD related to: (a) selection of AAC
modes, (b) the mobile technology revolution, (c) gen-
eralization of AAC and communication skills across
communicative functions, varied outcomes, numer-
ous contexts, and many communication partners, and
(d) avoidance of unconventional and unproven AAC
approaches.
Selection of AAC Modes
Parents and practitioners may have dif culty choos-
ing what modes of AAC may be most suitable for their
children or clients with ASD (Ganz, 2014). Certainly,
the rst step in determining the need for AAC and
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State of the Science in AAC and ASD 207
© 2015 International Society for Augmentative and Alternative Communication
selecting a method is to conduct a comprehensive
assessment with a strong focus on communication
skills and factors related to family and context (Ganz,
2014). Beyond assessment procedures, stakeholders
may consider the literature related to matching char-
acteristics of people with ASD to AAC, ef cacy stud-
ies for AAC with people with ASD, and preference and
choice studies. Aided AAC has been recommended as
a good match, given that many individuals with ASD
have dif culty understanding abstract concepts (e.g.,
spoken language), have strong interests in objects, and
have challenging behaviors that occur due to problems
with communicating (Durand, 1999; Ganz, Parker,
& Benson, 2009; Ganz, Simpson, & Lund, 2012;
Gernsbacher et al., 2008). It does appear that, given
the research to date and the core characteristics of
ASD, aided AAC is a more ef cacious means of
providing a functional communication system to indi-
viduals with ASD than unaided AAC, or sign language
(Ganz & Gilliland, 2014). Meta-analyses have begun
to investigate matching characteristics, such as age and
co-occurring disabilities, to particular modes of aided
AAC (Ganz, Earles-Vollrath, et al., 2011; Ganz, Mason,
et al., 2014). However, this work is in the early stages
and additional studies with larger numbers of partici-
pants are needed before stakeholders may relate conclu-
sions to particular individuals.
It is likely that a multimodal communication approach
is particularly effective in meeting the needs of people
with ASD and complex communication needs across
contexts (Light & Drager, 2007), although this has not
been investigated in the AAC and ASD research to date.
That said, it seems logical to provide multiple means
of communicating, including use of multiple modes
of AAC, speech approximations, gestures, and facial
expressions (DeRuyter & Becker, 1988; Light, 1997).
Thus, if a new means of communication is taught to
address a challenging behavior that occurs when the
individual is hungry, a laminated card with a picture
and text stating, I ’ M HUNGRY , may be carried in the
person ’ s pocket for easy access and use. In the classroom
during read-aloud, the teacher may program a page on
a mobile AAC app with hot spots that correspond with
language related to a book being read that week. There
may also be communication boards with a picture-
exchange system throughout the classroom related to
speci c activities, such as a selection of art supplies in
the art center. This same individual may also use some
speech approximations to indicate yes and no in concert
with nodding or shaking his or her head.
To date, the literature has not indicated with con-
dence that individuals with ASD consistently select
one particular mode of AAC (Ganz, Hong, & Goodwyn,
2013; van der Meer et al., 2011). However, people
with ASD often choose high-tech devices when offered
speech-generating devices, exchange-based systems,
or manual sign language (Couper et al., 2014; van der
Meer et al., 2012). This pattern was the same when adult
undergraduates were asked their perceptions of three
types of AAC (Achmadi et al., in press). That said, there
are implications that can be drawn from the research on
preference in AAC in people with ASD; clearly the pref-
erences of the individual with ASD and his or her family
members should be considered during the assessment
process (Ganz, 2014). This may involve providing pre-
liminary instruction in multiple forms of AAC, use of
word approximations, and gestures and facial expres-
sions, while collecting data to determine how quickly the
individual is able to master multiple messages with each
form of AAC (Cannella-Malone et al., 2009). Following
this initial instruction, a preference assessment may be
conducted, in which multiple modes of AAC may be
placed in front of the individual and he or she may be
asked to touch or pick up the preferred mode (van der
Meer et al., 2012). Alternately, a preference assessment
may be conducted during naturalistic communication
opportunities, wherein a number of AAC modes are in
reach, the placement of the modes is frequently ran-
domized, and data are collected to determine how often
the client selects each to communicate (Ganz, Hong, &
Goodwyn, 2013).
Implications of the Mobile Technology Revolution for AAC
and Individuals with ASD
Mobile devices are now ubiquitous in society (Gal et al.,
2009; McNaughton & Light, 2013), and are also used
by young children. There has been a rapid increase
in the availability of AAC mobile apps for multiple
operating systems (Gosnell, Costello, & Shane, 2011;
McNaughton & Light, 2013). A few recent studies
investigated the use of AAC mobile apps with people
with ASD and offered promising results (Flores et al.,
2012; Ganz, Hong, &
Goodwyn, 2013; Kagohara et al.,
2013; van der Meer et al., 2012). Such devices have a
number of advantages over picture-exchange AAC and
older stand-alone SGDs (Ganz, 2014). These include
lower cost, which enables families to more easily access
AAC (McNaughton & Light, 2013). These apps may
be downloaded onto lightweight and small, yet power-
ful devices that can be easily transported across settings
(Sennott & Bowker, 2009). Some people with ASD may
be enticed to use dynamic mobile apps because they
are appealing and associated with reinforcing activities
(Ganz, Hong, & Goodwyn, 2013). Thus, these devices
may be more appealing to family members due to the
acceptability of mobile devices throughout the com-
munity (McNaughton & Light, 2013). Furthermore,
the devices are easily programmable, which enables the
individuals with ASD and his or her communicative
partners to rapidly add vocabulary and personalize the
system (Ganz, Hong, & Goodwyn, 2013). All of these
factors may contribute to the increased use and accept-
ability of AAC (McNaughton & Light, 2013). Finally,
when AAC is integrated within multifunction mobile
technologies, individuals with ASD may have access to
more diverse means to communicate as they can quickly
refer to other apps and les (Hyatt, 2011).
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208 J. B. Ganz
Augmentative and Alternative Communication
Addressing Varied Communicative Functions, Outcomes,
Contexts, and Communication Partners
Although the majority of research on AAC for people
with ASD has focused on teaching AAC use pri-
marily for requesting items (Ganz, Earles-Vollrath,
et al., 2012), practitioners and family members
should consider a wider range of communicative func-
tions and other types of outcomes. A number of skills
beyond requesting have been demonstrated to improve
throughout AAC instruction (Ganz, Earles-Vollrath,
et al., 2012). For example, although family mem-
bers may be hesitant to use AAC out of concern that
speech would be inhibited (Romski & Sevcik, 2005),
a meta-analysis and a systematic review have dem-
onstrated the contrary – that speech is not negatively
impacted and is sometimes improved over the course
of AAC intervention (Ganz, Earles-Vollrath, et al.,
2012; Millar, Light, & Schlosser, 2006). While work
remains to determine characteristics of children who
may be most likely to gain speech concurrently with
AAC intervention, it is safe to advise family members
and practitioners that AAC will not be a detriment.
Furthermore, AAC has been shown to be a viable
intervention to treat both communication de cits
and related challenging behaviors in people with ASD
and complex communication needs (Ganz, Davis,
et al., 2012; Ganz, Earles-Vollrath, et al., 2012; Ganz
et al., 2009). This seems to be particularly true when
AAC is implemented in conjunction with functional
communication training, according to a recent meta-
analysis (Walker & Snell, 2013). Behavior analysts
may assist service providers in assessing the function
of challenging behaviors and incorporating functional
communication training into AAC interventions as
needed (Durand, 1999). Finally, although research
has not addressed a wide range of communicative
functions beyond behavior regulation (e.g., protesting,
requesting), it is clear that this lack of research also
re ects a tendency among practitioners in the eld to
provide instruction in requesting skills to the exclu-
sion of most other communicative functions (Ganz,
Earles-Vollrath, et al., 2012). Thus, it is imperative
that service providers and family members provide
instruction and opportunities to practice a range of
communicative functions, including social interaction
(e.g., sharing a social routing, greeting, showing off)
and joint attention (e.g., sharing attention to items or
information) (Shumway & Wetherby, 2009).
Practitioners and family members should focus on
providing AAC instruction and communication oppor-
tunities across all settings, contexts, and communicative
partners that people with ASD and complex commu-
nication needs may encounter (Ganz & Hong, 2014).
People with ASD frequently have dif culty generalizing
skills to conditions under which they were not initially
provided instruction. Therefore, it is critical for this pop-
ulation that instruction in any skill, particularly commu-
nication, which is used in all settings, is targeted in all
settings and contexts and with all possible communica-
tive 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 communica-
tion 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 elds of
medicine, allied health, and special education for prac-
titioners and family members to adopt unsubstantiated
treatments, it is not clear how to best educate and per-
suade practitioners and families to avoid unproven treat-
ments such as FC. The rise of the Internet, although
providing a means of gathering information, provides
an apparently equal voice to unproven and to evidence-
based practices, making it dif cult for stakeholders to
judge the accuracy and reliability of information. Ser-
vice 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 ef cacious 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 Inter-
agency Autism Coordinating Committee (iacc.hhs.gov).
A number of authors have discussed this issue at length
in relation to unsubstantiated fad treatments for indi-
viduals 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 physi-
cal 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 attribu-
tion 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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State of the Science in AAC and ASD 209
© 2015 International Society for Augmentative and Alternative Communication
Priorities for Future Research to Improve AAC
Interventions for People with ASD
Although great progress has been made in the quantity
and quality of research on the implementation of AAC
with people with ASD over the last several decades,
critical work remains to maximize outcomes for indi-
viduals with ASD and complex communication needs
and to best match individuals to particular AAC modes
and intervention approaches. Research is required to
evaluate the use of newly developed mobile AAC tech-
nologies and effective means of generalizing AAC skills
across outcomes and contexts.
Expansion of Research in Mobile Technologies
Although preliminary ef cacy studies have been con-
ducted involving the implementation of AAC via mobile
technology (Flores et al., 2012; Kagohara et al., 2013),
additional research is needed. As AAC apps rapidly
evolve, studies are needed to evaluate the ef cacy of
these apps and to compare mobile AAC apps and more
traditional AAC systems (McNaughton & Light, 2013).
In addition, although SGDs have frequently presented
icons in grid array formats (Wilkinson & McIlvane,
2013), newer formats, such as visual scene displays,
have been introduced. These displays use contextual
scenes in the form of photographs or drawings to pres-
ent in-context concepts (Wilkinson & Jagaroo, 2004).
The images have hot spots that produce voice or sounds
when selected or tapped (Wilkinson & Light, 2011).
These scenes are thought to be more appropriate for
young individuals with complex communication needs
and those who are in the early stages of learning lan-
guage concepts because they mimic the means by which
typically-developing children learn language through
contextual exposure (Drager, Light, Speltz, Fallon, &
Jeffries, 2003; Light et al., 2004). Although research on
this approach has been conducted with typically devel-
oping young children (Drager et al. 2003; Light et al.,
2004), future research is needed to investigate this for-
mat and other newer approaches with people with ASD
and complex communication needs.
Protocols and Interventions to Address Varied Skills
and Generalization
As noted previously, although deemed important by
experts, research into AAC for individuals with ASD
has frequently focused on addressing limited skills, in
highly structured settings, with limited communication
partners, and with participants with ASD of limited age
range (Ganz, Earles-Vollrath, et al., 2012). Thus, future
research should focus on the following areas. It should
provide family members and practitioners with distinct
protocols and curricula to address a range of commu-
nicative functions and skill areas. It should also address
the feasibility and delity of such treatments, to ensure
that they are implemented as intended and in a manner
in which stakeholders nd manageable.
Future research is needed to address how to best pro-
vide instruction that will generalize across natural con-
texts. 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 increas-
ing AAC use would be to promote multimodal AAC
use. Providing multiple means of communication, as
appropriate for particular contexts, may increase com-
munication 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 speci cally
related to educational content, and supplemented by
speech approximations.
Finally, there is a need for development and ef cacy
research that incorporates or packages communication
interventions into protocols speci cally designed to
meet the unique needs of people with ASD and com-
plex 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). Speci cally,
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 interven-
tions based on characteristics and functioning level.
Potential Methods to Address Research
Questions about AAC for Individuals with ASD
Meta-analyses are increasingly used to aggregate results
of single-case experimental designs to evaluate effective-
ness of interventions for people with disabilities (Parker,
Vannest, & Davis, 2011), including AAC interventions
for people with ASD (e.g., Ganz, Davis, et al., 2012;
Ganz, Rispoli, et
al., 2014). These techniques require
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210 J. B. Ganz
Augmentative and Alternative Communication
use of effect size measures, so small-N studies may be
aggregated to allow more con dence in determination
of effectiveness. There is some controversy regarding the
use of these measures in single-case research (Schlosser
& Pennington, 2005). There is not yet one universally
accepted method of meta-analysis that statisticians
agree upon, due to problems meeting the assumptions
of many of the proposed methods (Kratochwill et al.,
2013); however, single-case experts have noted that these
methods are beginning to gain acceptance (Kratochwill
et al., 2010). New effect sizes will continue to be evalu-
ated for their usefulness in aggregation of small-scale
research (Horner & Kratochwill, 2012). Indeed, meta-
analyses of single-case experimental designs are cur-
rently increasing in publication rate, particularly related
to AAC interventions including for people with ASD
(e.g., Flippin, Reszka, & Watson, 2010; Ganz, Davis,
et al., 2012; Ganz, Earles-Vollrath, et al., 2012; Ganz,
Rispoli, et al., 2014; Hart & Banda, 2010; Schlosser &
Lee, 2000; Walker & Snell, 2013). This is particularly
important given that single-case research makes up a
large proportion of intervention research for people
with ASD.
Much work remains in the development of and
acceptability of meta-analytic tools to aggregate single-
case research ndings. For one, new single-case effect
sizes are continuing to be developed and recommended,
and meta-analyses should be conducted using the most
up-to-date measures of magnitude of effect (Parker
et al., 2011). Additionally, previous meta-analyses on
AAC have not included evaluations of the quality of
the design of the included studies, which is critical in
establishing con dence in the results reported (Kra-
tochwill et al., 2010; Wendt & Miller, 2012). Future
meta-analyses should include rigorous design quality
criteria as well as established review protocols, such
as those recommended by the Cochrane Collabora-
tion or the Campbell Collaboration, to ensure adher-
ence to high standards for conducting the review or
meta-analysis (Schlosser, Wendt, & Sigafoos, 2007).
Furthermore, a number of methods would allow more
ne-grained analyses to determine for whom particu-
lar modes and protocols are best suited using current
effect sizes in meta-analysis, such as encouraging single-
case researchers to publish additional studies involving
the topics above, and funding and publication of large
group studies involving a range of people with ASD
across age ranges and geographic settings. Such expan-
sion will require the support and funding from granting
agencies.
Conclusion
The recommendations offered here are ambitious,
though possible, with suf cient 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,
individuals with ASD and complex communication
needs are at higher risk for relying on more services
into adulthood (Branson & Demchak, 2009; Hamm &
Mirenda, 2006). Thus, addressing communication de -
cits early and intensively via AAC is critical. The current
state of the science related to AAC for individuals with
ASD is promising, although much work remains both
in terms of research and the provision of resources for
people with ASD and their family members and service
providers.
Declaration of interest: The author reports no con-
ict of interest. The author alone is responsible for the
content and writing of the paper.
This work was supported by the Center on Disability
and Development at Texas A & M University, a federally
recognized University Center of Excellence in Develop-
mental Disabilities.
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